Skin CIS (Gomez) - SRS Flashcards
What structure is most likely to have a different appearance in axillary skin?
Structue number 6 - this is an eccrine sweat gland.
In the axilla you would see apocrine sweat glands
Spongiosis seen in eczematous dermatitis develops in which area?
2 - stratum spinosum
What is the cause/pathogenesis of allergic contact dermatitis?
Topically applied antigens
What will the histologic findings look like in the following…
Allergic contact dermatitis
Atopic dermatitis
Spongiotic dermatitis in both cases
Drug related eczematous dermatitis arises d/t systemically administered antigens or haptens (e.g. penicillin). What will the histologic findings look like?
Spongiotic dermatitis with deeper infiltrate and abundant eosinophils
Photoeczematous eruptions occur with UV light exposure and may require associated exposure to systemic or topical antigens.
What will the histologic findings be?
What manner of testing may help in dx?
Spongiotic dermatitis; infiltrate that diminishes gradually with depth.
Photopatch testing may help with DX
Eczematous insect bite reaction arise d/t locally injected antigen or toxins from arthropods and may appear with papules, nodules, plaques, and vesicles. They may be linear when multiple.
What does the spongiotic dermatitis found on histology look like?
Wedge-shaped infiltrate with many eosinophils
A 25 y/o female has been using lip balm continuously for months and the changes seen in the image are not improving. What is the presumptive dx?
Allergic or irritant contact exfoliative cheilitis
What should a patient with Allergic or irritant contact exfoliative cheilitis do?
What might you test for?
- Patient should: Stop using the lip balm and substitute moisturizer with limited ingredients and/or topical corticosteroid.
- Could consider cultures for S. aureus or C. albicans.
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.
What is the name of the oral lesion?
What is the presumptive diagnosis?
- Wickham striae
- lichen planus
What are the 6 P’s of lichen planus?
- Pruritic
- Purple
- Polygonal
- Planar
- Papules
- Plaques
What are the clinical entities associated with lichen planus? (one bold and 7 not bold)
- Hepatitis C,
- ulcerative colitis
- alopecia areata
- vitiligo
- dermatomyositis
- morphea
- lichen sclerosis
- myasthenia gravis
Atrophy of which structure leads to “dry skin”?
5 - Sebaceous gland
What are the changes shown here d/t?
Aging and chronic actinic skin damage (UV)
What is this condition?
What are some of the consequences?
Sunburn
- 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
- melanomas
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?
Ichtyosis
Newborn with blistering skin disease. What is the presumptive dx?
Epidermolysis bullosa
How would you definitively dx epidermolysis bullosa?
Skin biopsy to exclude other blistering disorders and EM to subclassify.
What is the mutation involved in the simplex type of epidermolysis bullosa?
keratin 14 of 5 mutation
What type of blisters are seen in the simplex type epidermolysis bullosa?
Intraepidermal (suprabasilar) blisters
What is the defect in the junctional type epidermolysis bullosa?
I.Junctional type: defect at lamina lucida (laminin or BPAG2 defects)
Where are the blisters in the junctional type epidermolysis bullosa?
Intra-lamina lucida subepidermal blisters
What is shown here?
Eczema
What is described by the following?
–food, insect, light, drug, allergen testing
–humoral mediation type I
–eosinophils prominent in inflammation
–responds to topical steroids
–history to differentiate from allergic contact
Allergic atopic
What is shown in this case?
Allergic contact
What is described here?
–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
Allergic Contact
What is described here?
–chemicals
–no prior exposure as direct damage to epidermis
–necrosis and ulceration with neutrophil response
Primary irritant
Into what subtype would you place this ichthyosis?
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
Based on the lymphadenopathy probably Icthyosis vulgaris, associated with lymphoma.
Icthyosis vulgaris is associated with what conditions?
- Lymphoma
- hypothyroidism
- sarcoidosis
- visceral or generalized cancers
- HIV
- medications (nicotinic acid and hydroxyurea)
What are the four types of Icthyosis?
- Ichthyosis vulgaris (autosomal dominant or acquired)
- Congenital ichthyosiform erythroderma (recessive)
- Lamellar ichthyosis (recessive)
- X-linked ichthyosis
What is this tumor on the back of the ladies neck?
What number indicated the origin of this tumor?
Epidermermal inclusion cyst
7 - follicular origin
If this cyst lining had no granular layer, what would the diagnosis be?
What would it be arising from in this case?
Trichilemmal/pilar cyst
Still number 7
What is this tumor?
What is the cell of origin?
7 - follicular
Trichoepithelioma - note the location it is arising in
What is presumptive dx?
Treatment?
Acne vulgaris
- Benzoyl peroxide
- Erythromycin or clindamycin
- Topical retinoids
In what patients should you be careful with using topical retinoids for acne?
Why?
- 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)
What should you be sure to check periodically in a patient taking retinoic acid?
Liver enzymes, vitamin A toxicity is possible.
What are the structures involved in acne?
Pilosebaceous gland
What are four factors that are important in the development of acne?
- 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
What is the difference in comedo in whitehead vs. black head?
Oxidation of melanin - if the pore is closed there will be no oxidation and you get a white head. If the pore is open you get oxidation and a blackhead.
What is the difference in presentation of a papule vs a pustule and what occurs in the pilosebaceous unit to lead to a pustule?
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.
What is the tumor type shown here?
What is the cell of origin?
6 - Eccrine sweat gland
Turban Tumor (cylindroma)
Tumor type?
Cell of origin?
3
Basal cell carcinoma
5 year prognosis for basal cell carcinoma?
What is the tx?
~100% survival with treatment. Tx with excision
Tumor type and cell of origin?
3
Squamous cell carcinoma
Classify the differentiation of this squamous cell carcinoma.
Well differentiated - can see squamous characteristics
What is the tumor type and cell of origin?
3
Seborrheic keratosis
What is this lesion?
How do you know?
Seborrheic keratosis - note the keratin sprouts indicated with the arrow
What is the tumor type?
Cell of origin?
4
Melanoma
What are the four gross clinical criteria for melanoma?
- Asymmetry
- Borders
- Color
- Diameter >6mm
What are poor prognostic indicators in melanoma and which factor is the #1 prognostic indicator?
•1 Breslow level (thickness)
–Mitotic activity and Clark (anatomic) level for tumors <1mm
- 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
Likely dx?
Compound nevus
Probable dx?
Prognosis?
Seborrheic keratosis - prognosis depends on the cancer setting it off.
What is this most likely?
Ephelis - freckle
This appeared recently and has enlarged.
What is the likely dx?
Do you need a biopsy?
Solar lentigo
Yes biopsy needed, solar lentigo is benign but must differentiate from lentigo maligna.
What are some possibilities for this?
- Amalgam tatoo
- graphite tatoo
- nevus
- melanoma
- smokers melanosis
What have we here?
Is a biopsy warranted?
Giant congenital nevus. Only biopsy if rapid changes occur as melanoma can arise in these.
This appeared on sun exposed skin and has telangiectasia.
What is the probable dx?
Biopsy needed?
Lentigo maligna (based only on appearance can’t tell from melanoma though)
Remove the lesion and test
What is this?
Do you need to biopsy?
How is the prognosis?
Acral lentiginous melanoma
Must biopsy.
Prognosis is terrible
Probable diagnosis?
Biopsy needed?
Natural history and prognosis?
Birthmark hemangioma
No biopsy
prognosis excellent
What is described here?
DNA repair after radiation injury/ataxia, dyskenesia and vascular telangiectasias of conjunctiva and skin
Ataxia-telangiectasia
What is this?
Developmental patterning gene/multiple basal cell carcinomas; odontogenic keratocysts, palmar and plantar pits, medulloblastomas and ovarian fibromas, calcification of falx cerebri
Nevoid basal cell carcinoma (Gorlin) syndrome
What is described here?
Lipid phosphatase/macrocephaly, benign follicular appendage (trichilemmomas) tumors; hamartomatous colon polyps; internal adenocarcinoma (often breast/endometrium); cerebellar dysplastic gangliocytoma
Cowden syndrome
What is this?
Involved in DNA mismatch repair/sebaceous adenoma, sebaceous epithelioma, or sebaceous carcinoma and a visceral malignancy (usually gastrointestinal or genitourinary carcinomas)
Muir-Torre syndrome
What is this?
Negatively regulates RAS signaling/neurofibromas (plexiform and solitary), optic nerve gliomas, Lisch nodules on iris, café au lait spots
Neurofibromatosis I
What is this?
Integrates cytoskeletal signaling/neurofibromas; meningiomas and bilateral acoustic neuromas; spinal cord ependymomas
Neurofibromatosis II
A 71 year old male with multiple yellowish nodules on the scalp and forehead. The patient has a history of adenocarcinoma of the colon.
Dx?
Sebaceous tumor - Muir torre syndrome
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.
Dx?
Syndrome?
Nevoid basal cell (Gorlin) syndrome with recurrent and metastatic basal cell carcinoma
What is the mutated gene in gorlin syndrome?
What else could be present in a patient with gorlin syndrome?
PTCH or SMO
Ovarian fibromas and cerebellar medulloblastomas also seen in this syndrome
Random basal-cell tumors have mutations in the hedgehog signaling pathway that do either one of what two things?
1- inactivate PTCH1 [7-9] (loss-of-function mutation)
2- constitutively activate SMO15 (gain-of-function mutation)
Basal cell carcinoma incidence is increased in what 6 genetic syndromes?
- –Albinism
- –Xeroderma pigmentosa
- –Nevoid basal cell carcinoma syndrome (Gorlin syndrome)
- –Bazex syndrome
- –Ramussen syndrome
- –Rombo syndrome
34 year old male presents to your office with a long history of pigmented skin lesions but one has been changing.
Dx?
Melanoma arising in dysplastic nevus syndrome
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.
Dx?
Rocky mountain spotted fever - acuired from a dog tick
How would you definitively dx rocky mountain spotted fever?
indirect immunofluorescence assay (IFA) with Rickettsia rickettsii antigen immediately and in 2-4 weeks
42 year old from Maryland who likes to garden presents with fever, chills, headache and a rash present for a few days. Felt fine previously.
Dx?
Test to confirm?
Erythema migrans of Lyme Disease
enzyme-linked immunosorbent assay (ELISA) or immunofluorescence assay (IFA) with Borrelia burgdorferi antigen
What should you use to treat lyme or rocky mountain spotted fever?
Doxycycline
What is the vector for lyme disease?
Deer tick
What is this likely from?
Either a bee or a wasp
What drugs would you use for anaphylaxis?
Epi
Steroids
Antihistamine
H2 blocker (spill over effect on H1 also)
What is this most likely?
Lice/pediculosis
Likely cause?
Bedbugs/cimicosis
Likely culprit?
Aedes aegypti bites primarily ankles and elbows during the day (mosquitos)
What is this most likely?
Fleas
What most likely caused this?
Trombiculosis = chiggers
Most likely organism?
Scabies
Sarcoptes scabiei (var hominis)
What is the most likely culprit heere?
Cutaneous larva migrans - dog and cat hookworms
