Dermatology Question #8

Dermatology Question #8

CY MD

A 39-year-old male with a prior history of myocardial infarction complains of yellow bumps on his elbows and buttocks. Yellow-colored cutaneous plaques are noted in those areas. The lesions occur in crops and have a surrounding reddish halo. Which of the following is the best next step in evaluation of this patient?

a/. Biopsy of skin lesions
b/. Lipid profile
c/. Uric acid level
d/. Chest x-ray

e/. Liver enzymes

Answer

The answer is b. 

The description and location of these lesions are suggestive of eruptive xanthomas. Eruptive
xanthomas occur primarily on buttocks or extensor surfaces and are associated with elevated triglycerides. Tophaceous gout can result in deposits of monosodium urate, usually in the skin around joints of the hands and feet, that may also be yellow (usually yellowish-white) in color. The cutaneous lesions of sarcoidosis are reddish-brown waxy papules, usually on the face. Obstructive liver disease can occasionally cause palmar xanthomas, which are seen as yellow plaques along the palmar creases. Xanthomatous skin lesions can be important cutaneous clues for underlying lipid disorders. Xanthelasma, yellowish plaques on the inner aspect of the upper eyelids, are nonspecific but may be associated with hyperlipidemia 50% of the time. Tendon xanthomas are important clues for the presence of familial hypercholesterolemia. Tuberous xanthomas, which often present as plaques or even polypoid nodules over pressure points, usually mean significant hypercholesterolemia. Eruptive xanthomas, again, are associated with triglyceride levels above 1000 mg/dL. Treatment of the hypertriglyceridemia usually results in resolution of lesions. Biopsy of a xanthoma would show lipid-containing macrophages, but is usually not necessary for diagnosis.

Dermatology Question #7

Dermatology Question #7

CY MD

A 53-year-old female presents to the clinic with an erythematous lesion on the dorsum of her right hand. The lesion has been present for the past 7 months and has not responded to corticosteroid treatment. She is concerned because the lesion occasionally bleeds and has grown in size during the past few months. On physical examination you notice an 11-mm erythematous plaque with a small central ulceration. The skin is also indurated with mild crusting on the surface. Which of the following is true about this process?

a/. It is a malignant neoplasm of the keratinocytes with the potential to metastasize.
b/. It is an allergic reaction resulting from elevation of serum IgE.
c/. It is a chronic inflammatory condition, which can be complicated by arthritis of small and medium-sized joints.
d/. It is a malignant neoplasm of the melanocytes with the potential to metastasize.
e/. It is the most common skin cancer.

Answer

The answer is a.

Cutaneous squamous cell carcinoma (SCC) is a malignant neoplasm of the keratinocytes; it can grow rapidly and may metastasize (1%-3% of cases). Clinically, SCC commonly presents as an ulcerated erythematous nodule or superficial erosion on the skin. SCC can occur anywhere on the body but is most common on areas of sun-damaged skin, including the lower lip. Elevation of serum IgE is associated with urticaria, which presents as pruritic, red wheals. Psoriasis is a chronic inflammatory disease characterized by well-marginated erythematous papules and plaques covered by a silvery scale. A complication of this disease is asymmetric arthritis of the distal and proximal interphalangeal joints. Ulceration is not seen in psoriatic plaques. Melanomas are malignant neoplasms of the melanocytes that have the potential to metastasize. Metastasis and prognosis are related to depth of invasion. Melanomas, however, usually have areas of definite hyperpigmentation. Basal cell carcinoma (BCC) is the most common skin cancer, accounting for 70% to 80% of nonmelanoma skin cancers. They usually have a characteristic rolled or undermined border with telangiectasias around the lesion. Local invasion can be a serious problem with BCCs, but they almost never metastasize.

Dermatology Question #6

Dermatology Question #6

CY MD

A 72-year-old woman presents with pruritus for the past 6 weeks. She is careful to moisturize her skin after her daily shower and uses soap sparingly. She has never had this symptom before. The itching is diffuse and keeps her awake at night. Over this time she has lost 15 lb of weight and has noticed diminished appetite. She has previously been healthy and takes no medications. Physical examination shows no evidence of rash; a few excoriations are present. She appears fatigued and shows mild temporal muscle wasting. The general examination is otherwise unremarkable. What is the best next step in her management?

a/. Topical corticosteroids
b/. Oral antihistamines
c/. Psychiatric referral for management of depression
d/. Skin biopsy at the edge of one of the excoriations
e/. Laboratory testing including CBC, comprehensive metabolic panel, and thyroid studies

Answer

The answer is e.

In 20% of cases, diffuse itching is a manifestation of systemic illness. Renal insufficiency, obstructive liver disease (especially primary biliary cirrhosis), hematological conditions such as polycythemia vera or lymphoma, and thyroid disorders can all present in this fashion. Although most patients with pruritus will have dry skin (xerosis) or dermatitis (usually the primary dermatitis is apparent from the examination), this patient’s weight loss and anorexia should prompt a search for an underlying disorder. Topical agents, oral antihistamines, or doxepin (a tricyclic antidepressant with potent H1 and H2 blocking effects) can be used for symptomatic purposes but should not replace a search for an underlying cause in this elderly patient with new onset of symptoms. Excoriations are nonspecific manifestations of scratching; unless a specific primary lesion (eg, papule, vesicle) is found, skin biopsy will rarely be helpful in the evaluation of pruritus.

Dermatology Question #5

Dermatology Question #5

CY MD

A 30-year-old black female has a 2-month history of nonproductive cough and a painful skin eruption in the lower extremities. She denies fever or weight loss. Physical examination shows several nontender raised plaques around the nares and scattered similar plaques around the base of the neck. In the lower extremities she has several erythematous tender nonulcerated nodules, measuring up to 4 cm in diameter. Chest x-ray reveals bilateral hilar adenopathy and a streaky interstitial density in the right upper lobe. What is the best way to establish a histological diagnosis?

a/. Punch biopsy of one of the plaques on the neck
b/. Incisional biopsy of one of the lower extremity nodules
c/. Sputum studies for AFB and fungi
d/. Mediastinoscopy and biopsy of one of the hilar or mediastinal nodes
e/. Serum angiotensin-converting enzyme assay

Answer

The answer is a.

This patient probably has sarcoidosis; rarely tuberculosis or granulomatous fungal infections can cause the same syndrome. The painful nodules on the legs represent erythema nodosum, a hypersensitivity reaction associated with this patient’s illness. Erythema nodosum can be associated with sarcoidosis, TB, inflammatory bowel disease, several infectious processes or can be idiopathic. Biopsy of one of these lesions would reveal a nonspecific panniculitis (inflammation of the subcutaneous fat) and would not be helpful diagnostically. Biopsy of one of the plaques, however, would reveal noncaseating granulomas characteristic of sarcoidosis and would be helpful in ruling out the less likely infectious pathogens. Skin biopsy is safer and less expensive than an invasive procedure. In the absence of sputum production, fever, or weight loss, AFB and fungal studies would be unlikely to be productive. The serum ACE assay is nonspecifically elevated in many systemic granulomatous diseases and plays a minor role in the assessment and management of a patient with sarcoidosis.

Dermatology Question #4

Dermatology Question #4

CY MD

A 64-year-old woman presents with diffuse hair loss. She says that her hair is “coming out by the handfuls” after shampooing. She was treated for severe community-acquired pneumonia 2 months ago but has regained her strength and is exercising regularly. She is taking no medications. Examination reveals diffuse hair loss. Several hairs can be removed by gentle tugging. The scalp is normal without scale or erythema. Her general examination is unremarkable; in particular, her vital signs are normal, she has no pallor or inflammatory synovitis, and her reflexes are normal with a normal relaxation phase. What is the best next step in her management?

a/. Reassurance
b/. Measurement of serum testosterone and DHEA-S levels
c/. Topical minoxidil
d/. Topical corticosteroids
e/. CBC and antinuclear antibodies

Answer

The answer is a

This patient’s diffuse hair loss after a severe illness is caused by telogen effluvium. Normal hair follicles go through a life cycle. Approximately 5% are in the death (telogen) phase where the hair shaft is released. In telogen effluvium, the hair follicles are “shocked” by the systemic stress, and many enter the telogen phase at the same time. The diagnosis is made by careful history and physical examination. CBC, ANA, and hormonal levels will be normal. The patient will recover fully in a month or two, although a wig may be necessary to hide cosmetically troubling alopecia in the meantime. Diffuse hair loss may be seen with many drugs or with systemic illnesses such as hypothyroidism, systemic lupus, syphilis, or iron deficiency, but there is no evidence of any of these illnesses in this patient. Male pattern baldness (androgen-dependent alopecia) is seen in normal men, in some older women, and in women with androgen excess, but the hair loss affects the crown and frontal region rather than the scalp diffusely. The dramatic and acute hair loss of telogen effluvium does not occur in male pattern baldness.

Dermatology Question #3

Dermatology Question #3

CY MD

A 17-year-old female presents with a pruritic rash localized to the wrist. Papules and vesicles are noted in a bandlike pattern, with slight oozing from some lesions. Which of the following is the most likely cause of the rash?

a/. Herpes simplex
b/. Shingles
c/. Atopic dermatitis
d/. Seborrheic dermatitis
e/. Contact dermatitis

Answer

The answer is e

Contact dermatitis causes pruritic plaques or vesicles localized to an area of contact. In this case, nickel in a bracelet or wristband would be the inciting agent. Contact dermatitis may produce vesicles with weeping lesions. The process is related to direct irritation of the skin from a chemical or physical irritant. It may also be immune mediated. Zoster would be painful and occur in a dermatomal distribution. Herpes simplex produces grouped vesicles, but they are painful and also unlikely to occur around the wrist. Atopic dermatitis usually affects skin creases (especially the antecubital fossae) and the hands. It may be vesicular but is more often associated with skin thickening (lichenification) as a result of constant scratching. Seborrheic dermatitis presents as red, scaly nonpruritic lesions localized to the eyebrows, nasolabial folds, scalp, and retroauricular areas.

Dermatology Question #2

Dermatology Question #2

CY MD

A 25-year-old complains of fever and myalgias for 5 days and now has developed a macular rash over his palms and soles with some petechial lesions. The patient recently returned from a summer camping trip in Tennessee. Which of the following is the most likely cause of the rash?

a/. Contact dermatitis
b/. Sexual exposure
c/. Tick exposure
d/. Contaminated water
e/. Undercooked pork

Answer

The answer is c

The rash described is most consistent with Rocky Mountain spotted fever, for which a tick is the intermediate vector. Secondary syphilis could present with a macular rash in the same distribution, but the associated symptoms would be atypical. Always think of these two diagnoses when a rash begins on the palms and soles. Contact dermatitis would not cause petechial lesions. The skin lesions in disseminated gonococcal infection can be distal, but are usually few in number and are pustular. Giardiasis does not cause a rash. Trichinosis, typically associated with periorbital edema and severe myalgias, can cause splinter hemorrhages and a maculopapular rash, but would rarely show the distal involvement seen in this patient.

Dermatology Question #1

Dermatology Question #1

CY MD

A 20-year-old woman complains of skin problems and is noted to have erythematous papules on her face with blackheads (open comedones) and whiteheads (closed comedones). She has also had cystic lesions. She is prescribed topical tretinoin, but without a totally acceptable result. You are considering oral antibiotics, but the patient requests oral isotretinoin, which several of her college classmates have used with benefit. Which of the following statements is correct?

a/. Intralesional triamcinolone should be avoided due to its systemic effects.
b/. Systemically administered isotretinoin therapy cannot be considered unless concomitant contraceptive therapy is provided.
c/. Antimicrobial therapy is of no value since bacteria are not part of the pathogenesis of the process.
d/. The teratogenic effects of isotretinoin are its only clinically important side effects.
e/. The patient will not benefit from topical antibiotics since she did not respond to topical retinoids.

Answer

The answer is B

In general, the treatment of acne is based on the stage of the disease. Comedonal acne is first managed with topical retinoids. Mild to moderate disease usually requires the use of topical antibiotics, and moderate to severe acne is often managed with oral antibiotics, usually tetracycline derivatives. The more severe papulonodular forms may require the addition of isotretinoin supplemented with intralesional steroids for cystic lesions.

Isotretinoin has a high potential for teratogenicity and should not be used in women in their childbearing years unless contraception (preferably dual contraception) is being practiced. The drug also causes hypertriglyceridemia, musculoskeletal pains, and drying of mucous membranes. It should be reserved for severe or refractory acne. Intralesional triamcinolone is effective for occasional cystic lesions and does not cause systemic side effects. Antimicrobial therapy is of value, in part due to its suppressive effect on Propionibacterium acnes. The combination of topical retinoids and topical antibiotics has been shown to be better than topical retinoids alone.