Spring Derm

Question 1

A 41 year old male experiences a painful, solitary bulla at the same location on his glans penis intermittently after episodes of constipation. He takes a laxative each time he experiences constipation. Which of the following drug reactions is the most likely Dx?
A) Drug-induced hypersensitivity syndrome
B) Exanthematous drug eruption
C) Fixed drug eruption
D) Stevens-Johnson Syndrome
E) Vasculitis

Answer 1

C) Fixed drug rxn

Genital skin is a common site of occurrence

Question 2

A man developed a diffuse red papular eruption 3 weeks after starting allopurinol for elevated uric acid. Skin lesions became confluence and were associated with anasarca, recurrent high fevers, arthralgias, myalgias, decreased urinary output, and proteinuria. Laboratory studies revealed a leukocytosis with dramatic eosinophilia, and elevated liver enzymes. Which drug rxn?
A) Drug-induced hypersensitivity syndrome
B) fixed drug eruption
C) Stevens-Johnson Syndrome
D) Toxic epidermal necrolysis
E) Vasculitis

Answer 2

A) Drug-induced hypersensitivity syndrome

Should be considered for any pt with diffuse papular eruption and systemic S/Sx

Question 3

A 32 yo woman presents to the emergency room with a rash covering 25% of her body surface area which began 2 weeks after starting TMP/SMX for a urinary tract infection. She also has oral and conjunctival erosions. What is Dx?
A) Disseminated zoster
B) Drug-induced hypersensitivity syndrome
C) Fixed drug eruption
D) Sepsis
E) Stevens-johnson syndrome/toxic epidermal necrolysis

Answer 3

E) Sevens-johnson syndrome/toxic epidermal necrolysis

10%-30% detached and detachable skin = SJS

Question 4

40 yo male who presented to ER with a diffuse pruritic rash that began on his trunk and spread peripherally. The rash started 10 days after he began taking ampicillin for “food poisoning”. There are no mucosal lesions or systemic sx. What is Dx?
A) disseminated zoster
B) Drug induced hypersensitivity syndrome
C) Exanthematous drug eruption
D) Fixed drug eruption
E) SJS

Answer 4

C) Exanthematous Drug eruption

hx of 10 day hiatus btw meds and rash onset as well as the clinical appearance of the rash in this case, are both typical of an exanthematous drug eruption

Question 5

A toddler presents to clinic with the lesions found in this photo. What is best decription?

Answer 5

Dome-shaped, umbilicated papules

Molluscum contagiosum

Question 6

You dx a healthy 6 yo boy with molluscum contagiosum (multiple, but not widespread).  Which of the following treatments would you recommend?
A) oral acyclovir 
B) reassurance
C) Topical salicylic Acid
D) Topical benzoyl peroxide
E) Topical corticosteriods

Answer 6

B) reassurance

Question 7

3 yo girl presents with these papules on her abdomen.  What causes this eruption?
A) bacteria
B) fungus
C) vascular
D) virus

Answer 7

D) Virus

Question 8

Mother brings her 9 yo daughter with molluscum contagiosum. The mother shares with you that she has 2 other kids home. She wants to know whether her other kids are at risk of catching virus. you tell her?
A) Not contagious once the skin lesions appear
B) trans through airborne resp droplets
C) Trans though skin-skin contact and fomite exposure
D) Trans through fecal-oral route
E) Trans by pets

Answer 8

C) transmitted though skin-skin contact and fomite exposure

Question 9

Which of the following is true regarding molluscum contagiosum?
A) all the lesions should be covered with a bandaid to avoid spread to others
B) Children should stay home from day care if they have molluscum
C) The eruption is self limiting and can last months to years
D) the eruption should be treated to avoid systemic involvement

Answer 9

C) the eruption is self liming and can last months to years

Question 10

A 27 yof presents with multiple koebnerized molluscum on her face. While reviewing her PMH you learn she had HIV and takes antiretroviral therapy. What is your next step?
A) Offer the pt antihistamines to provide itch relief
B) perform excisional biopsies
C) recommend that lesions be removed with curettage or cryosurgery
D) refer the pt to derm
E) Tell the pt that the lesion will resolve on their own

Answer 10

D) refer to derm

Question 11

For a pt with molluscum contagiosum, which of the following findings would indicate referral to a dermatologist?
A) Erythematous halos developing around multiple molluscum
B) Lesions are present in groups or linear patterns in more than one location
C) pt has concomitant poorly controlled atopic dermatitis
D) Pt non-responsive to 4 weeks of tx with 5% permethrin cream
E) Pt non-responsive to 4 weeks tx c mupirocin ointment

Answer 11

C) pt has concomitant poorly controlled atopic dermatitis

Question 12

Patchy hyperpigmentation on the forehead is commonly seen in which condition.

Answer 12

Melasma

Question 13

Of the following, what is the most important aspect of prevention and tx of melasma?
A) ammonium lactate lotion
B) hydroquinone 4% cream
C) Ketoconazole 2% cream
D) Low potency topical steroid 
E) Sun Protection

Answer 13

E) sun protection

Melasma can spread and/or worsen c sun exposure.

Question 14

A 50 yof presents for yearly f/u on populopustular rosacea. She is doing well on minocycline 100mg qd and metronidazole cream 1-2 a day. She is asking for refills and asking about long term SE. When looking for early signs of minocycline-induced pigmentation, at which of the following sites is the pigment first noticed?
A) anterior lower legs
B) Dorsal forearms
C) scalp
D) sclera
E) Urine

Answer 14

D) sclera

Minocycline-induced pigmentation tends to be first noticed at mucosal sites

Question 15

A 55 yo AA female presents for eval of an intermittently itchy rash on the legs for several months. WHat is the most likely dx?
A) cellulitis 
B) Diabetic dermopathy
C) Drug Eruption
D) Stasis dermatitis 
E) Tinea corporis

Answer 15

D) stasis dermatitis

Question 16

In addition to compression stockings, leg elevation, and management of underlying CVD and fluid status, which of the following is the best tx option for stasis dermatitis?
A) Bacitracin ointment
B) Clotrimazole cream
C) intravenous vancomycin
D) Lidocaine gel
E) triamcinolone 0.1% ointment

Answer 16

E) Triamcinolone 0.1% ointment

Question 17

A 30 yo AA female c hx of DM2 and obesity presents for evaluation of new dark spots on the back of her neck. The spots are asymptomatic. Her mother has a similar change on her neck and so the pt is wondering if it could possibly be an inherited condition. What is the next best step in management?
A) discuss relationship with insulin resistence and importance of weight loss
B) obtain a comprehensive hx and physical exam to rule out a relationship to occult cancer
C) Prescribe ketoconazole 2% shampoo as a body wash 3 times per week
D) prescribe triamconolone cream

Answer 17

A) Discuss relationship with insulin resistance and importance of weight loss

Question 18

A 10 yof presents with a several day hx of scalp pruritis. Which of the following tx recommendations would you recommend?
A) 1% permethrin lotion applied to clean hair for 10 min, retreat in 4 weeks
B) 1% permethrin lotion applied to clean, dry hair for 10 min, retreat in 1 week
C) 1% permethrin lotion applied to wet hair for 10 min retreat in 1 week
D) 1% permethrin lotion applied to wet hair for 10 min retreat in 4 weeks

Answer 18

B) 1% permethrin lotion applied to clean, dry hair for 10 minutes. Retreatment in 1 week.

Permethrin is an insecticide that acts on nerve cells membranes to disrupt the sodium channel transport. Eggs hatch q 8-10 days.

Question 19

A 42 yom presents with a 2 week hx of total body pruritus. On exam there are numerous excoriated papules on the abdomen, buttocks, glans penis, and scrotum. Which of the following is most likely to confirm the dx?
A) Bacterial culture
B) KOH prep
C) Skin bx
D) skin scraping
E) Viral culture

Answer 19

D) Skin Scraping

Quick and easy way to identify scabies. Cover burrow or papule with glycerol, mineral oil, or immersion oil in order to prevent loss of mite and other forensic evidence

Question 20

A 36 yof presents with 1 week hx of erythematous macules with center puncta in a linear distribution over her back. She recently attended a wedding with her BF and stayed at a hotel for the weekend. The rest of her exam is unremarkable. What is the best course of management for this pt?
A) 1% permethrin cream applied overnight with reapplication in 7 days
B) 5% permethrin cream applied overnight with reapplication in 7 days
C) OTC antihistamines and topical steroids as needed and instruction for the pt to contact exterminator
D) Viral serology for HIV, HBV, HCV

Answer 20

C) OTC antihistamines and topical steroids as needed and instruction for the pt to contact exterminator

Bedbug rashes are typically self-limiting (erythematous papules with hemorrhagic central puncta or wheals in linear classic “breakfast, lunch, dinner” distribution).

Question 21

A 40 yom from Arkansas presnts to the ER with progressively enlarging erythematous lesion with centrally-located purpura on his right calf. He says he noticed a pinching sensation and a brown spider a few hours ao. He states that his Lt calf is beginning to itch and the lesion is becoming painful. He does not have other complaints. What is appropriate initial management?
A) Early surgical debridement
B) RIcE of the injured site, tetanus booster as needed, and close monitoring for systemic sx or necrosis
C) rotation of heat packs and ice to site
D) systemic steroids

Answer 21

B) RIcE of the injured site, tetanus booster as needed, and close monitoring for systemic sx or necrosis (no compression though)

Question 22

A 43 yom presents to ER in mid-june with painful red-purple papules and nodules on Rt forearm. Lesions began about 2 months prior. He tried OTC topical abx but no other treatments. He works as a landscaper and stores his equipment in old shed, so he is worried that these are spider bites. Temp 38.3c, BP 122/60, HR 90.  What feature of this scenerio is the only consistent with brown recluse spider bite?
A) Elevated
B) number of lesions
C) time of year
D) Red center

Answer 22

C) time of year

NOT Recluse Mnemonic
NOT Red, elevated, chronic

Question 23

A 26 yof in her first trimester with her second prego, presents with a 2month hx of diffuse pruritic rash. She has erythematous papules in the webs of her fingers, flexor surfaces of wrists, axillary folds, and both breasts. You conduct a skin scraping and make a dx of scabies. Which 2 of the following treatments could be used for this pt?
A) 1% lindane lotion applied topically form neck to feet, rinsed after 6 hrs, and repeated in 7 days
B) 5% permethrin cream applied topically overnight from neck to feet, rinsed off after 8-12 hours, and applied for a second time 1 week later
C) 5-10% precipitated sulfur applied topically from neck to feet overnight, rinsed the following morning and repeated over 3 consecutive days
D) 200mcg/kg oral ivermectin taken a total of 2 times with each dose taken 1 week apart

Answer 23

B) 5% permethrin cream applied topically overnight from neck to feet, rinsed off after 8-12 hours, and applied for a second time 1 week later

Question 24

50 yom with new dx of scabies, confirmed by a skin scraping which revealed the presence of mites and mite eggs. You prescribe 5% permethrin cream to be applied overnight to the entire body and instruct the patient to apply the permethrin twice (2 doses, separated by one week). How much cream should you dispense to the patient? You are...
A) 15 grams
B) 30 grams
C) 60 grams
D) 120 grams

Answer 24

C) 60 grams

It takes 30g to cover average adult body for one application. 2 doses would require 60g.

Question 25

Which of the following topical steroids is most appropriate to use on the patient in the photo.
A) Clobetasol
B) Desonide
C) Fluocinonide
D) Triamcinolone

Answer 25

B) Desonide

For a limited period and on thinner skin area such as the face, class VII-VI are preferred.

Question 26

An 8 yo presents with moderate atopic dermatitis requiring topical corticosteroids. You counsel the parent about potential side effects of this medication. Which of the following is a common side effect of prolonged topical corticosteroid use?
A) Cushing's syndrome
B) Glaucoma
C) Photosensitivity
D) Skin atrophy
E) skin infections

Answer 26

D) Skin atrophy

Skin atrophy is a known common side effect of chronic topical steroid application

Question 27

Which of the following is a class 1 (super potent) topical steroid
A) clobetasol propionate 0.05% cream
B) Hydrocortisone butyrate 0.1% cream
C) hydrocortisone 2.5% ointment
D) mometasone furoate 0.1% lotion
E) triamcinolone acetonide 0.1% ointment

Answer 27

A) clobetasol propionate 0.05% cream

This is a class 1 topical steroid

Question 28

63 yom navajo with a hx of psoriasis, hep c, and HTN. He reports the scaling pink patches are now spreading to involve his entire back, and much of his arm and legs.  Hx of a worsening red, scaly rash on his body for the past 2 years. On exam, he has ~15% body surface area involved with scaling pink plaques of psoriasis. you also notice that his fingers have begun to swell and his movement and use of his hands is very limited. Based on this, which of the following tx do you recommend?
A) Adalimaumab
B) Acitretin
C) Cyclosporine 
D) Methotrexate
C) Narrowband UVB

Answer 28

A) Adalimumab

About 25% of pts c psoriasis may develop psoriatic arthritis (PsA) within 5-12 yrs of dx. Untreated, about half of the pts developing PsA may have progressive joint disease. Anti-TNF alpha inhibitors ahve been shown to slow the progression of joint destruction. Pts should be pre-screened for exposure to hep B and TB prior to tx

Question 29

37 yo, bi-racial woman. Her father is Hispanic, her mother is norther european descent. She grew up on ranch in S. arizona where she still lives and works.  She has had a somewhat pruritic rash on her abd for the past several months. She has used some topical hydrocortisone and calamine lotion which helps control the itching. Which of the following dx tests and tx would be best in this pt. 
A) Bx and oral terbinafine
B) Bx and topical naftfine
C) KOH and oral terbinafine
D) KOH and topical betamethasone
E) KOH and topical naftifine

Answer 29

C) KOH and oral terbinafine

KOH best dx test
Oral Terbinafine particualry bc she has been using topical steroid which may have exacerbated her existing tinea

Question 30

33 yom from turkey. He buys and re-sells cars at auction with his uncle and helps his family manage a couple of rental properties. He is married, denies new sexual partners, but does not endorse a runny nose and common cold sx recently. He does not recall if his rash had a preceding isolated lesion.  You discuss with  him that this rash is most likely a consequence of what exposure?
A) HHV-6 or HHV-7
B) HHV-8
C) Staphylococcus Aureus
D) Syphilis 
E) Trichophyton Rubrum (tina)

Answer 30

A) HHV-6 or HHV-7

HHV-6 and HHV-7 have been implicated in development of pityriasis rosea as well as infantile roseola. In adult patients, Acyclovir dosed at 800mg 5 times per day may attenuate symptoms and expedite resolution of the eruption. Most pts do not recall an antecedent herald patch

Question 31

This patient has pruritic macerated thin plaques in the inguinal folds and has been using OTC creams for "jock itch" No scale is visualized. The most appropriate next step in dx....
A) Bacterial Swab
B) Shave bx
C) KOH
D) Punch bx
E) Direct immunofluorescence

Answer 31

C) KOH

Inverse psoriasis - many times scale is not visualized in body folds (tinea cruris and inverse psoriasis)

KOH helps differentiate

Question 32

A 20 yof has a new “spot” on her shoulder. She tried some moisturizer and triple abx without improvement. It is mildly itchy. What is the next step in management?
A) perform a KOH prep of scraping
B) perform a shave or punch bx
C) use cryotherapy for destruction of lesion
D) Use terbinafine cream cream twice daily
E) use topical triamcinolone twice daily

Answer 32

A) perform a KOH prep of scraping

KOH to ensure that the lesion is not fungal. If the KOH is negative/NL without signs of fungus, the clinician can more confidently prescribe a topical steroid

Question 33

A 35 yof has ovoid scaly plaque on her hand. Similar scaly ovoid plaques have also appeared recently on her trunk. she otherwise feels well.  She denies any antecedent cold or flu sx. she has been using OTC hydrocortisone without any improvement. You examine her determine she has a papulosquamous eruption but it is unlike a classic presentation of psoriasis or pityriasis rosea, it is not photodistributed. An important dx to consider is...
A) Lichen Planus
B) Secondary Syphilis 
C) Tinea Maanum
D) Mycosis Fungoides
E) Subacute cutaneous lupus

Answer 33

B) Secondary Syphilis

Pts with scaly rash that is “atypical” is important to consider secondary syphilis. SS can closely resembe and eruption of pityriasis rosea in many cases and should alway be considered in the DDX. when in doubt bx is appropriate.

Question 34

A 28 yof presents for hypopigmented skin lesions across her chest and trunk. She recently returned from a beach vacation one week ago. The lesions are mildly pruritic but not painful. Skin exam shows the following hypopigmented lesions: what dx text would best confirm your dx?
A) dermoscopy
B) KOH prep
C) Skin bx
D) Swab for bacterial culture
E) Wood's lamp exam

Answer 34

B) KOH prep

KOH prep of skin scraping will show large, blunt hyphae and thick-walled buddy yeast (spaghetti and meatballs appearance”

Question 35

KOH prep reveals hyphae. what is best next step in tx?
A) Biologics (adalimumab)
B) Oral antihistamine (diphenhydramine)
C) PUVA therapy (photochemotherapy)
D) Topical antibiotic (mupirocin)
E) topical antifungal (ketoconazole 2%)

Answer 35

E) topical antifungal (ketoconazole 2%)

Topical antifungal agents may be non-specific (selenium sulfide 2.5%) or specific (ketoconazole 2%, clotimazole 1%) and are considered the first line therapy for tinea versicolor.

Question 36

A 65 yom presents with slowly progressive, patchy depigmentation involving the face, neck, hands. He has a medical history of HTN, DM, and RA. WHich of the following best explains the underlying cause of this disease?
A) autoimmune destruction of melanocytes
B) Fungal infection
C) Normal age-related depigmentation
D) Overuse of high potency topical corticosteroids
E) Post-inflammatory hypopigmentation

Answer 36

A) autoimmune destruction of melanocytes

Well-demarcated depigmented macules consistent with vitiligo. The pathogenesis is autoimmune destruction of melanocytes and may be associated with other autoimmune disease.

Question 37

Which of the following is the most appropriate tx for this lesion (white splashes on a foot).
A) high potency topical steroid ointment
B) Low potency topical steroid ointment
C) methotrexate
D) No tx is necessary as most lesions will resolve spontaneously
E) Topical retinoid cream

Answer 37

A) high potency topical steroid ointment

High potency topical steroids (clobetasol 0.05%) are first line therapy for the tx of vitillgo. other options include topical tacrolimus, narrowband ultraviolet B, and surgery.

Question 38

A 40 yom presence for eval of facial rash that he first noticed 2 months ago. The rash is mostly centered on the forehead, around the nose including the nasolabial folds, and behind the ears. He also complains of dry, itchy, and flaky scalp.  Examination of the skin reveals greasy-appearing patches with fine scales. Which of the follwing is the most likely dx?
A) acne rosacea 
B) Contact dermatitis 
C) Psoriasis
D) Seborrheic dermatitis 
E) Systemic lupus erythematous (SLE)

Answer 38

D) Seborrheic Dermatitis

This pt c dandruff and greasy scaly rash involving the central face is most consistent with seborrheic dermatitis. Topical antifungal agents (ketoconazole, selenium sulfide) are effective tx options.

Question 39

A 6yof is brought to the derm office for evaluation of “white patches” located on her cheeks and upper arms. her mother is worried that this might be an allergic rxn since she has a hx of severe food allergies. which of the following is true about this condition?
A) Fluorescence under Wood’s lamp exam will be seen
B) It is contagious
C) it is likely due to a bacterial infection
D) KOH preparation will show budding yeast
E) Sun protection and use of moisturizers is indicated for pts

Answer 39

E) Sun protection and use of moisturizers is indicated for patients