Derm from Book ?s

Question 1

What characterizes erythema toxicum neonatorum?

Answer 1

• -transient, benign, self-limited skin rash with lesions of varied morphology
• -erythematous macules; wheals, vesicles, and pustules in 50-60% of all newborns
• -lesions usually arise from erythematous base, with macular erythema fading w/in 2-3 days
• -occurs predominantly on the trunk, but may occur anywhere except soles and palms

Question 2

In order to confirm dx of Erythema toxicum neonatorum, you order a Wright’s stained smear. If your dx is correct, what are the suspected results?

a) Presence of eosinophils
b) Presence of neutrophils
c) Presence of keratinous material
d) Presence of Staphylococcus aureus

Answer 2

a) Presence of eosinophils

• -Wright’s stained smears of pustules identifies predominance of 90% eosinophils rather than neutrophils
  
  • -> rules out neonatal pustular melanosis

Question 3

Best tx for Erythema toxicum neonatorum?

Answer 3

no tx necessary!
–condition will resolve spontaneously in 5-7 days

(is benign and self-limiting)

Question 4

You examine a newborn and observe numerous white papular lesions on the cheeks, forehead, and nose. You suspect either milia or neonatal acne. Which physical findings helps to confirm a dx of milia?

a) papular lesions are intermixed w/pale yellow macules
b) papular lesions have an erythematous circular ring at the base
c) papular lesions are surrounded by lacy-blue area w/erythematous mottling
d) papular lesions, yellow in color, are observed on the hard palate

Answer 4

d) papular lesions, yellow in color, are observed on the hard palate

–in milia, there is an oral counterpart of yellow, papular lesions on the hard palate… aka Epstein’s Pearls!
(these do not occur in neonatal acne)

Question 5

What is a port-wine stain?

Answer 5

aka nevus flammeus

• -irregular dark red or purple macular lesions occurring on any body surface, predominantly on face and head
• -never fade and become thickened and raised in adulthood

Question 6

Management/counseling for port-wine stain?

Answer 6

• -referral for derm eval for consideration of pulsed dye laser tx
  
  • -> recommended to start as early as possible in infancy and definitely before 1 year of age
• -area may be camouflaged later in childhood with water-resistant cosmetics
• -using a steroid cream is not indicated

Question 7

Which condition is thought to be more apparent in darker-skinned individuals or during the summer months?

a) Tinea corporis
b) Psoriasis
c) Pityriasis alba
d) Pityriasis rosea

Answer 7

c) Pityriasis alba

–is more apparent in darker-skinned individuals and occurs in warmer months

Question 8

What characterizes pityriasis rosea?

Answer 8

• -is an acquired common mild inflammatory condition characterized by scaly, hypopigmented, and hyperpigmented lesions
• -predominantly on the trunk, upper arms, and upper thighs
• -also has a “herald” patch (often “fir tree” distribution) of 1cm to 5cm on trunk or buttocks

Question 9

What is most common symptom of pityriasis rosea?

Answer 9

pruritus, of varying degree of severity

–esp. at onset!

Question 10

Management for pityriasis rosea?

Answer 10

• -topical calamine lotion on lesions
• -oral antipruritic agents for severe pruritus (such as diphenhydramine)
• -cool bath or compresses on lesions
• -low-potency steroid creams

(no antibiotics!)

Question 11

Management for atopic dermatitis? How to treat secondary infection?

Answer 11

• -topical steroids to affected areas
• -wet compresses to affected skin areas
• -eliminate all substances that dry the skin
• -do NOT maintain a dry, warm environment
  
  • -> atopic derm worsens with sweating and temp extremes: warm, dry environment will make sx worse!

Secondary bacterial infection:

• -oral antibiotics
  
  • -> Bactrim, cefadroxil, cephalexin (Keflex), clindamycin

Question 12

What are capillary hemangiomas?

Answer 12

• -bright red or blue-red nodular tumors of varying sizes and shapes with a rubbery and rough surface
• -occur predominantly on the head and face
• -often are not present at birth, but the area of the eventual lesion may be blanched or slightly colored
• -grow quickly within 2 to 4 weeks to a red or blue-red, protuberant, rubbery nodule or plaque, with the most growth in the first 6 months
• -there is a gradual reduction in proliferation usually beginning between 9 and 12 mos

Question 13

How are cafe au lait spots characterized? What disease are they associated with?

Answer 13

light to medium brown pigmented macular lesions of varying sizes and shapes, found anywhere on the body

• -the color of coffee with milk
• -are usually present at birth but may develop at any age
• -20% of darker-skinned populations have them

–if there are 6 or more lesions, may be assoc. w/neurofibromatosis or Albright syndrome

Question 14

What is tx for pityriasis alba?

Answer 14

bland moisturizers to reduce overdrying

Question 15

What can we teach patients about the progress and prognosis of pityriasis alba?

Answer 15

resolves spontaneously in 3-4 months

Question 16

Malignant melanoma is more common in which populations?

Answer 16

• -females from birth to 40 years of age

- -light-skinned individuals

Question 17

What is characteristic of a lesion seen in chronic psoriasis vulgaris? Etiology/incidences of psoriasis?

Answer 17

large scaly silver-white plaque 5-10cm in diameter

(chronic psoriasis = characterized by erythematous plaques with silver-gray-white scaly plaques)
–> occurring predominantly on the head and face

• -seen in approx. 33% of children
• -more common in light-skinned than dark-skinned populations
• -occurs in those w/a positive family hx
• -assoc. w/constant rubbing or trauma to exposed areas such as elbows; assoc. w/overproduction of epithelial cells and epithelial cells that migrate to the skin surface much more quickly than normal

Question 18

Management of psoriasis?

Answer 18

• -apply topical steroids
• -apply mineral oil and moisturizers
• -decrease exposure to direct sunlight

Question 19

What symptom is most characteristic of contact dermatitis?

Answer 19

pruritus at site of affected areas

Question 20

Characteristics of contact dermatitis?

Answer 20

• -hypersensitivity to a substance within the environment when direct contact is made
• -may be caused by direct contact with topical meds, soaps, cosmetics, fabrics, and plants
• -caused by hypersensitivity to an allergen with reexposure
  
  • -> allergic response usually occurs w/in 24 hrs d/t prior sensitization
• -typical response = redness and edema at the site of contact, which may progress to papules and vesicles

Question 21

TX for contact dermatitis?

Answer 21

• -cool compresses w/Burrow’s solution
• -oral antihistamines
• -topical steroids to affected areas for 5 days

**skin testing during an acute episode is not recommended

Question 22

In what age groups do you see seborrhea dermatitis? Characteristics?

Answer 22

• -common in both infants and adolescents
• -can cause irritating pigment changes to include hyperpigmentation and hypopigmentation
• -is associated w/an overproduction of sebum in areas abundant with sebaceous glands

in newborns/infants:

• -is known as “cradle cap,” areas of underlying erythema with yellow crusts and greasy scaling on scalp and face
• -in more severe cases, lesions may be present on trunk and in diaper area

in adolescent:
–will have white flakes and greasy scaling on scalp, forehead, eyebrows, and face

Question 23

What is the best tx of seborrhea in the infant?

Answer 23

• -shampoo and wash affected areas with a non perfumed baby shampoo or baby wash
• -use mineral oil with brushing to loosen crusts prior to washing

Question 24

Classify burns according to skin layers:

Answer 24

1) First-degree/superficial: epidermis only
2) Second-degree/partial thickness: epidermis and part of dermis, which may be superficial or deep dermis
3) Third-degree/full-thickness: epidermis, dermis, and dermal appendages

Question 25

Classify burns according to extent of affected area:

Answer 25

1) Minor burns: hands, feet, eyes, ears, and perineal burns are always considered major burns, regardless of extent of body surface affected

Question 26

First and second degree burn would appear:

Answer 26

moist with edema, erythema, and a few vesicles

red, swollen, moist and blistered areas with tenderness

Question 27

Tx for 2nd degree burns?

Answer 27

evaluation at a tertiary care center is recommended

Question 28

What is folliculitis? Most common cause? Where does it most commonly occur?

Answer 28

an inflammatory condition involving the pilosebaceous follicle
–most commonly caused by Staphylococcus aureus
(less commonly caused by Streptococcus bacteria)

• -most commonly occurs on neck and scalp
  
  • -> on localized areas of erythema and edema with papular or pustular lesions on face, scalp, neck, buttocks, and other areas

Question 29

Tx for folliculitis if caused by staph?

Answer 29

dicloxacillin

Question 30

Which of the following antibiotics would you not consider for moderate chronic acne?

a) Topical clindamycin
b) Oral erythromycin
c) Oral minocycline
d) Oral tetracycline

Answer 30

b) Oral erythromycin

• -in moderate chronic acne, oral antibiotics may be considered
  
  • -> antibiotics of choice = tetracycline, doxycycline, minocycline

Question 31

What causes Molluscum contagiosum? What characterizes it?

Answer 31

a poxvirus

–a self-limiting skin condition characterized by waxy, firm papules that may occur on any skin surface, but predominantly on the face, axillae, abdomen, and arms

Question 32

Which tx would you not recommend for Molluscum?

a) Curettage lesions
b) Oral antibiotics
c) Observation
d) Topical imiquimod

Answer 32

b) Oral antibiotics

• -molluscum tx does not consist of antibiotics
• -may use imiquimod (also treats genital warts & basal cell carcinoma)

Question 33

What characterizes impetigo?

Answer 33

• -is caused by a localized bacterial infection of skin often precipitated by insect bites (spider, mosquito, flea) or other trauma that breaks protective skin barrier
• -predominantly involves the face and less commonly other body surfaces, including perineum
• -vesicles that erupt result in honey-colored serous crusts with erosion of the epidermis

Question 34

What characterizes lesions caused by tinea corporis?

Answer 34

• -scaly plaques of varying sizes from 3cm with mild erythematous active borders
• -lesions spread peripherally as they heal centrally and may be singular or several (numerous lesions are uncommon)

Question 35

Would you use topical antibiotics after 8 weeks of use of topical antifungals with additional lesions appearing?

Answer 35

no! use of antibiotics is not indicated.

–tx consists of: topical antifungal meds, clotrimazole, miconazole, naftifine, ciclopirox, or ketoconazole

Question 36

What characterizes spider bites? Where would you find common spiders?

Answer 36

–a dull burning or pain at the site of bite with two puncture marks surrounded by white area with bluish-red border

Black Widow: dry, warm, dark areas; grass, wood piles, gardens, sheds, basements, closets, trunks
Brown Recluse: trunks, carpets, old shoes, old clothes, closets, crates, shelves

Question 37

What is scabies characterized by?

Answer 37

• -intense pruritus, esp. at night in older children and adolescents
• -red bumps, blisters, pustules, and small burrow marks that may be obliterated by scratch marks
  
  • -> burrows are superficial, 2-8mm long, linear, and curved with small papules at the proximal end
  • -> burrows may be obliterated by scratch and excoriation marks resulting from scratching

Question 38

TX for scabies?

Answer 38

• -topical antiparasites
• -antihistamines or topical steroids
• -store non-washables in a plastic bag for a week

Question 39

Pediculosis us a highly communicable, common condition in children. Which of the following is not correct of Pediculus humanus?

a) An insect that does not fly or jump
b) Gravid females lay ova in seams of clothing
c) Likes hairy areas of the body better than the non-hairy body surfaces
d) Same medication used for scabies may be used to effectively eradicate this species

Answer 39

c) Likes hairy areas of the body better than the non-hairy body surfaces

–> Pediculus humanus prefers less-hairy body surfaces

(Pediculus capitis: affects scalp
Phthirus pubis: affects pubic and axilla areas, eyelashes, eyebrows)

Question 40

What is Pediculus humanus?

Answer 40

lice!

Question 41

Hypersensitivity may occur to a variety of substances, causing a variety of reactions. It is important to determine whether the body’s hypersensitivity reaction will cause erythema multiforme condition. Which of the following is not typical of the erythema multiforme reaction?

a) Target “bulls-eye” lesion with a necrotic center surrounded by a pale macular middle area and then by an erythematous peripheral ring
b) Itching at site of affected area
c) Pain at site of affected areas, esp. in the oral cavity
d) Lesions that all have the same morphology on the trunk

Answer 41

d) Lesions that all have the same morphology on the trunk

–lesions are not all the same size and morphology

Question 42

When do you see a target, “bulls-eye” lesion? What are its 3 distinct characteristics?

Answer 42

seen w/erythema multiforme

Lesion has:

1) a necrotic or vesicular center
2) a pale middle macular ring
3) an outer erythematous peripheral ring

Question 43

What is the key distinction b/t erythema multiforme minor and erythema multiforme major?

Answer 43

w/major, occurrence of prodromal systemic sx of fever, malaise, sore throat, HA, n/v

Question 44

Tx/management for erythema multiforme major?

Answer 44

need immediate attention at a hospital for a full medical evaluation

Question 45

A 7yo African American female presents with several hyperkeratotic raised, periungual lesions on the two middle fingers of her left hand. She has a hx of nail biting. The most likely dx is:

a) Impetigo
b) Molluscum contagiosum
c) Verruca vulgaris
d) Herpetic whitlow

Answer 45

c) Verruca vulgaris

–common warts are found most usually on fingers, hands, and feet in children, and are often preceded by trauma such as nail biting or picking at cuticles

Question 46

What skin changes are associated with atopic dermatitis?

Answer 46

• -thickened (lichenification)
• -pigment changes (hyperpigmented)
• -crusted (excoriations)

Question 47

In infants, the lesions associated with atopic dermatitis are most likely to be distributed on the:

a) cheeks and forehead
b) wrists and ankles
c) antecubital and popliteal fossae
d) flexural surfaces

Answer 47

a) cheeks and forehead

• -the infantile phase of atopic dermatitis follows a different distribution than that associated with the childhood phase
  
  • -> may include the face, trunk, and extensor surfaces

Question 48

During your newborn exam, you note a generalized lacy reticulated blue discoloration. This clinical presentation describes:

a) Harlequin color change
b) Mongolian spots
c) Blue nevus
d) Cutis marmorata

Answer 48

d) Cutis marmorata
- -> transient mottling of the neonate’s skin with a lacy, bluish appearance
- -> physiologic response of uneven blood flow that results from constriction of small blood vessels while others dilate
- -> more common in preemies, often precipitated by cold

–Harlequin color change isomer red than pale

Question 49

What is a salmon patch?

Answer 49

salmon patch = nevus simplex

• -a flat, light pink to light red mark seen on the eyelid, glabella, or nape of neck (“stork bite”) that intensifies with crying
• -benign! gradually fades and disappears with time
• -seen in 40-50% of newborns, more common in girls

Question 50

What would cause a beefy red macular-papular rash in the diaper area with satellite lesions on the abdomen? Tx?

Answer 50

Candida albicans

–treat w/an antifungal agent such as Clotrimazole

Question 51

How do you confirm a suspected case of scabies? Tx of choice?

Answer 51

microscopic skin scraping

• -will reveal the mite, eggs, or feces if scabies are present
  
  • -> are not routinely done, but are definitive if there is any doubt of the dx

–treat w/Permethrin 5%

Question 52

Which of the following statements regarding tx of pediculosis capitis is true?

a) Carpeting and furniture must be shampooed and spray with a pediculicide.
b) Nonwashable items that have come into contact w/an infected person should be sealed in plastic bags for 2-4 weeks.
c) Hair must be trimmed close to the scalp to ensure elimination of nits.
d) Frequent shampooing with permethrin 1% will prevent reinfestation.

Answer 52

b) Nonwashable items that have come into contact w/an infected person should be sealed in plastic bags for 2-4 weeks.
- -> since eggs mature in 7-10 days, 2-4 weeks should be sufficient to prevent reinfestation

• -frequent shampooing and close haircuts are unnecessary and may contribute to a feeling of shame and embarrassment
• -environmental cleaning includes vacuuming, although sprays are not recommended

Question 53

A 6yo comes in bc of “hives” that the mother describes as a red, raised rash. Which finding would support a dx of erythema multiforme rather than urticaria?

a) Lesions that blanch with pressure
b) Eyelid edema
c) Lesions that are present for more than 24 hours.
d) Intense pruritus

Answer 53

c) Lesions that are present for more than 24 hours

Urticaria:

• -tend to pruritic and blanch with pressure
• -generally fade w/in a few hours
• -edema is common d/t the large # of mast cells present in the eyelids

Multiforme lesions:
–are fixed and present for up to 2-3 weeks

Question 54

Characterize mild, comedonal, moderate, and severe acne.

Answer 54

Mild:
–open and closed comedones and occasional pustules

Comedonal:
–open and closed comedones only

Moderate:
–open and closed comedones, papules, and pustules

Severe:
–open and closed comedones, papules, pustules, plus cysts

Question 55

What medication is the appropriate choice for moderate acne?

Answer 55

• -oral antibiotics (such as minocycline) is used to control moderate papulopustular acne
  
  • -> (in addition to topical keratolytics such as salicylic acid)
• -antiandrogens are not recommended
• -corticosteroids may be used for more severe forms or the flare-ups assoc. w/isotretinoin therapy

Question 56

What type of rash is seen w/erythema toxicum?

Answer 56

• -located all over body
• -papule (not vesicle)
• -redness w/ yellow-white “bumps”

Question 57

DJ is a 4yo African American child w/a depigmented macular lesion on his forehead. The lesion has sharp borders. No scales are present. The most appropriate tx would be:

a) 1% hydrocortisone
b) Alpha hydroxy acid
c) Ketoconazole
d) Silver sulfadiazine

Answer 57

a) 1% hydrocortisone

- -> most likely dx is vitiligo: responds to steroids 30-50% of the time

Question 58

While examining 7yo SR’s scalp, you note 3 small patches of hair loss. Broken hair is present, as is erythema and scaling. On the basis of this information, which of the following dx’s is most likely?

a) Tinea captitis
b) Traction alopecia
c) Trichotillomania
d) Alopecia areata

Answer 58

a) Tinea captitis
- -> characteristic findings are erythema, scaling, and broken hair

• -traction alopecia may also have associated erythema, but no scaling
• -only alopecia areata is noted for total hair loss