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JEOPARDY!
Click Once to Begin

• IM-Derm Board Review
• Nita Kohli, MD, MPH
• PGY-4, Derm

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JEOPARDY!
Stop bugging me
Nail it
Sexy legs
Bubble- rap
Its not a tumah
Derma-what?
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Daily Double Graphic and Sound Effect!
Daily Double!!!

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• In slide view mode, copy the above (red) graphic
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• Locate the answer slide which you want to be the
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• Right-click and choose paste. If necessary,
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  the answer text.

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Question 1-100

• 49-y/o woman several-day hx of pruritic lesions
  on the abdomen. Noticed upon return from business
  trip to a large northeastern city. Didn't see any
  bugs in the hotel.
• Husband not itching and has no visible lesions,
  although he shared the same room and bed.
• No new meds or exposures to other persons with
  similar rashes.
• Medical hx unremarkable, takes no meds.

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Question 1-100

• Which of the following is the most appropriate
  treatment?
• A. Oral doxycycline
• B. Oral ivermectin
• C. Topical permethrin cream
• D. Topical triamcinolone acetonide cream

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D. Topical triamcinolone acetonide creamDx Bed
Bugs (Cimex lectularius)

• Itch topical TAC, antihistamines. Spont
  resolution in days.
• Characteristic grouping linear pattern series of
  bites close together. Small punctum or bite mark
  in center.
• May be bitten while visiting infested locations
  may unknowingly bring the bedbugs home in their
  luggage. Varied response in different
  individuals possible for different persons
  sharing the same room to have reactions ranging
  from no visible marks to larger, urticarial
  wheals.
• Bugs do not actively infest the skin,
  pediculicides not indicated. Can become
  secondarily infected if scratched.

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Question 1-200

• 82-y/o man w/ 6-wk hx of intensely itchy rash on
  trunk and extremities, worse at night.
• No new exposures or meds.
• PMH Alzheimers, lives in assisted care
  facility.
• Medsdonepezil, MVI.
• PE scratching intermittently lesions in finger
  webs, wrists, torso, umbilicus. Fine linear scale
  in a few areas.

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Question 1-200

• Which of the following is the most appropriate
  diagnostic test to perform next?
• A. Complete blood count
• B. Microscopic evaluation of skin scrapings
• C. Serum tissue transglutaminase level
• D. Skin biopsy for direct immunofluorescence
  microscopy

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B. microscopic eval of skin scrapingsDx scabies

• Dx by microscopic identification of the mite,
  feces, or eggs.
• Scrape many lesions.
• Unexplained itch, rash institutionalized pt.

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Question 1-300

• 35-y/o man sores on lips following trip to
  Caribbean 1 week ago, where he sustained a
  sunburn followed by painful blisters on the back,
  face, and especially the lips.
• Blisters on lips crusted.
• Otherwise well except for recurrent herpes
  labialis.
• Meds intermittent oral acyclovir.

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Question 1-300

• Which of the following is the most likely
  diagnosis?
• A. Actinic cheilitis
• B. Allergic contact dermatitis
• C. Coxsackievirus infection
• D. Reactivation of herpes simplex virus

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D. Reactivation of HSV

• Herpes labialis can be reactivated by UV.
• Actinic cheilitis--premalignant condition
  occurring in persons who have spent a significant
  time outdoors. It usually affects the lower lips.
• Contact dermatitis to sunscreen can occur on the
  lips, but it is usually pruritic (a hallmark of
  contact dermatitis) or irritating.
• Coxsackievirushand, foot, mouth dz primarily in
  kids. Intraoral and palmar/plantar lesions. Oral
  aphthae, fever, sore throat. Spares lips, gingiva
  (HSV does not).

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Question 1-400

• 20-y/o man single erythematous macule on L arm
  that rapidly changed to fluid-filled lesions,
  some of which were cloudy.
• PE vitals normal

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Question 1-400

• Which of the following is the most appropriate
  topical treatment?
• A. Bacitracin
• B. Clotrimazole
• C. Hydrocortisone
• D. Mupirocin

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D. MupirocinDx Impetigo

• Staphylococci or streptococci.
• Tx cleansing, wet dressings to remove crust,
  mupirocin treatment of choice.
• Bullous impetigo--always S. aureus. Systemic
  spread of the same toxins causes staphylococcal
  scalded skin syndrome. Most impetigo is
  nonbullous.
• Nonbullous impetigo--direct person-to-person
  contact, spreads rapidly. S. aureus or
  Streptococcus pyogenes.
• This pt localized infection, afebrile systemic
  Abx not indicated as first-line tx.
• Bacitracin--high rate of allergic contact
  dermatitis. Anaphylaxis reported with prior
  contact sensitization.

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Question 1-500

• 35 y/o woman w/
• recurrent salmon
• colored oval lesions on
• chest, upper back,
• occasionally itchy.
• Tried OTC selenium sulfide- shampoo with modest
  improvement.
• Lesions reappear every year during hot, humid
  weather.
• KOH spaghetti and meatballs pattern

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Question 1-500

• Which of the following is the most appropriate
  next step in treatment?
• A. Oral ketoconazole, single dose
• B. Topical corticosteroids
• C. Topical ketoconazole
• D. No treatment

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Topical ketoconazoleDx. Tinea versicolor

• aka pityriasis versicolor, a common superficial
  fungal infection caused by yeast Malassezia
  furfur (aka Pityrosporum ovale or Pityrosporum
  orbiculare).

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Question 2-100

• 30-y/o man w/ nail changes. Induction chemo for
  AML 1 mth ago.
• Afebrile, no systemic complaints.
• Kidney, liver chemistry studies normal.

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Question 2-100

• Which of the following is the most likely
  diagnosis?
• A. Beau lines
• B. Lichen planus
• C. Median nail dystrophy
• D. Psoriasis

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A. Beau linesChemo induced

• Transverse linear depressions in nails from
  significant systemic stress such as chemo,
  sepsis.
• Temporary disruption of nail production in nail
  matrix. Typically, all nails are involved.
• Harmless atypical portion will grow out, be
  clipped off as nail growth returns to normal.

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Lichen Planus
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Median Nail Dystrophy

• Longitudinal depression or canal in center of
  nail, down entire length.
• Typically 1-2 nails thumb nails prone to this
  condition
• Cause trauma.

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Psoriatic nails
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Question 2-200

• 25-y/o man w/persistent discoloration on a single
  nail x 1 yr.
• Enlarged slowly.
• No hx trauma.
• No other nails are affected

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Question 2-200

• Which of the following is the most likely
  diagnosis?
• A. Longitudinal melanonychia
• B.Hematoma
• C. Onychomycosis
• D.Subungual melanoma

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D. Subungual melanoma

• Pigmentation extending onto proximal nail fold or
  other adjacent skin (Hutchinson sign) and a wider
  diameter of the pigmented area at the proximal
  area of the lesion, indicating an expanding
  lesion.

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Question 2-300

• 65-y/o man 10-year hx of painful thickened
  fingernails. Started on L hand with two nails,
  gradually spread to all fingernails.
• Not improved after 3 mths of po terbinafine.
• PMH DM2 treated with metformin and glyburide.

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Question 2-300

• Which of the following is the most appropriate
  next step in management?
• A. Begin fluconazole
• B. Begin itraconazole
• C. Obtain nail clipping for histology and culture
• D. Repeat a second course of oral terbinafine

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C. Nail clipping for path, cx

• Up to 50 of all nail dystrophies are caused by
  conditions other than fungal infection, the dx
  should be confirmed before tx initiated.
• Oral antifungal agents are not without toxicities
• KOH, cx, PAS of clipping
• Causes dermatophytes, yeasts, molds, trauma,
  lichen planus, psoriasis

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Question 2-400

• 53-y/o woman rash gradual onset x 2 mths. Scalp
  pruritus, redness of face, pruritic rash on
  chest, arms.
• Started after baseball game where she sat in sun
  for hours.
• More fatigued lately, DOE.
• PE Violaceous erythema of periorbital face,
  malar area, nasolabial folds.
• Difficulty abducting arms above 90 degrees or
  rising from a chair without using her arms to
  help.
• DTRs nl, no obvious joint abnormalities.

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Question 2-400

• Which of the following is the most likely
  diagnosis?
• A. Dermatomyositis
• B. Psoriasis with psoriatic arthritis
• C. Rheumatoid arthritis
• D. Systemic lupus erythematosus

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A. Dermatomyositis

• Heliotrope rash, Gottron papules.
• Psoriasis--pink plaques with silvery scale,
  elbows, sites of trauma or pressure. No muscle
  weakness, malar rash, or V-neck erythema.
  Improved by UV.
• RA--rheumatoid nodules over extensor joints. No
  muscle weakness, photosensitivity, malar or
  V-neck erythema.
• SLE--malar erythema, can follow sun exposure
  rare muscle weakness. No Gottrons papules.

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Question 2-500

• 46 y/o woman 4-day hx intensely pruritic rash on
  face, neck. Started using new facial moisturizer
  1 week prior to onset.
• Stopped using moisturizer, rash persisted. Tried
  calamine lotion, no improvement.
• PMHneg takes no meds.
• PE poorly defined, red, weepy, eczematous
  patches on cheeks, neck. Few fine vesicles, some
  serous crusting.

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Question 2-500

• Which of the following is the most appropriate
  corticosteroid cream for this rash?
• A. Betamethasone dipropionate
• B. Clobetasol propionate
• C. Desoximetasone
• D. Hydrocortisone valerate

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D. Hydrocortisone valerateDx Allergic contact
dermatitis to moisturizer

• High-potency topical steroids cause thinning of
  skin, avoid on face, periorbital, occluded areas
  (intertriginous folds, axillae, under breasts,
  pannus), and on atrophic skin where absorption
  may be enhanced ? use low potency.
• Patient's rash involves face, neck ? lower
  potency steroid safest.
• Adverse effects thin skin, striae,
  hypopigmentation, telangiectasia.
• Clobetasol propionate--ultrapotent corticosteroid
• Betamethasone dipropionate, desoximetasone--high-p
  otency

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Question 3-100

• 54-y/o woman w/enlarging, painful ulcer medial
  leg x 3-4 mths.
• Unresponsive to several courses of po cephalexin.
  Remote hx DVT L leg.
• BLE skin feels somewhat thickened. Sensation in
  feet normal. Toes warm.
• ABI of left leg is 0.9.

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Question 3-100

• Which of the following is the most appropriate
  treatment?
• A. Arterial revascularization
• B. Contact casting
• C. Intravenous vancomycin
• D. Unna boot compression

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D. Unna Boot CompressionDx venous stasis ulcer

• Compression minimizes vascular HTN, edema.
• Risk factors chronic venous HTN, hx of DVT,
  trauma in affected limb. Classically medial
  malleolus, surrounding skin thickened with
  chronic hemosiderin deposition. May be assoc w/
  venous stasis dermatitis, which causes affected
  skin to become red, warm, and possibly tender and
  mimics cellulitis.
• Contact casting--to redistribute pressure on
  plantar feet in neuropathic ulcers.
• Venous stasis dermatitis vs cellulitis
• presence of chronic erythema in both lower legs,
  the absence of fever or leukocytosis, lack of
  response to appropriate Abx tx favor
  non-infectious.

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Arterial ulcers

• bony prominences, posterior calf. Punched-out,
  painful, limb may be cool to touch, poor
  capillary refill. Distal pulses may not be
  palpable. ABI lt than 0.9.

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Question 3-200

• 35 y/o man pain, increased warmth, erythema,
  swelling on RLE x 2 d. No pruritus.
• Hx tinea pedis, chronic lymphedema in RLE.
• No meds NKDA.
• PE T100.1 F other vital. BMI 30.

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Question 3-200

• Which of the following is the most likely
  diagnosis?
• A. Bullous tinea
• B. Cellulitis
• C. Contact dermatitis
• D. Stasis dermatitis

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B. Cellulitis

• Rapidly spreading, deep, SQ-based infection, w/
  well-demarcated area of warmth, swelling,
  tenderness, erythema, may have lymphatic
  streaking, fever, chills.
• Often secondary to streptococcal or staph
  infection. On legs, almost never bilateral.
• Risk factors hx of cellulitis in same location,
  chronic leg ulceration, varicose veins,
  thrombophlebitis, DM2, heart failure, lymphedema,
  obesity, onychomycosis, tinea pedis.
• Contact dermatitis--swelling, erythema, warmth,
  but almost always accompanied by pruritus
  vesicles, bullae if severe.

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Bullous Tinea

• Also inflammatory, erythematous usually
  localized to foot, occ spreads to lower ankle.
  Clues scales in a moccasin distribution.

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Stasis Dermatitis

• Looks similar to cellulitis when inflammatory,
  can become secondarily infected
• Almost always bilateral and usually not tender.

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Question 3-300

• 27-y/o man w/ rapidly progressive ulcer on leg,
  extremely tender, expanding x 1 week.
• Started 10 -14 days ago. Initial lesion a
  pimple.
• 2 mths abdominal pain, frequent BMs, watery
  stools, occ bloody.
• PE afebrile, other vitals nl. No streaking
  erythema, fluctuance, purulent discharge,
  expressible pus, or sinus tracts.

47
Question 3-300

• Which of the following is the most likely
  diagnosis?
• A. Calciphylaxis
• B. Ecthyma gangrenosum
• C. Necrotizing fasciitis
• D. Pyoderma gangrenosum

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D. Pyoderma gangrenosum

• Uncommon, neutrophilic, ulcerative skin disease
  assoc w
• inflammatory bowel disease,
• RA,
• seronegative spondyloarthritis,
• hematologic dz or malignancy, most commonly AML.

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Calciphylaxis

• Painful ulcerative process due to ectopic
  calcification of the arteries feeding the skin.
• Nearly always in pts w/ ESRD in setting of very
  high Ca-P products
• Reticulated, dusky erythema then ulcerates due to
  cutaneous ischemia.

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Ecthyma gangrenosum

• From perivascular bacterial invasion of blood
  vessel walls with secondary ischemic necrosis.
• Multiple lesions may be present at different
  stages of development.
• Pseudomonas aeruginosa
• Almost always occurs in a significantly
  immunocompromised pt who is clinically ill.

51
Necrotizing fasciitis

• Rapidly progressive infection of subcutis, often
  streptococcal or polymicrobial.
• Critically ill, disease progresses over hours.
• Extreme pain, dull or dusky skin, potentially
  with crepitus, and a clinical picture of sepsis.

52
Question 3-400

• 31-y/o woman 2-wk hx slightly tender lesions on
  anterior shins. Appeared suddenly.
• No joint pain, fevers, cough, ocular symptoms, GI
  problems.
• Recently started OCPs.
• PE vitals normal. 6-7 bilateral reddish-brown SQ
  nodules are present on anterior shins. No
  fluctuance.
• Rest of exam normal
• CXR normal.

53
Question 3-400

• Which of the following is the most appropriate
  next step in management?
• A. Discontinue oral contraceptives
• B. Initiate oral acyclovir
• C. Initiate oral cephalexin
• D. Initiate oral fluconazole

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A. D/C OCPsDx drug induced erythema nodosum

• Septal panniculitis w/ sudden onset of tender,
  erythematous nodules on the anterior legs
• Associated with infections, systemic diseases, or
  adverse drug reactions, particularly to Abx,
  OCPs, and hormone therapy.

55
Question 3-500

• 68-y/o man slightly pruritic, occ painful plaques
  on arms x 1 yr. Skin is now very tight, constant
  discomfort.
• 1 yr ago, had MRI w/ gadolinium to eval spinal
  stenosis and back pain.
• On hemodialysis for ESRD.
• Meds Epo-A, lisinopril, nifedipine, sevelamer,
  ASA.
• PE vital nl. Skin indurated, tight, woody,
  bound-down texture.
• Labs SPEP wnl ANA neg. Anticentromere Ab neg.
  
• Scl-70 antibody Neg

56
Question 3-500

• Most likely diagnosis?
• A. Lipodermatosclerosis
• B. Nephrogenic systemic fibrosis
• C. Scleroderma
• D. Scleromyxedema

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B. Nephrogenic Systemic Fibrosis

• Gadolinium contrast agents identified as
  potential cause of NSF in pts w/ CKD.
• Scleroderma is unlikely given the localization
  of the skin changes to the arms, lack of
  sclerosis of the face and perioral region, the
  lack of involvement of the fingers, and neg labs.
  

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Lipodermatosclerosis

• Pts w/ sig. venous insufficiency--can develop a
  severe fibrosing panniculitis.
• Darkly pigmented, indurated skin , bound down to
  subQ.
• Inverted champagne bottle legs

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Scleromyxedema

• Rare. Widespread erythematous, indurated skin
  w/near-confluent fleshy papules
• Face, fingers, extremities.
• Usually assoc w/ a serum paraprotein.

60
Question 4-100

• 65-y/o woman prodrome of pain on tip of nose
  followed by a painful eruption involving the
  right periorbital tissue.
• PE vitals nl.
• Grouped vesicles on an erythematous base on the
  tip of the nose and about the right eye.

• Which of the following is the most appropriate
  first step in management of this patient?
• A. Warm compresses
• B. Begin ophthalmic corticosteroids
• C. Begin valacyclovir and obtain urgent
  ophthalmology consultation
• D. Bacterial cx and start cephalexin

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C. Begin valacyclovir, consult ophthoDx Ocular
Herpes zoster

• Medical emergency, requires prompt referral
  ophthalmology, initiation of antiviral tx. If not
  txd promptly, can cause blindness.
• Eye redness, rash in the supratrochlear nerve
  distribution assoc w/ clinically relevant eye dz.
• DFA or PCR confirm dx however decision to start
  antivirals based on HP, rather than wait for lab
  testing.

62
Question 4-200

• 22-y/o man w/ lip erosions and new rash on the
  palms.

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Question 4-200

• Which of the following infections is most
  commonly associated with this skin finding?
• A. Herpes simplex virus
• B. Parvovirus B19
• C. Streptococcus, group A
• D. Varicella zoster

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A. HSVDx erythema multiforme

• Erythema multiforme is an acute dermatosis of the
  skin and mucosae that can be triggered by
  infections, most commonly herpes simplex virus.
• Tx symptomatic, prophylactic antiviral tx.

65
Question 4-300

• 64-y/o man in ER for rash x 3d, rapidly spread to
  most of body. Skin is painful.
• PMH psoriasis and asthma.
• Meds topical corticosteroids prn, inhaled
  corticosteroid, salmeterol, albuterol. 1 wk ago,
  completed 10-day course of oral corticosteroids
  for an acute exacerbation of asthma.
• PE appears ill. T102.0 F, BP 118/78 mm Hg, P
  112/min.
• gt 90 BSA erythematous, widespread coalescing
  erythematous patches and plaques, with pinpoint
  pustules coalescing into lakes of pus. Mucous
  membranes are normal.

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Question 4-300

• Which of the following is the most likely
  diagnosis?
• A. Candida albicans infection
• B. Pustular psoriasis
• C. Sweet syndrome
• D. Toxic shock syndrome

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A. Pustular psoriasis

• Pts w/ hx of psoriasis txd w/ systemic
  corticosteroids may develop an acute pustular
  erythrodermic flare after the systemic
  corticosteroids are discontinued.
• Tx underlying dz (psoriasis in this patient),
  supportive care.
• Most common causes of erythroderma drug
  eruptions, psoriasis, atopic dermatitis, CTCL

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Sweets syndrome(Acute febrile neutrophilic
dermatosis)

• More common in adults than children. Majority
  (50-80) of pts have a fever.
• Arthralgia, myalgia, and arthritis are seen in
  30 to 60 of patients.
• Often considered a reactive syndrome, assoc. with
  a preceding URI, GI illness
• Assoc. w/malignancy in about 10 of pts.
• First-line tx systemic corticosteroids.

69
Question 4-400

• 37-y/o woman 24-hour hx of peeling skin. Recently
  treated for UTI w/ bactrim. Developed fever ,
  red, itchy papules on her torso and extremities.
  She continued the Abx, rash worsened, skin became
  painful.
• No other meds, NKDA.
• PE acutely ill, pain. T102.9 F, BP 100/60 mm
  Hg, P106, RR20.
• Skin shears. Erythema, crusting around eyes,
  lips, open erosions in mouth, vulva

70
Question 4-400

• Patient is admitted to the ICU and aggressive
• IVF replacement is begun.
• Which of the following should be done next?
• A. Begin intravenous corticosteroids
• B. Begin topical corticosteroids
• C. Begin vancomycin
• D. Obtain a skin biopsy

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D. skin biopsyDx Toxic epidermal necrolysis

• Most important step is stopping the suspected
  causative medication and initiating supportive
  care in an ICU or burn unit.
• Emergent derm consult for evaluation, skin biopsy
  to ensure appropriate dx and mgmt.

72
Question 4-500
79- y/o woman pruritic blisters on chest,
abdomen, and lower extremities x 3 -4 weeks'
duration. The blisters arise in crops, drain
clear yellow fluid, and crust over before
healing. No recent illness, feels well. Cannot
identify precipitating causes. Takes no new meds,
no new topicals, no new exposures to plants. No
sick contacts. PMH Hashimoto thyroiditis
Meds levothyroxine.
73
Question 4-500

• What is the best next step?
• A. Bacterial cx
• B. PCR from blister fluid
• C. Skin biopsy and DIF
• D. Tzanck prep

74
C. Skin biopsy and DIFDx Bullous Pemphigoid

• Chronic, vesiculobullous eruption, mainly
  involves nonmucosal surfaces. Subepidermal tense
  blisters.
• Widespread lower abdomen, inner thighs, groin,
  axillae, flexural aspects arms and legs.
• Has been assoc. w/ psoriasis, DM, SLE,
  pernicious anemia, thyroiditis, polymyositis, RA.
  
• Path Subepidermal blister, DIF IgG, C3 at BMZ

75
Question 5-100

• 75 y/o man asymptomatic, dark brown, irregularly
  pigmented patch on cheek x 7 yrs enlarging
  slowly.

76
Question 5-100

• Which of the following is the most appropriate
  next step?
• A. Broad shave biopsy
• B. Cryotherapy
• C. Single punch biopsy
• D. Topical 5-fluorouracil

77
A. Broad shave biopsyDx Lentigo maligna

• Uniformly pigmented, light-brown patch on face or
  upper trunk in sun-damaged skin, enlarges slowly,
  variegated in color.
• Preferred method of bx for most atypical
  pigmented lesions worrisome for melanoma is
  excisional biopsy with 2-mm margins. This allows
  determination of both atypia and depth.
• 3 reasons why broad shave bx preferred for LM
• (1) most in situ or minimally invasive little
  risk of transecting base
• (2) the atypical cells are not distributed
  homogenously throughout the lesion performing a
  small punch biopsy carries a significant risk of
  a false-negative result and
• (3) cosmetic result superior compared with more
  invasive techniques.

78
Question 5-200

• 78-y/o man several-year hx of increasing number
  of irregularly pigmented moles on the back.
  Mostly asymptomatic, some itch, some getting
  larger.
• Concerned for melanoma, asking for removal of
  all.
• FHX sister with melanoma at 55 y/o.

79
Question 5-200

• Which of the following is the mostly likely
  diagnosis?
• A. Atypical nevi
• B. Melanomas
• C. Seborrheic keratoses
• D. Solar lentigines

80
C. Seborrheic keratoses

• Benign waxy, verrucous papules ranging in color
  from flesh colored, to yellow, to tan, may be
  irregularly pigmented.
• Torso, back, btwn breasts, face, scalp.
• Rare rapid development of multiple SKs--sign of
  Leser-Trélat--assoc with malignancy

81
Question 5-300

• 75-y/o man w/ asymptomatic smooth papule on his
  face x 7 mths.
• Enlarging steadily and periodically bleeds when
  traumatized.

82
Question 5-300

• Which of the following is the most likely
  diagnosis?
• A. Actinic keratosis
• B. Basal cell carcinoma
• C. Epidermal inclusion cyst
• D. Melanoma
• E. Squamous cell carcinoma

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B. Basal cell

• Smooth, pearly, asymptomatic telangiectatic
  papules that grow slowly, but may eventually
  cause substantial local tissue destruction if not
  removed.

84
Question 5-400

• 45-y/o kidney transplant recipient w/
  asymptomatic lesion below his right ear x 4-6
  wks. Unsure if it changed in size.
• Does not itch or bleed, but is occasionally
  painful.
• Med tacrolimus, lisinopril, atenolol, and
  trimethoprim-sulfamethoxazole.

85
Question 5-400

• Which of the following is the most likely
  diagnosis?
• A. Fixed drug reaction secondary to
  trimethoprim-sulfamethoxazole
• B. Nummular eczema
• C. Psoriasis
• D. Squamous cell carcinoma
• E. Tinea corporis

86
D. Squamous cell

• Transplant recipients are at increased risk for
  the development of skin cancer.
• Immunosuppressive agents increase the risk of
  malignancy.
• These skin cancers are more likely to be
  multiple, occur at a younger age, behave more
  aggressively with a significantly increased risk
  of metastasis and death.

87
Question 5-500

• 57-y/o man sore on lip x 3 mths.
• Former smoker quit 10 yrs ago.
• Which of the following is the most likely
  diagnosis?
• A. Actinic cheilitis
• B.Herpes simplex infection
• C. Impetigo
• D. Lichen planus
• E. Squamous cell carcinoma

88
E. Squamous cell carcinoma

• Most common type of oral malignancy, generally
  consists of red plaques or nodules that may be
  covered with scale, crust, and erosions.
• Risk factors smoking, alcohol, sun exposure.
• Biopsy

89
Question 6-100

• 27-y/o woman w/ 4-wk hx of wheals, burning
  sensation w/o pruritus. Each lesion persists x 48
  hrs, slowly resolves, leaving a bruise.
• Meds-- diphenhydramine, hydroxyzine, cetirizine,
  and oral contraceptives.
• MomSLE.
• PE vitals nl. Scattered ecchymoses at sites of
  fading lesions. No facial lesions, mucous
  membranes nl. No joint swelling or tenderness.

• Which of the following is the most appropriate
  management?
• A. Discontinue oral contraceptives
• B. Radioallergosorbent testing
• C. Skin biopsy
• D. Thyroid function testing

90
C. Skin biopsyDx urticarial vasculitis

• Lesions persist gt 24 hours and resolve with
  bruising should be biopsied to evaluate for
  urticarial vasculitis.
• 50 of pts have underlying autoimmune disease
  such as SLE.
• Less frequently caused by meds has not been
  associated with OCPs.

91
Question 6-200

• 34-y/o man progressive thickening of neck,
  axillae. Asymptomatic, but concerned about the
  cosmetic appearance.
• Has DM2, HTN, HLD
• Meds metformin, lisinopril, simvastatin.
• BMI 32.
• No nail changes. No lesions elsewhere.

92
Question 6-200

• Which of the following is the most likely
  diagnosis?
• A. Acanthosis nigricans
• B. Allergic contact dermatitis
• C. Inverse psoriasis
• D. Lichen simplex chronicus
• E. Tinea corporis

93
A. Acanthosis nigricans

• Skin thickening, velvety hyperpigmentation of
  intertriginous areas, particularly the axillae
  and the neck, in obese patients with
  hyperinsulinemia.
• Often develop multiple skin tags.
• Weight loss and improved control of
  hyperinsulinemia are primary interventions.
• Some cases associated with malignancy.

94
Question 6-300

• 22-y/o woman evaluated for acne, had since her
  teens. Now 2 mths pregnant, acne worsening.
• Using OTC benzoyl peroxide, no improvement.
• PMH neg. Meds PNV.

• Which of the following topical drugs is
  contraindicated in this patient?
• A. Azelaic acid
• B. Clindamycin
• C. Tazarotene
• D. Tretinoin

95
C. Tazarotene

• Tazarotene is rated pregnancy category X and is
  contraindicated during pregnancy.
• Tretinoin topical cat. C oral cat. D
• Clindamycin, azelaic acid cat. B

96
Question 6-400
59 y/o man 3 mo hx intermittent itching on
forearms, described as deep, with burning,
tingling sensation. Scratching helps, OTC
topical corticosteroids have not. Cooling
soothes. Did not notice a rash until he started
scratching. Itch worse after being in the sun,
but sun exposure does not cause redness or
rash. PE chronic sun damage,
hyperpigmentation, solar lentigines. Few
excoriations on the forearms, but no significant
dermatitis. Sensation normal. DTR normal.
97
Question 6-400

• Which of the following is the most likely
  diagnosis?
• A. Brachioradial pruritus
• B. Polymorphous light eruption
• C. Prurigo nodularis
• D. Solar urticaria

98
Brachioradial pruritis itch without a rash

• Neuropathic itch linked to abnormalities in
  C-spine
• Deep, crawling, or tingling sensation on the
  forearms, shoulders, and upper back no visible
  skin findings.
• Evaluation of the spine may reveal evidence of
  osteoarthritis or other structural abnormalities
  however, in absence of gross neurologic deficits,
  surgery unlikely to benefit.
• Tx short term pramoxine, topical analgesics
  long term gabapentin, pregabalin.

99
Notalgia paresthetica

• neuropathic itch on the mid, medial back.

100
Question 6-500
50-y/o man w/ asymptomatic pink-brown rash in
axillae x 3 mo. unresponsive to OTC topical
corticosteroids. Meds none. Coral-pink
fluorescence under Wood lamp. Diagnosis? A.Candid
iasis B.Erythrasma C.Inverse psoriasis D.Tinea
101
B. Erythrasma

• Well-defined, pink-brown patches w/ fine scale,
  in moist, occluded skin folds.
• G bacterium Corynebacterium minutissimum.
  Porphyrins produced by bacteria? illuminate
  bright coral-pink fluorescence
• Asymptomatic or mild pruritus.
• Tx topical abx such as erythromycin or
  clindamycin.

102
Cutaneous Candidiasis

• Red, itchy, inflamed. Sites of skin-to-skin
  contact, glazed, shiny, eroded.
• May be characterized by burning more than
  pruritus.
• Satellite pustules.

103
Inverse Psoriasis

• Intertriginous areas, sharp demarcation.
• Often mistaken for fungal or bacterial infection
  b/c no scaling.
• Improves w/ topical corticosteroids.