CIS

Question 1

Wickham striae and lichen planus

Answer 1

pruritic, purple, polygonal, planar, papules, and plaques

associated with Hep C

Question 2

seboerreic keratosis-

Answer 2

never need to biopsy

white things coming out

Question 3

What structure is most likely to have a different appearance in axillary skin?

Answer 3

Eccrine/apocrine sweat glands

Question 4

Spongiosis seen in eczematous dermatitis develops in which area?

Answer 4

Stratum spinosum

Question 5

Allergic atopic

“spongiotic dermatitis”

Answer 5

food, insect, light, drug, allergen testing
humoral mediation type I*
eosinophils prominent in inflammation
responds to topical steroids
history to differentiate from allergic contact

• family history of eczema, hay fever or asthma

Question 6

Allergic contact “spongiotic dermatitis”

Answer 6

poison ivy, nickel, other metals, rubber compounds
T-cell mediated type IV*
lymphocyte rich inflammation
Will not respond to topical steroids
no inflammation until 2nd exposure; > 24 hr delay

Often topically applied antigens

Question 7

Primary irritant “spongiotic dermatitis”

Answer 7

chemicals
no prior exposure as direct damage to epidermis
necrosis and ulceration with neutrophil response

• localized mechanical or chemical irritants (nonimmunologic)

Question 8

drug-related eczematous dermatitis

Answer 8

• infiltrate ofen deeper with *abundant eosinophils

Temporal relationship to drug administration

Question 9

photoeczematous eruption “spongiotic dermatitis”

Answer 9

occurs at sites of sun exposure, may require associated exposure to systemic or topical antigen

Question 10

eczematous insect bite reaction

Answer 10

spongiotic dermatitis

wedge-shaped infiltrate; many eosinophiles

Question 11

A 25 y/o female has been using lip balm continuously for months and the changes seen in the image are not improving. Presumptive dx? what to do?

Answer 11

Presumptive Diagnosis?
Allergic or irritant contact exfoliative cheilitis

What to do?
Stop using the lip balm and substitute moisturizer with limited ingredients and/or topical corticosteroid. Could consider cultures for S. aureus or C. albicans.

Question 12

A 34 year old female developed a pruritic rash that involved the skin. Her dentist also noted bluish and reddish white lesions in the mouth.

Answer 12

Wickham striae and lichen planus
Topical steroids were used to control itching
and problems resolved after a few months.

Test to order for definitive diagnosis?
None, biopsy can be done for difficult cases.

What clinical entities are associated with this disorder and what is the pathophysiology?

Hepatitis C, ulcerative colitis, alopecia areata, vitiligo, dermatomyositis, morphea, lichen sclerosis and myasthenia gravis

It is a cell-mediated immune response of unknown origin.

Question 13

Atrophy of which structure leads to “dry skin”?

Answer 13

Sebaceous gland

Question 14

old skin?

Answer 14

Aging and chronic actinic skin damage

Question 15

Sunburn

Answer 15

acute inflammation with pain, desquamation, blistering with secondary infections, chronic actinic skin damage including wrinkles, solar elastosis, solar lentigos, actinic keratoses, squamous cell carcinomas, basal cell carcinomas and melanomas

Question 16

A 52 year old male presents with a new skin rash not responding to topical cortisone and moisturizers. During the physical examination the rash is diffuse and there is also axillary and cervical lymphadenopathy. Presumptive dx?

Answer 16

Presumptive Diagnosis?
Ichthyosis

What subtype?

** Ichthyosis vulgaris (autosomal dominant or acquired)
other types:
Acquired associated with hypothyroidism, sarcoidosis, lymphoma, visceral or generalized cancer, HIV or medications (e.g. nicotinic acid and hydroxyurea)
Congenital ichthyosiform erythroderma (recessive)
Lamellar ichthyosis (recessive)
X-linked ichthyosis

Test(s) to order for definitive diagnosis?
Search for underlying etiology and continue
topical treatment until underlying cause
is found and treated - CBC with diff, lymph node biopsy in this case of probable lymphoma

Question 17

Newborn with blistering skin disease. Presumptive Diagnosis?

Answer 17

Epidermolysis bullosa
Supportive care with treatment of infections and contractions as they occur

Test to order for definitive diagnosis?

Skin biopsy to exclude other blistering disorders and electron microscopy to sub-classify the disease if epidermolysis bullosa is the diagnosis

I. Simplex type: keratin 14 or 5 mutation
Intraepidermal (suprabasilar) blisters
II. Junctional type: defect at lamina lucida (laminin or BPAG2 defects)
Intra-lamina lucida subepidermal blisters

Question 18

A 14 year old female presents with a chronic skin rash. Presumptive Diagnosis and treatment?

Answer 18

Acne vulgaris
Rx- 
1. Benzoyl peroxide 
2. Erythromycin or clindamycin
3. Topical retinoids - Be careful with retinoids in child-bearing age females as they may be potentially teratogenic in topical forms and definitely teratogenic in oral forms (affects HOX gene expression leading to neural crest migration craniofacial defects and also increased abortions)

Structures involved and need for further testing?
Pilosebaceous gland – no further testing needed (classic clinical presentation)

Question 19

Factors important in development of acne?

Answer 19

Plugging of the hair follicle with desquamated cells
Sebaceous gland hyperactivity (begins at puberty with influence of testosterone)
Proliferation of bacteria (especially Propionibacterium acnes)
Inflammatory response to bacteria & entrapped keratin

Question 20

Difference in comedo in whitehead vs blackhead?

Answer 20

Superficial oxidized sebum

Question 21

What is the difference in presentation of a papule vs a pustule and what occurs in the pilosebaceous unit to lead to a pustule?

Answer 21

Papule is dome shaped skin elevation that can occur in blackheads or whiteheads without pus.
Pustule occurs when skin pore is blocked and accumulated infected debris is accompanied by purulent material.

Question 22

Pile of lumps on scalp. Tumor Type and Cell of Origin?

Answer 22

Turban tumor (cylindromas)

Question 23

basal cell carcinoma 5-year prognosis?

Answer 23

Excellent, expect almost 100% survival

Question 24

What are the gross clinical criteria for melanoma?

Answer 24

Asymmetry
Irregular Borders
Uneven Color
Diameter >6mm

Question 25

Melanoma Poor Prognostic Indicators

Answer 25

#1 Breslow level (thickness) 
Tumor ulceration
Nodal metastases (sentinel node biopsy)

Distant metastases (visceral mets are worse)
Lactate dehydrogenase elevation
Location (head and neck worst, palmar and plantar bad)

High mitotic activity
Lack of tumor infiltrating lymphocytes
Older age (>65 worse)
Male sex (for younger people)
High tumoral vascularity (angiogenesis)
Satellitosis
Tumor regression

Question 26

Ataxia-telangiectasia

Answer 26

familial cancer syndrome- ataxia, dyskinesia and vascular telangiectasias of conjunctiva and skin

Question 27

Nevoid basal cell carcinoma

Answer 27

= Gorlin syndrome
multiple basal cell carcinomas; odontogenic keratocysts, palmar and plantar pits, medulloblastomas and ovarian fibromas; calcifications of falx cerebri

Question 28

Cowden syndrome

Answer 28

benign follicular appendage (trichilemmomas) tumors; hamartomatous colon polyps; internal adenocarcinoma (often breast/ endometrium); cerebellar dysplastic gangliocytoma

Question 29

Muir-Torre syndrome

Answer 29

mismatch repair
sebaceous adenoma, sebaceous epithelioma, or sebaceous carcinoma and a visceral malignancy (usually gastrointestinal or GU carcinomas)

Question 30

Neurofibromatosis 1

Answer 30

neurofibromas (plexiform and solitary), optic nerve gliomas, Lisch nodule on iris; cafe au lait spots

Question 31

Neurofibromatosis 2

Answer 31

neurofibromas, meningiomas and bilateral acustic neuromas; spinal cord ependymomas

Question 32

Tuberous sclerosis

Answer 32

hamartomatous brain tumors; mental retardation; renal angiomyolipomas; retinal hamartomas; pulmonary lymphangioleiomyomatosis; cardiac rhabodmyomas

Question 33

A 71 year old male with multiple yellowish nodules on the scalp and forehead. The patient has a history of adenocarcinoma of the colon. Presumptive Diagnosis of lesion and syndrome?

Answer 33

Sebaceous tumor – specifically sebaceous adenoma, arising in patient with Muir Torre Syndrome

Question 34

A 66-year-old male patient presented with multiple asymptomatic skin lesions and a history of recurrent basal cell carcinoma. Also present are exophthalmos and numerous pits over the palms and soles. Surgical procedures for the basal cell carcinoma took place 12 and 6 years ago. Biopsy of the mass and a lung nodule demonstrated basaloid squamous cells.

Answer 34

Presumptive Diagnosis of lesions and syndrome?

Nevoid basal cell (Gorlin) syndrome with recurrent and metastatic basal cell carcinoma

Tests to order for follow up?
X-rays of skull, vertebra and jaws to look for calcified falx cerebri, odontogenic keratocysts, malformations of vertebrae

Mutated genes and additional neoplasms that may arise?
PTCH or SMO
Ovarian fibromas and cerebellar medulloblastomas

Question 35

Gorlin Syndome

Answer 35

Random basal-cell tumors have mutations in the hedgehog signaling pathway that either
1- inactivate PTCH1 [7-9] (loss-of-function mutation)
2- constitutively activate SMO15 (gain-of-function mutation)

Question 36

Basal Cell Carcinoma- Increased incidence in genetic syndromes

Answer 36

Albinism
Xeroderma pigmentosa
Nevoid basal cell carcinoma syndrome (Gorlin syndrome)

Question 37

34 year old male presents to your office with a long history of pigmented skin lesions but one has been changing. Presumptive Diagnosis?

Answer 37

Melanoma arising in dysplastic nevus syndrome

Test to order for definitive diagnosis?

Intact excisional biopsy of the worrisome lesions. Continue surveillance of all other lesions.

Question 38

42 year old from North Carolina who likes to bird hunt presents with fever, rash and abdominal pain for a few days. Felt fine previously. His hunting dogs also not feeling well and he has been treating them for ticks.

Answer 38

Presumptive Diagnosis?

Petechial rash of Rocky Mountain Spotted Fever
Patient started on Doxycycline

Question 39

Two ticks that carry R. rickettsii

Answer 39

Rocky Mountain wood tick - Northwest

American dog tick - pacific coast, eastern and central USA

Question 40

lyme disease treatment and dx test?

Answer 40

Patient started on Doxycycline

Test to order for definitive diagnosis?

Enzyme-linked immunosorbent assay (ELISA) or immunofluorescence assay (IFA) with Borrelia burgdorferi antigen

Question 41

vector for lyme disease

Answer 41

deer tick

Question 42

Male who raises bees is brought to the emergency room by his friend. Bee keeper had marked itching of the face and abdominal discomfort. He had reacted to bee stings before but not as much. Shortly after arrival he became unresponsive and was noted to have a fast pulse rate.

Presumptive Diagnosis and treatment

Answer 42

Anaphylactic Reaction to Hymenoptera stings
Start epinephrine, steroid, antihistamine and H2 blocker.
Search bite sites to remove stingers (diminish antigen)

Test to order for definitive diagnosis?

Question 43

A young child developed swollen lips and tongue after eating a ham sandwich at a restaurant. The child had previously had localized reactions to latex.

Presumptive diagnosis and immediate treatment?

Answer 43

Latex allergy
Start patient on liquid Benadryl (diphenhydramine) and Tagamet (cimetidine)
(purchase at nearby pharmacy/grocery store if epinephrine is not readily available

Test to order for definitive diagnosis?

None, contact testing for this degree of reaction may lead to anaphylactic shock.

Question 44

Trombiculosis = Chiggers

Answer 44

Larvae of red mites or harvest mites

Attach to skin of ankles, waistline, armpits and perianal area after the host walks through a grassy environment

They pierce skin near a hair
follicle and feed on partially
digested skin cells then drop off the host

The host reacts to the mite saliva
with intense itching.