1. A middle-aged, diabetic woman presents with well-demarcated, yellow-brown, atrophic, telangiectatic plaques with a raised, violaceous border on her shins. What is the most likely diagnosis?
a. Lipodermatosclerosis
b. Pyoderma gangrenosum
c. Necrobiosis lipoidica
d. Erythema nodosum
2. Which of the following types of fruit is most likely to cause phytophotodermatitis?
a. Pineapple
b. Grapefruit
c. Kiwi
d. Peach
3. Hypothyroidism can cause several changes to the skin and skin appendages including all of the following, except:
a. Hyperpigmentation
b. Easy bruising
c. Thin, brittle nails
d. Dry, coarse skin
4. In a patient with neurofibromatosis, which sign refers to the presence of bilateral axillary freckling?
a. Auspitz sign
b. Crowe sign
c. Russell sign
d. Gorlin sign
5. Which of the following keratinization disorders is inherited in an autosomal recessive fashion?
a. Darier disease
b. Ichthyosis vulgaris
c. Hailey-Hailey disease
d. Lamellar ichthyosis
6. What is the estimated 5-year survival rate for melanoma that has spread beyond the original area of involvement to the nearby lymph nodes (but not to distant nodes or organs)?
a. 25%
b. 41%
c. 63%
d. 87%
7. What is another name for leprosy?
a. von Recklinghausen's disease
b. Mucha-Habermann disease
c. Schamberg's disease
d. Hansen's disease
8. Which of the following is not an expected extracutaneous finding in patients with Henoch-Schonlein purpura?
a. Abdominal pain
b. Hematuria
c. Shortness of breath
d. Arthralgias
9. When the term "papillomatous" is used to describe a skin lesion, it means that the lesion is
a. characterized by multiple fine surface projections.
b. erupting like a mushroom or fungus.
c. characterized by fine fissures and cracks in the skin.
d. sieve like and contains many perforations.
10. Which systemic medication can cause whip-like, linear, erythematous wheals that are similar in appearance to shiitake dermatitis?
a. Pimecrolimus
b. Bleomycin
c. Dapsone
d. Cyclosporine
ANSWERS
1. c. Necrobiosis lipoidica. Necrobiosis lipoidica begins with brownish-red papules and nodules that slowly evolve and flatten to form well-demarcated, yellow-brown, atrophic plaques in which telangiectasias are often visible. These lesions have a raised, violaceous, irregular border and are described as appearing glazed or glistening. The pretibial region is most commonly affected. Other sites of predilection include the ankles, calves, thighs, and feet. Involvement of the trunk and upper extremities is rare but possible. Most lesions are asymptomatic. About 60% of affected individuals also have diabetes, and women are three times more commonly affected than men. The course of necrobiosis lipoidica is often indolent and unresponsive to treatment. Erythema nodosum is the most common panniculitis and the prototypical septal panniculitis. It presents with an eruption of bilateral, symmetrical, deep, tender nodules and plaques 1-10 cm in diameter, usually on the pretibial area and lateral shins. It is an acute condition that can result from various medications, infections, or other precipitating factors. Lipodermatosclerosis (also called sclerosing panniculitis) is characterized by indurated, woody plaques with erythema, edema, telangiectasia, and hyperpigmentation involving the lower legs with a stocking distribution. It is a chronic disorder usually associated with chronic venous insufficiency. Pyoderma gangrenosum is a rare inflammatory disease of unknown etiology that is characterized by neutrophilic infiltration of the dermis and tissue destruction. The clinical appearance is highly variable and can generally be categorized as being either ulcerative, bullous, pustular, or vegetative.
James, W. D., Berger, T. G., & Elston, D. M. (2011). Andrews' diseases of the skin: Clinical dermatology (11th ed.). Philadelphia, PA: Saunders/Elsevier.
Wolff, K., Goldsmith, L. A., Katz, S. I., Gilchrest, B. A., Paller, A. S., & Leffell, D. J. (2008). Fitzpatrick's dermatology in general medicine (7th ed.). New York, NY: McGraw-Hill Medical.
2. b. Grapefruit. Phytophotodermatitis is a reaction caused by the combination of a topical photosensitizing agent and subsequent exposure to the appropriate wavelength of ultraviolet radiation. This combination results in an inflammatory reaction consisting of erythema, with or without blistering, and delayed hyperpigmentation. Foods that belong to the plant families most likely to cause phytophotodermatitis include celery, fennel, parsnip, parsley, wild rhubarb, grapefruit, some limes, some oranges, and some lemons.
Bolognia, J. L., Jorizzo, J. L., & Schaffer, J. V. (2012). Dermatology (3rd ed.). St. Louis, MO: Elsevier/Mosby.
3. a. Hyperpigmentation. Hyperpigmentation is not associated with hypothyroidism, but localized and generalized hyperpigmentation can occur in individuals with hyperthyroidism. Individuals with hypothyroidism often have hair that grows slowly and tends to be dull, coarse, and brittle. In addition, affected individuals may experience alopecia on the lateral third of their eyebrows. Nail changes associated with hypothyroidism include thin, brittle, striated nails; slow growth rate; and rarely, onycholysis. Other cutaneous manifestations of hypothyroidism include dry, rough, coarse skin; cold, pale skin; myxedema; yellow discoloration (carotenemia); and easy bruising. In contrast, cutaneous manifestations of hyperthyroidism include velvety, smooth skin; warm, moist skin because of increased sweating; hyperpigmentation; pruritis; onycholysis; and mild, diffuse alopecia.
Bolognia, J. L., Jorizzo, J. L., & Schaffer, J. V. (2012). Dermatology (3rd ed.). St. Louis, MO: Elsevier/Mosby.
4. b. Crowe sign. Crowe sign refers to the bilateral axillary freckling that is seen in neurofibromatosis. Auspitz sign refers to the appearance of pinpoint areas of bleeding when scale is removed from psoriatic plaques. Russell sign refers to erosions and sometimes thickening of the metacarpophalangeal and interphalangeal joints on the dorsum of the hand as seen in patients with anorexia bulimia nervosa. Gorlin sign refers to the ability to touch the tip of the nose with the tip of the tongue and is associated with Ehlers-Danlos syndrome.
Ko, J., Hawryluk, E., & Taylor, C. R. (2011). Part II: High-yield dermatologic signs. Journal of Drugs in Dermatology, 10(2), 197-198.
5. d. Lamellar ichthyosis. Lamellar ichthyosis is inherited through an autosomal recessive pathway. Affected neonates are encased in a collodion membrane with underlying erythroderma that is gradually replaced by large scales. Lamellar ichthyosis persists unremittingly throughout life and is characterized by large, dark-brown, and plate-like scales that form a mosaic or bark-like pattern with minimal-to-no erythroderma. Darier's disease is an autosomal dominantly inherited condition that begins with small, firm papules that are almost the color of normal skin. Over time, these lesions darken, develop a greasy gray-brown-colored crust, and tend to coalesce into patches. Commonly affected areas include the neck, shoulders, face, extremities, front of the chest, and midline of the back. Ichthyosis vulgaris is inherited in an autosomal semidominant manner with many cases of incomplete penetrance. Affected individuals usually develop dry skin and mild-to-moderate scaling in early childhood that is most prominent on the extensor surfaces of the extremities. Other cutaneous findings often include accentuated skin markings and hyperkeratosis of the palms, keratosis pilaris, and atopic changes. Hailey-Hailey disease (also called familial benign chronic pemphigus) is an autosomal dominant dermatosis characterized by a persistently recurrent bullous and vesicular dermatitis on the sides of the neck, axillae, and intertriginous areas. The lesions usually develop during the second or third decade but may be delayed until the fourth or fifth decade. The initial lesion is a flaccid vesicle on erythematous or normal skin that ruptures easily and is therefore often overlooked. The blisters give rise to macerated or crusted erosions, which tend to spread peripherally, producing a circinate or figurate border with crusts and small vesicles.
Bolognia, J. L., Jorizzo, J. L., & Schaffer, J. V. (2012). Dermatology (3rd ed.). St. Louis, MO: Elsevier/Mosby.
James, W. D., Berger, T. G., & Elston, D. M. (2011). Andrews' diseases of the skin: Clinical dermatology (11th ed.). Philadelphia, PA: Saunders/Elsevier.
6. c. 63%. The overall 5- and 10-year relative survival rates for people with melanoma are 91% and 89%, respectively. For localized melanoma, which accounts for about 84% of cases, the 5-year survival rate is 98%. Survival declines to 63% for melanoma that has spread beyond the original area of the skin to the nearby lymph nodes. The survival rate for cases of melanoma that have spread to distant lymph nodes and/or organs is estimated to be about 16%.
American Cancer Society. (2015). Cancer fact & figures 2015. Retrieved from http://www.cancer.org/acs/groups/content/@editorial/documents/document/acspc-044
7. d. Hansen's disease. Leprosy is also known as Hansen's disease. Mucha-Habermann disease is another name for pityriasis lichenoides et varioliformis acuta. Neurofibromatosis is also known as von Recklinghausen's disease. Schamberg's disease is the most common variant of pigmentary purpuric eruption.
James, W. D., Berger, T. G., & Elston, D. M. (2011). Andrews' diseases of the skin: Clinical dermatology (11th ed.). Philadelphia, PA: Saunders/Elsevier.
8. c. Shortness of breath. Henoch-Schonlein purpura (HSP) is a small-vessel vasculitis that is characterized by mottled purpura that appears on the extensor surfaces of the extremities and become hemorrhagic within a day. The initial lesions start to fade in about 5 days, but new crops may appear over the next few weeks. HSP occurs primarily in 4- to 8-year-old male children, although adults can be affected. Possible triggers for HSP include a viral or streptococcal pharyngitis, bacterial infections, foods, drugs, and lymphoma. In about 40% of cases, the cutaneous manifestations are preceded by mild fever, joint symptoms, and abdominal pain for up to 2 weeks. Arthralgias occur in 74%-84% of cases and often progress to periarticular swelling around the knees and ankles. Abdominal pain occurs in 61%-76% of affected individuals, and complications such as gastrointestinal bleeding, paralytic ileus, vomiting, and distension may occur. Renal disease occurs in 44%-47% of cases, and about 25% of patients have microscopic or gross hematuria. Progressive glomerular disease and renal failure may develop in a small percentage of patients, although the prognosis for children with gross hematuria is generally very good.
James, W. D., Berger, T. G., & Elston, D. M. (2011). Andrews' diseases of the skin: Clinical dermatology (11th ed.). Philadelphia, PA: Saunders/Elsevier.
9. a. Characterized by multiple fine surface projections. Papillomatous lesions are papules or plaques that are characterized by multiple fine surface projections. Large malignant tumors that appear to be erupting like a mushroom or fungus are described as fungating. Dermatoses with fine fissures and cracks in the skin are referred to as having a crackled appearance. Lesions that appear sieve like and contain many perforations are described as cribiform.
Linton, C. P. (2011). Describing skin lesions. Journal of the Dermatology Nurses' Association, 3(3), 166-167.
10. b. Bleomycin. Bleomycin can induce a characteristic pattern of whip-like, linear, erythematous wheals within hours or days of infusion. The lesions are pruritic and continue to appear for days to weeks. A similar eruption develops 1-2 days after the ingestion of raw or cooked shiitake mushrooms. The underlying mechanism for both eruptions is unclear. In bleomycin-induced lesions, linear hyperpigmentation follows the initial erythema, whereas shiitake dermatitis generally resolves without pigmentary changes.
Chu, E. Y., Anand, D., Dawn, A., Elenitsas, R., & Adler, D. J. (2013). Shiitake dermatitis: A report of 3 cases and a review of the literature. Cutis, 91, 287-290.
James, W. D., Berger, T. G., & Elston, D. M. (2011). Andrews' diseases of the skin: Clinical dermatology (11th ed.). Philadelphia, PA: Saunders/Elsevier