JEOPARDY!
Click Once to Begin
IM-Derm Board Review
Nita Kohli, MD, MPH
PGY-4, Derm
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
JEOPARDY!
Stop
bugging
me
Nail it
Sexy legs
Bubblerap
“It’s not a
tumah”
Dermawhat?
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Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
D. Topical triamcinolone acetonide cream
Dx: 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.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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: Alzheimer’s, lives
in assisted care facility.
• Meds—donepezil, MVI.
• PE: scratching
intermittently; lesions in
finger webs, wrists,
torso, umbilicus. Fine
linear scale in a few
areas.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
B. microscopic eval of skin scrapings
Dx: scabies
• Dx by microscopic
identification of the
mite, feces, or eggs.
• Scrape many
lesions.
• Unexplained itch,
rash;
institutionalized pt.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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.
• Coxsackievirus—hand, foot, mouth dz primarily in kids.
Intraoral and palmar/plantar lesions. Oral aphthae, fever,
sore throat. Spares lips, gingiva (HSV does not).
Template by
Bill Arcuri, WCSD
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Chad Vance, CCISD
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
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
Question 1-400
• Which of the following is the most
appropriate topical treatment?
• A. Bacitracin
• B. Clotrimazole
• C. Hydrocortisone
• D. Mupirocin
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
D. Mupirocin
Dx: 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.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
C. Topical ketoconazole
Dx. Tinea versicolor
• aka pityriasis versicolor, a common superficial fungal
infection caused by yeast Malassezia furfur (aka Pityrosporum
ovale or Pityrosporum orbiculare).
Template by
Bill Arcuri, WCSD
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Chad Vance, CCISD
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.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
Question 2-100
• Which of the following is the most likely
diagnosis?
• A. Beau lines
• B. Lichen planus
• C. Median nail dystrophy
• D. Psoriasis
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
A. Beau lines
Chemo 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.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
Lichen Planus
Template by
Bill Arcuri, WCSD
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Chad Vance, CCISD
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.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
Psoriatic nails
Template by
Bill Arcuri, WCSD
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Chad Vance, CCISD
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
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
Question 2-200
• Which of the following is the most likely
diagnosis?
• A. Longitudinal melanonychia
• B.Hematoma
• C. Onychomycosis
• D.Subungual melanoma
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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 Vneck erythema.
• SLE--malar erythema, can follow sun exposure;
rare muscle weakness. No Gottron’s papules.
Template by
Bill Arcuri, WCSD
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Chad Vance, CCISD
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.
• PMH—neg; takes no meds.
• PE: poorly defined, red, weepy, eczematous
patches on cheeks, neck. Few fine vesicles,
some serous crusting.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
D. Hydrocortisone valerate
Dx: 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--highpotency
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
D. Unna Boot Compression
Dx: 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.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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 < than 0.9.
Template by
Bill Arcuri, WCSD
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Chad Vance, CCISD
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.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
Question 3-200
• Which of the following is the most likely
diagnosis?
• A. Bullous tinea
• B. Cellulitis
• C. Contact dermatitis
• D. Stasis dermatitis
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
B. Cellulitis
• Rapidly spreading, deep, SQ-based infection, w/ welldemarcated 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.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
Bullous Tinea
• Also inflammatory, erythematous; usually localized to
foot, occ spreads to lower ankle. Clues: scales in a
“moccasin” distribution.
Template by
Bill Arcuri, WCSD
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Chad Vance, CCISD
Stasis Dermatitis
• Looks similar to cellulitis
when inflammatory, can
become secondarily
infected;
• Almost always bilateral
and usually not tender.
Template by
Bill Arcuri, WCSD
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Chad Vance, CCISD
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.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
Question 3-300
• Which of the following is the most likely
diagnosis?
• A. Calciphylaxis
• B. Ecthyma gangrenosum
• C. Necrotizing fasciitis
• D. Pyoderma gangrenosum
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
D. Pyoderma gangrenosum
• Uncommon, neutrophilic, ulcerative skin
disease assoc w:
– inflammatory bowel disease,
– RA,
– seronegative spondyloarthritis,
– hematologic dz or malignancy, most
commonly AML.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
A. D/C OCPs
Dx: 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.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
Question 3-500
Most likely diagnosis?
• A. Lipodermatosclerosis
• B. Nephrogenic systemic fibrosis
• C. Scleroderma
• D. Scleromyxedema
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
Lipodermatosclerosis
• Pts w/ sig. venous
insufficiency--can
develop a severe
fibrosing panniculitis.
• Darkly pigmented,
indurated skin , bound
down to subQ.
• Inverted champagne
bottle legs
Template by
Bill Arcuri, WCSD
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Chad Vance, CCISD
Scleromyxedema
• Rare. Widespread
erythematous, indurated
skin w/near-confluent fleshy
papules;
• Face, fingers, extremities.
• Usually assoc w/ a serum
paraprotein.
Template by
Bill Arcuri, WCSD
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Chad Vance, CCISD
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
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
C. Begin valacyclovir, consult ophtho
Dx: Ocular Herpes zoster
• Medical emergency, requires prompt referral
ophthalmology, initiation of antiviral tx. If not tx’d
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 H&P, rather than wait for lab
testing.
Template by
Bill Arcuri, WCSD
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Chad Vance, CCISD
Question 4-200
• 22-y/o
man w/ lip
erosions
and new
rash on
the palms.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
A. HSV
Dx: 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.
Template by
Bill Arcuri, WCSD
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Chad Vance, CCISD
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.
• > 90% BSA erythematous, widespread coalescing
erythematous patches and plaques, with pinpoint pustules
coalescing into lakes of pus. Mucous membranes are
normal.
Template by
Bill Arcuri, WCSD
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Chad Vance, CCISD
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
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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
Template by
Bill Arcuri, WCSD
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Chad Vance, CCISD
Sweet’s 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.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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
Template by
Bill Arcuri, WCSD
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Chad Vance, CCISD
D. skin biopsy
Dx: 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.
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Bill Arcuri, WCSD
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Chad Vance, CCISD
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.
Template by
Bill Arcuri, WCSD
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Chad Vance, CCISD
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
Template by
Bill Arcuri, WCSD
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Chad Vance, CCISD
C. Skin biopsy and DIF
Dx: 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
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Bill Arcuri, WCSD
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Chad Vance, CCISD
Question 5-100
• 75 y/o man asymptomatic, dark brown, irregularly
pigmented patch on cheek x 7 yrs; enlarging slowly.
Template by
Bill Arcuri, WCSD
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Chad Vance, CCISD
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
Template by
Bill Arcuri, WCSD
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Chad Vance, CCISD
A. Broad shave biopsy
Dx: 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.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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.
Template by
Bill Arcuri, WCSD
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Chad Vance, CCISD
Question 5-200
• Which of the following is the mostly
likely diagnosis?
• A. Atypical nevi
• B. Melanomas
• C. Seborrheic keratoses
• D. Solar lentigines
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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
Template by
Bill Arcuri, WCSD
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Chad Vance, CCISD
Question 5-300
• 75-y/o man w/
asymptomatic
smooth papule on
his face x 7 mths.
• Enlarging steadily
and periodically
bleeds when
traumatized.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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
Template by
Bill Arcuri, WCSD
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Chad Vance, CCISD
B. Basal cell
• Smooth, pearly, asymptomatic telangiectatic
papules that grow slowly, but may eventually
cause substantial local tissue destruction if
not removed.
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Bill Arcuri, WCSD
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Chad Vance, CCISD
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
trimethoprimsulfamethoxazole.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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
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Bill Arcuri, WCSD
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Chad Vance, CCISD
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
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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.
• Mom—SLE.
• 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
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
C. Skin biopsy
Dx: urticarial vasculitis
• Lesions persist > 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.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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
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Bill Arcuri, WCSD
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Chad Vance, CCISD
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.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
A. 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.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
Notalgia paresthetica
• neuropathic itch on the mid, medial
back.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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.Candidiasis
B.Erythrasma
C.Inverse psoriasis
D.Tinea
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
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.
Template by
Bill Arcuri, WCSD
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Chad Vance, CCISD
Cutaneous Candidiasis
• Red, itchy, inflamed.
Sites of skin-to-skin
contact, glazed, shiny,
eroded.
• May be characterized
by burning more than
pruritus.
• Satellite pustules.
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD
Inverse Psoriasis
•Intertriginous areas, sharp
demarcation.
•Often mistaken for fungal or
bacterial infection b/c no
scaling.
•Improves w/ topical
Template by
Bill Arcuri, WCSD
Modified by
Chad Vance, CCISD