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A. Nodular melanoma
B. Lentigo maligna melanoma
C. Acral lentiginous melanoma
D. Superficial spreading melanoma
E. Amelanocytic melanoma
Explanation:
Nodular melanoma is seen over the legs and trunk with rapid growth over weeks.
It presents as dark brown to black papule or dome shaped nodule, which
ulcerate and bleed with minor trauma.
Acral lentiginous melanoma is the least common sub type and it occurs in palms,
soles, or beneath nail plate in dark skinned individuals. The histopathology is
similar to superficial spreading.
Educational Objective:
Superficial spreading melanoma, the most common sub-type of malignant
melanoma, presents as a flat or slightly elevated brown lesion with variegate
pigmentation and the histopathology shows increased number of intraepithelial
atypical melanocytes.
33% of people answered this question correctly
A. Contact dermatitis
B. Scabies
C. Exfoliative dermatitis
D. Atopic dermatitis
E. Seborrheic dermatitis
Explanation:
Atopic dermatitis typically manifests in infants of less than 6 months. The most
common symptom is pruritus. These skin lesions usually start as erosions with
serous exudates, intensely itchy papules, or plaques over erythematic skin as in
this patient. In infants the lesions are usually symmetrical over cheeks, forehead,
scalp, trunk, and extensor surfaces. Etiology is unknown, but anything that can
dry the skin can exacerbate the condition. Prevention is the main stay of the
treatment: avoid triggers; take short baths in lukewarm water; use moisturizer to
skin. Acute attacks respond to low-moderate potency corticosteroid.
Educational Objective:
Atopic dermatitis presents with pruritus and skin lesions which usually start as
erosions with serous exudates, intensely itchy papules, or plaques over
erythematic skin. In infants the lesions are usually symmetrical over cheeks,
forehead, scalp, trunk, and extensor surfaces.
A. Dietary modifications
B. Cream-based cleansers
C. Topical retinoids
D. Topical erythromycin
E. Oral doxycycline
F. Oral isotretinoin
Explanation:
Educational Objective:
In patients who present with non-inflammatory comedones (mild acne), topical
retinoids are usually tried first. Oral antibiotics are usually used if moderate-to-
severe inflammation (papular and inflammatory acne) is present. Oral isotretinoin
is reserved for patients with nodulocystic and scarring acne.
A. Acne vulgaris.
B. Seborrheic dermatitis.
C. Carcinoid syndrome.
D. Systemic lupus erythematosus.
E. Rosacea.
Explanation:
The rosy hue with telangiectasia over the cheeks, nose, and chin is suggestive of
rosacea. Typically hot drinks, heat, emotion, and other causes of rapid body
temperature changes precipitate flushing. Episodes are usually intermittent but
can progressively lead to permanently flushed skin. Sometimes papules and
pustules may be present as in this patient. It most commonly occurs in patients
between who are 30-60 years of age, fair skinned, with light hair and eye color.
Pathogenesis is not known though hair follicle mites have been thought to play a
role. Medical treatment only aims at the inflammatory papules, pustules, and
erythema. Telangiectasias require laser surgery.
Choice (A): Acne vulgaris tends to occur in much younger individuals and
comedones are usually present in acne vulgaris and are not seen in rosacea.
Telangiectasia is not seen in acne.
Choice (B): Seborrheic dermatitis lacks pustules and papules; scales are usually
present around the nose, eyebrows, ears and scalp.
Choice (C): Carcinoid syndrome patients experience flushing and may develop
telangiectasias too, but the flushing in rosacea tends to last much longer,
whereas 20-30 sec flushing is characteristic of carcinoid. They also have
diarrhea and cyanosis.
Choice (D): Systemic lupus erythematosus is associated with facial rash similar
in distribution to rosacea but there are no papules and pustules; they will have
other systemic complaints such as fever, arthralgias, mailase, renal involvement
etc.
Educational Objective:
Rosy hue with telangiectasia over the cheeks, nose, and chin is suggestive of
rosacea that usually occurs in patients of 30-60 years of age.
Educational Objective:
Stevens Johnson syndrome is an immune complex mediated hypersensitivity
and is characterized by sudden onset of mucocutaneous lesions as well as
systemic signs of toxicity. Lesions are typically target shaped.
Choice (A). Most common presentation is papule or nodule with a central scab
or erosion. Occasionally the nodules have brown gray color or have stippled
pigment
Choice (B). Changing mole is the most common symptom. Seborrheic keratosis
may be difficult to distinguish from the lentigo maligna variant of malignant
melanoma but the surface of the lesion in seborrheic keratosis is less lustrous
and follicular orifices are plugged.
Choice (E). Also called skin tags. They are flesh colored or hyperpigmented.
Educational Objective:
Benign plaques of 3-20mm size, with greasy surface and stuck on appearance in
an elderly person is characteristic for seborrheic keratosis. Extremely high yeild
for USMLE.
Choice (C): Varicella zoster causes chicken pox. After a prodrome of fever,
malaise, and anorexia a characteristic rash appears on the trunk and spreads
peripherally. It rapidly develops into vesicles, which breaks to form scabs.
Educational Objective:
Measles, caused by paramyxovirus, is characterized by prodrome of cough,
coryza and conjunctivitis, koplik’s spots, and maculopapular rash initially
appearing on the face.
A. Sunlight
B. Arsenic
C. Aromatic hydrocarbons
D. Chronic osteomyelitis
E. Chronic scars
Explanation:
Educational Objective:
Squamous cell carcinoma is the second most common form of non-melanoma
skin cancer. The single most important risk factor for the development of
squamous cell carcinoma is exposure to sunlight.
Patients with herpetic whitlow often present with throbbing pain in the distal pulp
space, which is swollen, soft and may be tender. Lateral nailfold may also be
affected and non-purulent vesicles on volar aspects are clinically diagnostic.
Diagnosis is confirmed by the presence of a history of exposure and
multinucleated giant cells on Tzanck smear of vesicles. Systemic symptoms, like
fever and lymphadenopathy, may occur. This is a self-limiting illness; however,
oral acyclovir and topical bacitracin to prevent secondary infection may be used.
(Choice B) Commercial sex workers with genital herpes or oral herpes can
develop whitlow; however, this patient has no history of either.
Educational Objective:
Herpetic whitlow is the most common viral infection of the hand, caused by either
type 1 or 2 herpes simplex virus and is self-limiting. Health care workers who
come in direct contact with orotracheal secretion are at increased risk of
developing whitlow.
*Extremely high yield question for USMLE!!!
A. Insect bites
B. Urticaria
C. Scabies
D. Body lice
E. Bed bugs
Explanation:
Choice (A): Insect bites typically appear as pruritic papules, grouped in the bite
area. Vesicular and bullous bite reactions are common.
Choice (B): Urticaria occurs as evanescent wheals or hives with intense itching.
Most incidents are acute, self-limited and can result from immunologic or non-
immunologic basis.
Choice (D): Body lice infect the seams of clothing. Nits are found in the seams,
not on human hairs. Maculae caerulea, hemosiderin stained purpuric spots
where lice have fed, is diagnostic of body lice infestation.
Choice (E): Bed bugs can be seen anywhere but tends to occur often in old
furniture and hide in seams and folds of mattresses. The bites are painless but
pruritus and purpuric macules may appear. Bites are noted in groups of threes
over exposed areas.
Educational Objective:
Scabies is highly contagious disease and it presents with generalized itching and
pruritic papules over penis and scrotum in males and areolas and breasts in
females.
A. Necrotizing fasciitis.
B. Venous gangrene.
C. Warfarin induced necrosis.
D. Pyoderrma gangrenosum.
E. Cholesterol embolisation syndrome.
Explanation:
Educational Objective:
Warfarin induced skin necrosis presents with pain followed by bullae formation
and skin necrosis and it commonly involves breasts, buttocks, thighs, and
abdomen.
Choice (B) and (C) are for symptomatic patients not responding to other modes
of treatment.
Choice (D) is for large lesions; hot compresses may allow them to drain.
Educational Objective:
Recurrent chalazion requires histopathologic examination because of the risk of
underlying squamous cell carcinoma.
Choice (B): Psoriasis has the typical salmon colored patches with silvery scaling
and peeling over extensor surfaces of elbows, knees and scalp.
Choice (C): Erythema multiforme does not have a peripheral scaly border and is
mostly acral in distribution. It is often associated with a recent herpes simplex
infection.
Choice (D): Pityriasis rosea lesions are numerous. They are oval and scaly
plaques, and follow the cleavage lines of the trunk. The centers of the lesion
have a crinkled, cigarette paper like appearance. It often presents with an initial
lesion called the herald patch much larger than the later lesions.
Educational Objective:
Rash of tinea corporis is often pruritis and is in the form of ring-shaped scaly
patches with central clearing.
A. Erythema multiforme.
B. Bullous pemphigoid.
C. Dermatitis herpetiformis.
D. Kaposi’s sarcoma.
E. Acantholytic dermatosis.
Explanation:
The presence of pruritic papules and vesicles over extensor surfaces of elbows,
knees, posterior aspect of neck and scalp in a patient with gastrointestinal
symptoms, suggestive of malabsorption are typical of dermatitis herpetiformis.
The presence of anti-endomysial antibodies is also characteristic of this
condition. These patients also suffer from celiac sprue or gluten sensitive
enteropathy. There is an increased risk of gastro-intestinal lymphomas, which
can be reduced by following a gluten free diet.
Choice (D): Kaposi’s sarcoma is a rare malignant skin lesion seen in patients
with AIDS. It appears as red, purple or dark plaques or nodules on cutaneous
and mucosal surfaces. It is managed aggressively with intralesional
chemotherapy, radiation, and systemic chemotherapy.
Educational Objective:
Dermatitis herpetiformis is suggested by the presence of pruritic papules and
vesicles over extensor surfaces and by the presence of anti-endomysial
antibodies in the serum.
Choice (A): Herpes simplex virus infection usually presents as small grouped
vesicles on an erythematous base located over the oro-labial and genital areas.
Regional lymphadenopathy is present. Dermatomal distribution is quite atypical
for Herpes simplex.
Choice (C): Poison-ivy can cause contact dermatitis in a streak, after single
brushing with the plant and is pruritic, whereas shingles is painful.
Choice (D): Human papilloma virus causes warts, which appear as verrucous
papules anywhere on the skin or mucous membranes. These lesions are
asymptomatic.
Educational Objective:
Shingles caused by varicella zoster virus is characterized by vesicular eruption
that occurs in dermatomal distribution and is often preceded by pain.
The history, and the clinical features, are all classic presentations of allergic
contact dermatitis. The patient appears to have allergic reactions to poison oak
or ivy. The typical linear streaked vesicles are suggestive of this. Allergic contact
dermatitis presents with erythema, edema, pruritus, tiny vesicles and weepy and
crusted lesions. This is an example of type IV hypersensitivity, also called
delayed-type hypersensitivity or cell-mediated hypersensitivity. The allergen
causes dermal inflammation on direct contact with the skin. The reaction occurs
after 24-48 hours from the time of contact.
Choice (C). Immune complex mediated hypersensitivity is also called type III
hypersensitivity. Antibodies of IgG or IGM forms complexes with allergens and
activates complement cascade. Examples of this reaction are serum sickness
and Arthus reaction.
Educational Objective:
Allergic contact dermatitis presents with erythema, edema, pruritus, tiny vesicles
and weepy and crusted lesions 24-48 hours after the contact with the allergen
and is due to cell-mediated hypersensitivity.
A. Warts
B. Lichen planus
C. Molluscum contagiosum
D. Dermatitis herpetiformis
E. Miliaria
Explanation:
Educational Objective:
Molluscum contagiosum presents as single or multiple rounded, dome shaped
papules with central umbilication.
A. Bullous pemphigoid.
B. Bullous impetigo.
C. Pemphigus vulgaris.
D. Erythema multiforme.
E. Dermatitis herpetiformis.
Explanation:
Educational Objective:
Pemphigus vulgaris is a mucocutaneous blistering disease and is characterized
by flaccid bullae and intracellular IgG deposits in the epidermis.
The above image shows a tense blister on leg. The features of tense blisters in
flexural areas with no oral lesions with an antecedent history of months of
urticaria in an elderly patient of more than 60 year old are characteristic of
bullous pemphigoid. It usually presents with pruritus and is precipitated by ultra-
violet rays, NSAIDs, and antibiotics. The pathophysiology is IgG binding to skin
basement membrane, which activates compliment and releases the inflammatory
mediators. Immunofluorescence microscopy reveals diagnostic finding of
deposits of IgG and C3 at the dermal-epidermal junction.
Educational Objective:
IgG and C3 deposits at the dermal-epidermal junction are diagnostic of bullous
pemphigoid. Know the pathology of pemhigoid and pemphigus vulgaris
thoroughly. Very hot topic for USMLE.
A. Contact dermatitis.
B. Impetigo.
C. Herpes simplex infection.
D. Erythema multiforme.
E. Varicella zoster infection.
F. Erysipelas.
Explanation:
Choice (C): Herpes simplex infection presents as small grouped vesicles over
erythematous skin especially in oro-labial and genital areas. It usually follows
minor infections, trauma, as well as stress or sun exposure.
Choice (E): Varicella zoster infection initially starts as a pruritic rash, then later
develops into teardrop vesicles, which then ruptures to leave scabs. Usually
several stages of lesions (macules, papules, vesicles etc.) are present at the
same time.
Option (F): Erysipelas begins as a small erythematous patch that progresses to
a red, indurated, tense, and shiny plaque. It usually occurs over the cheek and
often there is a history of trauma or pharyngitis. Presence of a ‘raised sharply
demarcated’ advancing margins is a classic feature. Local signs of inflammation
are universal. Overlying skin streaking and regional lymphadenopathy indicates
lymphatic involvement. Over 80% of the cases are due to Streptococci; thus
penicillin is the drug of choice.
Educational Objective:
Impetigo presents as an erythematous macule, which then rapidly evolves into
vesicles and pustules that rupture-leaving honey colored crusted exudates.
A. Tinea versicolor
B. Seborrheic dermatitis
C. Pityriasis rosea
D. Dermatophytosis
E. Lichen simplex chronicus
Explanation:
The above said signs and symptoms of rigidity, resting tremors, and bradykinesia
are diagnostic features of Parkinsonism. These patients have an expressionless
(mask like) face, positive Myerson’ s sign (repetitive tapping over the bridge of
the nose produces a sustained blink response), soft voice, micrographia, and a
mild decline in intellectual function. The skin condition, which is a common
association with Parkinsonism, is seborrheic dermatitis and is characterized by
dry scales with underlying erythema in scalp, central face, presternal region,
interscapular areas, umbilicus and body folds. These areas may be oily or dry
with scales or yellow scurf. The condition is frequently seen in patients with
Parkinson’s disease, acutely ill patients who’ve been hospitalized, and HIV
positive individuals. Choices A, C, D, E are not associated with Parkinson’s
disease.
Choice (A) is tinea versicolor that either appears as pale macules that will not
tan or appears as hyper-pigmented macules.
Educational Objective:
Seborrheic dermatitis may be seen in association with Parkinsonism and is
characterized by dry scales with underlying erythema in scalp, central face,
presternal region, interscapular areas, umbilicus and body folds.
Educational Objective:
Staphylococcal scalded skin syndrome, a disease of children, presents with
sudden onset of diffuse erythema, skin tenderness, fever, flaccid bullae, facial
edema and perioral crusting.
Choice (D): Pellagra is the late stage of Niacin deficiency with a classic triad of
dermatitis, diarrhea, and dementia.
Choice (E): Though diabetes mellitus and hyperpigmentation of skin are features
of hemochromatosis, the skin findings are different from those of acanthosis. The
coloration is brownish or bronze and at times slate gray.
Educational Objective:
Acanthosis nigricans is characterized by symmetrical, hyperpigmented, velvety
plaques in axilla, groin, and neck; it is associated with diabetes mellitus in
younger patients and gastrointestinal malignancy in older individuals.
A. Varicella
B. Impetigo contagiosa
C. Contact dermatitis
D. Atopic dermatitis exacerbation
E. Eczema herpeticum
Explanation:
The clinical scenario described is characteristic for eczema herpeticum. Eczema
herpeticum is a form of a primary herpes simplex virus infection that is
associated with atopic dermatitis. It is usually superimposed on healing atopic
dermatitis lesions after the exposure to the herpes simplex virus. Numerous
umbilicated vesicles over the area of healing atopic dermatitis are typical. It is
frequently accompanied with fever and adenopathy. In infants, the infection may
be life threatening, and acyclovir treatment should be initiated as soon as
possible.
Atopic dermatitis, itself (Choice D), can cause eczematous skin lesions, but the
clinical scenario described is not typical for this disorder.
Educational Objective:
Eczema herpeticum is a form of a primary herpes simplex virus infection
associated with atopic dermatitis. Numerous vesicles over the area of atopic
dermatitis are typical. The infection can be life threatening in infants, and prompt
treatment should be initiated.
A. Exfoliative dermatitis.
B. Staphylococcal scalded skin syndrome.
C. Toxic epidermal necrolysis.
D. Erythema multiforme minor.
E. Stevens Johnson’s syndrome.
Explanation:
Choice (D): Erythema multiforme minor lesions can be macular, papular, bullous
or purpuric. “Target” lesions can be noted and they favor the extensor surface,
palms, soles and mucous membranes.
Educational Objective:
Toxic epidermal necrolysis is a severe mucocutaneous exfoliative disease and is
characterized by an erythematous morbilliform eruption that rapidly evolves into
exfoliation of skin.
A. C3 inhibitor deficiency.
B. Antibody mediated hypersensitivity.
C. C1 inhibitor deficiency.
D. Immune complex mediated hypersensitivity.
E. Cell mediated hypersensitivity.
Explanation:
Angioedema can be easily diagnosed from the rapid onset of symptoms which
include non-inflammatory edema of face, limbs, genitalia; laryngeal edema; and
edema of the bowels resulting in colicky pain. Laryngeal edema can result in life
threatening airway compromise. Both hereditary and acquired forms of C1
inhibitor deficiency exist with similar clinical manifestations. The deficiency leads
to elevated levels of edema-producing factors C2b and bradykinin. Patients with
hereditary angioedema usually present in late childhood. Usually, episodes of
angioedema follow infection, dental procedures, or trauma.
Choices (A), (B), (D), (E) are not involved in the pathological process of
angioedema.
Educational Objective:
Angioedema is characterized by rapid onset of non-inflammatory edema and is
due to deficiency of C1 esterase inhibitor which results in elevated levels of
edema-producing factors C2b and bradykinin.
39% of people answered this question correctly
A. Metoprolol
B. Isosorbide mononitrate
C. Clopidogrel
D. Aspirin
E. Enalapril
F. Simvastatin
Explanation:
ACE inhibitors are usually started on the first post-infarction day, in non-
hypotensive patients. ACE inhibitors are notorious for causing isolated
angioedema seen in emergency rooms. Patients present with symptoms of non-
inflammatory subcutaneous edema in non-dependent areas and laryngeal
edema which can be life threatening. Angioedema is believed to be due to pro-
inflammatory action of substance-P. Substance-P release is stimulated by
bradykinin. Bradykinin can be broken down in several ways, of which one is
cleavage by angiotensin converting enzyme. When this enzyme is blocked by
ACE inhibitors the levels of bradykinin increase, leading to angioedema. Patients
typically present within days to weeks, after starting therapy, as in this patient.
Risk of recurrence with continuation of the drug is much higher. The patient
should first be assessed for airway compromise and vasomotor instability. The
presence of which requires subcutaneous epinephrine administration. If airway
obstruction fails to respond to epinephrine, emergency tracheostomy is done.
Even though all the above-mentioned drugs can cause allergic reactions,
angioedema is not typical for any medication other than enalapril.
Educational Objective:
ACE inhibitor is an important cause of angioedema.
A. Keratoacanthoma
B. Blue nevi
C. Malignant melanoma
D. Melanocytic nevi
E. Lentigo simplex
Explanation:
Melanoma occurs as solitary lesion anywhere on the skin but frequently over the
back and other areas easy to miss on self-inspection. The A, B, C, D, E ‘s of
melanoma help in screening and early detection. These letters represent
Asymmetry, Border irregularities, Color variegations, Diameter greater than
6mm, and Enlargement. 7 points checklist is designed in England, which consists
of 3 major, and 4 minor features, designed to be used by lay people. The 3 major
features are change in size, change in color, change in shape. The 4 minor
features are inflammation, bleeding or crusting, sensory changes, and lesion of
7mm or more. A changing mole is the most common symptom. Symptoms such
as bleeding, itching, ulceration, and pain in a pigmented lesion are less common
but needs evaluation. The risk factors are sun sensitive skin,
immunosuppression, xeroderma pigmentosa, family history of melanoma,
dysplastic mole syndrome, and atypical nevi. The lesion shown in the above
picture is raised, black in color with irregular border and most likley is malignant
melanoma.
Keratoacanthoma is a low-grade malignancy that pathologically resembles
squamous cell carcinoma. It appears as a solitary, firm, round, skin colored or
reddish plaque that develops into a nodule with central keratin plug.
Blue nevi are smooth surfaced dome shaped papules that develop from a
macule to papule, tend to be less than 1cm, and are due to arrest in the
migration of neural crest melanocytes.
Melanocytic nevi are common lesions found in the integument of most individuals
and have a malignant potential.
Lentigo simplex is not induced by sun exposure and not associated with systemic
disease. Clinically the lesions are round or oval macules with even pigmentation.
Educational Objective:
Whenever a patient presents with a changing mole, always suspect malignant
melanoma.
A. Thrombophlebitis
B. Cellulitis
C. Necrotizing fasciitis
D. Erythema induratum
E. Toxic shock syndrome
Explanation:
Choice (E): Toxic shock syndrome is characterized by invasion of skin and soft
tissues, acute respiratory distress, and renal failure. Infants, elderly, and those
with underlying medical conditions are at risk for a very invasive disease.
Educational Objective:
In necrotizing fasciitis, there is purplish discoloration of skin with gangrenous
changes as well as systemic signs of toxicity. Differentaite it from cellulitis.
The above described multiple dome shaped lesions, with central umbilication, is
highly suggestive of molluscum contagiosum caused by Poxvirus. It’s usually
disseminated in immunodeficient conditions, such as AIDS, especially when the
CD4 count is less than 100/uL. A chronic conjunctivitis, as in this patient, may
occur if it is located in the lid margins. Molluscum resolves spontaneously in one
year. Treatment options are simple excision, cryotherapy or desiccation.
Choice (A) is also known as KSHV or Kaposi’s sarcoma associated herpes virus
(HHV8). These lesions are reddish purple, dark plaques or nodules on cutaneous
or mucosal surfaces.
Choice (D) may cause corneal ulceration and vesicles on skin but not dome
shaped central umbilicated skin leasions.
Choice (E) causes skin warts, which are verrucous papules anywhere on the
skin or mucous membranes.
Educational Objective:
Molluscum contagiosum, characterized by multiple dome shaped lesion, with
central umbilication, is caused by poxvirus and is an opportunistic skin infection
in HIV-infected patients.
A. Vitiligo
B. Seborrheic dermatitis
C. Tinea versicolor
D. Pityriasis rosea
E. Tinea corporis
Explanation:
This eruption often comes to the patient’s attention by the fact that the involved
areas never tan and the hypopigmentation is often considered as vitiligo. Pale,
velvety pink or whitish, macules that do not tan and do not appear scaly but scale
on scraping are the features suggestive of tinea versicolor. It is caused by
Malassezia furfur, a superficial fungal infection of the skin. Microscopic
examination of the skin scraping, after KOH preparation reveals large, blunt
hyphae and thick walled budding spores called as “spaghetti and meatballs”
appearance. Sometimes it presents as hyper-pigmented macules velvety tan or
brownish; this form is not so uncommon. Topical treatment with selenium sulfide
lotion and ketoconazole shampoo can be used. The change in pigmentation
requires months to get back to normal.
Choice (A) Vitiligo usually presents with peri-orificial lesions or lesions on the
tips of fingers. It is characterized by total depigmentation and not just lessened
pigmentation, as in tinea versicolor.
Choice (D) Pityriasis rosea lesions appear as oval, fawn colored plaques that
measures upto 2 cms in diameter and occur in a Christmas tree pattern. The
initial lesion is called the herald patch, which is followed by a generalized
eruption in 1-2wks.
Educational Objective:
Pale, velvety pink or whitish, hypopigmented macules that do not tan and do not
appear scaly are suggestive of tinea versicolor.
A. Post inflammatory.
B. Destruction of melanocytes.
C. Inherited absence of melanocytes.
D. Infection with mycobacterium leprae.
E. Superficial fungal infection.
Explanation:
Choice (D): Infection with mycobacterium leprae causes leprosy. Areas of hypo
pigmentation with anesthesia characterize it.
Choice (E): Superficial fungal infection can result in pale macules due to
lessening of pigmentation rather than total absence as in vitiligo. These macules
can be velvety pink or whitish; sometimes there are hyper-pigmented patches.
Educational Objective:
Vitiligo presents with depigmentation in the form of macules and it involves acral
and peri-orificial areas and is caused by autoimmune destruction of melanocytes.
Educational objective:
Toxic shock syndrome (TSS) is a potentially fatal condition caused by toxins
produced by specific strains of staphylococci, including epidermal exfoliating
toxin and is related to females using tampons and other intravaginal articles.
A. Topical retinoids
B. Topical antibiotic
C. Oral antibiotic
D. Benzyl peroxide
E. Oral isotretinoin
Explanation:
(Choice A) Topical retinoids are the initial drugs of choice for noninflammatory
comedones-type acne.
Educational Objective:
In patients with moderate-to-severe acne with predominantly a nodulocystic form
and who have developed scars, should be treated with oral isotretinoin.
Basal cell carcinoma is the most common malignant tumor of the eyelid. It
usually occurs in fair skinned individuals with history of prolonged sun exposure.
These are usually slow growing, pearly, and indurated. Lower eyelid margin is
the most common location followed by medial canthus, upper eyelid, and lateral
canthus. These tumors are locally invasive and rarely metastasize. There are two
modes of therapy for basal cell carcinoma in the eyelid, chemosurgery and
excision with frozen section control.
Choice (A). Squamous cell carcinoma is much less common and faster growing.
It presents as nodules or plaques with everted edges.
Choice (D). Squamous papilloma is a most common benign tumor of the eyelid,
caused by HPV. It presents as a frond-like or lobular projection.
Educational Objective:
Basal cell carcinoma is the most common malignant tumor of the eyelid and
presents as slow growing, pearly, and indurated lesion.
A. Sunbaths
B. Ibuprofen
C. Over the counter vitamins
D. Gabapentin
E. Lamotrigine
F. Carbamazepine
G. Lithium
H. Valproic acid
I. Fluoxetine
J. Phenytoin
Explanation:
The patient is most likely suffering from psoriasis. The image given above clearly
shows red, sharply defined plaques covered with whitish scales over knees and
is typical of psoriasis. The history suggests that patient is also suffering from
psoriatic arthritis and has been taking Ibuprofen, which may have been
prescribed to him by a physician earlier. Lithium may precipitate or exacerbate
psoriasis. Ibuprofen, on the other hand, increases lithium blood levels which will
further increase the chance of psoriasis exacerbation.
Choice (F). Lamotrigine does cause disease with skin manifestations - Steven
Johnson Syndrome, which is a potentially life-threatening condition. However,
the patient’s clinical picture is not compatible with this diagnosis.
Choice (I). Valproic acid is an important drug used in the treatment of bipolar
disorder and its main side effects include nausea, vomiting, diarrhea, weight
gain, alopecia, hepatotoxicity, and teratogenicity.
Educational Objective:
Lithium precipitates and exacerbates psoriasis which is characterized by sharply
defined erythematous areas with whitish, silvery and scaly plaques.
RNA toga virus, transmitted via respiratory droplets, causes rubella. The disease
progresses in the following order:
Educational Objective:
Rubella is characterized by maculopapular rash, posterior cervical and posterior
auricular lymphadenopathy and polyarthralgia.
The clinical scenario described is typical for the acute graft-versus-host disease
(GVHD). GVHD is common after bone marrow transplantation. Up to 50% of the
patients with bone marrow transplantation from matched siblings develop the
disease. The target organs for GVHD are the skin (a maculopapular rash
involving palms, soles, and face that may generalize is typical), intestine (blood-
positive diarrhea), and liver (abnormal liver function tests and jaundice). The
basic pathophysiologic mechanism involved in GVHD is the recognition of the
host major and minor HLA-antigens by the donor T-cells and cell-mediated
immune response. The donor B-lymphocytes (Choice B) has less importance in
the development of GVHD. Activation of the host T lymphocytes (Choice C)
mediates the rejection of the graft; and, as a result, the depression of the
myelopoiesis (Choice E). Failure to generate blood cells manifests as severe
neutropenia for several consecutive days and increased risk of infection. Graft
rejection may occur in up to 20% of high-risk patients.
Educational Objective:
GVHD is caused by the recognition of the host major and minor HLA-antigens by
the donor T-cells and cell-mediated immune response. The organs typically
affected include skin, intestine, and liver.
A. Chalazion
B. Hordeolum
C. Molluscum contagiosum
D. Xanthelasma
E. Stye
Explanation:
Choice (A): Chalazion is inflammatory lesion of the meibomian tear glands and
is usually seen in patients with rosacea and in those with blepharitis.
Educational Objective:
Xanthelasma, cholesterol filled yellow plaques that appear on the medial aspects
of eyelids bilaterally, may occur in the setting of primary biliary cirrhosis.
62% of people answered this question correctly
A. Shave biopsy
B. Excisional biopsy
C. Dermoscopy
D. Immunohistochemical staining for lineage
E. Incisional biopsy
Explanation:
Her clinical features are all suspicious of malignant melanoma. The first step
towards diagnosis will be skin biopsy for histopathological analysis. Excisional
biopsy with narrow margins is preferred as it helps to study the tumor depth
(Breslow’ s classification), ulceration, level of invasion (Clark level), presence of
mitosis, regression, lymphatic and vascular involvement, and host response.
Wider margins of more than 1cm may disrupt afferent cutaneous lymph flow and
the ability to identify sentinel nodes. So, wider margins are not usually
recommended.
Incisional biopsy is usually indicated when the suspicion for melanoma is low or if
the melanoma is larger where excision is not practical.
Shave biopsy should not be used because partial removal of the primary
melanoma does not provide accurate depth measurement, which is the most
important prognostic factor.
Educational Objective:
Excisional biopsy with narrow margins is the preferred study for the diagnosis of
malignant melanoma.
A. Allergic dermatitis
B. Erythromycin induced phototoxicity
C. Epidermolysis bullosa
D. Tetracycline induced photosensitivity
E. Benzyl peroxide induced phototoxicity
Explanation:
Choice (A): Allergic dermatitis occurs on contact with the suspected agent. It
presents as erythema, edema with pruritus, later followed by vesicles in the area
of contact.
Choice (B): Erythromycin can cause GI upset and cholestatic jaundice but
usually does not cause photosensitivity.
Choice (E): The common side effects of benzyl peroxide include irritation,
contact dermatitis, dryness, erythema, peeling, and stinging. Photosensitive
reactions are usually rare.
Educational Objective:
Tetracyclines are an important cause of photosensitivity that appears after sun
exposure with erythema, edema, and vesicles over sun-exposed areas.
51% of people answered this question correctly
A. Copper
B. Silver
C. Gold
D. Platinum
E. Nickel
Explanation:
Plant urushiol found in poison ivy, poison oak, poison sumac, ginkgo fruit and the
skin of mangos is the most common sensitizer in North America. However, other
common sensitizers include nickel found in jewelry, formaldehyde found in
clothing and nail polish, certain fragrances, preservatives, rubber and chemicals
in shoes. Allergic contact dermatitis generally presents with an intensely pruritic
rash at the area of contact. Treatment includes avoidance of further exposure to
the trigger. Other options include calamine lotion, topical antihistamines, topical
corticosteroids, and even oral steroids in severe cases.
Educational Objective:
Poison ivy and the nickel jewelry can cause allergic contact dermatitis, a type IV
hypersensitivity reaction.
The signs and symptoms are suggestive of dermatitis herpetiformis; celiac sprue
is often an associated condition in these patients. Dapsone is the drug of choice
in this condition. Improvement to dapsone is also considered as a diagnostic
feature of this condition. The skin lesions start to heal within hours after
beginning the drug.
Options (A), (B), (C), and (D) are not useful in the treatment of this condition.
Choice (B): Acyclovir is an antiviral drug used in the treatment of HSV and HZV
infections.
Educational Objective:
Dapsone is an effective treatment of dermatitis herpetiformis.
The history of normal skin at birth, with gradual progression to dry scaly skin, is
typical of ichthyosis. This condition can be hereditary or acquired. The skin is
usually dry and rough with horny plates over the extensor surfaces of limbs. The
above picture shows all these typical features of ichthyosis. The condition
worsens in the winter because of incresaed dryness and sometimes refered as
“lizard skin”. There is relative sparing of face and diaper area in children.
Choice (A): Usually occurs in infancy and pruritus is the only symptom and there
is involvement of cheeks, forehead, and limbs.
Choice (E): Usually presents as silvery scales over the extensor surfaces of
elbows, knees, scalp, and trunk.
Educational Objective:
Dry and rough skin with horny plates over the extensor surfaces of limbs is
hallmark of ichthyosis.
A. Oral itraconazole
B. Oral terbinafine
C. IV nafcillin
D. Oral dicloxacillin
E. IV aqueous crystalline penicillin G
Explanation:
Cellulitis is the inflammation of skin which may extend into the deeper tissues.
Beta-hemolytic streptococci mostly cause it but staphylococcus aureus is also a
common cause. Clinical features are systemic as well as local. Systemic signs of
toxicity are high-grade fever with rigors and chills, malaise, fatigue, and
confusion. Local findings are generalized swelling which is erythematous, warm,
tender, and less well demarcated than erysipelas. Tinea pedis may be a portal of
entry for lower leg cellulitis.
Antifungal agents like itraconazole and terbinafine may reduce the recurrence of
lower leg cellulitis when tinea pedis infection coexists but they would not
ameliorate the toxicity in acute cases.
When systemic signs of toxicity are present, IV nafcillin is the preferred treatment
for cellulitis.
Oral dicloxacillin can be used for the acute treatment of cellulitis when it is mild
with no systemic signs.
Educational Objective:
IV nafcillin is the treatment of choice for cellulitis with systemic signs.