Dermclinic

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A Photo Quiz to Hone Dermatologic Skills

DAVID L. KAPLAN, MDSeries Editor
University of Missouri Kansas City, University of Kansas

Case 1:

A 63-year-old woman comes to you

for a second opinion after a plastic
surgeon recommends excision of an
asymptomatic lesion that has been
growing in the part line on the top
of her scalp for several months.
There is no personal or family history of skin cancer, and the patient
has no similar lesions.
Your next step is to . . .
A. Reassure the patient and send
her home.
B. Perform a punch biopsy.
C. Perform a shave biopsy.
D. Excise the lesion.
E. Refer the patient to a
dermatologist.
(Answer on page 286.)

Case 2:

A concerned mother brings her

7-year-old son to your office for examination of a black mole on his
shoulder. She is convinced that the
lesion, which appeared 6 months
ago, is growing larger.
Which of the following do you
suspect?
A. Combined nevus.
B. Junctional nevus.
C. Dysplastic nevus.
D. Melanoma.
E. Spitz nevus.

(Answer on page 286.)

DAVID L. KAPLAN, MDSeries Editor: Dr Kaplan is clinical assistant professor of dermatology at the University of Missouri Kansas
City School of Medicine and at the University of Kansas School of Medicine. He practices adult and pediatric dermatology in
Overland Park, Kan.
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Case 3:

Changes in a pigmented lesion on

her arm send a 68-year-old woman
for medical consultation. A red area
has recently developed in the longstanding, asymptomatic lesion.
Which of the following would
you offer?
A. Reassurance.
B. A topical corticosteroid cream.
C. A shave biopsy.
D. A punch biopsy of the red area.
E. Excision of the entire lesion.

(Answer on page 287.)

Case 4:

A 69-year-old man is disturbed by

the condition of the nails on both
great toes.
What does this look like to
you?
A. Onychomadesis.
B. Onycholysis.
C. Onychogryphosis.
D. Trachyonychia.
E. Onychoschizia.

(Answer on page 287.)

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DermclinicAnswers
Cases begin on page 282

Case 1: Seborrheic keratosis

This is a seborrheic keratosis, a common, benign tumor that can erupt
on the face or trunk of persons older
than age 30. Reassurance, A, is the
only treatment necessary.
If the atypical appearance of
the lesion concerns you or you are
uncertain of the diagnosis, refer
the patient to a dermatologist or
perform a punch or incisional biopsy of the lesions most atypical region. Histopathologic examination
of the specimen will confirm the
diagnosis.

Case 2: Spitz nevus

The clinical suspicion of Spitz
nevus, E, was confirmed by a punch
biopsy. Spitz nevi, which occur
commonly in the pediatric population, erupt as red or darkly pigmented papules. All the diagnoses in the
differential are reasonable in this
setting; melanoma does occur in
children, albeit rarely. No treatment
is needed.

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Case 3: Seborrheic keratosis

Like the lesion described in Case 1,
this is a seborrheic keratosis. The
red area is irritation from mild
trauma, which the patient could not
recall. The erythema usually resolves without treatment, and only
reassurance, A, needs to be offered.

Case 4: Onychogryphosis
This condition is onychogryphosis,
C, hypertrophy of the nails that
leads to curved growth and a clawlike configuration. Onychogryphosis usually affects the nail of the
great toe; it can be caused by trauma, hallux valgus, chronic venous
insufficiency, and epidermal dysplasias. Filing the nail and applications
of urea paste may ease the condition; nail removal or matrixectomy
may be necessary in resistant
cases.
Onychomadesis is nail shedding; onycholysis is separation of the
nail plate from the nail bed. Rough,
brittle nails characterize trachyonychia; lamellar splitting of the distal
nail plate is onychoschizia.
n

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