2023 Reviewer Flashcards

Question

Cause of solar erythema

Answer 1

Dermatoheliosis 5 skin involvement: Epidermis (actinic keratosis) Dermis (solar elastosis) Blood vessels (telangiectasia) Sebaceous glands (solar comedones) Melanocytes (diffuse or mottled brown patches)

Answer 2

Favre-Racouchot syndrome Treated with oral Isotretinoi (0.05-0.1 mg/kg/day)

Answer 3

Furocoumarins or Psoralens (Apiaceae or Umbelliferae family) includes weeds, edible plants such as carrots, parsnip. Dill, fennel, celery and anise. Lesions will appear within 8-24 hours of exposure to the sap of a psoralen-containing plant followed by sun exposure

Answer 4

fragrance products containing bergamot oil or a psoralen are applied to the skin, followed by exposure to sunlight

Answer 5

Polymorphous light eruption (The most common photosensitivity is to UVA. Mainly, exposure to visible light triggers porphyria)

Answer 6

Stage 1: just erythema of the skin. Stage 2: erythema with the loss of partial thickness of the skin including epidermis and part of the superficial dermis. Stage 3: full thickness ulcer that might involve the subcutaneous fat. Stage 4: full thickness ulcer with the involvement of the muscle or bones

Answer 7

Pelvic area The bony prominences of the body are the most frequently affected sites. About 95% of all pressure ulcers develop on the lower body, with 65% in the pelvic area and 30% on the legs. The ulcer usually begins with erythema at the pressure point; in a short time a “punched-out” ulcer develops.

Answer 8

Pentazocine Narcotic Dermopathy 1. Heroin (diacetylmorphine) IV injection - thrombosed, cordlike, thickened veins at the sites of injection. SubQ injection (“skin popping”) - multiple, scattered ulcerations, which heal with discrete atrophic scars Cutaneous manifestation include camptodactylia, edema of the eyelids, persistent nonpitting edema of the hands, urticaria, abscesses, atrophic scars, and hyperpigmentation 2. Cocaine - cause ulcers because of its direct vasospastic effect 3. Penrazocine - typical clinical picture of tense woody fibrosis, irregular punched-out ulcerations, and a rim of hyperpigmentation at injection sites. Extensive calcification may occur within the thickened sites.

Answer 9

Third-degree (full thickness) burns

Answer 10

Third-degree (full thickness) burns

Answer 11

Zone of Hyperemia Zone of Stasis Zone of Coagulation

Answer 12

Darier’s Sign

Answer 13

Epidermal Nevi

Answer 14

Basal cell CA Intermittent intense sun exposure, as identified by prior sunburns; radiation therapy; a positive family history of BCC; immunosuppression; a fair complexion, especially red hair; easy sunburning (skin types I or II); and blistering sunburns in childhood are risk factors for the development of BCC. Indoor tanning is a strong risk factor for early-onset BCC, particularly among women. The classic or nodular BCC constitutes 50%–80% of all BCCs.

Answer 15

Chronic Kidney Disease - most common systemic cause of pruritus; 20%–80% of patients with chronic renal failure have itching The most important internal causes of itching include liver disease, especially obstructive and hepatitis C (with or without evidence of jaundice or liver failure), renal failure, diabetes mellitus, hypothyroidism and hyperthyroidism, hematopoietic diseases (e.g., iron deficiency anemia, polycythemia vera), neoplastic diseases (e.g., lymphoma [especially Hodgkin disease and cutaneous T-cell lymphoma], leukemia, myeloma), internal solid-tissue malignancies, intestinal parasites, carcinoid, multiple sclerosis, acquired immunodeficiency syndrome (AIDS), connective tissue disease (particularly dermatomyositis) and neuropsychiatric diseases, especially anorexia nervosa.

Answer 16

Bulimia with its self-induced vomiting, results in Russell sign—crusted papules on the dorsum of the dominant hand from cuts by the teeth. Clenching of the hand produces swelling and ecchymosis of the fingertips and subungual hemorrhage.

Answer 17

Self-biting may be manifested by biting the nails (onychophagia) or recurrent manipulation of components of the nail unit (onychotillomania)

Answer 18

Delusional infestation (Ekbom syndrome or Delusions of Parasitosis) firm fixation in a person’s mind that he or she suffers from a parasitic infestation of the skin. Usually, the only symptom is pruritus or a stinging, biting, or crawling sensation. Intranasal formication, or a crawling sensation of the nasal mucosa, is common in this condition. Pimozide was the long-standing treatment of choice given at relatively low dosages, in the 1–4 mg range.

Answer 19

LICHEN PLANOPILARIS Graham-Little syndrome is a very rare condition that predominantly affects female adults. It is characterized by LPP of the scalp, noncicatricial of the eyebrows, axilla, and groin, and keratosis pilaris. The most likely drugs to cause lichenoid drug eruption are quinine and thiazide diuretics. First-line treatment for moderately active classic LPP lesions is intralesional triamcinolone acetonide at a concentration of 10 mg/mL every 4 to 6 weeks or in combination with topical class I or class II corticosteroids.

Answer 20

CENTRAL CENTRIFUGAL CICATRICIAL ALOPECIA

Answer 21

Tinea capitis (Trichophyton tonsurans) Ectothrix infection - most commonly caused by Microsporum spp. (especially Microsporum canis) and Epidermophyton spp. destroy the hair cuticle and masses of spores are located outside of the hair shaft. Yellow-green under Woods Lamp Endothrix infection - most commonly caused by Trichophyton spp. (especially T. tonsurans subspecies sulfureum). The hair breaks off directly at the skin surface, which clinically presents as “black dots.” Favus is a specific type of tinea capitis characterized by patelliform scales (scutula), which are sulfuric-yellow concretions of hyphae and skin debris in the follicular orifices and exhibit a distinct malodorous smell. A kerion is a deep, highly inflammatory fungal infection of the scalp. It presents as a highly suppurative, boggy, nodular, deep folliculitis with fistulas and pus secretion. Favus and kerion may lead to scarring hair loss and should be treated aggressively.

Answer 22

Trichotillomania form of traumatic alopecia caused by an irresistible compulsion to pull out or twist or break of one’s own hair.

Answer 23

Deck-chair sign,

Answer 24

Paget’s disease of the breast Most commonly affected sites: unilateral nipple/ areola (mammary Paget’s disease [MPD]); vulva, perianal skin, scrotum, and penis (extramammary Paget’s disease [EMPD]). Mammary Paget’s disease (MPD; also called Paget’s disease of the breast) is an intraepidermal adenocarcinoma of the nipple and/or areola, typically associated with underlying breast carcinoma. Extramammary Paget’s disease (EMPD) is a clinically distinct condition that affects extramammary sites, such as the vulva, penis, scrotum, perineum, and anus.

Answer 25

Hansens Disease Seen in Late (Parenchymatous) Neurosyphilis. Tabes dorsalis is the degeneration of the dorsal roots of the spinal nerves and of the posterior columns of the spinal cord. Gastric crisis with severe pain and vomiting is the most frequent symptom. The signs that may be present are Argyll Robertson pupils, absent or reduced reflexes, Romberg sign, deep tendon tenderness, loss of proprioception and vibratory sensation, atonic bladder, trophic changes, malum perforans pedis, Charcot joints, and optic atrophy.

Answer 26

AD is a chronic or chronically relapsing disorder with major features of: ■ Pruritus ■ Eczematous dermatitis (acute, subacute, or chronic) with typical morphology and agespecific patterns ■ Facial and extensor involvement in infancy ■ Flexural eczema or lichenification in children and adults Commonly associated with the following: ■ Personal or family history of atopy (allergic rhinitis, asthma, atopic dermatitis) ■ Xerosis or skin barrier dysfunction ■ Immunoglobulin E reactivity Pathogenesis driven by skin barrier defects (most importantly in the FLG gene), environmental effects and alterations in immunologic responses in T cells, antigen processing, inflammatory cytokines, host defense proteins, allergen sensitivity, and infection

Answer 27

Hertoghe’s sign

Answer 28

IV or oral Antivirals (Acyclovir, 400 mg orally three times daily; famciclovir, 500 mg twice daily; or valacyclovir, 1 g twice daily, all for a minimum of 5–10 days, is used.) The three clinical hallmarks of HSV infection are pain, an active vesicular border, and a scalloped periphery.

Answer 29

Corticosteroids (like hydrocortisone) applied to your skin. Oral (taken by mouth) corticosteroids. Topical Calcineurin inhibitors

Answer 30

Emollients Patients with AD have abnormal skin barrier function with increased transepidermal water loss and decreased water content and dry skin (xerosis) contributing to disease morbidity by the development of microfissures and cracks in the skin. The daily use of an effective emollient helps to restore and preserve the stratum corneum barrier, decreases the need for topical glucocorticoids and NSAIDs and improves outcomes.

Answer 31

Topical Corticosteroids use topical glucocorticoids only to control acute exacerbations of AD.

Answer 32

Topical Neomycin and Bacitracin

Answer 33

Patch testing With this protocol the allergens are placed on the back under occlusion, removed at 48 hours, and a final delayed read is performed at 72 or 96 hours. The International Contact Dermatitis Research Group recommends using the grading scale for positive patch test reactions outlined by Wilkinson and colleagues, 114 which is a + to +++ scoring system, where + represents a weak nonvesicular reaction but with palpable erythema, ++ represents a strong (edematous or vesicular) reaction, and +++ represents an extreme (bullous or ulcerative) reaction

Answer 34

Nickel Nickel is the most frequently patch test-positive allergen worldwide, with sensitization rates that hover mostly in the range of 18% to 30%.76

Answer 35

Dyshidrotic Eczema (Dyshidrosis or Pompholyx) Vesiculobullous Hand Eczema (Pompholyx, Dyshidrosis). Primary lesions of dyshidrosis are deep-seated multilocular vesicles resembling tapioca on the sides of the fingers, palms, and soles. The eruption is symmetric and pruritic, with pruritus often preceding the eruption. Coalescence of smaller lesions may lead to bulla formation severe enough to prevent ambulation. Potent and ultrapotent topical corticosteroids are first-line pharmacologic therapy.

Answer 36

Tacrolimus and cyclospirin Topical calcineurin inhibitors (TCIs) work by altering the immune system and have been developed for treating atopic eczema. There are two types available: tacrolimus ointment (Protopic) for moderate to severe eczema and pimecrolimus cream (Elidel) for mild to moderate eczema. SE: nephrotoxicity

Answer 37

Nummular Dermatitis

Answer 38

Koebner’s phenomenon

Answer 39

Capsaicin Hand irritation produced by capsaicin in hot peppers used in Korean and North Chinese cuisine (Hunan hand) may be severe and prolonged, sometimes necessitating stellate ganglion blockade and gabapentin. Pepper spray, used by police in high concentrations and by civilians in less concentrated formulas, contains capsaicin and may produce severe burns. Acetic acid 5% (white vinegar) or antacids (Maalox) may completely relieve the burning, even if applied an hour or more after the contact.

Answer 40

Type IV ACD represents a classic cell-mediated (type IV), delayed hypersensitivity reaction. Type IV hypersensitivity reactions result from exposure and sensitization of a genetically susceptible host to an environmental allergen, followed by subsequent reexposure that triggers a complex inflammatory reaction

Answer 41

48H With this protocol the allergens are placed on the back under occlusion, removed at 48 hours, and a final delayed read is performed at 72 or 96 hours.

Answer 42

Zinc Oxide Black Dermatographism. Black or greenish staining under rings, metal wristbands, bracelets, and clasps is caused by the abrasive effect of cosmetics or other powders containing zinc or titanium oxide on gold jewelry. This skin discoloration is black because of the deposit of metal particles on skin that has been powdered and that has metal, such as gold, silver, or platinum, rubbing on it. Abrasion of the metal results because some powders are hard (zinc oxide) and can abrade the metal.

Answer 43

HLA B*1502 HLA-B*1502 is present in the vast majority of carbamazepineinduced SJS/TEN patients SJS is defined as <10% epidermal detachment, TEN as >30% epidermal detachment, and SJS/TEN overlap as 10%–30% detachment, measured at the worst extent of the disease.

Answer 44

3 weeks the average time for epidermal regrowth is 3 weeks. The most common sequelae are ocular scarring and vision loss. The only predictor of eventual visual complications is the severity of ocular involvement during the acute phase. A sicca-like syndrome with dry eyes may also result, even in patients who never had clinical ocular involvement during the acute episode.

Answer 45

Aspirin and NSAIDs Aspirin and NSAIDs are the most common causes of nonimmunologic urticarial reactions. They alter prostaglandin metabolism, enhancing degranulation of mast cells. Urticarial drug eruptions are the second most common type of cutaneous adverse drug eruption, and can be induced by immunologic and nonimmunologic mechanisms.

Answer 46

penicillin and related β-lactam antibiotics

Answer 47

cetirizine and hydroxyzine

Answer 48

Angioedema Lisinopril and enalapril produce a edema more frequently than captopril

Answer 49

IV infusion of vancomycin

Answer 50

Zidovudine Zidovudine causes a blue or brown hyperpigmentation that is most frequently observed in the nails. The lunula may be blue, or the whole nail plate may become dark brown. Clofazimine - appearance of a pink discoloration that gradually becomes reddish blue or brown and is concentrated in the lesions of patients with Hansen disease. Histologically, a PAS-positive, brown, granular pigment is variably seen within foamy macrophages in the dermis. This has been called “drug-induced lipofuscinosis.” Chlorpromazine, thioridazine, imipramine, and clomipramine may cause a slate-gray hyperpigmentation in sun-exposed areas after long periods of ingestion. Frequently, corneal and lens opacities are also present Amiodarone - photosensitivity Chloroquine, hydroxychloroquine, and quinacrine - blue-black pigmentation of the face, extremities, ear cartilage, oral mucosa, and nails, in up to 29% of patients. Pretibial hyperpigmentation is the most common pattern.

Answer 51

zinc oxide or titanium dioxide Vitamin D supplementation is recommended with the most stringent sun protection practices. The dose is 600 IU daily for those 70 and younger and 800 IU for older patients.

Answer 52

Mycoplasma pneumoniae high-risk drugs are antibacterial sulfonamides, aromatic antiepileptic drugs, allopurinol, oxicam nonsteroidal antiinflammatory drugs, lamotrigine, and nevirapine. most inducing medications revealed the first continuous exposure between 4 and 28 days before reaction onset.

Answer 53

Captopril and Penicillamine

Answer 54

Cyclosporine (Management of TEN) The proposed mechanism of action of IVIG in TEN is by IVIG blocking the binding of sFasL to Fas, stopping keratinocyte apoptosis. The presence of cytotoxic T lymphocytes and NK cells within the dermis subjacent to the necrotic epidermis suggests that immunosuppressive agents that block immune function could also be effective in SJS or TEN. Cyclosporine is the most promising agent.

Answer 55

10th day Erythema toxicum neonatorum occurs in a quarter to under half of healthy full-term newborns, usually on the second or third day of life. Lesions involve the face, trunk, and proximal extremities and appear rarely on the soles or palms.

Answer 56

HSV EM minus (EMm, also called EM minor) if only the skin and lips are involved and EM majus (EMM, also called EM major) when mucous membranes are affected ■ Erythema multiforme is a rare cutaneous or mucocutaneous eruption characterized by “target” lesions, predominantly on the face and extremities. ■ The highest incidence was found in male children and young adults. ■ Most cases are related to infections (herpes simplex virus [HSV] and Mycoplasma pneumoniae). A total of 66% of EM patients have HLA-DQB1 ∗ 0301 allele

Answer 57

HLA-DQB1 ∗ 0301 A total of 66% of EM patients have HLA-DQB1 ∗ 0301 allele

Answer 58

Erythema gyratum repens ■ Usually a paraneoplastic phenomenon. ■ Characteristic wood grain appearance with multiple concentric rings.

Answer 59

Zinc deficiency As necrolytic migratory erythema is considered a deficiency dermatosis, the repletion of various nutrients has been utilized in the literature to target this entity specifically. In particular, supplementation of zinc, essential fatty acids, and amino acids have been shown in some cases to resolve NME. NME is a very rare paraneoplastic skin disorder that is considered a hallmark of glucagonoma. ■ Painful, eroded, crusted intertriginous, and facial skin eruption. ■ Highly suggestive of pancreatic malignancy (Glucagonoma is an extremely rare, slow-growing neuroendocrine tumor of the α cells of the pancreas).

Answer 60

Microcystic Lymphatic Malformation (Lymphangioma Circumscriptum) a congenital malformation of the superficial lymphatics. An MLM presents as groups of deep-seated, vesicle-like papules, resembling frog spawn, at birth or shortly thereafter. The sites of predilection are the abdomen, axillae, genitalia, and mouth, particularly the tongue.

Answer 61

acute myelogenous leukemia (AML) Sweet's syndrome is an acute febrile neutrophilic dermatosis in which approximately 20% of the reported patients have an associated cancer. The most common underlying neoplasm was acute myelogenous leukemia (AML) Sweet syndrome may occur with myelodysplastic syndromes or with hemoproliferative malignancies including leukemias (usually acute myelogenous) and lymphomas. One study reported an increased frequency of FLT3 mutations or del(5q) karyotype in AML patients with Sweets. Solid tumors are of any type but are most often genitourinary, breast (in women), or gastrointestinal (in men). Anemia is found in 93% of men and 71% of women with malignancy-associated Sweet syndrome. The majority of cases of Sweet syndrome follow a URI or viral gastroenteritis

Answer 62

Vegetative PG (or superficial granulomatous pyoderma) PG is a rare disease that affects people of all ages. Approximately 50% of patients with PG have an associated underlying medical condition or trigger, particularly inflammatory bowel disease. Lesions heal with characteristic thin, atrophic, crosslike “cribriform” scars. Nearly one-third of PG cases are associated with IBD, with similar frequency of both Crohn disease and ulcerative colitis (UC), although most of the Crohn disease cases have colonic involvement. Hematologic malignancy has been seen in up to 7% of PG cases, with the most common subtype reported being acute myeloid leukemia Ulcerative PG is the most common and most common initial clinical lesion in a patient with ulcerative PG is an intensely painful erythematous papule, pustule, or nodular furuncle with the most common site being the leg. Vegetative PG (or superficial granulomatous pyoderma) presents as a single furunculoid nodule, abscess, plaque, or superficial ulcer, typically on the trunk. It is the least aggressive form of PG. Lesions present as chronic, superficial, cribriform ulcerations, usually of the trunk. Bullous PG (sometimes called atypical PG) presents as a painful, rapidly expanding superficial inflammatory blister that quickly erodes. It is more superficial and less destructive than the ulcerative type. Bullous PG is commonly associated with hematologic disease and most often appears on the upper limbs The mainstays of management are systemic immunosuppressive agents together with appropriate local and topical therapy.

Answer 63

Wells syndrome or eosinophilic cellulitis acute onset of plaques resembling cellulitis that persisted for many weeks. Degranulation of dermal eosinophils produces the flame figures seen in histologic sections. These consist of dermal collagen with adherent eosinophil granules. Eosinophilic panniculitis may also be present. The most frequent systemic complaint in patients with Wells syndrome is malaise ■ Peripheral blood eosinophilia common. ■ Histologic pattern characterized by dermal infiltration with eosinophils, and flame figures surrounded by histiocytes. ■ Systemic glucocorticoids usually therapeutic.

Answer 64

Sweet’s syndrome Sweet syndrome, also referred to as acute febrile neutrophilic dermatosis, is characterized by a constellation of symptoms and ﬁndings: the acute onset of fever, neutrophilia, tender erythematous skin lesions that typically show mature neutrophils in the upper dermis The primary skin lesion is a sharply marginated, rapidly extending, tender, erythematous or violaceous, painful, elevated plaque, 2–10 cm in diameter. Lesions may appear intensely edematous (“juicy”), or merely indurated. They typically involve the face, neck, upper trunk, and extremities. Corticosteroids, potassium iodide, and colchicine are the ﬁrst-line oral systemic agents for treating Sweet syndrome.

Answer 65

Crohn’s disease

Answer 66

H1 antihistamines (terfenadine, astemizole, loratadine, and cetirizine hydrochloride)

Answer 67

95% Discoid lupus erythematosus (DLE) begin as dull-red macules or indurated plaques that develop an adherent scale, then evolve with atrophy, scarring, and pigment changes. The hyperkeratosis characteristically extends into patulous follicles, producing carpet tacklike spines on the undersurface of the scale. Classical discoid lupus erythematosus causes scarring and can be permanently disfiguring. Subacute cutaneous lupus and acute cutaneous lupus erythematosus are highly photosensitive and are characteristically nonscarring. Treatment consists of physical sun protection, topical sunscreens, local and short-term systemic glucocorticoids, antimalarials, retinoids, thalidomide/lenalidomide, conventional immunosuppressives, and biologic therapies. Both systemic lupus erythematosus and cutaneous lupus erythematosus are associated with upregulation of type 1 interferon signaling.

Answer 68

Hypertrophic LE Hypertrophic DLE, also referred to as hyperkeratotic or verrucous DLE, is a rare variant of CCLE in which the hyperkeratosis normally found in classic DLE lesions is greatly exaggerated.

Answer 69

DLE, together with lichen planopilaris (LPP) Hydroxychloroquine at a dose of 200 to 400 mg daily in adults or 4 to 6 mg/kg in children is highly effective at managing.

Answer 70

Raccoon eyes characterized by an annular rash with central regression or mild atrophy in the scalp and around the eyes, as well as hepatic and hematologic abnormalities. Periocular involvement (raccoon eyes) may be prominent. The skin lesions usually resolve spontaneously by 6 months of age, and usually heal without significant scarring

Answer 71

Subacute cutaneous LE Lesions are scaly and evolve as polycyclic annular lesions or psoriasiform plaques

Answer 72

Anti-dsDNA Double-stranded DNA. Anti-dsDNA, anti–native DNA. This is specific, but not very sensitive. It indicates a high risk of renal disease, and correlates with a shrunken peripheral ANA pattern and positive DIF in sun-protected skin. ANA test. This is positive in 95% of cases of SLE. Anti-Ro antibodies. These are found in about 25% of SLE and 40% of Sjögren patients. They are more common in patients with SCLE (70%), neonatal LE (95%), C2- and C4-deficient LE (50%–75%), late-onset LE (75%), and Asian patients with LE (50%–60%). Photosensitivity may be striking, and externalization of the antigen is seen after UV exposure.

Answer 73

Gottron’s sign and papules A pink to reddish purple atrophic or scaling eruption often occurs over the knuckles, knees, and elbows (Gottron sign). Flat-topped, polygonal, violaceous papules over the knuckles (Gottron papules)

Answer 74

interstitial lung disease The presence of these antibodies has been associated with a clinical subset characterized by myositis, ILD, arthritis, fever, Raynaud phenomenon and mechanic's hands, referred to as the antisynthetase syndrome. Diagnostic Criteria The following criteria are used to define DM/PM: • Skin lesions • Heliotrope rash (red-purple edematous erythema on upper palpebra) • Gottron papules or sign (red-purple flat-topped papules, atrophy, or erythema on extensor surfaces and finger joints) • Proximal muscle weakness (upper or lower extremity and trunk) • Elevated serum CK or aldolase level • Muscle pain on grasping or spontaneous pain • Myogenic changes on EMG (short-duration, polyphasic motor unit potentials with spontaneous fibrillation potentials) • Positive anti–Jo-1 (histadyl tRNA synthetase) antibody • Nondestructive arthritis or arthralgias • Systemic inflammatory signs (fever >37°C at axilla, elevated serum CRP level or accelerated ESR of >20 mm/hr by Westergren method) • Pathologic findings compatible with inflammatory myositis

Answer 75

anticentromere antibody CREST develop calcinosis cutis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia Anticentromere antibodies are highly specific for the CREST syndrome, being positive in 50%–90% of cases and only 2%–10% of patients with progressive sclerosis.

Answer 76

creatinine kinase The serum CK levels are elevated in most patients. Aldolase, lactic dehydrogenase (LDH), and transaminases (AST in particularly, but also ALT) are other indicators of active muscle disease. There may be leukocytosis, anemia with low serum iron, and an increased ESR. Ferritin may be elevated. Positive ANA tests are seen in 60%–80% of patients

Answer 77

frontoparietal area of the head (forehead) Linear scleroderma “en coup de sabre” (LScs) denotes linear scleroderma of the frontoparietal area of the head. Lesions may also occur parasagittally on the frontal scalp and extend partly down the forehead (en coup de sabre

Answer 78

Rowell’s syndrome Rowell syndrome (RS) is a rare disease characterized by a combination of lupus erythematosus (LE) and erythema multiforme (EM)-like lesions and a characteristic immunologic pattern, including speckled pattern of antinuclear antibody (ANA), positive anti-Ro/SSA or anti-La/SSB, and positive rheumatoid factor (RF).

Answer 79

EOSINOPHILIC FASCIITIS Classically, patients had engaged in strenuous muscular activity for a few days or weeks before the acute onset of weakness, fatigability, and pain and swelling of the extremities. The skin is usually edematous and erythematous, with a coarse peau d’orange appearance, and a “pseudocellulite” appearance most noticeable inside the upper arms, thighs, or flanks. The hands and face are usually spared. When the patient holds the arms laterally or vertically, linear depressions occur within the thickened skin. This “groove sign” or “dry riverbed sign” follows the course of underlying vessels

Answer 80

diabetes mellitus Scleredema is a skin disease characterized by a stiffening and hardening of the subcutaneous tissues, as if infiltrated with paraffin. It occurs in two forms: with and without diabetes mellitus. In the more generalized, nondiabetic condition, a sudden onset after an infection, typically streptococcal, may occur. This reactive variant may also present as a drug eruption. In other cases, onset is insidious and chronic and has no preceding infection. In the more common diabetes-associated disease, a long-lasting induration of the upper back is characteristic. Skin tightness and induration begin on the neck and/or face, spreading symmetrically to involve the arms, shoulders, back, and chest. The distal extremities are spared.

Answer 81

Mycosis fungoides FOLLICULAR MUCINOSIS (ALOPECIA MUCINOSA) characterized by inflammatory plaques with alopecia that demonstrate mucinous deposits in the outer root sheath of the hair follicle on histopathology. The plaques may be simply hypopigmented or erythematous and scaly, eczematous, or composed of flesh-colored, follicular papules. The disease may be limited to skin and benign (primary follicular mucinosis) or may be associated with follicular mycosis fungoides. Hydroxychloroquine is an excellent first-line systemic therapy.

Answer 82

bony prominences, especially on the extensor surface of the forearm Subcutaneous nodules are seen in 20%–30% of patients. They may arise anywhere on the body but most frequently are found over the bony prominences, especially on the extensor surface of the forearm just below the elbow and the dorsal hands. The lesions are nontender, firm, skin-colored, round nodules, which may or may not be attached to the underlying tissue. Accelerated RN may occur with the appearance of multiple RNs, typically following initiation of a treatment for RA, most commonly methotrexate

Answer 83

scleromyxoedema The primary lesions are multiple, waxy, 2–4 mm, dome-shaped or flat-topped papules. A diffuse infiltration develops, leading to “woody” sclerosis of the skin. On the glabella and forehead, coalescence of lesions leads to the prominent furrowing of a “leonine facies.” At the proximal interphalangeal joint, induration surrounding a centrally depressed area has been called the “doughnut sign.” Pruritus may occur. Scleromyxedema is often associated with visceral disease. Gastrointestinal findings are most common. Plasmapheresis and intravenous immune globulin (IVIG) may result in dramatic recovery from this life-threatening emergency.

Answer 84

Erythema nodosum Erythema nodosum (EN) is the most common inflammatory panniculitis. The eruption consists of bilateral, symmetric, deep, tender nodules and plaques 1–10 cm in diameter. The most common location is the pretibial area and lateral shins. Over a few days, the lesions flatten, leaving a purple or blue-green color resembling a deep bruise (erythema contusiforme). It is frequently associated with a streptococcal infection (especially in children). EN is frequently seen in patients with inflammatory bowel disease (IBD), more often Crohn disease than ulcerative colitis Drugs may also induce EN. Currently, oral c tives, hormone replacement therapy, sulfonamides, and penicillins are the most common medications inducing EN.

Answer 85

Auspitz’s sign

Answer 86

HLA B27 Risk factors for axial PsA are the presence of onycholysis, inflammatory back pain symptoms, PsA duration/young age at onset, positive HLA-B27, and inflammatory bowel disease. HLA-B27 has the strongest evidence for being a genetic risk factor for PsA in people with psoriasis.

Answer 87

Methotrexate Methotrexate. This folic acid antagonist remains the standard against which other systemic treatments are measured. The indications for methotrexate include psoriatic erythroderma, psoriatic arthritis, acute pustular psoriasis (von Zumbusch type), or widespread body surface area (BSA) involvement. Methotrexate can be toxic to the liver, and decreased renal clearance can enhance toxicity. The weekly dose varies from 5 mg to more than 50 mg, with most patients requiring 15–30 mg a week.

Answer 88

Reiter syndrome Keratoderma Blennorrhagicum (Reiter Syndrome) Keratoderma blennorrhagicum resembles psoriasis both histologically and clinically, except for its tendency for thicker keratotic lesions. Patients are often positive for HLA-B27 and develop reactive arthritis and skin disease after a bout of urethritis or enteritis.

Answer 89

Woronoff ring Woronoff ring is concentric b ing of the erythematous skin at or near the periphery of a healing psoriatic plaque. It is often the first sign that the patient’s psoriasis is responding to phototherapy.

Answer 90

Conjunctivitis , urethritis and arthritis

Answer 91

Guttate Psoriasis typical lesions are the size of water drops, 2–5 mm in diameter. Lesions typically occur as an abrupt eruption after acute infection, such as a streptococcal pharyngitis. responds rapidly to broad-band ultraviolet B (UVB) at erythemogenic doses. Minimal erythemogenic (erythema) dose (MED) testing is recommended to allow for appropriately aggressive treatment. A course of a semisynthetic penicillin (e.g., dicloxacillin, 250 mg four times daily for 10 days) with rifampin (600 mg/day for adults) may be required to clear chronic streptococcal carriage.

Answer 92

120-150mg/kg

Answer 93

Pityriasis lichenoides et varioloformis acuta Pityriasis Lichenoides Et Varioliformis Acuta (Mucha-Habermann Disease) a disorder characterized by papulonecrotic lesions, often in children or young adults. Individual lesions are erythematous macules, papules, or papulovesicles. Lesions tend to be brownish red and evolve through stages of crusting, necrosis, and varioliform scarring.

Answer 94

Pityriasis rosea Pityriasis rosea is a mild inflammatory exanthem characterized by salmon-colored thin papules and plaques that are at first discrete but may become confluent. The individual patches are oval or circinate and covered with finely crinkled, dry epidermis, which often desquamates, leaving a collarette of scaling in the center. When stretched across the long axis, the scales tend to fold across the lines of stretch, the so-called hanging curtain sign or Christmas tree sign. The most commonly implicated viruses are herpes viridae such as human herpesvirus (HHV)–6 and HHV-7. A pityriasis rosea–like eruption may occur as a reaction to medications such as captopril, imatinib mesylate, interferon, ketotifen, arsenicals, gold, bismuth, clonidine, methoxypromazine, tripelennamine hydrochloride, ergotamine, lisinopril, acyclovir, lithium, adalimumab, nortriptyline, lamotrigine, rituximab, imatinib, asenapine, barbiturates, or bacille Calmette-Guérin (BCG) vaccine. Most patients with pityriasis rosea require no therapy because they are asymptomatic, however, use of acyclovir with multiple trials showing decrease the eruption and itching.

Answer 95

Koebner phenomenon

Answer 96

Irreversible pterygium Ultrapotent topical and intralesional corticosteroids (5 to 10 mg/mL injected on a weekly basis) are firstline therapies. Lichen planus (LP) is a common, pruritic, inflammatory disease of the skin, mucous membranes, and hair follicles. The primary lesions of LP are characteristic, almost pathognomonic: small, flat-topped, polygonal papules. On the surface, gray or white puncta or streaks (Wickham striae) cross the lesions—a feature seen more easily with dermoscopy. Nail changes are present in approximately 5%–10% of patients with fingernails more often affected than toenails. Involvement of the nail can occur as an initial manifestation, especially in children. Longitudinal ridging and splitting are most common, seen in 90% of patients with nail involvement. Onycholysis and subungual debris may be present, indicating involvement of the nail bed. The lunulae are red in 30% of patients with nail LP. Involvement of the entire matrix may lead to obliteration of the whole nail plate (anonychia). Pterygium formation is characteristic of LP of the nails, but seen in only about 20% of patients.

Answer 97

Ulcerative form Oral LP in women begins 10 years later than in men (age 57 vs. 47). Oral lesions may be reticulate (reticular), the oral version of Wickham striae, erythematous, or ulcerative. The most common pattern in oral LP is the ulcerative form (40% of patients). Oral mucosal LP is the most common form of mucosal LP, and it is usually chronic. The cornerstone of treatment in oral lichen planus is good oral hygiene with regular professional dental cleanings.

Answer 98

Buccal mucosa The buccal mucosa is involved in 90%, the gingiva in more than 50%, and the tongue in about 40%.

Answer 99

12 months The active lesions of lichen striatus last for an average of 1 year but may persist for up to 4 years. ■ Lichen striatus is a rare, idiopathic, papular eruption that usually resolves in 6 to 12 months. ■ Lichen striatus occurs most commonly in children aged 3 to 5 years, on the limbs, and in females. ■ In lichen striatus, the eruption is characterized by the sudden onset of flat-topped, 1- to 3-mm, pink, tan, or hypopigmented papules in a linear configuration or Blaschkoid distribution. The most common locations on the body are the extremities (75% to 77%) and the trunk (9% to 21%). a young child with sudden onset of an eruption following the lines of Blaschko ■ Lichen striatus is associated with an atopic diathesis. Lichen striatus is a self-limited disease with a mean duration of approximately 6 to 12 months.

Answer 100

LICHEN SCLEROSUS (LICHEN SCLEROSUS ET ATROPHICUS) Lichen sclerosus is a chronic disease of the skin and mucosa. The initial lesions of LS are white, polygonal, flat-topped papules, plaques, or atrophic patches. Lesions may be surrounded by an erythematous to violaceous halo. In atrophic lesions, the skin is smooth, slightly wrinkled, soft, and white. In women, this perineal involvement typically affects the vulvar and perianal areas, giving a figure-8 or hourglass appearance. Pregnancy leads to improvement and often complete resolution. Oral contraceptive (OC) use is common in premenopausal women with LS.

Answer 101

least 1 month

Answer 102

Anterior Shin NECROBIOSIS LIPOIDICA/NECROBIOSIS LIPOIDICA DIABETICORUM Necrobiosis lipoidica (NL) is characterized by well-circumscribed, firm, depressed, waxy, yellow-brown plaques, usually of the anterior shin. The earliest changes are small, sharply bordered, red papules that may be capped by a slight scale and that do not disappear under diascopic pressure. Later, the lesions develop into irregularly round or oval lesions with well-defined borders and a smooth, glistening (glazed) surface. The most common location of the lesions is the shins

Answer 103

HHV 6 Causes exanthem subitum (roseola infantum, sixth disease). β-Herpesviridae subfamily. The hallmark of ES is the development of “rose”-colored macules and papules measuring 2 to 5 mm and surrounded by a white halo. The exanthem lasts 3 to 5 days and is widespread spread on the neck and trunk. High seroprevalence in general population by 1 year of age. HHV-6 is a common viral infection with up to 80% of the population acquiring the infection by 2 year of age. Reactivation in immunocompromised individuals is a cause of morbidity. HHV-6 transmission occurs via shared saliva and can readily be detected in the saliva of adults and children. The incubation period for HHV-6 infection is 5 to 15 days, with an average of 10 days. Prophylaxis with ganciclovir may prevent HHV-6 reactivation in bone marrow transplantation and stem cell transplantation recipients, but low-dose prophylaxis may facilitate the development of resistance.

Answer 104

Hutchinson sign In herpes zoster ophthalmicus, the ophthalmic division of the fifth cranial nerve is involved. If the external division of the nasociliary branch is affected, with vesicles on the side and tip of the nose (Hutchinson sign). Ocular involvement is most often in the form of uveitis (92%) and keratitis (50%).

Answer 105

adenocarcinoma of the stomach Most cases are associated with adenocarcinoma, especially of the gastrointestinal tract (60% stomach). Type I AN should be highly suspected if widespread lesions develop in a nonobese man over age 40. Tripe palms (acanthosis palmaris) are characterized by thickened, velvety palms with pronounced dermatoglyphics. In 40% of these patients, tripe palms are the presenting sign of an undiagnosed malignancy. Acanthosis nigricans (AN) is characterized by hyperpigmentation and velvet-textured plaques, which are symmetrically distributed.

Answer 106

zinc is at a dose of 1 – 2 mg/kg/day Replacement is with zinc sulfate, 1–2 mg/kg/day (50 mg of elemental zinc per 220 mg zinc sulfate tablet). In patients with genetic causes of acrodermatitis enteropathica, zinc supplementation is 3 mg/ kg/day and should be lifelong. Zinc deficiency may be an inherited abnormality, acrodermatitis enteropathica, or it may be acquired. Acrodermatitis enteropathica is an autosomal recessive disorder caused by mutations in the SLC39A4 gene, which encodes the zinc transporter ZIP4. The diagnosis of zinc deficiency should be suspected in at-risk individuals with acral or periorificial dermatitis. In particular, chronic diaper rash with diarrhea in an infant should lead to evaluation for zinc deficiency

Answer 107

Hidradenitis suppurativa (acne inversa) chronic disease characterized by recurrent abscess formation, primarily within the folded areas of skin that contain both terminal hairs and apocrine glands. The primary site of inflammation terminal hair. The axilla is the most frequently affected site. HS is characterized by recurrent, deep-seated, painful, subcutaneous nodules, sinus tracts, and hypertrophic scarring. ■ Lesions are characterized by inflammatory nodules, subcutaneous abscesses, and sinus tracts. ■ Hyperkeratotic plugging of the terminal hair follicle is a consistent histologic finding of early disease and is thought to be the primary pathophysiologic event. The microbiome is altered and secondary bacterial infection with S. aureus, Streptococcus pyogenes, and various gramnegative organisms may occur. Daily cleansing with chlorhexidine gluconate (Hibiclens) solution or benzoyl peroxide wash is an important preventive measure.

Answer 108

Use of fluorinated topical steroids Periorbital (periocular) dermatitis is a variant of perioral dermatitis occurring on the lower eyelids and skin adjacent to the upper and lower eyelids. Fluorinated topical corticosteroids have been implicated as the cause.

Answer 109

Crusted scabies (Norwegian or hyperkeratotic scabies) Crusted scabies (Norwegian or hyperkeratotic scabies) is found in immunocompromised or debilitated patients, including those with neurologic disorders, Down syndrome, organ transplants, graft-versus-host disease, adult T-cell leukemia, Hansen disease, or AIDS. Scabies. Sarcoptes scabiei, the itch mite, is an oval, ventrally flattened mite with dorsal spines. The fertilized female burrows into the stratum corneum and deposits her eggs. Scabies is characterized by pruritic papular lesions, excoriations, and burrows. Sites of predilection include the finger webs, wrists, axillae, areolae, umbilicus, lower abdomen, genitals, and buttocks. An imaginary circle intersecting the main sites of involvement—axillae, elbow flexures, wrists and hands, and crotch—has long been called the circle of Hebra. To identify burrows quickly, a drop of India ink or gentian violet can be applied to the infested area, then removed with alcohol. Permethrin 5% cream, 6%–10% precipitated sulfur in petrolatum, and benzyl benzoate are the most widely used topical agents. In the crusted type of scabies, ivermectin should be used in conjunction with a topical agent.

Answer 110

Pentavalent antimony ■ Leishmaniasis is a complex of diseases caused by the protozoa Leishmania and transmitted by the bite of infected phlebotomine sandﬂies. leishmaniasis is the third most frequent infectious disease transmitted by a vector. ■ Four major human diseases: (a) localized cutaneous leishmaniasis, (b) diffuse cutaneous leishmaniasis, (c) mucocutaneous leishmaniasis, and (d) visceral leishmaniasis. The main reservoir hosts are the great gerbil, the fat sand rat, Meriones spp., and other rodents, as well as dogs, the opossum, sloths, and others.

Answer 111

Pentavalent antimony

Answer 112

Pentavalent antimony

Answer 113

HPV 16,18 The most common low-risk genital HPV types are HPV-6 and HPV-11, and most HPV-induced genital dysplasias are caused by HPV-16 and HPV-18. all condylomata acuminata are caused by “benign” HPV-6 and HPV-11. High-risk HPV-16/18 produce flat or sessile, often hyperpigmented lesions. Genital warts are the most common STD.

Answer 114

Genital warts In patients with multiple recurrences, acetic acid soaking may determine the extent of infection, helping to define the area for application of topical therapies. The procedure is performed by soaking the external genitalia in men and the vagina and cervix in women with 3%–5% acetic acid for up to 10 minutes. Genital warts turn white (acetowhitening), making them easily identifiable.

Answer 115

Fifth disease – Erythema infectiosum Parvovirus B19 is the most common agent in this Erythrovirus genus to cause human disease. Erythema infectiosum is a worldwide benign infectious exanthem that occurs in epidemics in the late winter and early spring. Erythema infectiosum (ﬁfth disease): childhood illness with “slapped cheeks” followed by an erythematous, lacy eruption on the trunk and extremities. ■ Symmetric polyarthritis, particularly of the small joints in adults. ■ Papular purpuric gloves-and-socks syndrome: pruritic erythema, edema, and petechiae of the hands and feet, fever, and oral erosions in adolescents. occurs primarily in teenagers and young adults. ■ Aplastic crisis in patients with increased red blood cell turnover, chronic anemia in immunocompromised persons, and fetal hydrops.

Answer 116

Roseola exanthem subitum or roseola infantum The hallmark of ES is the development of “rose”-colored macules and papules measuring 2 to 5 mm and surrounded by a white halo

Answer 117

buccal mucosa near the second molars (lower molars) MEASLES (Rubeola) enveloped RNA virus. Paramyxoviridae family ■ Prodrome of fever, cough, coryza, and conjunctivitis. The prodrome consists of fever (as high as 40.5°C [104.9°F]), malaise, conjunctivitis (palpebral, extending to lid margin), coryza, and cough (brassy or barking) and can last up to 4 days. Koplik spots are the pathognomonic enanthem of measles and develop during the prodrome. The spots begin as small, bright red macules that have a 1- to 2-mm blue-white speck within them and are typically found on the buccal mucosa near the second molars ■ Koplik spots on the buccal mucosa are pathognomonic ■ Morbilliform eruption lasts 3 to 5 days ■ Severe complications include pneumonia and postmeasles encephalomyelitis ■ Vitamin A treatment may reduce morbidity and mortality The measles virus can be isolated using real-time reverse transcription polymerase chain reaction (PCR) from nasopharyngeal aspirates, throat swabs, blood or urine. Viral detection is most successful when collection occurs within 3 days of the rash’s onset.

Answer 118

Forscheimer’s sign (soft palate and uvula) As the prodrome resolves and the rash begins to appear, some patients develop an enanthem consisting of tiny red macules on the soft palate and uvula (Forchheimer spots). Rubella is an enveloped positive-stranded RNA virus in the Togaviridae family ■ Also called German measles and 3-day measles. ■ Epidemic disease; worldwide distribution. ■ Short prodrome; rash duration of 2 to 3 days. The prodrome is characterized by low-grade fever, myalgia, headache, conjunctivitis, rhinitis, cough, sore throat, and lymphadenopathy ■ Enlargement of cervical, suboccipital, and postauricular glands. ■ High risk of fetal malformations with congenital infection (microcephaly, congenital heart disease, and deafness), particularly in the first trimester. Diagnosis is typically made using serology to detect rubella-specific IgM antibody (up to 8 weeks after infection)

Answer 119

Giannoti Crosti syndrome Gianotti-Crosti syndrome (GCS), also known as infantile papular acrodermatitis and papular acrodermatitis of childhood, is a common, self-limited exanthem. ■ Papular acrodermatitis of childhood. affects children between the ages of 3 months and 15 years, with the peak age of onset being 1 to 6 years. ■ Common, self-limited dermatosis. ■ Monomorphic dome-shaped or ﬂat-topped papules symmetrically distributed on face and extensor extremities. ■ Associated with multiple viral triggers and immunizations. Viral infections are the most common trigger of GCS. ■ Historically associated with hepatitis B infection, but now more often triggered by Epstein-Barr virus.

Answer 120

T. tonsurans (endothrix - inside follicle) -do not fluoresce with Wood’s light. T. tonsurans is the most common type of tinea capitis. Trichophyton tonsurans can produce black dot tinea, scaling alopecic plaques, subtle seborrheic-like scaling, and/or inflammatory kerion. Tinea capitis, known colloquially as scalp “ringworm,” can be caused by all of the pathogenic dermatophytes. In the United States most cases are caused by Trichophyton tonsurans. Pet exposure (especially cat) is associated with tinea capitis caused by Microsporum canis (small-spore ectothrix) - fluoresce under Wood’s light examination. Deep, tender, boggy plaques exuding pus are known as kerion celsii, Kerion may be followed by scarring and permanent alopecia in the areas of inflammation and suppuration. Kerion - scalp Favus - scalp but may affect the glabrous skin and nails (concave sulfur-yellow crusts form around loose, wiry hairs) Griseofulvin remains the most frequently used antifungal agent in children. Also terbinafine. Griseofulvin must be given with a fatty food to ensure absorption.

Answer 121

scutulae Favus, On the glabrous skin, the lesions are pinhead to 2 cm in diameter with cup-shaped crusts called scutulae, usually pierced by a hair as on the scalp. The scutulae have a distinctive mousy odor.

Answer 122

365-nm wavelength Ultraviolet (UV) light of 365-nm wavelength commonly known as the Wood’s light, is used to demonstrate fungal fluorescence. Skin - blue Dandruff - bright blue-white

Answer 123

Tinea imbricata (Tokelau) imbRINGcata Tinea imbricata is a superficial fungal infection limited to southwest Polynesia, Melanesia, Southeast Asia, India, and Central America. It is characterized by concentric rings of scales forming extensive patches with polycyclic borders. The causative fungus is Trichophyton concentricum. Terbinafine has been shown to be very effective while the recurrence rate may be high with griseofulvin.

Answer 124

T. rubrum Dermatophytosis of the feet, “athlete’s foot,” is the most common fungal disease. T. rubrum causes the majority of infections. T. rubrum typically produces a relatively noninflammatory type of dermatophytosis characterized by a dull erythema and pronounced silvery scaling that may involve the entire sole and sides of the foot, giving a moccasin or sandal appearance. Hyperhidrosis is a predisposing factor for tinea infections.

Answer 125

Candida Onychomycosis is defined as the infection of the nail plate by fungus and represents up to 30% of diagnosed superficial fungal infections. T. rubrum accounts for most cases. four classic types of onychomycosis: 1.) Distal subungual onychomycosis - distal nail bed and the hyponychium 2.) White superficial onychomycosis (leukonychia trichophytica) - toenail plate. In the HIV-positive population, it is typically caused by T. rubrum. 3.) Proximal subungual onychomycosis - proximal nailfold. It is produced by T. rubrum and Trichophyton megninii and may be an indication of HIV infection. 4.) Candida - destruction of the nail and massive nail bed hyperkeratosis. It is caused by C. albicans and is seen in patients with chronic mucocutaneous candidiasis

Answer 126

Tinea nigra Hortaea werneckii (formerly Phaeoannellomyces werneckii) is a black, yeastlike hyphomycete that is widely distributed in hot, humid environments. Tinea nigra presents as one or several brown or black spots on the palms or soles. The fungus can easily be demonstrated by means of KOH or culture. In KOH preparations, the hyphae appear brown or golden in color. The pigment produced by the fungal hyphae is melanin. Culture will identify the organism, and polymerase chain reaction (PCR) can be useful for rapid identification of H. werneckii. Topical imidazoles and allylamines, such as clotrimazole, miconazole, ketoconazole, sulconazole, econazole, and terbinafine, have been reported as effective.

Answer 127

Cryptococcosis (C. neoformans - pleomorphic budding yeast) Cryptococcosis generally begins as a pulmonary infection and remains localized to the lung in 90% of patients. Risk factors include outdoor activities and exposure to bird droppings. Cryptococcosis is the fourth leading cause of opportunistic infection and the second most common fungal opportunist, with 5%–9% of patients manifesting symptomatic disease. Cryptococcosis is the most common cause of mycotic meningitis. The patient may have restlessness, hallucinations, depression, severe headache, vertigo, nausea and vomiting, nuchal rigidity, seizures, and symptoms of intraocular hypertension. Skin infection with cryptococcosis occurs most frequently on the head and neck. In these patients, there is often a central hemorrhagic crust. For mild to moderately ill non-AIDS patients - fluconazole, 400 mg/ day for 8–24 weeks In seriously ill non-HIV patients-amphotericin B intravenously

Answer 128

Sporotrichosis (Sporothrix schenckii - cigar-shaped yeast form at 37°C and in a mycelial form at room temperature) results from direct inoculation by a thorn, cat’s claw, or other minor penetrating injury. Most often, the primary invasion is seen as an occupational disease in gardeners, florists, and laborers after injuries by thorns, straw, or sphagnum moss. The earliest manifestation may be a small nodule that may heal and disappear before the onset of other lesions. In the course of a few weeks, nodules generally develop along the draining lymphatics. Regional lymphangitic sporotrichosis is the common type, accounting for 75% of cases. Cutaneous disease typically presents with palisading granulomatous dermatitis surrounding a stellate suppurative abscess. Itraconazole is effective for cutaneous and lymphocutaneous sporotrichosis at a dose of 200 mg/day for 2–4 weeks after all lesions have resolved, usually 3–6 months.

Answer 129

Mycetoma Mycetoma, also known as Madura foot and maduromycosis, is a chronic, granulomatous, subcutaneous, inflammatory disease caused by filamentous bacteria (actinomycetoma) or true fungi (eumycetoma). generally begin on the instep or the toe webs. triad of progressive subcutaneous swelling with sinus tracts that discharge grains. Mycetoma may be diagnosed when the triad of signs, tumefaction, sinuses, and granules, are present. magnetic resonance images may show the “dot in a circle” sign, corresponding to grains. Actinomycetomas generally respond to antibiotic therapy

Answer 130

Tuberculosis verrucosa cutis (exogenous inoculation of bacilli) Tuberculosis verrucosa cutis (also known as "Lupus verrucosus," "Prosector's wart," and "Warty tuberculosis")is a rash of small, red papular nodules in the skin that may appear 2–4 weeks after inoculation by Mycobacterium tuberculosis in a previously infected and immunocompetent individual. common occupational disease of prosectors, the preparers of dissections and autopsies.

Answer 131

cervical lymph nodes Scrofuloderma is subcutaneous tuberculosis leading to cold abscess formation and a secondary breakdown of the overlying skin. It may be either multibacillary or paucibacillary. It occurs most frequently over the cervical lymph nodes but also may occur over bone or around joints if these are involved.

Answer 132

Lupus vulgaris (TUBERCULOSIS LUPOSA) LV is an extremely chronic, progressive form of cutaneous tuberculosis occurring in individuals with moderate immunity and a high degree of tuberculin sensitivity. The apple jelly nodules revealed by diascopy are highly characteristic. Squamous cell carcinomas outnumber basal cell carcinomas by far, and the risk of metastases is high.

Answer 133

Papulonecrotic tuberculid Papulonecrotic tuberculid is usually an asymptomatic, chronic disorder, presenting in successive crops. Lesions are symmetrically distributed on the extensor extremities, especially on the tips of the elbows and on the knees; dorsal surfaces of the hands and feet; buttocks; face and ears; and glans penis. Typical lesions vary in size from 2–8 mm and are firm, inflammatory papules that become pustular or necrotic. Varioliform scarring follows the lesions.

Answer 134

Erythema induratum (Bazin disease - back calf) Lesions favor the posterior lower calf, which may also show acrocyanosis. Individual lesions are tender, erythematous or violaceous, 1–2 cm subcutaneous nodules Biopsy with acid-fast staining should be done when the history and physical examination suggest cutaneous TB. For all forms of cutaneous TB, multidrug chemotherapy is recommended.

Answer 135

M. marinum acid-fast, nontuberculous mycobacterium. It is responsible for fish tank granuloma (also known as swimming pool granuloma), a distinct infection presenting as a warty nodule or plaque usually at a point of trauma, often 6 weeks after exposure. clarithromycin (500 mg twice daily) seems to be the best single agent

Answer 136

Round or oval, painless, indurated, cartilage-like consistency and eroded papule. first cutaneous lesion, appearing 18–21 days after infection. In men, the chancre is commonly located in the coronal sulcus or on either side of the frenum. tends to heal spontaneously in 1–4 months. Syphilis, also known as lues, is a contagious, sexually transmitted disease caused by the spirochete Treponema pallidum subspecies pallidum. It can be demonstrated in preparations from fresh primary or secondary lesions by darkfield microscopy or by fluorescent antibody techniques.

Answer 137

Involvement of the palms and soles is a characteristic feature of secondary syphilis. Lues maligna, condyloma lata, livedo reticularis, syphilitic alopecia Rupial syphilid - covered with a pile of terraced crusts resembling an oyster shell Lues maligna - severe ulcerations, pustules, or rupioid lesions, accompanied by severe constitutional symptoms. Condylomata lata - papular lesions, relatively broad and flat, located on folds of moist skin, especially around the genitalia and anus Syphilitic alopecia - moth-eaten appearance

Answer 138

Jarisch-Herxheimer febrile reaction often occurs after the initial dose of antisyphilitic treatment, especially penicillin. The reaction generally occurs 6–8 hours after treatment and consists of shaking chills, fever, malaise, sore throat, myalgia, headache, tachycardia, and exacerbation of the inflammatory reaction at sites of localized spirochetal infection. Sexual partners of persons with syphilis should be identified. Persons who are exposed within 90 days of the diagnosis of primary, secondary, or early latent syphilis, even if seronegative, should be treated presumptively.

Answer 139

Pseudotumor cerebri

Answer 140

Dermatitis herpetiformis Dermatitis herpetiformis (DH) is a chronic, relapsing, severely pruritic disease characterized by grouped, symmetric lesions on extensor surfaces, the scalp, nuchal area, and buttocks. The lesions are severely pruritic and thus generally present as excoriations. HLA-B8 positive, similar frequency to that observed in gluten-sensitive enteropathy (GSE). IgA deposits

Answer 141

Pemphigus erythematosus (Senear-Usher syndrome) early lesions are circumscribed patches of erythema and crusting that clinically resemble lupus erythematosus. The lesions are erythematous and thickly crusted, bullous, or even hyperkeratotic. These are usually localized on the nose, cheeks, and ears, sites frequently affected by lupus erythematosus. DIF shows IgG and complement localized in both intercellular and BMZ sites.

Answer 142

Bullous pemphigoid IgG and/ or C3 are best found in nonbullous lesional or perilesional skin. Clinically, BP is characterized by large, tense, subepidermal bullae with a predilection for the groin, axillae, trunk, thighs, and flexor surfaces of the forearms BP230 and BP180. BP may begin at a localized site, frequently on the thighs or shins. vesicular pemphigoid - tense, small, occasionally grouped pemphigoid nodularis - resembling prurigo nodularis pemphigoid vegetans - IgG and C3 at the BMZ lichen planus pemphigoides - lichen planus. Linear IgG and C3 are noted at the BMZ

Answer 143

Paraneoplastic pemphigus painful mucosal ulcerations and polymorphous skin lesions, which progressed to blistering eruptions. Most patients described since then have had associated neoplasms or Castleman disease. DIF reveals IgG and C3 deposition in the intercellular spaces of the epithelium. The most common associations ar e hematologic malignancies, including non-Hodgkin lymphoma, chronic lymphocytic leukemia (CLL), Castleman tumor, acute myeloid leukemia (AML), and thymoma

Answer 144

Chronic bullous disease of childhood Chronic bullous disease of childhood (CBDC) is an acquired, self-limited bullous disease that may begin by the time the patient is 2 or 3 years old and usually remits by age 13. Bullae are often arranged in rosettes or an annular array, the so-called string of pearls configuration. Pruritus is often severe. presence of a subepidermal bulla filled with NEUTROPHILS. DIF reveals a linear deposition of IgA at the BMZ

Answer 145

Cicatricial pemphigus (C for conjunctiva) ocular pemphigus, cicatricial pemphigoid, or essential shrinkage of the conjunctiva. Because of its scarring nature, the designation cicatricial pemphigoid (CP) has gained predominance In most patients, the vesicles primarily occur on the mucous membranes, especially the conjunctiva Cyclophosphamide or rituximab-containing regimens are generally advised.

Answer 146

Pemphigus vulgaris Pemphigus vulgaris (PV) is characterized by mucosal erosions and by thin-walled, relatively flaccid, easily ruptured bullae that appear on apparently normal skin and mucous membranes or on erythematous bases. PV appears first in the mouth (60%) Nikolsky sign is present. (intact epidermis shearing away from underlying dermis, leaving a moist surface) “bulla-spread phenomenon” (Asboe-Hansen sign) is elicited by pressure on an intact bulla, gently forcing the fluid to spread under the adjacent skin. Antibodies in PV are most often directed against Dsg3 DIF demonstrates a “chicken wire” pattern of intercellular IgG in perilesional skin or plucked hairs.

Answer 147

suprabasilar a tholysis with intraepidermal blister formation

Answer 148

groins and flexors

Answer 149

Pemphigus vegetans Pemphigus vegetans may begin with flaccid bullae that become erosions and form fungating vegetations or papillomatous proliferations, especially in body folds or on the scalp.

Answer 150

Crabs Phthirus pubis, the crab louse, is found in the pubic region, as well as hairy areas of the legs, abdomen, chest, axillae, and arms. Pubic lice may also infest the eyelashes and scalp. Occasionally, blue or slate-colored macules occur in association with pediculosis pubis. Called maculae ceruleae, these are located chiefly on the sides of the trunk and the inner aspects of the thighs

Answer 151

Ecthyma Ecthyma is an ulcerative streptococcal or less commonly staphylococcal pyoderma. The disease begins with a vesicle or vesicopustule, which enlarges and in a few days becomes thickly crusted. When the crust is removed, there is a superficial, saucer-shaped ulcer with a raw base and elevated edges

Answer 152

The classic findings are the oralocular-genital syndrome. The lips are prominently affected with angular cheilitis (perlèche) and cheilosis. The tongue is atrophic and magenta in color. There is a confluent dermatitis of the scrotum, sparing the midline, with extension onto the thighs. Balanitis and phimosis may occur, requiring circumcision. Vitamin B 2 (riboflavin) deficiency is seen most often in alcoholic patients

Answer 153

Burning edematous red tongue, peripheral neuropathy, CHF Vitamin B 1(thiamine) deficiency results in beriberi.

Answer 154

Hypovitaminosis A The earliest finding is delayed adaptation to the dark (nyctalopia). Some patients have circumscribed areas of xerosis of the conjunctiva lateral to the cornea, occasionally forming well-defined white spots (Bitot spots) Vitamin A is a fat-soluble vitamin found as retinyl esters in milk, fish oil, liver, and eggs and as carotenoids in plants. Vitamin A is required for the normal keratinization of many mucosal surfaces. Vitamin A supplementation of 200,000 IU/day for 2 days is recommended for children with measles. The diagnosis of vitamin A deficiency is confirmed by determination of the serum retinol level. The treatment is oral vitamin A, 100,000 IU/day for 2–3 days, followed by the recommended dietary requirement. The skin eruption, termed follicular hyperkeratosis or phrynoderma (“toadskin”), resembles keratosis pilaris and the genodermatosis keratosis follicularis spinuloas decalvans. Individual lesions are usually asymptomatic firm, pigmented papules containing a central, intrafollicular keratotic plug that projects from the follicle as a horny spine and leaves a pit when expressed. Lesions are of two sizes: 1–2 mm papules closely resembling keratosis pilaris and the more diagnostic, large, 2–6 mm, crateriform papules filled with a central keratotic plug. elbows were the most common initial site in 84%.

Answer 155

Pseudotumor cerebri with papilledema may occur early In adults, the early signs are dryness of the lips and anorexia.

Answer 156

may occur in patients with uremia and cirrhosis Skin changes include a seborrheic dermatitis–like eruption, atrophic glossitis with ulceration, angular cheilitis, conjunctivitis, and intertrigo. Occasionally, a pellagra-like eruption may occur.

Answer 157

absorbed through the distal ileum after binding to gastric intrinsic factor in an acid pH. Glossitis, hyperpigmentation, and canities are the main dermatologic manifestations of vitamin B 12deficiency. Linear atrophic lesions may be an early sign.

Answer 158

The “four Hs” are characteristic of scurvy: hemorrhagic signs, hyperkeratosis of the hair follicles, hypochondriasis, and hematologic abnormalities. Perifollicular petechiae are the characteristic cutaneous finding. Henoch-Schönlein purpura can easily be confused with scurvy. Another characteristic finding is keratotic plugging of the hair follicles, chiefly on the anterior forearms, abdomen, and posterior thighs. The hair shafts are curled in follicles capped by keratotic plugs, a distinctive finding called “corkscrew hairs.” Hemorrhagic gingivitis occurs adjacent to teeth and presents as swelling and bleeding of the gums Treatment is with ascorbic acid, 1000 mg/ day for a few days to 1 week, and a maintenance dose of 100 mg/ day should be considered.

Answer 159

niacin B3 Pellaga three Ds”—diarrhea, dementia, and dermatitis.

Answer 160

Kytococcus sedentarius (Corynebacteria, Dermatophilus congolensis, Actinomyces, Streptomyces) bacterial infection of the plantar stratum corneum, the thick, weight-bearing portions of the soles Topical erythromycin, mupirocin, or clindamycin is curative in pitted keratolysis.

Answer 161

P. aeruginosa opalescent, tense vesicles or pustules are surrounded by narrow, pink to violaceous halos. These lesions quickly become hemorrhagic and violaceous and rupture to become round ulcers with necrotic black centers. Ecthyma gangrenosum occurs in debilitated persons who may be suffering from leukemia, in the severely burned patient, in pancytopenia or neutropenia, or in patients with a functional neutrophilic defect, terminal carcinoma, or other severe chronic disease. Recommended treatment is the immediate institution of IV antipseudomonal penicillin.

Answer 162

Corynebacterium minutissimum Erythrasma is characterized by sharply delineated, dry, brown, slightly scaling patches occurring in the intertriginous areas, especially the axillae, the genitocrural crease, and the webs between the fourth and fifth toes and less often the third and fourth toes. The Wood’s light is the diagnostic medium for erythrasma. The affected areas show a coral-red fluorescence, which results from the presence of a porphyrin. Topical erythromycin

Answer 163

Erythrasma

Answer 164

Permethrin

Answer 165

Methotrexate Given once a week

Answer 166

Dapsone Dermatitis herpetiformis (DH) The drugs chiefly used for DH are dapsone and sulfapyridine. The most effective sulfone is diaminodiphenylsulfone (dapsone). Acute hemolytic anemia (which may be severe) occurs in patients with glucose6-phosphate dehydrogenase (G6PD) deficiency; therefore G6PD level should be measured before therapy.

Answer 167

Cyclosporine

Answer 168

120-150 mg

Answer 169

Gumma, Neurosyphilis, Nodular Syphilid Tertiary syphilids most often occur 3–5 years after infection. Gummas - may occur as unilateral, isolated, single or disseminated lesions, or in serpiginous patterns resembling those of the nodular syphilid. most frequent site of isolated gummas is the lower legs