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Cards In This Set
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 A 3-year-old female is brought to your office with a 3-hour history of skin lesions that are prominent, warm, papular, and serpiginous (see Figure). What is the most likely cause of these lesions?A) Heredity B) Physical abuse C) Infection D) A topical agent E) An oral medication |
 Acute urticaria occurs when an allergen activates mast cells in the skin, and is commonly caused by oral and parenteral drugs, food, and, less frequently, infections. Topical agents and physical abuse are unlikely to present in this manner, and hereditary angioedema is more a systemic illness than a skin disorder. |
 A 12-year-old male who lives on a farm presents with lesions on his toes (shown in Figure). Which one of the following items from the patient’s history is relevant to the diagnosis? A) Recent tooth extraction and gingival surgery B) A family history of systemic lupus erythematosus C) Recurrent fevers for the past 2 weeks D) Exposure to cold temperatures E) Vaccination of the sheep he is raising for a 4-H project |
 This patient has pernio, or chilblains, which is a localized inflammatory lesion of the skin, usually found in the extremities following exposure to nonfreezing cold temperatures. It is generally a benign condition, and is not associated with any systemic diseases. These lesions are red-purple plaques with deep swelling, and are accompanied by itching or burning. They are not associated with infections or connective tissue disease. |
 A 90-year-old female nursing-home patient has a 1.5×2.0-cm lesion on her face (shown in Figure). She states that the “spot” has been present for years and that it doesn’t bother her. Closer examination reveals a flat maculopapular lesion with varying colors and an irregular border. Which one of the following is the most likely diagnosis? A) Actinic keratosis B) Metastatic breast carcinoma C) Seborrheic keratosis D) Lentigo maligna melanoma E) Basal cell carcinoma |
 This patient has a malignant melanoma, often called lentigo maligna melanoma. These lesions typically appear during the seventh or eighth decade of life, and are most often located on the face. This patient's age, health status, and wishes must be considered in any treatment plans. The other skin lesions listed can be seen in this age group, but they are easily distinguished from this malignant lesion. |
 A 27-year-old female office worker presents with the inflamed lesion shown in Figure 2. She is in good health otherwise and takes only iron supplements and oral contraceptives. She has not had any recent illnesses, but she states that she may have had a similar lesion as a teenager. Which one of the following is the most likely diagnosis? A) Orf virus infection B) Herpes simplex C) Herpes zoster nasociliary infection D) Staphylococcal infection E) Contact dermatitis from cosmetics |
 Although the consequences of nasal (or facial) staphylococcal lesions demand that they receive careful evaluation and culture, most lesions in this area of the face are related to HSV-1 infections. The painful grouped vesicles on an erythematous base indicate a viral infection, likely HSV-1. Herpes zoster would be unlikely because the lesion involves only the distal nose area without other lesions, and symptoms would be unlikely. The appearance of staphylococcal infection would be quite different, contact dermatitis would be more widespread, and orf virus is a sheep-related virus usually seen on the hands. |
 A 24-year-old generally healthy female presents with a rash that developed quickly over her extremities and trunk earlier in the day (see Figure). The lesions started as round erythematous macules, but over the course of a few hours have evolved. Some of the areas that were affected initially have already cleared. The affected skin is mildly pruritic, but she has no other symptoms or physical findings. Her mucous membranes are normal. Which one of the following would be the most appropriate first-line treatment for this patient’s condition? A) An oral antibiotic B) An oral antihistamine C) Oral corticosteroids D) Topical corticosteroids E) A topical antifungal agent |
 The lesions shown are typical of wheals associated with urticaria. Acute urticaria has a variety of causes, but often is idiopathic. The lesions are sharply defined and can range from <1 cm to >8 cm. The color is erythematous, or white with an erythematous rim, and lesions can be round, oval, acriform, annular (as with this patient), or serpiginous. The lesions are often transient, fluctuating from hour to hour, and sometimes are associated with angioedema (edematous areas of dermis and subcutaneous tissue).Appropriate treatment for mildly symptomatic cases begins with antihistamines. Oral or parenteralcorticosteroids would be appropriate if angioedema were significant (i.e., swelling of the face, mouth, orlarynx). |
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An otherwise healthy 10-year-old female presents with a
papulovesicular eruption on one leg. It extends from the lateral buttock, down the posterolateral thigh, to
the lateral calf. It is mildly painful. The patient’s immunizations are up to date, including
varicella and MMR. Her family has a pet cat at home, and another child at her school was sent home
with a rash earlier in the week.
Which one of the following is the most likely diagnosis?
A) Contact dermatitis
B) Herpes zoster dermatitis
C) Tinea corporis
D) Scabies
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ANSWER: BHerpes zoster can occur from either a wild strain or a vaccine strain of varicella-zoster virus in vaccinatedchildren, but the incidence is low. All cases are mild and uncomplicated.
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A 4-year-old male presents with a 3-day history of sores on his right
leg. The sores began as small red papules but have progressed in size and now are crusting and
weeping. Otherwise he is in good health and is up to date with immunizations.
On examination he has three lesions on the right anterior lower leg
that are 0.5–1.5 cm in
diameter, with red bases and honey-colored crusts. There is no
regional lymphangitis or
lymphadenitis.
Which one of the following is the preferred first-line therapy?
A) Oral erythromycin (Erythrocin)
B) Oral penicillin V
C) Topical hexachlorophene (pHisoHex)
D) Topical mupirocin
(Bactroban)
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ANSWER: DThe lesions described are nonbullous impetigo, due to either Staphylococcus aureus or Streptococcus pyogenes. Topical antibiotics, such as mupirocin, but not compounds containing neomycin, are the preferred first-line therapy for impetigo involving a limited area. Oral antibiotics are widely used, based on expert opinion and traditional practice, but are usually reserved for patients with more extensive impetigo or with systemic symptoms or signs. Penicillin V and hexachlorophene have both been shownto be no more effective than placebo. Topical antibiotics have been shown to be as effective aserythromycin, which has a common adverse effect of nausea.
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A 69-year-old female sees you for an annual examination. She asks you
to look at her toes, and you note a fungal infection in five toenails. She says
the condition is painful and limits her ability to complete her morning walks. She asks for treatment that
will allow her to resume her daily walks as soon as possible. Her only other medical problem is
allergic rhinitis which is well controlled.
Which one of the following would be the most appropriate treatment for
this patient?
A) Oral griseofulvin ultramicrosize (Gris-PEG) daily for 12 weeks
B) Oral terbinafine (Lamisil) daily for 12 weeks
C) Topical terbinafine (Lamisil AT) daily for 12 weeks
D) Topical ciclopirox (Penlac Nail Lacquer) daily for 12 weeks
E) Toenail removal
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ANSWER: BContinuous therapy with oral terbinafine for 12 weeks has the highest cure rate and best long-termresolution rate of the therapies listed. Other agents and pulsed dosing regimens have lower cure rates.Topical creams are not appropriate for onychomycosis because the infection resides in the cell of the toenail. Antifungal nail lacquers have a lower cure rate than systemic therapy and should be used only when oral agents would not be safe. Toenail removal is reserved for patients with an isolated infected nail or in cases involving a dermatophytoma.
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Which one of the following is the preferred treatment for scabies?
A) Topical benzoyl peroxide, 10%
B) Topical crotamiton (Eurax), 10%
C) Topical permethrin (Elimite), 5%
D) Topical lindane, 1%
E) Oral ivermectin (Stromectol), 200 mg
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ANSWER: CPermethrin and lindane are the two most studied topical treatments for scabies. A Cochrane meta-analysis of four randomized trials comparing these agents indicates that a single overnight application of permethrin is more effective than lindane (odds ratio for clinical failure, 0.66; 95% confidence interval, 0.46–0.95). The potential neurotoxicity of lindane, especially with repeated applications, has limited its use.Other topical treatments include benzoyl benzoate and crotamiton. Crotamiton has significantly lessefficacy than permethrin at 4 weeks (61% versus 89%). Several controlled trials have assessed the efficacy of a single dose of ivermectin (200 g/kg) for the treatment of scabies. In one placebo-controlled trial, 37 of 50 patients treated with ivermectin (74%) were cured.
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A 25-year-old female presents with a maculopapular rash that has
progressed to multiple areas and exhibits target lesions. A cold sore appeared
on her upper lip 2 days before the rash appeared. She is not systemically ill and is on no medications.
Which one of the following is true concerning this problem?
A) Herpes simplex virus is a likely cause
B) A skin biopsy will confirm the diagnosis
C) The lesions usually disappear within 24 hours
D) The palms of the hands and soles of the feet are not involved
E) Scarring from the lesions is often seen after resolution
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ANSWER: AHerpes simplex virus is the most common etiologic agent of erythema multiforme. Other infections,particularly Mycoplasma pneumoniae infections and fungal infections, may also be associated with this hypersensitivity reaction. Other causes include medications and vaccines. Skin biopsy findings are not specific for erythema multiforme. As opposed to the lesions of urticaria, the lesions of erythemamultiforme usually are present and fixed for at least 1 week and may evolve into target lesions. The palms of the hands and soles of the feet may be involved. The lesions of erythema multiforme usually resolve spontaneously over 3–5 weeks without sequelae.
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A
newborn male has a skin eruption on his forehead, nose, and cheeks. The lesions
are mostly closed
comedones with a few open comedones, papules, and pustules. No significant
erythema is
seen.
Which
one of the following is the most likely diagnosis?
A)
Erythema toxicum neonatorum
B)
Localized superficial Candida infection
C)
Herpes simplex
D)
Milia
E) Acne neonatorum
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ANSWER: EAcne neonatorum occurs in up to 20% of newborns. It typically consists of closed comedones on the forehead, nose, and cheeks, and is thought to result from stimulation of sebaceous glands by maternal and infant androgens. Parents should be counseled that lesions usually resolve spontaneously within 4 months without scarring. Findings in erythema toxicum neonatorum include papules, pustules, and erythema.Candida and herpes lesions usually present with vesiculopustular lesions in the neonatal period. Milia consists of 1- to 2-mm pearly keratin plugs without erythema, and may occur on the trunk and limbs.
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A
72-year-old white male in otherwise good health complains of generalized
pruritus that
worsens
in the winter. The itching is most intense after he bathes. He recently noticed
a rash on
his abdomen and legs as well. On examination you note poorly defined red, scaly
plaques with
fine fissures on the abdomen. No eruption is present at other pruritic sites.
Which
one of the following is the most likely cause of this problem?
A)
Stasis dermatitis
B)
Lichen simplex chronicus
C)
Xerosis
D)
Rosacea
E) Candidiasis
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ANSWER: CXerosis is a pathologic dryness of the skin that is especially prominent in the elderly. It is probably caused by minor abnormalities in maturation of the epidermis that lead to decreased hydration of the superficial portion of the stratum corneum. Xerosis often intensifies in winter, because of the lower humidity and cold temperatures.Stasis dermatitis, due to chronic venous insufficiency, appears as a reddish-brown discoloration of the lower leg. Lichen simplex chronicus, the end result of habitual scratching or rubbing, usually presents as isolated hyperpigmented, edematous lesions, which become scaly and thickened in the center. Rosacea is most often seen on the face as an erythematous, acneiform eruption, which flushes easily and is surrounded by telangiectasia. Candidiasis is an opportunistic infection favoring areas that are warm, moist, and macerated, such as the perianal and inguinal folds, inframammary folds, axillae, interdigital areas, and corners of the mouth.
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A
65-year-old white male comes to your office with a 0.5-cm nodule that has
developed on his right
forearm over the past 4 weeks. The lesion is dome shaped and has a central
plug. You schedule
a biopsy but he does not return to your office for 1 year. At that time the
lesion appears
to have healed spontaneously.
The
most likely diagnosis is
A)
benign lentigo
B)
lentigo maligna
C)
basal cell carcinoma
D)
squamous cell carcinoma
E) keratoacanthoma
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ANSWER: EKeratoacanthoma grows rapidly and may heal within 6 months to a year. Squamous cell carcinoma may appear grossly and histologically similar to keratoacanthoma but does not heal spontaneously. The other lesions do not resemble keratoacanthoma.
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Which
one of the following is true concerning scabies?
A)
It is typically spread by contact with infected bedding
B)
The classic diagnostic sign is the mite burrow
C)
The distribution of lesions is the same in adults and children
D)
The absence of a history of itching among family members excludes the diagnosis
E) Recurrence of symptoms
after treatment indicates another diagnosis
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ANSWER: BThe mite burrow confirms the diagnosis of scabies, but can be missed if the skin is excoriated. Scabiesspreads by direct skin contact, and is seldom spread by transfer from bedding. Children frequently have scabies lesions on the face or neck, while this rarely happens in adults. Scabies infections usually cause itching among several family members, but they may not admit it. Scabies can recur after treatment, usually because of incorrect or insufficient application of the treatment.
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You
are counseling a 24-year-old female about treatment for her acne. Despite
conventional treatment
with topical agents and systemic antibiotics, she continues to experience
flares of inflammatory
acne and believes that her acne is severely limiting her social relationships
and her ability
to make a favorable impression during job interviews. She asks you about using isotretinoin
(Accutane).
Which
one of the following would be accurate advice?
A)
Isotretinoin is most useful in treating comedonal acne
B)
Concomitant therapy with topical keratolytic agents is usually well tolerated
C)
Teratogenicity is the most devastating adverse effect
D)
Elevations in liver enzymes often necessitate discontinuing treatment
E) Osteoporosis and osteophyte formation are common
late complications of treatment
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ANSWER: CIsotretinoin is FDA-labeled only for treatment of severe, recalcitrant, nodular acne. Because ofdocumented clinical experience with the drug, however, in addition to additional published evidence, there is international consensus that isotretinoin may be appropriate in other situations. These include an inadequate response to appropriate conventional therapy for less severe acne, scarring inflammatory acne, and acne that causes severe psychologic distress. When isotretinoin is used, adjuvant therapy with topical keratolytics and drying agents should be discontinued because concomitant use may lead to excessive dryness.The most devastating adverse effect of isotretinoin is teratogenicity. Major malformations may occur in25%–30% of fetuses exposed to the drug. Liver enzyme levels should be monitored periodically, although elevations beyond the reference range are rare. If elevations do occur, it may be necessary to reduce the dosage, or in rare instances to discontinue therapy. Long-term retinoid therapy may be complicated by skeletal changes, including osteoporosis and osteophyte formation. No studies have reported notable bony changes associated with short-term therapy of the duration typical for treatment of acne (usually 5 months).
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