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Michael W. Wangia, M.D. Clinical Assistant Professor

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1 Dermatology Pearls for 2014 American Board of Dermatology certifying exam
Michael W. Wangia, M.D. Clinical Assistant Professor Dermatopathology Fellow University of Florida Department of Dermatology

2 Objectives 30 high-yield pearls What I did to prepare

3 “For every pearl at the bottom of the ocean, there is a ton of whale shit.” —Ernest Lee, M.D.

4 1. Ipilimumab Mechanism of action
Blocks CTLA-4 receptor†‡ on cytotoxic T lymphocytes, preventing their inhibition, allowing them to destroy melanoma cells Adverse effects include Facial swelling Colitis †Also known as CD152 ‡Normally CTLA-4 stimulation inhibits T-cells

5 2. Vemurafenib† Mechanism of action B-Raf protein inhibitor Indication
Treatment of BRAF V600E mutation‡ positive unresectable or metastatic melanoma †Also known as PLX4032 and by the brand name Zelboraf® ‡Substitution of valine (V) with glutamic acid (E) at codon 600 The most severe dermatologic adverse effects are the development of eruptive squamous cell carcinomas and keratoacanthomas.

6 3. Dimethylaminopropylamine
DMAPA is used in the formation of cocamidopropyl betaine Cocamidopropyl betaine is found in liquid soaps and shampoos DMAPA remains in products as contaminant DMAPA is important cause of eyelid dermatitis

7 4. Angiopoietin receptors
Tie-1 and Tie-2 are cell-surface receptors† Angiopoietins bind these receptors and promote angiogenesis There are four angiopoietins Serum Ang2 levels are elevated in patients with angiosarcoma †Mutations that lead to dysfunction of the Tie-2 receptor are associated with vascular malformations

8 5. Viral-associated trichodysplasia
Closely linked with organ transplantation, immunosuppression†, and pre-B cell leukemia Follicular spiny papules erupt on face Likely due to a polyomavirus‡ Treat with valganciclovir †Cyclosporin often cited ‡A dsDNA virus and member of papovavirus family

9 6. Merkel cell carcinoma Merkel cell polyomavirus (MCPyV) Wide local excision Sentinel lymph node biopsy in all cases Adjuvant radiotherapy for lesions on head and neck with locoregional spread

10 7. Coding excision size Malignant lesions are excised with margins Diameter of resulting surgical defect (lesion + margins) termed “excised diameter” Excised diameter used to select proper CPT code to bill excision A 6mm BCC on back excised with 4mm margins would result in a 1.4cm excised diameter (11602)

11 Modifiers -25 -59 -79 Review these in the AAD website

12 8. Disseminated infundibulofolliculitis
Young dark-skinned patients Uniform 1—2mm papules on neck and upper trunk Figure in Andrews’ 10th edition on page 776 Treat with topical steroids, PUVA or isotretinoin

13 9. Syringomas Occur not just on face but also neck, chest, axillae, upper arms, and periumbilically Figure B in Bolongia’s 2nd edition on page 1704 Figure in Andrews’ 10th edition on page 664 Associated with Down syndrome, Nicolau–Balus syndrome, and Brooke-Spiegler syndrome

14 10. Lupus miliaris disseminatus faciei
Red-to-yellow papules on central face and around eyelids Histology shows single superficial BB-like nodule Central caseation necrosis

15 11. Defects in keratin 5†‡ Epidermolysis bullosa simplex§
Dowling–Degos' disease Olmsted syndrome †For list of cutaneous conditions caused by mutations in keratins see: ‡For more lists (some good, some not so good) of board-related fodder see: §May be due to mutation in gene encoding keratin 5 and/or 14

16 12. “Migrating” conditions
Creeping eruption (Cutaneous larva migrans) 2cm/day Larva migrans profundus (Gnathostomiasis) 1cm/hour Larva currens 10cm/day Erythema gyratum repens 1cm/day

17 13. Schöpf–Schulz–Passarge syndrome
Ectodermal dysplasia Diffuse symmetric palmoplantar keratoderma Hypodontia Multiple eyelid apocrine hidrocystomas Syringofibroadenomas on extremities Poromas

18 14. Erythrodontia Congenital erythropoietic porphyria Hepatoerythropoietic porphyria

19 15. Paraneoplastic pemphigus
Target antigens: desmoglein 1, desmoglein 3, BPAG1, plectin, desmoplakin 1, desmoplakin 2, envoplakin, periplakin, unknown antigen (170kDa) Notably not BPAG2† †Do not confuse the various BP antigen synonyms due to exam stress: BPAG1 (BP230) BPAG2 (BP180, type XVII collagen)

20 16. Eruptive xanthomas Arise on buttocks and extensor surfaces of extremities Hypertriglyceridemia

21 17. Voriconazole Azole antifungal
Prophylaxis against Aspergillus infection Accelerates development of SCC’s† Photosensitivity‡ and premature photodamage †Skin cancer most frequent malignancy in organ transplant recipients (95% NMSC | SCC > BCC) ‡UVA-induced like most medication-related photosensitivity

22 18. “Trench” conditions Trench fever Bartonella quintana Pediculus humanus corporis Trench mouth Mixed population of bacteria Prevotella intermedia, Fusobacterium, Treponema and Selenomonas spp., Trench foot

23 19. Defects in p genes p53 Li–Fraumeni syndrome Actinic keratoses Squamous cell carcinoma p57 Beckwith–Wiedemann syndrome p63 Hay–Wells syndrome (AEC syndrome) EEC syndrome Rapp–Hodgkin syndrome

24 20. Vismodegib† Mechanism of action
Antagonizes membrane bound smoothened receptor leading to less activity of GLI transcription factor and ultimately decreased expression of tumor mediating genes‡ Adverse effects include Muscle spasms Alopecia †Used to treat locally advanced or metastatic BCC’s ‡Inactivating PTCH mutations and activating SMO mutations cause most BCC's. Normal pathway: SSH binds PTCH, together they inhibit SMO leading to less GLI transcription factor going to nucleus (net result: decreased expression of tumor mediating genes).

25 21. Becker’s nevus Associated with a smooth muscle hamartoma Transient induration/elevation upon rubbing in 80% (pseudo-Darier's sign) May occur on the forehead, cheek, chest, shoulder, forearm, wrist, abdomen, buttock, and shin Be ready to see a Becker’s nevus that is not on the shoulder

26 22. Cold panniculitis Cheeks of toddlers and young children Results from contact with popsicle or ice bag No treatment necessary

27 23. Extracellular matrix protein-1
ECM-1 mutated in lipoid proteinosis†‡ Targeted by autoantibodies in lichen sclerosus †Also know as Urbach–Wiethe disease ‡Beaded papules on eyelid margin not the only finding. First clinical sign is weak cry due to deposition of hyaline-like material in laryngeal mucosa. Hoarseness remains throughout life. “Ice-pick”-like acneiform scars occur on face.

28 24. Collagen types in cartilage
II (2)† IX (9)† X (10) XI (11)† XII (12) XX (20) XXVII (27) †Autoantibodies to collagen type 2, as well as 9 and 11, have been reported to cause relapsing polychondritis. This targeting of cartilage results in the red ears (sparing the lobes), arthritis, aortic aneurysms, and tracheal collapse.

29 25. Clofazimine Mechanism of action Unknown Indication
Multibacillary leprosy (>5 lesions) Adverse effects include Orange–pink skin and body fluid discoloration Ichthyosis Fatal enteropathy† †Due to crystal deposition in the small bowel mucosa The skin discoloration and ichthyosis are reversible.

30 26. GNAS1 gene Encodes G protein α-subunit that regulates adenylate cyclase activity Normal function is to negatively regulate bone formation Mutated in several conditions including Progressive osseous heteroplasia Plate-like osteoma cutis Albright hereditary osteodystrophy McCune–Albright syndrome

31 27. WHIM syndrome Warts Hypogammaglobulinemia Infections†
Myelokathexis‡ Mutated chemokine receptor CXCR4 gene§ †Namely recurrent bacterial infections such as sinusitis, cellulitis, periodontitis, and meningitis ‡Chronic peripheral neutropenia due to retention of neutrophils in the bone marrow §Autosomal dominant

32 28. Paraphenylenediamine (PPD)
Common contact allergen found in Black hair dye, scuba gear, henna† Cross-reacts with Para-aminobenzoic acid (PABA), azo dyes, sulfonamides/sulfonylureas, thiazides, ester anesthetics‡ Neutrophilic and eosinophilic dermatitis †Not found in pure henna ‡PPD + PASTE

33 29. Omalizumab Mechanism of action
Humanized monoclonal IgG1 antibody that binds to IgE preventing interaction with receptor (FcϵRI) on mast cells and basophils Has been used to treat urticaria, atopic dermatitis, and bullous pemphigoid† †IgG not only circulating auto-antibody isotype in bullous pemphigoid, but also IgE Xolair is an anti-IgE approved for mod-severe allergic asthma not responding to steroids. Its finding its way off-label, in management of several IgE mediated disease including chronic urticarial, atopic derm, mastocytosis and even BP.

34 30. Oral fibroma Most common “tumor” of the oral cavity Located along bite line of the buccal mucosa Cured by conservative surgical excision

35 Miscellaneous Randoms Imatinib/Gleevec
Treatment of DFSP with + PDGFR-COL1A1 mutation Treatment of hypereosinophilic syndrome with mutation in FIP1L1-PDGFR alpha mutation.

36 IP Mutation? NEMO. Affects NF-KB. What is the purpose of NF-KB? - protects against TNF-induced apoptosis

37 Vascular lesions? Wiebel palade bodies. These are essentially storage granules of endothelial cells. Contain vWF and P-selectin. Play dual role in both hemostasis and inflammation Bier spots are small erythematous blanching macules. Essentially benign physiologic vascular anomaly of no significance clinically. Know both malignant and benign vascular tumors and lesions.

38 Fibromatosis Juvenile hyaline fibromatosis – (nodular lesions on hands, scalp and face with gingival hypertrophy and associated joint contractures). Bx shows nodular hyaline fibrosis). Genetic mutation associated? CMG2 (capillary morphogenesis protein-2). Or ANTXR2 mutations (anthrax toxin receptor 2).


40 What I did to prepare Note taking and memorization Clinical images Pathology Practice questions

41 Note taking and memorization (I)
Leading up to month prior to exam Read through and took notes from Bolognia’s – put more emphasis on photos and tables entire 2nd edition (ISBN ) Read entire Andrews 2 months prior to the boards Spent 2 weeks prior to the test day My goal was to review, re-review, and memorizing above notes every two weeks

42 Note taking and memorization (II)
During one month prior to exam Skimmed Genodermatoses (i.e. "Spitz" | ISBN ) and added to my notes when needed Reviewed notes from 2013 Florida Dermatology & Dermatopathology Board Review Course Re-reviewed my own notes

43 Clinical images During one month prior to exam reviewed all images in: Andrews’ 11th editions Bolognia’s 2nd edition Color Atlas of Dermatology 1st and 2nd editions (i.e. "Callen" | ISBN and ) Atlas of Clinical dermatology 4th ed Du Vivier

44 Dermatopathology During one month prior to exam†
Reviewed Elston front to back Watched all the PowerPoint lectures by Dr. Elston found on the Dermatopathology: Requisites in Dermatology website‡ Reviewed all the online DLCS study slide sets§ †Note: I also attended two review courses, the Barron Board Review and the Florida Dermatology & Dermatopathology Board Review Course, both of which had slide reviews ‡ §

45 Practice questions During one month prior
Reviewed all ETAS practice questions† Reviewed all questions in the ASDS Primer in Dermatologic Surgery: A Study Companion‡ † ‡

46 What I did NOT do to prepare
Galderma Preboard Seminar review course Quizes in McGraw-Hill Specialty Board Review Dermatology: A Pictorial Review (ISBN ) Journal review

47 **** REVIEW SCLEROTHERAPY (slerosing agents, side effects etc); HAIR TRANSPLANTATION; AND FOCUS ON TECHNIQUE AND MAJOR COMPLICATIONS. - Recommend using Bolognia and Surgery Primer

48 Questions?

49 References Books (ISBN): Andrews' Diseases of the Skin: Clinical Dermatology ( ) Dermatology ( ) Hurwitz Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence ( ) Papers (PMID): A review of radiotherapy for merkel cell carcinoma of the head and neck ( ) Clofazimine: a review of its medical uses and mechanisms of action ( ) Cutaneous toxic effects associated with vemurafenib and inhibition of the BRAF pathway ( ) Disseminate and recurrent infundibulofolliculitis: response to isotretinoin ( ) Eyelid dermatitis: contact allergy to 3-(dimethylamino)propylamine ( ) Human papillomavirus typing of verrucae in a patient with WHIM syndrome ( ) Neutrophilic and eosinophilic dermatitis caused by contact allergic reaction to paraphenylenediamine in hair dye ( ) Observations on angiopoietin 2 in patients with angiosarcoma ( ) Routine omission of sentinel lymph node biopsy for merkel cell carcinoma <= 1 cm is not justified ( ) Schöpf-Schulz-Passarge syndrome: further delineation of the phenotype and genetic considerations ( ) Skin cancer in solid organ transplant recipients: advances in therapy and management ( ) Successful treatment of bullous pemphigoid with omalizumab ( ) The genesis of Zelboraf: Targeting mutant B-Raf in melanoma ( ) Trichodysplasia of immunosuppression treated with oral valganciclovir ( ) Viral-associated trichodysplasia in patients who are immunocompromised ( ) Voriconazole-associated phototoxicity ( )

50 Thank Dr. Brendan Thomas for his input

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