[AST ear-old man comes tothe pysiian because ofa -mont history of muliple papules and plaques ons body. Hens had b1cos In fis stolfor 3 weeks, He has had an 11g (2618) weigh los duting the pastear. He takes no medications Examination e shown ‘abonts sin sions are most hel related to when of he following condor? (© A. acqureaimmune aetceney synerome (03) (0B. contact alerar Oe Hemapnita A © b.metanoma © E Stoptoxnceal infection “The correct answer's A. Tis paiarthas Kaposi sarcoma (KS) Inthe patient descrbedhere, tis most likly related AIDS. The lesions, when Denave ike a malignant vascular sarcoma, are asscciated wih Infection by human nerpeswrus pe. KS occurs in Astinetsetings: clic KS that occurs mast commonly in elder men, endemic KS that occurs (independent rom AIDS) in canal ‘mca, organ vansplartrecperts en immunosuppressive meaicatons, ang ADS-elated KS. ADS elatac KS 1s charsctenzed by ‘widely lssemainatea skin inokement (see in.age), oral micasal woNement (see mage), anainternalergan Imeement tat may lado bleeding n he unne ans G tract necause othe ‘ormaton ef{niable vasculartumors atinose sites. On histopatalogy, <8 tumors are enarseieaea by spinele-shapes andotnelalcels arming alsoganzee sitike vascular 2paces ‘hat may seed onuscly afer mince rauma KS In ADS patents is ated win nighy ace antretowral Merapy in acation to systemic enememerapy, Suen 3s liposomal snimagyeines. Patents wno nave disease localzed ony fo the skin maybe testec wih destuctve modaiiles such a3 ‘exosion er raoteton meray‘Eaton Proto Creat Copyright 2008 CMS P.- Custom Medica Sock Proto, Al Rights Reserved ‘Contact ateray (enoice B can cause ertieme oblong but Would not Usually cause gastolntesthal bleBdina. Tyecaly, contact dermatls flows a paterson the skn hat indicates the spec sts of posure tothe allergen, suchas linear steaks on the aim resulting tom brushing pasta potson iy bush ‘Hemopniia A (enolee C) can cause bleeding but would net cause persistent skn lesions chertan purpura Melanoma (choice 0) tends fo produce lesions that may varyin color and may metastasize to other regions on the skin Alhouch melanema lesions may ucerate and bised with miner raums, they would nat be execed to cause castointestnal Blessing, ‘Steprococzalintection (choice E} can cause a dleseminatea skin rash, and post steptococea!glomerulonephatis causes hematuria, Streptococcal infecton would net, nowover, cause a conic erupon as described re anc would not cause ‘acrontestnal bleeding ‘¢ Kaposi sarcomas a vascular turer associsted wit human herpesvirus 8 infection * In AIDS patients, volaceous vascular turnors rapidly formin multiple locations on the skin, muccus membranes, and internal ‘organs, castointastna loeaing may occur ‘+ The bestieatment for ADS-elated Kapos! satcoma Is ueatment of HV wit highly-acive anevovral therapy ‘As@yoar-olafatmer ct ongin nas non-neaiing. indolent, 0§-cm cer on his lowar Ho, ansing om me vormilon Dora. The ulcor thas been present and growing forthe past months. The patent does not drink, butsmokes 1 pack f cigarettes per day. Physical ‘examination shows no ober ulcets oF enlarged mph nodes. His blood pressure fs 1420 mm Ha, pulse TR!min nd respirations ‘6imin. whic ofme folowing Ise mostwely lagnosis ante Dest way to cont? (© A-Adenocarcinom: biopsy the center ofthe ulcer (© B.sseai col eatcinoma, tne-naode aspirton (© €.8enign rung ulceration: cure serapings (© D.metanoms; na mickness Diopsy © E:squamous cel earonoma: hl nickness Blopey ate edge of Me eston ‘The correct answors E. Tho ulcers lacalon andthe patontshistry are classi for squamous cal catenama (SCC) of he lower lp. ‘Tho sbsonce ofmetastale: nodes dvs notiWaldato he agnosie, a6 most cancers ins locaion donot metastasize unl tat. Tho ‘agnosis of conic veers ote stants best made win fu cmess bionsy at me eaae otme lesion |Adencesreinoma (choice A) would be very rte in the lower i Basal cell carcinoma (choice B) favors tne uoperparto he face. incusing the upper i {and ofen has s histor measuredin years, ‘nd as noted would not be best dlagnased wah FNA Benign ulceraton (choice C) is always & possibly, butt could be a terible mistake to make such an assumption As discussed, this vignette i pica for SCC. Nelanoma (choice D} is aise very rae inthis locaton. Ahistoy ofa pigmented lesion thatundenvert changes incor, sppearance, or diameter would have been suggestive Ful thickness biopsy mould have been appropise, bul one should adhe preferred locaton atthe edge of te lesion. Cassicingicators for squamous cell carcinoma (SC) are ulcer located on the lower lip in a patient offarcomplesion, wih history of “sun exoosure Thetimettle is ofen messured in month.'}40yearolawoman comes ote physian because ota 2yeerhistoy of sions on her nec that she finds cosmetealy unstracne ‘She nas ad no fevers, cis, night seas, or weigh 13s. Her meses sto s unretanaole. Se takes no medeaions ang she nas ‘no alletcies fo medications. Examination shows mulple sal, ght brown, cedunculatedlesions on te neck. The largest lesion is & mm In dareler. Which ofthe folowing isthe most ily agnosis? ‘OA Atochotdons OB Lentoines ‘© €.tisomas OD.senonmec erates (© E-spiser angiomas “The correct answers A. The lesions descrized ae "skin tas," more formally kncwn as acrochordons. They ate common benign {sions that ean occur at any si ste but nave a prelecton fr rooions at expertoneychroni¢ Micon, such 3¢ the neck, ada, and ‘roi. Multpi lesions are common, and we lesions tend io incease in number wit age, The is atarial predisposition, Tey are ‘usually asymptomate put can ba pain it raumatzec.Meroscontcaly, an acrochordan consists ota Morevsscular core, cometrmos ‘algo win Tat cals, coved by an unremarkable epidermis. Asymptomatic skin tags do nctrequio treatment Many motnods can po sedi remove disfiguring cr istedslon tags, including feezina wth tquidnitrogen,oht elecrodesiczation, cr excision th scalpel LLentigines (choice B) are fat macules characterized microscopically by an incteased number of melancestes occuring singly. rather ‘han in nests inthe basal eridermis within elongated rete pegs Linomas (choice C) ace soft ciscete, mobile subcutaneous nodules cormpose ofratire acipase tissue Seborrheic keratoses (choice D) are pigmented superficial epithelial lesions that are usually warn consistency and have away, “suckon appearance Histological, hese lesions are characerizesby epidetmal acanhosis and hon cyst formation These ae not melanocytic lesions. ‘Spider angiomas (choice E) are bright red vascular lesions of the skin characterized by = ental feeding vessel and outwardly Faddatng telanglecato veces. Te lesions blanche when pressure te applied. ‘* The appropriate medical ttm for “skin tags” fs aerosnordon. '* Acrochordons are benign cutaneous polyps that do notreauiretestmentunless they are symptomatic They appesr as ‘peduricuated, sal, fesiy lesions in ateas of enroni tition |* There is @farilialprecispositon and an associaton between acrochortons and cbesty and insulin resistanceFrom ’A 44-year-old woman comes for #roufna heath maintenance examination. She has has faigue and an crease inthe equancy of lunnaton. Se weions 100 kg (220i) ands 170 cm (66 ma: ner body mass indexls 34.6 muko. Her tempetabte is 36.7°C (38) Doe pressure is 178180 mm Hg. and pulse i 86min. Examination is shown ‘The remainder cf he examination shows no abnormalities. Which ofthe following ndings is mostikly inthis patent? OA. corabred fuorescence OBHemogionin A, of7.2 © G.Lowdensty popratin cholesterl level of 230 (0 D.Pesitve carcinoembryonic angen (© E:Presence orpseusonychae on skin serpngs ‘The correct answeris 8. This patienthas cutaneous ndings consistent with acanthosis nigicans (AN) AN is 3 common cuaneous {nding characerizd by a hyperplgmented, vevaytickening ofthe Skin in plagues. mast commonly occu onthe poster nack ana ‘aa, bul may also afectine goin, inne tigh's, perianal area, Next suaces, andmucosal sutaces, particulate orl cay. ‘Acrochordans (san tgs) are commonly observed In the sening otAN, partculanin sites at ae subjected to regur Micon, such 3s ‘he aullae ang groin. Histooatcay AN may demonstrat tnckening ofthe ecicermis as wel as hyperkerstosts and rapilomtosis. ‘Aitionaly, AN commonly cccus in the absence of an assocsted condition; such cases are idcpathic and may have familial causes ‘The most common diseases associated wih AN incuds insulin resistance and diabeles melitus. The paint described, with har ‘obesity and possible poli, is most Hkely suering fom undiagnosed inulin resistance fnottank diabetes melts, and thus she 4s most tkolyto nave an elovatog namogtobin& ,..otmalnomogionin A, 16 6.0%, AN can alse Indicate the onset ot malignancy, Dartculana cactomtesinal neoplasm. | superfical pactena infection tat commonly affects ihe aiae anc causes well demarcated reclbrown patches is enthrasma. The ‘causabye organism is Connebacteium minubssimum, Examinaton wih a Woods lamp revels coral-re fuorescence (choice A) Vasious fms ofhypeipdemia (choice C) can cause diferent types ofskin manifestations, although hypeipidemi is nol ypicaly _sssociaed with AN. Tendinous and uberous canthoras are associated wth hyparcholesterolemia, CCateinoomoryoni artigen (CEA) (choice 0) is a tumor matkorprocuced by approdmaely 70% of colorectal and pancreatic cance, ‘atthaught.can also be produced by gastric and reast carenomas. AN can rarely bea skin manifestation of intemal malignancy. In these cases, gasiric malignancies are the most comman esuse, athougn overalls fs nota eommon cause of AN | supercia fungal infection that commonly aflects th hair the ail fs white peda Tchosporosis) Clncaliythis infection rmaniests withthe formation of sof white concretions on fe har shafts (choice E). Tina corporis caused by standard dermalophie ‘ungl would, nowevet, be the mast common fungal infection in tis st, ‘Acaninoeisnlorcane ts characteneed oy tick, voNoy, hyzerlementecplacuss on fxuralsuraces. is most commonly tamil or ‘sesoctated wth obesty, nein resistance, and ype 2 clabetes molitus. Acantnosis nigricans can slo be cesn win malignancies, ‘especially gasitic cancer’)S24oar-old man comes tothe piysiian bacause of cin lsions on his arms and fogs for 6 months. Ho Nas a history of ypotyidsm, ‘abeles, severe hypetliideria, coronary slay disease, andchtonicrenalinsuficency. He had been on renal dass forthe past 2 years Defoe uncergoinga Maney transplant 3 weeks ago. Cuter medestons mcluGec/closponne precnisone, metformin, espinn and ‘alam, Examination of ie skin snows nuriorous dome-shaped pagulbs onthe gs and arms. Some asians havo & conta Karate ‘scale and ater lesions are excoited and have 2 cerralpustule Vihich tthe folowing conction is most key associates wth he _sppestance ortese shin sions” OA, coronary ater tsasb0 OB. cycospoxne uso OG. Endstage renalsisease OD Hypeipiseris OE Hypotcidsm “The correct answers C. Ths palenthas acquitecperforaing dermatosis (APD), zisohnown as Kyle disease. APD has been associated most commoniy with chronic renal fslure and aianetes melits, whieh onen coesst Lesions are charactezea cinicaly oy dome-shaped or umoilested papules with 2 central Kereitc crust onthe les or. less offen, onthe trunk nck. arms or slp. Prutus is variable but usualy prominent Esty esions may be pustular, whereas lie lesions resemble putge nodularis Histological, collagen foers can be sean extruding tough te epidermis, The disease may remit ae cenaltansplanation, but unfortunatly tis fs notaluays te case. Topicaltrnon, inalesional and topical stercids, and ulate ig teatment may be allerpted,ahough ‘veatmentot mis conden s usual” not ststatn. coronary artery cisease (cholce A} tset|s not associates any spedtte sin lesions, athough venous forms ofxaninomata have been associated wih ypercholesterclemia, a isk factrfor hear disease. [Cyeosporne (choice 8) Is lily eng usedin ts patent to prevent ejection of his wansplaned Maney andnerefore would not ‘conotogicaly 26 an explancton fr this pallens kin fnings. Cutaneous adverse eects of cyclosporine incude hyperuicnoss, ‘angval mperpissa, and an acneform eruption. Ofrerimportantaaverse ees Incluce renal ingumiciene, hypertension, and an Increased nek for malignancies Hypesipideria (choice D) is 2ssociated withthe appearance ofxanthomas ofthe skin Eruplve xarthomas are the most common, ‘ype, with redsistyelon, dome-shaped papules evabing in cops on the extensor asped ofthe forearms and lower legs. tis _assucltod most onon with primary (yp IV ot Vnypat popetsinemia) or secondary nypartigycordami, Himotytolaism (enolce £} may be aséccatod win sin changes known 25:myxodema. The cn becomes ory andrough, Mucin {enosis may develop sround he eyes and onthe forehead, cing ta put, doughy appearance. fearotenemia develops, he skin has a ylloish tnt that's especaly prominent on he palms ano soles Hatr and nals become hin anc bile Acquires paroratng dermatosis (Krie dsease) Is most onen associated wih chron renal fare ang ctabetes melitus. Cisicaly, patients prosont wih pruttus anc excoiatod or unbilicatod papules with 2 contra Krateic cust favoring the lower oxtremitics.'A85-7earola woman is agmited to ne nosptal because of chest pain and shorness of brea She is alerictohepann Utrasound ‘shows athyombus inne right supertlfeoral vin, Venilatior-pertusion scan shows a parusion defect in he ichttuna. She fs ‘adrinisterec supplemental angen snd losang cose of watsnn ARer 3 das, she develops pain sno redness inner letoreast. ‘Examinalon shows enhema andtenderness offhe lek breast wth a cata atea of scar formation blopsy specimen ofthe lesion ‘snows etensietrornbosis wih microvascular Injuy and Bon deposits me postapilay venules and srial veins. Loss of union of which ofthe folowing isthe most ike cause of his patients skin lesion? OA.Faaor OB Faaor Oc Platelets OD. Prtain © © E.von wiebranaracor ‘The correct answor is O. This patents sutored a pulmonary embolism secondary to a deep vein tombosis inner Hightower ‘enemy. Because ct ner slerayto necann, sre was sntezagulsted in wartenn alone. Wartann unctons 3s an anicosgulant oy epleting al othe vitamin K-dependent coting factors, namely, factors Il (prothrombin, VK, and X The anticoagulant proteins C and are aise vitsmin K-dependent and treatment wit wsracin wil decrease tne crculating levels of hese proteins also. The circulating halEfe of protein C is much shovterthan that of an ofthe ling tacos, so eat nthe course of warfarin therapy a hypercaagulable Slate ists Forthis reason, patents staring watarin therapy are oflen teated wit low molecular-weight heparin also, unl ther INR |s witin ne target range. This procoagulant state predisposes to cutaneous necioss esulng om thiombosis and occusion ofme ermal vasculature. The most comon sles for wala induced skin necrosis te areas wih considerable subcutaneous fl such a6 ho breasts, hips, and wigns. Factor (choica A) isa via K-dopondent clting factor a, togetnor wih Hssue Tato, plas a Koy flo In ampiting We cting cascade. nnibticn tins factors the goal of wartan terspy. Factor (enolce 8) Is also a vlamin K-dependenttactr Mattorms pat ot tne munsic cloting cascade. nnotton otis actors the ‘900 of warfarin therapy deficiency causes hemophilia & (Christmas cisease). Platelets (choice C) are notinhibited by wararin orheparin Aniplatlet agents include aspicn, clopidogrel, and ghycoprctein tla iniotors ‘von Willebrand acor (choles E) is a glcoptotein involved in hemostasis and is pocuced in endothelium, megakanoqtes, and “subendathetial comecine issues defciency is associated wih spontaneous bleeding From mucous membranes, prolonged Dleoaing rom wounds, and mencunagia In young females. van Willebrand isnot innted by wat ‘¢ Warlann-induced shin necrosis is caused by ear depletion of protein C resulting in a parsdontc hypercosgulble state in the fst ‘sovetal daje afer wartann sarunistston. ‘Patients present ith pan, errhema, nemormagle bullae, and fu-bickness sin necrosis with scar formation days ae inition of warfarin therapy ‘© The mostcommen sites of wefann-induced shin necrosis include the breasts, his, and thighs.'A24-yearold woman comes tothe emergency deparimant because ofthe acule onset of abdominal camping and hives for 12 hous. She states that2 days ago she had = sor threat andtook timethoprim-sullamebizazole and an uersne-counter cold medicine that contine dtromotarpan, cpnenyaramina, pseudoephedine,andibuprafen, Shenae had agenaralzed Wh. She has had no shortness of bresh oaticuty swallowing. She has a history ct asthma. Shes in mid dss. Her temperature is 36°C (95 BF), blood pressure is 108165 mm Hg, pulseis Gomi, and espiaions ate 24min. Examinaton shows multe 1-10 1-¢m, eink nd whit ual papules ana plaques ont unk anc proximal ectremies. Which one following is he rast icly cause of ne conden? © A.Domomemerpnan © B.ciphennyaramine © e.tbuprefen OD Pseudosphecine (© E.THmotopdsutamemorazolo ‘Tne correct ancwor eC. This patent nas unica and angioedema induces by 2 nyporsensibvtyreacton, mastuKoW fo a nonsteroidal at-ntammatory cup (NSAID), inthis case ituprofen, This patents sbcominal complains are caused by angioedema ct the bowel wall which ean cause coliciy pain, nausea, and vomiting. Orugs are the most requent cause ofuricais and angioedema, wit penciin andrelated antbiotcs bsing the most tequent offenders. Saloales, including asin, oriates, NSAIDs, conast media, and angiolensinconvering enzyme inhibitors are commonly implicated causes of uiicai, DDoxromatnorshan (choles A) Is acougn euppressant commen found n vor to-countor cold mestenes. mis csssitod as an Haba N-mamit-D-aeparat)Inniotor, Ie saffo use.nas fow side ees, ana dzes not interact sigiMeanty win citar modiestons. ‘An alegy to Gesromethorpnan is much less liver than an NSAID alergyin an asthmatic patent Diphentydramine (choice B) is 3fist-genersion H1 anhistamine, Systemic adverse elects include sedation, inability, impaired ‘cognvefuncion, increased appetite, constpaton ly mouth, dsusia, erectile ysfuncion, tachycardia, dythytimia, and blared ein. Its used inthe weatmontot mastcollrmodiatea urticaria ana angioedema, Peeucoeonsanne (enolee 0 is a decongaetant common usec Tortne treatment of aleraic or ifectous mints. Rs main aaverse ‘fects xetosiomia itis nota common csuse of uricara and angioedema ‘Tiimethoprin-sulfamethzarale TMF-SN) (choice E) most commonly shows a€verse reaction in the gastrointestinal system an the ‘skin, aculopapular exanthemats are seen in patienis who have AIDS. Otherwise, pustular or maculopapular ashes, Sweet _synarom, Stevens-Johnson syndrome, and ore epidermal necrolysis ave been rast commonly reported, Cental nervous system ‘tects include wemo. fous, and nesdacne, TMP-SMX Is nota common cause of ucara in immunocompetent patonts. ‘The drugs most commoniy associated with urbcana and acute ensphylais induce salicriates such 68 aspirin, opiates, NSADs, ‘contrast mec antblotcs, and anglotansin-convoring onzym inhibitors. ‘¢ THP-Silk may cause a mscuiocapular orcustlar skin ruption (estimatedin 30% ofthe population), butt does notusualy ‘cause uricana‘Av 4yenrola gi has been staresto 8 dermatologist because otaone The gi nad rst gone toa wasn cnc bacause she was concemed about warsening ofthe lesions despt ner use ot an overtne-coumter sone medcaton. On exsminston, she nes open snd ‘cosas comednes, axpacialy onthe ferahead Inaction, she has some comadones and many papules andlge pustules on her chin, In me nasolabial roi, and onthe cheeks. Tere are a ew lesions on ne uoper neck Cutnone on te cnet of dela ares Wich of he following is the MOST appropriate herapy at's bine? OA tstetnoin (© B.cial dowovcine ous tone sta 06 Topical adapatne (0D Tories zeae sci © E.Topteal enzoyl perowce pus cinasmycn get ‘Tne correct anewor's 8. The caso dscusses te classcation and eaiment of acne wlgais. There arfour primar lesions present open and closed comedones, pales, pustules, and noduloeystc lesions nthe mildest orm, there are comecones mostiy onthe central face. They may also Gepresent onthe chest upper back, and shoulders. arked tunkinvchementis seen most ofen in boys, whereas a predominance of dosed comedones onthe forsheadis seen mors afer in gil and ofen attibuted te prolonged use ot groasy nav preparations. Therapy prevents comecone formation by dacreasing folcular Mmparksraosie, sebum production, P. ‘acnee inte folie openines, and Wee fat actd production. Flares ate more common in wine. win genet imorovementin the ‘summer There is no evidence showing tht ditinfuences the course of acne in any way Cleansing afcis te surace ipa in terms ofthe skin appearing less ci, but no evidence demonsiraes that surface pis have anyhing fo do wth acne. Fercomedones, the {opical preparations ate efecive. benzoy peroxide gels, reiolc aid, edapalene, and topical anbiots. Preparations are avaltbl in varlous concentiatons. The single mos! etectve agent for comedonl aegis UeUnoin (RelA) To reduce fares, benzoy peroxide may be started a few weeks pror ote star of etmin Adapalene (choice C) is a comedic and antirlammator Hl may have fewer side eft than tenon (titation, sens ity to ‘suri Topical antbates (choles E) Incude eindamycn and enérvornycn and serve as an acne! to init grow of gongs. They are ‘not, nowavet, 25 efecvo 2s oral antolotes cr benzo petodcd. The efecvonses Ic enhancod in combination wih bonzoy Peron oF areinoid Acelncacis (choice) is sntimversbial ane Keratalyic may be used for comedonal acne. Oral antootcs (teracichne) are incest for pallens who have notresponded fo opical therapy or have moderate lo severe papulopustilr or rosulaysic acne. They ae most ‘ataclve win topical benzo peronids oF Watinoin but shouts nat be ghen wit topical antootes. Isotretinoin (enolce A) (Accutane) Is usec Tor moderate to severe nogulratic acne Mat nas not responded to conventional Merapy oF tmat 5 worsening quicey despite erapy Mis guen Cal for 16 1 20 weeks. Major side eects are nypenipidemia ineeato check baseline profil) and ts teratogenic effect Pregnancy needs fs be avsided or 1 month ater discontinuing ts use. In addon, should ot be administered concurenty with evacidine because te combination may produce benign itacranal hypertension, Type of acne management: ‘comedona! gene: Topcarctnote(ratnan, adapalna) + 26r207 pore or zal ats. Mic raula-custar acne Topical benzos peroxide + topical anit or an oral atin with atoicl retinoid ‘Sore papul-pusular gone: ora amibcte + topealretinas adulocrs acne acne cessiant o above ewan sotretnoin‘A £2-year-old woman witha Naty of yperenision, ype 2 diabetes, and dabelcnephvoraty comes fora folowup ual she has 3 3-monm histor of worsening rash en her nightleg. Sne denies fever or rauma to he ares. Curent meaestons Imcude is! hyorochioronizide, metformin, and piltazone. Her temperature is 385°C (97 TF), blood pressure 148/80 mm Hg. and pulse 74/rin Examination shows 3 Gm aroohic patch with erfreratous borders and aylow-colored cenle, Hemaglotin Ay is 11.2%, Which of tho flowing is tio moet key agnosis? © Aacannosts nionicans © B.Enthems nodosum OC nectoviosistpcisics (©. Fyocerms ganarenosumn OE. seeraderma, ‘The correct answers C. NecrotiosisIipedicsis a granulomatous cutaneous lesion tatis commenly though nol acustely ‘associated wit dabetes. This condivon most commonly manifests a= area yolow plaquo wit indurated, volacbous borders cn the ‘shins: telanaleciasias may also be seen in teselesions. ume, te plaques Decome atrophic and at they may occasionally lucerate. Women ae far more commontyatected then men, Oiterlesions assccitedwmn dapetes incude alabetc cermonatny, neutopathicucers, and sceredema, Acannoss nigricans (choice A) isa skin nding characienzed oy 2 dark velvety slaquein the alae, neck or grin. though various ‘othe sites may be involved incuding the oral cay Acarhosis nigricans most commonly found in paben’s who have insula resistance, but tay also rarely be 3 marker fr intemal malignancy Enthems nodosum (choice B) consists of ed painful, warm nodules that usualy appear onthe shins. Ils 2 form of pannicultis ‘ses ocied with sarcoidosis, intammtory bowel disease, tuberculosis, fungal infecioneand medicaions. Pyodeima ganotensum (choieo D) is an intammatoy ulcer wit undermines Borders Mat may occu at any sito on tho body ke fen sssoctatec win iarnmstory bowel asesse, meumatoid arts, leukemia, and chronic ache hepatitis Sclerocerma (enoice E) Npicaly presents win Raynaud phenomenon and oiateal simnmetnc cutaneous sclerosis Nplcally mown tne face and hands, Noctobiceis poids (NL) ie a granulomatous condtion afectna ne logs. Clinically, NL presonts ac 2 rod.yellow plaquo wih rsicod, iolaceous borders. tis commonly associated with diabetes, bt cabeles nead nat be presentio make the ciagnasis itis more ‘common in waren than in men,rrr) 'A-44year-ola woman comes toe ohsisn because of@ mole on ner right punoo« tat teas ater minor trauma. Shenas nad 2 ne roses 4and ayears ago, respecvel at were not malignant Her motner nas Noe 2claetes meitus ana er raner nas hypenension and hypeipideria. Examination is shown ‘Tnere\s s smalireion oF uceraton in te center ofte lesion Laboreor stucles show poste S-100, whic othe following factors ts ‘me single mest imponant prognestic eer wren determining tumor stag? © A.DoGI00 of collar ayia ‘© B.0epm ar melanooste masion ‘© c.Prasence or abeonce of vestaton ‘© Dusty etinammatery innate (© E-Santinel moh node invowoment ‘The correct answeris 8. Tis patient exhibits classic presentation of melanoma, The incidence af melanomais inereasingin the ‘general population Risfactors for melanema include far skin ypes wih ightcolored yes andhair a istry ofinfermtlent sun ‘exposure and sunbums, exposure to aia ural ight numerous matanecyéc new (>100),cnicaly areca melanocytic nev, anc ‘afar history of melanoma. Melanoma most comment prasents onthe backin mon and ie putocss ances m woman Wien assessing the sevety ofthe biologic behavior ofa melanoma, allot he tatrs listed inthe answer choices are taken ito “consideration, but the single mostimpariant prognesicfatris he depth of melanosye invasion as messurad from the most “superal recon of stratum granulosum. This is known 25 the Breslow dept. Melanoma in sity of melanoma wit 2 dept of invasion Jose man 1 mm nas an excellant prognces flowing suical excision. The sk for nodal and widespread retasiasis increases with ‘he aepin otinvasion. Tumor markers shouldot de used 3s te primar oo for cancer diagnosis. They may be used t coma ‘agnosis, to moniter for tumor recumtence, andto assess response to therapy. $-100 82 turnor marker usedto ident rabents who have melanomas, neural tumors, and astocyomas ‘The deeree of melanccite apia {choice A} and he quaiy ofthe ilammatoy ifrate {choice D) around 2 melanoma ate not ‘commoniy used inne stsang of melanoma. Thay af vowed as adverse features ofa melanorma(Lo. many mios9s, severe ‘regression respectively) and can be sed to jusby more advanced staging procedures, such as sentinel nove Diopsy or PET-CT presentin stage disease ‘The presence oF absence of ulceration (choice C) Is used to uostege a melanome of glen depth rom ana tumor te B tumor. ‘ough this upstaging dovs afec prognosis, tis notas important a dopih of imasion. ‘Sentine| mph node biopsy (choice ) is tically usedor melanomas wih a.depthofinvasion 1 mm, This procedure has no eect ‘on marti in melanoma, out can crue some adcttonslcrognostc information when usedn conjuncon wth the depth of invasion Rsk factors for melanoma include far skin ypes with light-colored eyes and hai, a history ofinlemitent sun exposure and sunbuns, xposurs to artical utravilet ight, numerous molanodjte nod (=100), clinical aypieal molanoeytcned, and atamiyhistory ot ‘olanoma, Tho single most importantracorn staging and procnosis of melanoma is te daptnoftumor invasion 36 Indicated by no Breslow depth. Omer tacors which confer a poor prognosis in melanoma include mito rate, ulceration of ne lesion, meh node metastasis, and otter metastases.‘A37-ear-ld woman comes othe physician necsuse ota severe chy rash on her legs tor 2 days. Four days ago, se a yard workin her backyard She has a history of hypelension contolle wih diet and exercise, and she has asthma, Curent medcabonsinciude an fouterat inhaler. Her temperature is 372°C 88") ana boa pressure 13 13880 mmHg. Examinaton snows mule lsree, nest, ferfhematous plaques wit ovshingvesicles. Which ofthe following is the most ly cause of his paints condition? ‘©-A.Arnoey dependent clr mectatea coronoty (© B.Aotvoes-devendont complement actvaion 0.6. celzmesiated delayed hypersensiivty © D.crossiintng or een suace IgE by angen (© E- Fastin of complement by immune compleres ‘Tho corroct answor Is C. This patlontis sufeing om aera contact dormaits caused by exposure to poison ly. Poison v7, polson ‘ak and poison sumac ate ll members ofthe Todcedandion genus of ants, which ae all characterized by ne production of ‘uushiol.an ol mat uncions as anapten when eroosedts the skin, Alforms at algi contact cermatts(reactons to so=ps, ‘detergents, latex, sunscreens, neamjcin, and jew) are mediated by celavec-ype (cele meaiced) hyzersensityerefore, aera: ‘contact derma is ste W typersensivty reaction. Urishiol binds to cel surace preteine. ana together wth these proteins is ‘ecognzed asa oreign antigen bythe T-cell receptor on memory CDs T mohoertes. Because this process requires acbvaton of memory cells, prior exposure tothe antigen orhapian is required before reaction can be generated The contac dermatitis ‘Craratristically has linear steaks (see image) on her legs atthe sles where her leg brushed past the plan while she was working inher yar These linear, erythematous plaques wih overjing vesiculon ate hehallmark ofpoison iy. Trestment includes the “denitcaton othe causalve agent and treatment wih antihistamines and topical steroids. Systemic cortcosteoids may be used in Ine case of sevete dermal, especial involving he Fae ot genital region Antbody- dependent celulsr etotoicty and antbody-cepencent complement actuation (cnoloes &and 8) are mechanisms inched in type I nypersensitvty. Examples of tps inypersensitv-mediated diseases include autoimmune hemotic anemia, Goodpastre syndrome, and aulcirmunetytidits Crosslinking ofall surface IgFby antigens (choice D) is the mechanism of ype lhypersensituly reactions. Examples of diseases mediated by lype I hypersensily inclde allergic hints, sllergicasthms, urticaria, and anaphylas Faation of complement byimmune complexes (choice E) occus in ype Il hypersensibiy Serum sickness, systemic lupus ‘er7hematosus, and certain forms of napus are caused by tis immune process. _Mlergte contac cermatis is 2 dalajectyce (ype 1) nypersensitvtyreacton to sozps, detergents, latex, sunscreens, nzorwcmn, Jal, and poison iy The rash of contact dermalits is characterized by enthemstous plaques wi near, skeaked vesicles ai the ‘os of exposure toro allergen Treatment ot alerolecontsc dormatts i anthistamnes and opal storoids"A 22-year-old woman comes tothe physician because ofa 2-year history of slump inher right upper am. She has had ne pan andthe lump has not grownin size. She has a isto ofhypertytociom. Curent medicatons inde atenolol and methimezole Her mother has histo of breastcancer. Examination shows 2 3cm, so, subcutaneous mass onthe righ upper Ileal arm, the mass is mobile and nontender. vimien athe lowing is me most appropriate nest step n management? OA.chemeerapy (© Bcancalobsenaton 0 C.Exision (© D.inraesiona corcasteroids (©-E Sentinel nmpn node biopsy ‘Tne correct ancwor's & Tic patent mact ikly nas alipoma (seo mage}. Lpamas ate te mast common einicaly eneourteroa Sottesue mors. They cassiall precent as siowy enlarging, cezasionaltondor, sok seue masses on the tunk and pro«mal letremities.On examination, subcutaneous tomas are tically freely mobile: uncommon variants of ioms that ie within or below rmusde may beless mobile Histologically, ipomas consist of mature sdipootes within fine Rbrous capsule. Lipomas maybe Clinical observed because they ate benign lesions thus, obsewation is tie mos! conserve treatment Reproduced with permission fom Chatles Goldberg, MD,mecicina ucsd edu Magnan! tansformation (cholee A) ofa pom is extoroly uncommon, thus, chamoterapy enol a weatment tora simple Hpoma Exalson (enolee C) of tpomas is both @agnoste and cursive ana would ve Inaested for elt ot pan, cosmese, oF oncom about the diagnosis Inralesional cortcasteraids (choice D} have no role inthe treatment oflipomas, They are used the focal teatment of intammatory condlions, suchas pyoderma gangresosum and sloped arsat, andin the treatment ofnonlammatry lesions, such as ulcerated hemangiomas of infancy and keloid. ‘Sentinel ph node biopsy (choice D) as no ole inte dlagnosis 0: Westmient ofa ipoma. Its lp as a prognostic inser for Cutaneous malignancies, such as melanoma and metastatic squamous cell carcinoma. Alipoms is benign tumor of mature acipootes surounded by a thin, fbrous capsule. does noteauie treatment unless itis ‘symptomatic excision is eutave and diagnostic. Lome clinically maniests a8 sof, moble, subcutaneous nodule‘A50-year-oldman comes te physician because of pronrassve ticcning and swoling ofthe skin on his ays and ame for 2 wooks. He has had no fevers, wechllos, chest in, hearbum, orweainess. Kis medical history is unremarkable, His blood pressure is 120/32 mm Hg Examination shows paicnes of hickened entnematous skn over reanfenorsuaces ofthe upper and lower enemies wh an ‘orange-pest appearance. There ara no lesions on the thats. There arene flangletstas orcalemosis one cin. Which othe following i the mostliely agnosis? OA.CREST synerome © B.Dermatomyosins © G.eosinopniterasciis (© D.Potmvaica moumates 0 E-roumyosits “The corract answers C. & puckered “orange pesttike” (eau dorangs) apoearance ofthe skins atypical finding on helegs and ‘higne in patents who have eosinophil fascis (EF, Schulman syndrome) EF is a Rotate disorder invoking the ams and tog that ‘yplaly anects midale-agea men. Atnough the causes unknown, te dsesse nas been associates wih stenuous exercise andthe ination of hemodiajsis. The pathophysiology is believed tobe caused by anigeicty cf the muscle fascia wih 2 subsequent immune response, Symptoms usualy develop rapicly and lead ta evental faxionconiractres oftieatms and legs caused by foros of he ‘muscle abc. Biopsy should bo doep enough to sample the muscle fascia Hisoadology shows 2 mixed innate win nistootes, plasma eal, ymphocies, and eosinophils prmafy in We fesca; to dorms te olaolysparod,Troalmant is usally with prodnisone orertotonie agents. ‘CREST smctome (choice A) is variant of sclerodeims with prominent ivoWemant of he hands (slerodact),calcnosis, Remaud ‘phenomenan, letangledasias, and esophageal dysfunction. Dermatomyositis (choice 8) produces intanmatary and degeneratve changes in muscies and stn. Sun manifestations inlude \woiacoous cscolorston othe ojos and chooks (nelotepe rash), entrema ofthe uppor chest and shouldors (shaw! sign, ontnoma ‘verme edensor suraces ort tnger joins (Gotvon sign), and ragged cuticles wn prominentral-od ielangletesias, Proumal ‘muscle weakness and. predisposition fer visceral malignancies are other ciassic associations Poimnyalola meumatca (choice 0) Is n intammatry csoraertnatleads fo proximal muse'e pain and snes and is often _assuclatod wih tamporal ators. Amnouch famporalatotis may cause scalp tondorness and necrosis, are are no sesociatod skin manifestations win coiryaio meumatcs. Polmyosits (choice E) by ise does not csuse skin manifestations: itis accompanied by cassie cutaneous findings, itis ealed lermatompsits, as descrived ear Eosinopilicfasciis (Schulman syndrome) ‘+ Eosinophilic fascis (Schulman synérome)is arate dermatologic condtion resuling in tapid-onse, immune-mediated muscle fascia Nbrosis leading fo fexon conracures and “orange pesl-ihe” sppeatanceof te shin onthe eerie. ‘= Untke scleroderma, the cutaneous fndngs cf eosinophilic fascitis spare the cigs ‘© Eosinophilic ascites alco aesoctates wih peripheral eosinophilia,‘A“year-sld man comes to the physician because cf an enyrash on nis highs fer weeks. He reparts tnatthe chess subsides ‘oommight, His medical history is unremarkable and takes no meications. He Nas no Keown allo‘ies to mecieaions. Ho reparts that he cannot wear a metal watch necause ne dbvelops 8 rash on his Wns. Examination shows poory ckeumnzendes erfemstous, sea, ‘and custed plagues wit mullpleexcoriations on bah upper highs. There are tn, anslucent vesicles within he plaques. As the patent fnisn9s ciossina no piacos nis car keys nto one wouserGockat and some loose ciange info he ote. Which of following is te most likey underizng mechanism for tis patents candtion? OA.Cybtoxc hypersensiity OB Delayed typersensinvty © C.immedtatenypersensivvty (OD.immune complex-mesiated rypersensibvty © E. trauma induces ‘Tho correct anewor Is B. This patont most ikoly nab allot contact doxmatis to metal, most Hkey caused by hyporsensitA to ‘ical. role contact dormams Is e2used Dy 2 colayoctipe rypersancittyreacton, an immunctoatcaly epeacreacton, whicn takes core nouts to reach a maximum ana accurs inte absence of demonetable antoods in serum. The reaction i madiated by T ‘umoncertes win recertors for specticanigon on trol momorane. Ths patent nac develops ertnema, edema, 2nd vesieulaton at ‘he ite of contact with metal objects care in his pockets, and he alreag) Hnowe thathe develops a rach when he wears a metal \waten. Tis ail poits fo a metal lorax, na otal metals lckl 1s to most common ofencor. ‘Crotocrypersensitvy (enolce A) reculsn cel damage caused by aniuogy spocteter an antigen thathas become intimately _s0s0r00d of Incorporatecin te stucure of ace Examples of crotods nsporsenemvtyInluce autoallergy and rojecon ot ‘nomoorats. omer examcles include lalopaihicthrombocitopenic purpura and autoimmune nematic anemia. Immectate npateonsiiaty (choles C), of anaphytavs, ectatod by IgE antbodos, occurs wnon mast co's or basophils n Hesus, passiel sensitzed wih artcocy, ae exposed to specie antigen. The Immediate weal and tate ot 3 pnek testresponse ofan ‘anapnyiacteal seneitzod person is 2 goed example ot an anaprstacc or mmdlate- yoo nyperseneitvt reaction. Unicana sna ‘angloedems ae dassic signs of etaneous anephviads Immune compiox-mestatod nyperseneivy(chotce D is clstsical representec by serum sloanses. Solubio immune comotexoe ‘esut om tne union ct sntbeay wn antigen inne blood nc are clspersed trougnoutine entre Doay. The asorders ncuces are ‘lssominatog or local noctotzng vascults, lomowulonennrts, and rts Trauma-induced (enolce E) lesions are usualy well emarcstea stn lesions devo ofa sionmicantmtammatory component. They ‘may presen as lichenfied papules or plaques (rom persistent scratching), Kestoiclesions tom picking). or ulcerations rom pteaton otstong physical or enerical tants) “© Aleraic contact dermatitis i a type Iv, delavedtype hypersensituty reaction mediated by T Ymphocites. ‘© Symptoms occur nours afer exposure and include severe prumts, enema, edema, andvesiculaton in and around the area of posure '¢ The most common culprts include metas (most common nickel) and plants (such a8 poison ma)reer er) 'AG7-year-old man comes for folow-upwsit He has been clagnased mth 10 squamous calcarcnomas inthe last 18 months. Piste thi, ne naa 3104 acini erases. He nas histor othyperension, qjspidemia, ype 2 aabetes metus, ang lsbetcnephropaty leacing o renal fare; ne receved a renal tansplant6 years ago. Curent medications inclu hyeeachsrobiazie, sensi, lovastatin, ‘ycosponne recisone, and mcoohenalte meth He has smoked 2 "Vs packs ofaaretes calor 43 ear. He ebe42 ers 200 from ns ob a8 8 eacher Wh fine flowing i he most sigan nk tactr fortis patents quamaus cl carcinoma? (© A.immunsuporession © B.tovastain © G.Renal transplant ©. smoning nisin) © E.sun posure ‘The correct answor is A. Squamous cell eaicinoma (SCC) Is the second most common form of skin cancer nas been cea) _ass0cttod win addi Mote sun excosure and Npically aces nom precusor lesions suchas actinic koratos9s or Bowen disease {squamous cel earcinomain stu) Oszasional esses of SCC arise from chronic nfiamimatory processes, such as icnensclerosus or lichen planus, fom eronic nonhealing wounds, such 2s in epiermolssis bullosz, rom burn wounds, and om stes chronically Infected by human papilloma virus (HPV). Because ofs abl 1o metastasize, patients aris fr SCC should be monitored sels ‘Some chronialyimmunasuopressed patents, paricuay patients wno nave sold organ tansplants, ate ata slgifeanty nicher ke for developing SCC The medcstions used for antrejecion tat are most commoniyimplicated in ncessing the risk for SCC ‘allowing ‘organ transplantation are qcosparine preshisone, and azathioprine Lovastatin (choice B) is slipitowering agentthat has na known efecton the development of sin cancers, The msjorasverse ‘tects associated win ovestetn are myopathy and msbdomtiss. Renaltraneplantation (choice C) alone does notinzease thersk or SOC development. The meceations used suppress Immunclogicrejecton ofthe transplanted organ ae tie cause, ‘anaugn smokers (enoles D) maynave some mctessed nektor cutaneous SCC, snot slanticant2nskractor as Immunosuppressien or sun exposure ‘Sum exposure (choice) is al the rool ofthis patients risk for development ofacinic Keraoses and SCO, but it does not eplin his cent crastc increase in SCC development This patient does aot have significant history ofsun exposure (ie, employment as a teimer ortanascaper. ‘Theimmunosuppression induced aera solid organ transplant érasicaly increases a patient risk for development ofcutanecus ‘squamous cel carcinoma in the general populton, cumulative sun exposure isthe most significant isk factor forthe cevelorment of ‘cutaneous scusmous eal carcinoma.omer eTry) "A 35,year-ald woman comes io the physician because ofa pigmentedlesion on the palm ofher righthand. Her medical history is lunremarraote. Examination snows 3 2-mm oh oown cacule rh well demarcated ecges. A kn biopsy specimen snows custenng ot Plomeried melanecles atthe dermcenidermal junction. There are na clusters ofmelanects inthe dermis. Which ofthe fling isthe mast inety leanosis? OA. Compound news OB Hao news 0 Ciinkadermal news (OD sunctonal news © E-Lomtoo ‘To corroct answoris O. This patentnas 2 unctonal novus, ono suotps of melanoa¥icnews. Junconal nevi may be lant Brown to ‘nea b1aex and rango in sea rom 110 10 mm. They may be ole Nt of very samy raised Ris Dolloved that almost all molanocric ‘new may begin as junctonal new. In acuthood he lesions are seen most fequentl on te palms, soles, and genitalia. Custring ot malanaeytes atthe dermal-epidermal uncon i characteristic microscopical, These lesions are very comman, and eemnoval is usualy undertaken only when the neats ecb changes in shape er eolror becomes syrnptomatic (2, prs, pain, bleeding). ‘They may also be removed or cosmetic reasons, bul 3s descibed in the question, al pigmented sions should be sertfor bistopathologic confirmation ofthe diagnosis. CCompoundnowus (choice A} Is charactoruod by custrs of molanaeres both atte dormoapidernaljnetion and witn te demi. ‘Molanoojt win te dermis enould exhibit maturaton and 2 progresene decrease in size ‘malo nevus (choice B) 13a compound or inrsderms! nevus suttounced by a symmetnealy round area of Geplarentaton. The nalo Is believed to resuttrom ntammaton caused Dy an immune response tat destroys ine sdlacent melanooves. Intredermal ness (choice C) Is characterized by nests of melanocxtes within te dermis but not tthe dermoepidermaljuncion, Cinicaly, lentigo (choice E) closely resembles junctional nevus, bt microscopical here are an increases numberof melanocrtes occuring as isolated cal’, rather than inmasts inthe basal ayer epidermis, offen within elongaled rete ridges * Wetanacite new are characerzed by nests of melanacites displaying symmetry anc maturation # watanoojte nests ean be at ne dermoopidermal juncion (unctonal no), a th juncton and within the dorms (compound nev, ‘or sooty hin tro dsrmis (riradormai now}. ‘© Jundional ne are benign stn lesions thal only require removal when they ei changes in shape or color or hecome “symploralic (9, pure, painful bleeding)‘A SBsyear-cld man comesto the physician Because cfs lesion onthe side of his forehead thathe Nas Nad for anprowmaty 10 years, He has nadno tov, ght swe, or woigh loss. Hs medica Mision Ic unremarkable. He has playod gulf ary day since reting 3 yours ‘ago. Examination 's shown, fae Bok Be Theis an ashen easy sale The lesions nordnder Teves nomghadenopaty ic fhe fllovngis he mes ihe aranosis? OA Ati tents © Bel calcarcnoma © 6.bermateftroma OD.Neanoma © Ercwtass © F-sebotc hrasis 0.6. squamous eetlcarcinoma ‘The correct answer iF, The lesion shown represents seborrheic Kerlosis, which charactetistically presents as ight browm to black ‘papules or plaques wih an acherent way, gr9a5y scale. The stuck-on” appearance i very charactors. is most olan found on ‘sun-erp0sed 2038 such as ho face and tunk Seborhec Koratosas a nol promalgnan’ and do notrequle Westmont Despite is lis notimpossiale fora cutaneous malignancy form winin a seborhelc Keralosis, tase losions possess the same iskt01 ‘malignant tenstormation as any omer etronicaly sun-exposed region of skin For tis teason, seborhelc keratoses should nt be «tegorealy Ignored on skin examinations, and symotome such 3s bleeding, prurtus, or endemess i such alsion should promot ops) for nstologie aagneat, [Copynght NICHAEL ENGLISH, HLO. - Custom Mesa! Stock Peto Adinc keratosi (choice A) is characterized by an eréhemisious papule wih an adherent ough scale. ti most commen on sun-exposed shin andis considered a precusr of sqvamous cel carcinoma. ‘Basal cellcarcnom (enolee B) Is cassically caractenzec by 3 papule win 3 Cental ulceration and a peary, rsd order ts ‘most commen on sun-camaged sian Uceration 1s not a unversal nang DDormaiotbroma {choice ¢) Is charactorzed by 2 frm, feat Drown nodule wit a dimpling of he stn tat eecuts wat aera pressure on examination. Dermatoftroma can occur anywhere bulis mectcommon on te logs folowing miner aura, such 26 an ingot stingolanoma (choice D) is craracterzod by an asymm, trequlaly lamented papule or elaque wh an regular order. Any change in an eising pigmented shin lesion shoule be evaluated for melanoma by a dermatologist Arelanote variants resembling clically Denign tesions, suc as pyogonic aranuloma, ay occu and presenta dagnostc cralonge unlaes propaty excised for bistopatnologic examination Feotasis (choice E) ic characterized by wol demarcated entiematous plaques and papules covered with 3 siWor.micaceous scale The most comonsiles ate the elbows, knees, scalp, and ghieal def, Piting ofthe nals or onycholysis ay be present ‘Squamous cel caronoma {cnolce G) Is classically charactanzeaby a hypertetaotc or ulcerated pspule favoring chontcaly sunexposed ateas ofthe bod The lowe lip, eas, ané geitala (Secondary to HPV) ate hich-isk sites ofialvement. Sebortheickeraosis isa benign skin lesion that appears as a pigmented, way, stuccon papule lt most commonly occur on hronicalysur-exposed areas. These lesions ste not considered premalignant and require no biopsy or estment unless srrptomatic ‘A0,ear-ola woman cormos fo tte physician pocause ota rash above both other antes for 2 woos. She nac also nad swoling ofbotn anléss for3 morths. Physical examination shows pedal edema wit enthems, ile scaling, anda brown siscoloraton ofthe skin cfthe stl legs proximal tothe mesial malleol, There are varicose veins bilateral inte lower series. Which o the fllowingis te most Ney agnosis? OA Aton dermatitis OB conus © 6.ienen simpiexcrvoncus (OD. Nummutar dermati © E.siasis gematts ‘Te correct answers E. The pallet destribed nas stasis dermal’, which Is te resul of persistent ntammaton orte stan ana suveuls othe lower legs. The conto fs elated to venous nsuffcency and creniclowerexsemiy edema resuling in extravasation ofplsema proteins and infammator cle, utimateyleacingto pervascular nonin deposiwon and cormal Toesic.stase darmattic ‘ypicall resents with ler nyperpigmentaton and sealing one meaiallegs proxmalto the medial malleolus. Most patents are relabvelyasymptomate and may net seek medical atenton unt ie edema beexmes severe orthe lesions become eomplcsted by secondary Sactrial infection or ulation (see image), Commerstones of rentment sim fo decrease edema inthe legs Elevation of he legs while resing and use of propel ftec compression stockings are commonly recommended, Topical corkcosterids can aid in alledatng ruttus and scaling, Linodermatoscleross is an advanced form of stasis dermaiisresuting Fom fibrosis ofthe subcutaneous fal. In his conion the legis said to ake on the appearance of an iveted wine bt CCopstight CMSP - Custom Nica! Stock Photo All Rights Reserved‘Aopic dermaits (choice A) is hypersensiviy skin condition typically inching te antecubital and poptealfossas,eyelis, neck and wrists; pallens mest commonly complain of severe prurus an have 2 family history of atopy (Calis (choice B) is a bacterial infection ofthe subcutaneous issues most ln caused by Staphylococcus aureus or S. pyogenes. causes local enthema, warmih, and tendemess. ef unkeated, ymphangis and bactsemia can develop. Calais can be acomplicaton ofstass dermatts, bul when cellulitis occurs itis rarely iter Lichen simplex chronicus (choice C) is a stn fring that is caused by chronic rubbing or scratching and is characterized by lichenifed, excoriated, and hyperpigrented plaques. Nummular detmatis (choice D) is characterized by widespread coin-shaped, eczemalous skin lesions thas no association wih ‘top, butt may be ralaleto an occult dus of infection in hal of patients who have this cordon. ‘Stasis dormatis i sesoctatod win yonous insumency and chronic lower trornity oder. It clsesicaly manifests with hyperpigrientes scaling patches ang ulceration verthe bilateral medial ankes proximal tothe medal malleal Acammon complications bacteil superinfectionreer erry | Thyearold man comes the physician because of days of painfulrash He has had no fevers, chils or weightloss. His medical history is untemartabl, He ives wth his cousin who has ADS. Mis temperature is 37.2" Hemoglotin 14 gid, Hemogfobin 180. Mean corpuscular volume won Lousocrt count 500i Platelet count 360000 * Which ofthe followings the most appropriate pharmacotherapy? OA. Amitiptine ana gabapentin © B.vexemernasone © Ccematabine, enor, and etavens ©. Gancisovr 0 Evalaorionir ‘Tho correct answoris This patont nas nefpes zoster, neh ¢ causes oy he rescivaon of latent varicella zoster vrus VZV) Infection Aller inal infection by VZV Cehickenpor), he vius isnot eraccated rom te body Rater remains latent in the cel bodies ‘of sensory neurons inthe dorsal rt ganglion. Reactivation ofVZV from tis locaton, 2 conaton commonly own as “shinges,"S ‘characterized by a prosrore of pain and dysesthesiain 3 detmatomal pale. This pans followed by an eruption of grouped vesicles ‘onan erjnematous base, also Ina dermatomal astibuton, Herpes 20S ter most commonly occurs in older Inladuals, classically tolling an emotonal or pmysicalstossor. Postersate neuralgia Is enaractonzed ty chronic persistent pain nt actnouton of ro ‘yav erat, lasting months afer resolaion of the rash. Earl ana aggressive systemic reatment wih valacjcoar or acyciowrnas| bean shown to reduce te severty and curation cf ne eruption tselkand ot pasiherpatc nuraig. Amine and gabapentin (choice A) are used io teat postheipeic neuralgia, but his pallens sill experiencing the acute erupion ‘anit Is mereore not possible to determine ihe wil experience postnerpellc neuaig'2. The mostimportant invention at Wis te Is systemic antral nerepy. Early se of systemic eortcosteroids such as dexamethasone (choice B) is not recommended. The most recent evdence has demonstrated that any beneft of systemic slersids i no sufcien o outweigh te isis Enmivctatine tenofovt, and efavirenz (choice €) are medications that make uphighl) active anbretovral medication usedte teat HV Infecion. Abiough HIVINDS patlonts nave an ineweased isk or zor, this patent does not have signs or symtoms of HV. CGancicour (enoice O} Is an antral mocicaton used 1 west sovers @toregalowusInfoctons in KIVINDS patonts ot postirensclant CMV complications itis not used test zoster \aricelzostervnis reaction (shingles) is characterized by a proctome of sin followed by an erution of grouped vesicles on an cethematous base in a dermatomal distbution Postherpetc neuralgia a pin syncrorne that ay last months ater V2V reactivation. Early treatment with systemic antral herany such as acyclovir or valacsciour can reduce the seventy ofthe acute eruption andthe Incidence and severty of postheretic neural. (€(29.0F). Examination is shown. There is no hmohadencpsthy Laboratory studies show.Err "ATayearold man develops a pati, re rash {hour aller undergoing an anciogram He has hd no ip sweling,shorness of reat, Gdarmes, or absominal pain. He nas ahistoy cttype 2habetes meliis, ange underwent coronary ater bypass graftng S years ago. “Current mecicatons induda motrin, asp, and amprazoe. Ho rogots an aetayogenfclin He i inno acu dstuess. His lemperaiur is 36.7 (28.0%), blood pressure 130180 mm He pulse Tamin, and respirations 18min. Examination ofbe skin shows amuse enters ana edema ore eylits.The née, sodomen, back anc prowmal enemies nave dlscree ana contuent nmemsious ‘macules and patches ta blanen with prossu, Dermographism is presen. The fomaindorcftie examination Is unvemarkabo. Wich of ‘ne folowing s the most ely uneing mechanism forth patent's sii lesions? OA.Cel-metdated hrersensitity OB Cytotode mypersensiity (© 6 iret mast cegranulabon © D.IgE meaatea nypersenamaty © E:immune complermedictes mpersenstivt “The correct answer Is C. This pallet nas developed an immediate Mypersensittyreston 0 Intavencus radoeontrast medum a a resut ot cect matt cal deoranulston. Such reatone are alferon rom IaE-medted nyoersonstity restos (ansphviactc reactone), 36 tne are not IOE-coponcent and do not regio cit sensitzaton. The testmont is tne came in bath reactons, nowoyet. The seventy ofthe rescionis oten deserved mle, madera, or severe Wild casee pnmarlyeshitit mucneanecus symptoms ‘suchas uficana, angloegema, and nausea, wnereas severe reactions incuse reepirsery dsress,hypatensan, andcarciac arytmias Dect elaase of mast.cell medifors can be especialy problematic in indviduals wha have mastoctosis, though all patois ae potently suscepubie io such reactons. Examples of poten masl-cel deoranulatng agents ole tnanracioconast ‘aleals include aspirn and other WSADDs, alcoho}, opiates, polymypn B,anichalinraic agents such as aiopine,andvaous ‘systemic anestotcs sven 3 tupoeurann. ‘TypolY col:medated nypercenciivty feactons (enolee A) afe exempted dermatological by aera contact dsrmats. Suen ‘teactons require several hours to manfest wth signs and symptoms of disease, and act oly indkiua's prevously sensitzedto the ‘contact llergen Common contact allergens inthe general popultion clude nickel sufste (metal alos), potassium dichromate (cement, leanats), paraphenylenediamine (nar dyes, photographic chemicals) and mercaplaberaothiazole (uubbet) to name afew. Typell hyparsensivlyis also known 2s ofcloc (choice B) hypersenstty and may afecta vate of organs and tssues ‘Diuc-ncucecnemotic anemia, ranuloctopents, and ombocytopena ate erampes of haplen-mectated disease. Type Hl ‘ypatsensiovy is mediatad primal by artboaes of te Igo IgG classes togebiar wih complement ‘ype | nypersensituy also known 2s enaphyacic reaction sa result of IgE-mediated nypersenstiMy (Choice 0). The reaction may invoke ston (rtcai), yes (conjunc), nasosharx (minonhea, hints), bronchopulmonary tissues (asthe), anc astcntestinal act (pow wal edema). may cause a range of symptoms from allergic shins to anaphyactc shock and death Type i hypersensitiy is also known as immune complex hypersensithity (choice F).Cisical examples of his frm of hypersensitiy include serum siciness, systemic lupus erthematosus, he Aus reaction, lupus nephris, polaris nodosa, and ‘meumatoid athlls. Tis reaction is mediate by salute immune complexes oflyG oF lo. Anaptylacoidreacions ar idiosyncratic reactions o substances such a ioncinravencus contrast and resulfrom the ect ‘degranulation cf mast cells bythe corrast agent IF nd prior sensiization are not required. Manifestations of hypersensitivity to ‘aciocontast media include fushing, runt, uficara, angioedema, bronchospasm lanmgeal edems,rypotension, shock. and loss of ‘consciousness. Other agents that may independent degranulte mast cells incude NSAIDs, sonal ociates, rolmn B, ‘antenctne‘olc agents sucn 2s atop, and various systemic ancemetce such ac moocursne'A62:yearals woman comes or aroun hean maintenance examination ne enes fever, weights, ortatgua She has a ison of Iypouroiism. Curent medicatons incude lvstyroxine anda rulttamin Her lmporaurs ts 27°C (98.8°F) Examination shows a ‘om, fim, nontencer, pearly nodule onthe lower eyelicimagin wih scents indentation nat nas mile using and wceration. There are ‘Some sal olanglecasise spreading outward fom tie lesion. Examination ofthe eye shows no abnormallos. Theres 00 |ympnadenopatny. Wich ofthe folowing Ise most appropiate next step In management? (© A.iosey andresocion of nodule win Fozan section examination ot supa! mataing (OB Hot compresses and topical antic ointment sppliegto lesion mes daly © C.tnasion ana crainage of nodule, apply not compresses, retumnto he cinicin 1 week (0. ntalesionalinjecton of long-acting corticosteroid follow up in 4 month OE. No further intervention ‘The correct answers A. This patlentnas a basal cell carcinoma (BCC), wih i the most common form a sla cancer and also accounts for approniataly 90% ofall malgnantiumors ofthe eval. Mis imzortantte note that. atmough ECC sho most common ‘malignanttumor of tne eyalid sebaccous carcinoma. high agoressive nooplasm, Is also possible n hs locaton, BCC cassicaly presents 2s 8 pear papule (see image) wi peripheral elanglecasias and a central ulceration as descivedin te question stem When a cutaneous malignancy is suspected, abiops/is slwaysthe mest apprepriste nex step in management Aprocedure unique to dermatologic surgey i the Wohs micrographic technique for skin cancer ecsion. This technique proces the highest cre rate ofall lreatments available for skin cancer and has the added benefit being the mos! tssue-spating surccal modal for stn cancer. The procedure invchas seal cisions with intaoperatve fran secon analysis of 100% ofthe peripheral and deep margins. Kis a abo ntonsive procedure recorvedor large or reourent tumors, tumors exhbring aggressive histologic benado, or turiors in ‘igh-tek locations, euch asthe eyelids, ip, vars, ng nose, Hot compresses anatopical antoioes (cnolce 8) can be used to testa norasolum (st), whieh is @waim and paintul lesion mt ‘curs onthe eyelid Hat compresses andtonicalanbitcs wil nothelp tis malignant lesion For nordoolum or chaazions nat nolesolve, an ophtaimoloast may perform an incision ang drainage (chotee C) Tis technique Is not aperocate tor sou ters. Inaestonalnjectons of ertensteroids (choice D) are used fora vary of eyelid lesions, icuding petsistent calzone and Kalle cats. This is notte teatment for basal cll eatcinoma, nowever, whieh mustbe surges removed. “The paian shouldbe ackised thatthe lesion, athough curable is dangerous, and tha fuer inenventon isnacessary (choice ). is varyunlitey to metastasize, howe ‘Basal call carcinomais the most corimon skin cancer in general ands alsothe mest common malignancy af he eyelid. Suspected ‘malignancies shoul! be biopsied for histologic ciagnosis. Dermatologic surgeons use the Mohs micographiclechnicue fo eat ‘ecurent skin cancets, skin cancers exhibiting aggressive biologic behavior, shin cancers in high-isklocatons, anc lsige tumors, This {technique provides the highest cue rate of all valle skn-cancerrestmenstem: 22 of 44 Pesode Io SaIEEET SN EET TSE ER oF ‘2Byearolaman comes'o me physician oecause oFa srnrash his gens notcea ons enestana back 1 week ago. He nasnea ceasional prutls ater oteccing He has nad no overs or walgtoss. His mecleat histo is umomartable. Heras no args to medications. He wor in a demanding eb and exercises in gym Srighis a week His mother die of areast cancer at age 62 years. He Is inno acute distess. Examinatonis shown, There ate numerous hypopigmerted patcnes wih 2 ine scale thats accentuated by rubbing over tie noek anlar chest shoulders, and upper vac. The romaindar ofthe examination shows no abnoumalits. which ottie folowing isthe most likely underying mechanism fr this pigmentary change? ‘© A. abnormal tanctor of melanasomos 0B. Autoimmune destucton of melanocytes © G. Competitive inhibition of rosinase by azeaic acid OD. Lysosomal detect © €. soitntitod physica vauma“The corract answers C. This patient has tnea versicolor, a commen skin infection in young adults. Tinea verscoloris caused by the hyphal form ofthe nondermatophyle dmerphic fungus Malasseziaclabosa. Wis Wpicall promoted by exposure to warm, hui fomifonmonts and Is commonly encounteredin poopie whe ongage in gular stonous physical acy. IIs charactrzoa by hrpostgmentes oval patcnes wih ane everng scale most commonly onthe chest shoulders, and back The mypostamentaton resuts tom competive iniaton ofthe enzyme tosinase by azlaic 3c, 2 clcaraonic acd produced bythe mypnal frm ctihe yeast ‘Apotassium hydroxide preparation from scaling lesions wil demonstrate short yphae and round yeastforms Cspagheth and meatballs"). Hycooigmentaton may persist for months folowing treatment of he infecton because of lasting melanootte tocty caused by azeaic sci. Slo though, the afected areas wilrepigment Abnormal transfer of melanosomes (choice A) is seen in Hermansky-Pucak symdrome and Grscall syndrome, both _aulosomal-recessive disorders in cellar tacking machinery characterized by generalized pigment cuton Auoimmune destucion of melanostes (choice B) is oe ofthe hypothesized pathagenelic mechanisms of ili. A cyotoxic ‘ymohocite-medated reaction would be responsible or aactucton of melanocytes in well demarcated areas, producing thecal ‘wal demarcated, denlomentedlestons surrounded oy normst-aopearng sin. Tetcly,vilige manvestsn acietouton voting the ‘hands, toe, extensor sunsess,perortl aco, and conta regions. |Alysosomal defect (choice Dis responsible for hyporigmented skin lesions seen in Chesiak-Higashi syncrome, an ‘auesomalecsssive disorder characterized ty oculceutaneous albinism and immunologic decency. Gant inrsetapiasmic inclusion bodies are seenin neutrophils and malanastes. This causes dion of pigment, with mypepigmantaton cfthe skin, hair, and is Seltiniced physicaltraume (choice F) can resutin hypo or hyperpigmented macules and atrophic scars on areas of he body within easy each ofthe hands. There are no primary lesions, only excoritons and scaring wih postinfarimstery dyspigmentaton Tinea versicolor is caused bythe nondermatophrte dierchic fungus Malasseriaolobosa.Malasseria causes derigmentation through Iniotion of trosinase and txt to melanocves caused by he Gesrbowc aod azelaic acc which is produced bythe hyohal form of ‘to organism. Tinea etscolor is charscorzoc bynumercus nypoplgmentec maculse wan afin scslo'A‘Gxjenrold gt comes ta pysieian bacause of = sever sunburn afer mouing te lawn day ago She stale hat she nas never ‘nag sunbum ike is betoe. She does not sunoame or use indoor tanning Gevioes. She nas a ston ofasinms and acne. Curent mesicaions include inhaled fulicason, inhaled abuso orl dasycine, and tical benzo petorde. Skin rain shows deep red ‘enthema onthe malar chests, dorsal orearms and hands, and te cnest The remainder of he examination shows no abnctmaliies inch afte folowing te most tkoly cause of is pants conattan? (© A.antbodies arcs against nctoar antigens (0 B.Complerent-mediated vascular intamnation (0.6 tmmune-meciatd reason te ulailt ight (© D.tneracton of uate ight wih benzo peroxide OE tneraction of utaolet ight with consoyeine ‘Tue correct answor Is E. This patlentis mostly experiencing a photloic dug eruption caused by UV light ntracion wth ‘dogoyina. Proto dug eruptions may oes. in anyone, and because Mey donot depend on immune mechanisms, they donot ‘require a period of sensitization tefore causing sreackon. Pootoi dug reachone result fom the interaction of ulravlet ign th ‘he drug in queston within the skin. When certain drugs (or ther meteboites) are struck by ultra olt ign photons, reactvecxygen “species are generated that direct cause necrosis ofkeratnoets in he epidarmis. This process isnot une 2 simple susburn, in \wnichovee6sWo cosos of uraxolot ght overwnoim colar DNA repalr mechanisms ang ezuco te afocod keratnccros to undergo ‘apoptosis. The aMerence les nthe fact nat much lower cose of utevlet ightis required to cause severe sunouTT-tKe reactions Clinically Patients ofen present wih enthema consistent with sunturing in reas typically exposed to sunlight during routine aches, ‘as described inthe question Severe cases may present wih biseing, whereas chronic cases may present with finger dst ‘caused by damago tonal mati Kerainocrtos. Commonly implicalod drugs include toacjcines (parleuay duryeyno tlazides, ‘sulfonamides, tueroquinclones, and NEADS. Systemic lupus erthematosus (choice A) is 3 multsjstem, autoimmune condition causes by antbodies against nuclear antigens: t ‘ay present wih cutaneous Fading (nchusing photosensibvly and a malsr erupion) Systemic symptoms, however, especially cit symptoms, would be expected aso. Dermatomyosits (choice 8), which results rom complement meatated vascular Imammaton's 2 conaiton in vinih patents exh Classic cutaneous findings, such 23a neliotope enution, shawl sign, Gotton sign, Gatton papules, an rapged cuticles with prominent capita loops in the prcsimal rails. Polymorprious ight eruption (noice C) Is an dlopatic immune-medFatedreacton o ulaoet Hot exposure characteraed by contuent prunte papules ang plaques In photocisticuted pater. Srvad zones of enmems consistent win an exagaersted suncum fr 1895 common n is conaton, ‘Berzoy!peronide (choice D) is opical drug thats usacto tea mild formadstate acne Although patients using his medication can ‘sunbum more eas iis nct associated wih a photoioc erupion caused by WV lightineracions and hus does nol cause reactions ‘5 severe a¢ tne eruption presented in gatontsroeetng cowcrcine Prototodciys aronimmune reaction caused by te producton orreactvs ciygon species telewing excosure to urate tight (causing kerainocte necrosis) The sunbum of chetotoxict only occurs in sun-excosed ateas. Medications that cause phootodciy Incude doxoyene,tlaxdes, sufonamides, tuoroguistones, ana NSAIDS.‘Aad-yearold man wih a 2-ear history of @rash on his scalp, face, and chest comes fora fellows examination the rash has persistes ‘espe teatment win topes ketoconazole, open conicosterlas, ana cue coaHar snamgoo. Te rssh snot pail, out hasbeen fehy fon cecasion Current medications include topical tiameinaione cam He's avteran who fought inthe Gut War He has smoked one ck ofcgarees da tor 25 years Examination snows enrhems wit a weny Seale onthe stp, e8r3,mictace, and central chest, Which of he lowing complicaing actors is mos iy to explain the weatment resistance ofbhis paints disease? (© A.Agent Orange exposure © B.coaitar eatenogenesis © Gata seropastty (© B.Pirosporum colonization © E-Staphococeal superinfection ‘The correct aneworis C. This patlentnas a cassic caso of setormeic ermate. Seormeledarmatite Wpleal aes the sealo {600 image, ears, prosuriclar tos, contal race (cartels he oyeDr0Ns, mesonaca folds, and moustacho regions}, anc corral ‘chest. tipcal eruption is characterized by faint enema, oly skin, and waxy scale. The cause of seborneic dermatts has nat been completely elucidated, butts likely the resut at colonizabon by Payrosporurn ovale, which is sutsequenty atacred by the hosts immune system This explains the use ofthe most pica treatments, which include topical antifungals (ksloconazole) and topical antflammatories (ccricosteroids) Crude coal-tar shampoos also effective butts mechanism af acon, whichis most likely antntammatory, is unclear Seborle dermatitis nas Deen associated wit Parkinson disease, HIV nfecon, eplepsy, and certain rugs. in gatonts who are aznefert to therapy and who domonstate eebormnelc deimatic Matis rcictantto teatment testing tory eropoctvty should pe considereg, because seDornelc dermatts inthis population ic goneraly amcut to rot Agent Orange exposure (choice A) has been associated wth chlorsne but oes not cause sebonheic demattis. ‘Ctude coaliar (choice 8) is = polenta cacnogen on the shin buts also 2 widely accepted therapy fr inlammatoy dermatoses, “such as sebotthsic dermaiis and psoriasis. Fyrosporum colonkation (choice D} Is a possible cause of sebormle dorms, lis Not he reason for westment resistance in is patent nowover ‘Stapnvfocooesl supenintecion (choice E) nas been shown to cause testmenteststant eczema; eaiment of tne staphfococcsl ‘surennfecton oten leads to improvement in eczema in such patients. ‘Sebortheic dermal is characeized ty waty scale and mild enema onthe scalp, cena face, and midchest HIV seropostnly anc Parkinson disease are associated wth seborheic dermatis: sebortheic dermatiis i patients who have His generally ificut io treat| z2-earold woman eomesto te physician because ofa 2-year stony of spots on herfoce nd angers tat began a3 sma ‘aie-colare areas. They stow eriaxgea and nave not ekumedto he normal skin coor Hor medical Noy Is urwemarabe, She works 235 acid engineer Her mother has hrpotyridsm ander father has hypetipidemia. Her lemperaiue is 37°C (98°F) Examination is shown ‘There re several seplgmented patches surounding te patents eyes and mouth Which ofthe flowing is the masts esuse ofthis patents contton? © A-autormmune sestucion ot metanoctes © B. Damage to motanoesies by acarbowicadd © .porecve proauaion of melanin fom twosine (©D.Exposu to phenols © E inocton win ade ast vastus ‘The correct answers A. This patienthas a classic presentation of utlign. Viigo hae no racial or gender predlection, out 2 reported more requenty ty patents who have darker pigmentation an by eras because of increased wstity and cosmete concer. Viigo isthe result cf autoimmune assault on melanccytes. The regions cf skin fected byviligo are described 2s ebigmented, because no melanacies or melanin remain n these sts. This must te afereniated tom rypopiamentaton. which refers to a decrease in pigmentation, nota complete absence of plgmentston. ecause vig is an autoimmune ilness, it has been ssociated wth other forms of autoimmunity, doth inthe affected patent andin the family. The mast common autoimmune disease ‘sociated with villg is autsimmune tyridds, both Hashimeto and Graves. Othe forms of autoimmunity associated wih vligo include pemicious anemia, Adison disease, alopecia areata. and diabetes mellus. Villgo classically aects the dorsal hands (see image), perioral sites, and genital with depigmented patches that enhance on Woods lamp examinationDieaani aaa (enolee B) isa chemical produced by ne runqus Walsssoaiatunur (Prvrosporum oialo), he causatve agent ot nea vorseoor. This enomical causes nypoplomentston,nct copigmentaten, pall on tne shoulders, rack and chest Ooulecutancous albinism consists of 4 suttpes ofinnenites disease charactenzed ty a decrease in igmentston of he sin, nar. ‘and eyes; these diseases are caused by detective production of melanin by melanocites (choice C) Exposure fo phencis (choice 0), chemicals foundin clearing products, causes hypopigmentation ofthe skinin the ares of exposure Itis more commonly found in patents wh havea histor of prolonged exposure to chemical cleaning agents (ie, job as a janitor or house-deaner) Leprosy, the disease caused by Mycobacterium leprae, which is an acdfas!bacls (choice E), can cause hypopigmented macules. 11s unt ini gation, wno gies no hist of ving ortavling io an endemic area ‘tiga i an autoimmune cisease cnaractrzed by destucton of melanocies, resulting in cepigmerted patches, mast commonly affecting he periorfcial ace, dorsal hands, and genitalia Viigo is frequently associted wih other autoimmune disorders, most commonly. hyoid disease (Hashimeto or raves). reeaereor ry ‘a 3eeareia Woman eames fo Me phsiaan Because oTRumpS Mat nave eveloned on her garages or 3 mons. Se states hat hey hav boon lay ana nave 2e9n enlaaing She nad nor oats pietead 8 monins ago. Hor medical histori unvomarkabo. Examination of her ears shows Blateral rubbery, skn-clored nodules on her posterior earlobes adjacent tothe sites of he piercing. The) are ‘somewhat mnie ana are tener to palpation Examinaten ner back ana shoulders are shown. Which cf Me following is he most appropiate net step in management ofthe lesions on her ears? OA. Compressive earings © Bimmeaate sugieal excision © Ccintatesionaleontosteots nection OD. sistemic coricasteroias (OE Topical coticosterid ‘The correct answers C. This patent has Keloids that are inthe proliferating stage is important to make the distinction between kelolas ang hypervopnic scars. Both nyperwophic Seats and kaloigs ae forms of excessne collagen deposition al wound sites, oth arg more eommonin indvdvals who nave darker sin plomentaton, and vo ypically Gccur a body ses under regular tension, such a to cnost, cack and shoulders. n contastto nypentophic scar, kolols fend o tow cusico of he poundares ort enanal \wound and ate npleal sesoctaos win craDiie projectons om Me onginal wound 60, as cssarced in me queston.Kaloids alco tend nt to ivlute sportaneousty, ten to recurfollowing excision, and tendo be pain. though here is no completly efechve ‘reatmentforkeloide and hypenrophic scars, the use of inalesional corkcosteroids (ofr flowing preteatment wis fqud vogen cryotherap)is the treatment ofchoice Prevention of keled formation has been ater using avait of reakmens following surgical procedures on pallets prone to keloid. naoperae or postoperstve coticosterclds, inteton, &-Auorourae, bleomycin, compression dressings, dressings composed of scone sheeting, postoperative last reaiments, nd pastoperatve radiation Meraoy havo al Deon atormpted, win marginal ane varabio success. ‘CompreseNe carnnge (enolce A) are used io proven kloiss om recuting atte sts ct ner excision on no sarones. They may Do cfecve in some cases, but only fused before te Keoishas fred. Appiing compression to already exsbng Keloids will ot Improve ther appearance and may be extremely uncomfortable or painful forthe patent. Immesiate surgical etcision (choice B) isnot recommended, because recurence is pradicaly guaranteed unless the abnormal olferave stata is cutaled before surge. ‘Sstemie crtcosteroids (cholce 0} arerot efectve in tie ueatient keloid. The Ussue levels ataled win systemic tnerapy ate ‘ot high enough o strestarropiast acy, and tne aqverse etocs ct systemic cortcosterlas cutwelgn the pon Donate ‘Topical cortcosterolds (choice £) nave almost no afoct cn kelocs. Massaging the now scar tes = day win 2 Muonnatog coricosteoid creams recommended athough most ofthe benef may be the resultof massage and not of he medicabon setKeloids are benign fibrous growtns of scar tissue hat extend beyond the borders ofthe causctve wound with near prjectons and pseudotumorlike growth, Keloids tend tobe symptomatic tender. pric) esryin their course. Trestment of choice inalesional ‘cofteostericinjecions. ExisionIs discouraged because tne chance of recuencels ety high 9) 42,bar oldman comes to he omeigeney department Decause o 3 pant acon on ns rig bute Tor 1 Wook. Tho lesion Nas been ‘taning pus fr 1 day. Hs madical isto is unerartable. He doos not smoke bt ho dass inka bate ofwino daly. He works a6 3 rmecharic andis frequent exposed oil and machin ols. Examination shows an enberrsous, edemstous, &-cm, indurated plaque on ris night butces hat nas mutiple necrotic, suppursing focuar asta wit The plagues ildehned and blends ite the surrounding ‘fn. Theres maursin papsoie beyond me enthemstous ecge. Which of te foowng Is te most key agnosis? OA crounce OB Epicermal ost Oc Faitcums ‘OD Herpes sirtox (© Eterpes zoster ‘The correct answeris A. This pabenthas a carounce, scalecton of mulicle canuentturunces wih separse felicular ostia. A furunal, ors bol fs an acute, round tender, crcurnscrive,fliculer abscess that generally ends in cental suppuratin. The lesions beginin hairfolicles(liculs) and contre for 2 prolonged period through ausinoculabon. Several adjoining furuncles wil coalesce Inte 3 painful, erythematous, edematous, mulple-veaded plague called 2 carbundle, The lesions undergo cental necrosis andrupture onto me sian, cecnaroina purist, necrotic deons. Common sites are tre napa tthe nock (eee image), axlize, and eutocks,Patonss ‘who have lorgecarbuncies wil onen present wih fever and malaise ss wel ‘An epidermal et (choice 8) san often fuctuant,fnse swelling varying fom 0.5 to several centimeters in ameter. The surface of the lesion is emootn an shiny rom the undoriing pressure anc onen damonstats a contal punctum, Macorst koratn and choosy ‘sebaceous material comonse tne ost contents. wil ecur ifs incomplete excises Folicuits (choice C) iss suparfcialstaphiocceca infection otal flicles that presents 28 small thinswalled pustules atthe folicular openings. Most commanly they appear onthe scalp, stound the mouth, or onthe eames. These aol yellowsh-wit, {dome pustules develop in cops and hea i afew days. Stapnylococcus aureus is the most common cause Herpes simi (enolce 0) iris (5) infecton usualy Dégins van 3 prodrome oftingtng or Buming Yor several ours fooWed Dy ‘ne appearance of atender. enthematous plague studded win Wenehicent orauped vesicles that easy rupture, cust over, and usualy heal within 7 fo 10 days The most common locations ate the poral mucosa andthe gerial ares,Hames zoster (choice E) or shingles, is caused by the varicella zster ius. Clinical, a procrome of pain may orecede sin lesions j Several days. San lesions aro usualy located along 2 dermatame and ta me form of aroupod vesicles onan on7namatous base ‘Acarbuncte resuts rom coalescing fruncies, wich themsehes originate most often from folicliis, sn infecton ofthe harfolce. ‘can be accompanied ty systemic symptoms sucn as fever and malaise. Capuncies and uruncies most cornmonty oecut on Inae-beating stn exposediotcton, suct as the butbets, alae, and nape of the neck ‘A 15:7earola boy comesto te physician for aduce about Ns fata acne. He Is very concerned wi hs appearance ana wnen questioned, tno says hana washes his fa wo Umos a day mi a vor id soap. wos to cata heathy wal: balanced cet butlows chocoata and ‘pic foods, He plays onthe righ school unirvaraty basketball team. On examinaton, the paienthas mildto moderate sene, masty ‘consisting of open comedanes, som cosed comedonas, and a fow pustlos on Be forehead and chooks, Tha rmaindar of no ‘eaminaton is unremarkable. Which ofthe folowing is the best acice to ve his patient? (© A.avicance of enocoate anc spi foods (0 B Frequent face washing with stons soap (0.6.oral weatmentwin soratncin (©. Topical anptcaton ot retain or acspaiene (©-E-Treaimant win oa ansbatic ‘Tmo correct answor's D. Acne vulgans afects the majony of agolesconts snc is more orovalont n mals. Hormonal ntuonces, abnormal Kerainzaton of plosebaceous units and colonzaton ty baciena (Propionibacteum acres ) ae important pathogenetic ‘slemenis,Trestmant of acne depends on the sever ofthe concton. Topical zpplicaton of comedaltic agents such as retinoids (Wetinon, adapalene, andthe new yeast-derived agent azalaic ac) i effecve frm fo moderate forms of nor-intammatory acne, ‘craraconzed oy open exmedones. Dal applieston of ose compounds vil rosutmimerovernont thin soveral wocks ater staring ‘teatment iid skin maton and sealing may be minimized by staring wit iow-concentaton creems, and then orogtessh=ly Increasing the concentration Ancther side efecto enoids is increases phetosensitvy, The patient mustte instucteto avoid prolonged exposure tothe sun and fo use a sunscreen ‘Avoidance of cnacolate and spicy foods (choice A) wouldhave no beneficial ects on sene. Ris well estabshed tat tere sno ‘cotelaton petween acne and speci tines ottoods. Freauentiace washing wih strong soap (choice 8) wil probably cause exacerbation of sone. This sion condtion isnot causes by cit Gente face washing once orice daly wih mild sozps is recommended. Oral treatment wih isctetincin (choice C) is used for severe cases of acne nol responding to topical comedolsics anc antibiotics ‘This compound acts by dacreasing sebum producton. in sdciton to vanous NBOs o side ofoes koretno!n Is teratogenic. Female patents of cldbeanng age snould be required o use efecive means of contraception ceoimning one month oefore westmentto one month ater treatment “Tresimant with orl anisoae (choice ) is simed at decreasing bactra colonization tis used for patents who flo respondto {topical teatments or have sevete forms ofiammaton acne, The anibolic of choles Incude teracycines and eratvoryen. ‘Tretncin or agapalone topical rotnca) can te used as monotnerap or stent o paints win excuswly comedonal aon. ‘Benzoyl geronige or azelaic acid could be added as adjuvant terapyimere isan intammaory component present. is Impotant to role that eating spicy fod or chcolate has not bean associated with acne, and that Fequent washing with sttong soap may aca ‘exacerbate the symptoms,'A25:yearaid woman comes othe physician because ct scaling sb since chlahood. Snehas a ister of alopy. Her mater and brother ‘nav nad siilareymptome. Examination shows a ganaralzedfne scale over the Dod. Tete ar0 Ketan lugs inthe otc of Nair folicles over ine oackand extensor surfaces. The alms and soles show hyperineanty. ich othe following isthe most likely ‘agnosie? OA.epidemattcnmperterateais © B.tonmosis toatis © .C.Lametiariehinosis © D.x:nkea eyosis © E xeroderma “The correct answers B. This patent has ichtiyosis vulgaris, he most common form efinhatited ichtyosis.Icthyosis vulgaris is an uosomal dominant hsorder resulting Yom a dfect in profiaggrn. The concen usually begins in cahood and is characterized by 2 goneralzod fro, white scale that classically spars te exutal and inforuginous aroas. Hyporinear palms and solos aio charactanetc mains. Assocatons clude atop and Kertosis plans. This 6 Denign conditon mats rated consenatvoy wrth ‘2g0rossWe moistirzaton wit Dland omolonts and use ottatnng proquct Wee ot ayes and taotances. Patents cton rare Deter ‘when thing in war, uri ervronments. Epidermottenyperkerstosis (chotee A) 1s a fre, sutosomal-dominant ienthyosts resutng tom defects in keratns 1 and 10. nis manifest t th 2s cfuse enema wt enicermal sloughing (bullous congenital icthyosform entocerma) [Lamellar ichhyosis (choice C) isa rare, autosomalrecessive form of iethyasis arising ftom a defect n ransghtarinase thatis| ‘presenter bh ane causes large plates scales over most cfthe body Infants who have this condition are olen born 48 ‘callodion infants “Xinked icthyesis (Choice D) isa relatively common form ofichthyesis resulting from a defect in steroid sulfalase: Only males are ‘atecled because De disease is inked recessive, The scale is similar to hat of erhyos's vulgaris, Oui tends to Favor Nexor and Ineruiginous surtaces. The palms and soles are ypicaly normal. Cassie features incude Flue o onset of labor and ‘coma-shaped corneal opacities. orodorma (choice E) 1s 3 mil, acquted orm of iy sido, somotmos wit cracking or mid scalinglehithyosis vulgaris is inherited ss an autesomsl-dominantcefectin proflagann. is cnaracterized by generalized fne, white scale thet Spares tne Nexures, as well as hypercarato's‘A 35.year-old woman comes lo the physician because of ful breathing, non-producive cough, and a rashfr 1 yer. Overthe past 6 monine, nor shonnass ot reat nas worsened and ner coughing nas Invessed, Sno does not smioks.storal wheszos are neardon auscutston. Her serum esicum lve 15 12.1 mg. Aniniaderral injection of Cencida angen ects no response afer 72 nouts. AN 21a fm ofthe chest shows bilateral hilar fulless. Which ofthe olowingis tre mas ely cutaneous finding in his patent? (OA Enthema marginatum © B.enmema miorane (© Genter nodosum (OD Pyoderma gansrenosum (© E-Pyogonic aranuloma ‘The correct ansueris C. This patients sufringtiom sarcsidosi, a multisystem cisease wih numerous mniestations and an ‘uncertain immunologic evology. Sarcoidosis Is mast common in populations thatve awa om the equator. n te United Sats, ‘sacoldasie i most cormman and most severe in Afican Americans. The most common presenting icsues af reaprtary and ‘catsnecus asease. The dagnosis ofsarcoldsis nes 3 requiterents: cinicl ang racograrhicmnaings suagesive of sarcoidosis, ‘clusion of othe similarly presenting d'sesses, and histopstlogic examination ctissue showing non-csseating granuloma This pallet has anergy the lack of response ale inradermal injection of foreign antigen, wich can also be seen in palients who have ‘sa1coldosis. Hypercalcemia can also be seen In patents who have sarcoidosis, a 2 result of increased actly by macrophages. ‘Biopsy specimens of afeted crgans (Le, skin lungs) can also support the d-agnosis. The mast common culanoous manifestation of ‘sarcoidosis enthems nodosum (EN), whieh is characterizes cinicaly by tender, entreratous, subcutaneous nodules symmeticaly ‘dstrbuted on the lower legs. EN is panniclts andis nota diectresult ofthe granulomatous inammation characteristic of ‘sacsidosis tis heteore regarded as anonspecifc sin fincngin sarcoidosis Specific skinincings are dverse buypically show ‘ranulomatousintammaton yoical of sarcoidosis on histopatnoly. [Enmema margintum {choles A) 16 an annuiar nema associated wi meumatic over, potental complcaton of gous A ‘Streptococcal pharm. EEnthems migrans (choice 8) is an annular enshams associated with Lime disensa, caused bythe telebome organism Barrelia urgdorter, yodaima gangionosum {choice D) ica pustuar and uiceratne dsease matrnay occur on Hs own or in assoctaion wth Itammstory dowel cisease or omer systemic tinesses (malignancy. arts). Pyogenic granuloma (choice &) is 2 common vascular growth Vabularcapilarynemangiom) that may occurin adults or chore. is associated wih pregnancy and sites of ecent minor uma [Entnema nodosum, a tender. enthematous, subcutaneous nodule, isthe most common sin finda in sarcoidosis. The histopatnoloaic lesion of sarcoidosis is a non-caseating aranulama, Other ndings in sarcoidosis include hla ymphedenepath, Inyprcalcerntamypercaleula, and anergy.‘4 38,yoar-old woman wih HIV comes too physician because ofa 100k history ofa progfassivorash on nit face, arms, and ans. She denies fever, puri, nicht sweas, or weight loss. She kas no medications. Her temperate is 208°C (98.2°F) bloodpressure 12680 ‘mim Hg, and pulse 82min. There are rumerous papules win central umbitestons over Me ace, uPper and lower enemies, anges, and tho paims of ie hands. Ther ae no lesions on Bi fee The romaindrof te vaminalon shows no abnormalles. CD4+T HrmghocAts counts 100 cesimm?. Which af thefelluing isthe mos ly agnosis? OA Disseminated vacela OB Enthera muttrme © G.enihema nososum ©. xap9s1 sarcoma © E:notoscum cartagiosum (© F.ptiiasis rosea O6.scabies “The correct answers E. This woman who has AIDS nas developed molluscum contaoiosum, 2rash characterized by waK, peatly pues tat nude a “cheesy matortal when squoezed. The ctology isthe human cows. To aiseaso ie so0n in Immunceamastent and mmunocompromised indduas, cut n he later Wels to be alsseminatec, most commonly in these vmo nave low CD4+ T Iymphoeve counts. The papules are asymptomatic and nenprutic an important ciagnostic ue. They canbe contagious with drect contact In immunocornpetent patents the cisease is setsimitng and does not need speci teaiment Fistine treatments for molluscurncontagiosum incuce fessng,cuetlage,cantharicin, and podotloc In immunocorpromised patents, ona, ito, or Initon or highly acuveantratoiral tnerap (net alaay receiving It Is used for veatment DDiscominatod acl (enolce A) Is ypcaly prute oF painful and the lesions are In dmerent stages of developmont, cnaractestics notaescnoes nts vanete Enmems mutiforme (choice B) is a cermatoloac mantestation chetactetzea oy targeakeleslons, especialy on ne palms ana ‘soles iis caused by some infectious agants, autoimmune disaases,andug and vaccine reactions, HW has not been daseibed as _attigger for enfhera mutiforms, Enthema nodosum (choice C) isa resulta immune complex deposition seen in many cisases. The typical appearance is = ain, ulcerated, raised, and red nodule found onthe anor surface of the lower eters. Kaposi sarcoma (choice D) coneisis of Mat ofen pupiscolorecpiaques, etcnos, or nodules on ho sien They are usualy located (on th lower exromos and trunk ie caused by KH-9 ands toquenty seen n catonts who nave acvanced AIDS. Pitiasis rosea (choice F) isa pute eruction thet begins witha red scaly heraldpatch 700 80% ofthe ime. then evolves into.a ‘isseminsted macular rash that spares the palms and soles, ‘Scabies (choice G) is caused by an ecoparasicinfecion ands hpically extremely prutic and more predominantin skin flés. The ‘superficial burows produced bythe parasite are often seen Inimmunacompromised patient lt can be disseminated Notusum eentaglosum Is charsctenzed by mutple Benign shiny papules tt ae ursbilcated ane nongrurte. Cheesy white material ‘ano squeezed rom lesions. most eommenty sean in immunceompromised patents. Forimmunacompetont patents it nods no spectre teatment for ne irmunceompromised, teat wih lomavt ox cdot.ern ‘A 73earold woman comes tote physician oecause ofa G-montn histor ofan enlarging dak shin lesion on her ignttemple. She had al col carcinoma removed tom nor ac 2 years ago. She Nat a history of labels and nypetansion, Curent mediatonsincude imaternin, pentootiing nd ntedipine. Examination shows a2» em, dat brown, wa, Kea plaqua wth a verucous suace punctual by multe psoudooysts onthe righ fovenead appears to bo pasted on nor face. Gente sexaping a he suTace causes keraote abso csiodge. When of he fllowngi the most ely diagnosis? OAs keratosis (© B.Basa cet carcinoma OC tetanoms (OD. senonmec keratosis © E-soler tengo “The correct answeris D. This patenthas developed a seborheic keratosis on her ightemple, Sebonhsickeraloses are oval tanto lack, sharply demarcated papulos or plaquoe witha stuck-on appearance (cow Imago). Taro ate alco at (macular) and ‘nonglamenteavatans. Thay aro most commonly located on chrcncally sun- (©.A.Drug rashwiheosinopniia and systemic symptoms (DRESS) (© Benheme muttorme minor ©.G.serm siemess ne reaction (OD. stevens tonnson sinerome (© E-Tode opigorma necrosis ‘The correct answer's 0. This manis surfering rom Stevens-iahnscn syndrome (SIS) SUS andtexic epidermal necrosis (TEN) (choice) exist on a spectrum ofdiseases invehing epidermal nacralysie (EN) Seth diseases invoke painful erosions and sloughing ofthe in and mucous membranes: the key cision is that GUS volves sloughing of ese than 10to 15% of the etl body sutace _102 (TESA), whereas TEN invoNes ~308% of the TESA The sloughing of skin by genlle traction on examinationis releredo a5 the Nikotsy sign. AGlagnosis of ether $8 or TEN also requies the imoleren ofa least 2 mucous membranes. The oral mucosa is almost unvarsaly ateciod, ctor commonly invoked mucosal stes Indude the eyec, genitals, and upper aerodgestve rat (coe |mage)-For this reason, ophtnaimoloaic care and away maintenance are nacvesary ness palms. EN, which sal rofrs to widespread aportosis of epidermal cess the ful of eal-medtsted ofatodety andis most common te resuit ot wpersensttvty toa dup Rare cases have been reporesin association wit Mycoplasma pneumoniae infecions, and these cases tendo imo the ‘mucous membranes alone, sparing he skin Commonly implicated drugs include the sutfnamices (a8 inthis paiant with TUP-S10), ‘phenytoin, shenobartita, and NSAIDs, but any dug may be implicated ‘Daug rash with eosinophilia anc systemic symploms (ORES) (choice A) is form of drug hypersensly cassicaly assocaled ‘win ancomuisantdugs, suc as phenvoin, The euption Is Woicaly erantieratous.Peishera blood eosinophil is commonly ‘noted, and invoWementf intemal organs, Suen 2s the Hae oF et, Is Nplcally manifested by alterations in te BUNIC or he ALTIST.rospachoy. Enthams multforme minor (choice B) is an uncommon cutaneous eruption thatis identi by charactesticenthemsious, farget-shaped lesions wih dusky centers that occur especialy onthe palms and soles. Enthems mulforme of tis tipe usualy does fot involve mucous membranes. is ofen 2 seliiniled process associated wih herpes simplay ius or Mycoplasma athough can be caused by medications, such 2s peniclins, phemyoin, NSA, and sulla drugs ‘Serum sietness-ke reaction (choice C) 1s an eruption charactered by annufat utara tnatleaves postintammator hyperpiomentaton (uncommon in standard uricara). Low-orade fever and aralgias ate also corimonly observed, but patients ate ‘ot usualy acutoW HL Cofactor Iso classical implicated anuiot. Epicermal necrosis consists of 2 spectum of diseases that include SJS (<10-18% TESA involvernent) and TEN (320% TBSA InvoNernent, These dsoiders may aise 2s a Mypersensitvly response nine same set of medications, suet as penielins, sua ‘drugs, NSAIDs, phenysin, and phenobarbital Clinicaly, epidermal necrosis is characerzed by fever, a painfulrash, epidermal ‘sloughing (Nikolsty sign) anc invoNementof atleast 2 mucous membrane sites.‘Asiyearold woman comes ote physician because ofa -monf history of an itchy sin ash Shefstnoiced 2 large pinkpaich on her rig tank Ten days later, many smalerregoish, seal spots appeared on ner stomach, back and shoulder. She expentencea rele ome Pruriis withthe use of lopcal seri cream. Her medical history is unremariable. Examination shows 2 cn mildy enthemalou, ‘va-shaped paten on theright flank. There are multiple 0 - -em erthernstous macules on the unk and back wth scale atthe parphary ofte lesions. Te longeradis ono esions are aloned wih te cutaneous cleavage ngs. Which oft folowing Is he most Wey ciagnosis? OA Pimasis roses OB Pscnasis gars (© e.senonmeisaermants “The correct answer is A. Pbyissis rosea is @ mild intammatoy exanthem ofunceriain etclogy but zssociated wih HH 6, 7,8, nd 2008-2010 pandemic HIN influenza Avirus. Mequenly Begins wit a single "heralpalch (see image) Batis usual larger than ‘succeeding lesions and may persist alone or a wBek of co Lofore the othe lesions appear. ndvidual panes are oval ot crenata and covered wi frly wsini4ed scala, hon tis scale shods, oon aporiphral colarete of scale remains. By thal Uma, inoution of ‘he neralg paten nas begun ana tre salmor-colored macular and papular alscrete and coalescing lestons staging away ater a {ofa of 3-8 weeks. The ily developed eruption has 2 Christmas tee pattem, vith the longer ais ofthe oval macules and papules ‘onented along thetnes of skin cleavage Treatments symptomatic as tis eruption is seiHimed. Topical steroids and orl anthistamines provide symplomatic relief to patents who experience prurts, butthey do net afecthe duration of the exuption.Feotasis wulgars (eholoe 8} isa conic papulosquamous intarimator sin disease Hat resents clinical with well domarcateg, onfmematous plaques covered win siver-wnite coherent ssle.TyoIcaly, he elbows, inees, umotlcus, lower back and scalp are ‘atected. may Deain atany ume, but hee are 2 peaks: n enlaren 1010 72years ofage anc acuts 40 to £0 Years of aoe. Sebortneic dermatitis (choice C) isan intammatoy stn disease that most commonly appears in teenagers or young aduts 23 Drurtic enthemstous patches wth greasy yellow or brown scale inthe scsip (especially the froniotemporal aire). supraorbtal area, label, nasolabial folds, exemal er canals, postrir ears, and anterior chest Tinea versicolor (choice D) 's & commen skin infection vnh the yeast Malasseziaglodasa in young acs in warm, humid feiionmenis Typical lesions consis of ova, scaly macules, papules, and palches on the chest shoulders, and back They fen ‘29p6ar as ypopigmentes areas Treatment should be atempled win a topical anituncal Varicella (choice £), or chicken, an infectious disease mos! commonly seam in ciléren from counkies where immunization for this isoaso fe not rowinely porformed is caused bythe vaiolls zoster vius and is characterized by macules, rapulos vsices, and crusts in various stages of evolution, Firiasis rosea is characterized by an erthemaious scaling ruption in a"Chisimas ee" pattem, ofen preceded by 3 slay large lesion onthe unk knoum a8 a"haralé patch” Ris associaed with HHV-7, HEV-C, HHV-8, and H1N' influenea viuses. His almost always seltimiied and ypicaly asymplomate; opical corostorolts may bo used for ee of purus bu donot shrton to coutse ot dseace,‘A Byenrolaman comesto he physician or aroun heath mainienance examination, He nas a history ohyperipisema rated wih pravastatin, He ¢ rete tom nis|ob 23 aminer Examination shows numerous smallkerao¥e papules onthe palms ana Soles: tere are ‘more lesions over the henar andhypotnenarerinences. Thee is ahypetkeratotc plaque n the abdomen. The remainder ofthe {examination shows no abrotmaites. A blopsy specimen shows inasie squamous cel eafcinoma (SCO) srsing fom SCC mn sit ‘Chronic exposure to which of he folowing is most key responsible fr this patient's condition? OA arsenic OB.clvomie aaa Oe.coa dust (OD.Pars-phensienesiamine OE stics ‘Tho correct answoris A. This paletis suronng tem palmoplantar keratoses and squamous call carcinoma (SCO)in areaion ot tis ogy nsinas not been chroniealyexpesecto ultrayoletignt Chronic uttevolet excosure over many years ise mast common ‘isktactor for SCC, s0 oher causes af SCC shouldbe scughtvnen alesion ansesin the absence cf such exposure light. OF the choices chen, arsericis the most kel) cause ofthis paian’s palmoplanlar keratoses and SCC. Arsenic and aromatic hyrocabans ‘are wal now environmental carcinogens that increase Wye risk or cutaneous SCC. Chvonc arsenic eposue classical causes ‘inicalnaings simarto tose cesarted in he cnical vanete; spectcaly, palmoslantar“arsenical” keratoses ana SCCASCC in sis ‘in non-sun-exposed areas ofthe body. Endronmental arsenic exposure can occur inthe folowing occupational setings «Farming: Inthe past arsenic was present in bth herbicides and animal feed 1 Mining. Dect exposure while mining and contaminated groundwaterin mining towns ' somieanauctor manufacturing: Azonic 1s used in certain nonsiieon semeonauctars ‘© Some metaturalc ang alsss-mateng occupations Chromic aac (choice) i6 2 hight coreste acid thatcanraciay cause “cutaneous ulcefetios folowing exposure isnot known to cause malignancy Accumulaton of col dust (choice C) inthe longs can lead to coal workers peumaconicsis, This condition is also seen in miners Dutisrestictedto lungs, and itis not assceated with palmoplantatKeralosis or cutaneous SCC. Para‘gnensenesiamine (choles D) Is an aromatc amine fund in progucts such a8 henna, alr ayes. na venous oer POGUES. 1s a common cause of contact aera. ‘Cystaling silica or sicon iesde (choice E) can lead! silicosis, which is 2 foronedularlung disease. Excosure groups include eundy workers, quay worker, and sancblasats. This condi is associated wih increased rikfor primarylung cancer but nat ‘wit cutaneous SCC orgalmonlantar Ketatosie,a¢ seen inthis patent Chronic arsenic exposure can cause ware, arsenal keratoses on the palms and soles, particular over eminences. This twe of exposure Increases tne risk for SCC in all teas ofthe body, ncuding non-sun-sxpesed areas; SCC I enfonic arsenic exoosure oes not dopanc.on utravote exposure'8dD-yearold woman coms othe physician because of multiple pigmented skin lsions.Examinaton ofthe stn and scalp shows >100 ‘uns pigmented macclas from 5-10 min darneter Thelasions are most dense on sun-exposed skin avaral maculs have nctened Dordore and ae Sghty aeymmebic. These pamented macules are unchanged fom Me prevous examinston that was phatooranhod 1 yest ago. Which of he flloningis the most ily lagnosis? OR Apes nea 8. compound new Oc Hao new OD Lentgines © Eeianomas ‘The correct answorie A. Mctancortic now are vory common inthe general population. Apical new torment eaiog splaste now) _are an intermediate category between benign net and malignant melanoma. They ae characterized by size grater than 5 mr in {tion to any of he following: asymmetry, vanable color, and instinct border (sae images). Although nct considered cancerous themseves pattants uno nave atcial nev are at greater isk for developing melanoma, expecially when s patient has sumercs nev. Isolated dysplasic nev ate often excised to rule oul matanoma, removal ofall dysplastic ne has not bean shown to decrease the risk formstanema in patients whe have numerous lesions. In pallens whe have numerous nevi, such asthe patent described here, ‘carotu monitoring wit sera photographs or mole mapping can dently any changing lesions tal may vo undergoing malignant ranstormatio,Copmngrt CM SP. - Custom Metical Stock Photo, All Rights Resenes ‘Compound nevi (choice B) are usualy dat, elevated, > to €-mm lesions wih very regular and symmetric shape and eal. Halo nev (choice C) are pigmented macules or papules surtounded by = ing of derigmented skin Histology demonsrates lymphocyte inflarnmatin around the nevomelancces. Leniigines (choice D), commonly nown 2s eches, are fat, sharply marginated, uniformly pigmented skin lesions characterized by an increased numberof metanoojes in he Dasallayer oft epiceris elanomas {choice E) are olen asymmetic in shape, and the color varies more widely han in dysplastic nev, potently showing {an, brown, black blue, ed, of nonplomentod areas. AlMough anyingkdual lesion on tis gallon may cnicaly bo incisnguishabio ‘tom melanoma, is vey unlike) that allesons would be melanoma, Apical (hsplasic melanocytic) new display clinical characterises sinilarto melanome, such 2s size 25 mm, inegular borders, _asymmetn, and cole variaton. Although patents who have rumetous dysplasic nei have an increased isk for melanoma, removal of ‘all dysplastened conveys na improvement in iskfor melanoma Patents wha have djsplasticne requie close clinical and _selFmonilring for changes that may inicale matignant transformation.' 4b yoarold man comes tho physician Decause ofan Hey rat InN goin fOr WeokE. He has hadno role er using ‘orno counter anttungal cream. Ho nse nad no fevers. He nas ahistory oftyoe 2 dabetes motu conlled wih dt and nypetonsion ‘rested wih osaran. Hehas no known aegis to mesicaens, He does not ink or smate. Examination shows sharply semarcste, dy, own, sight Seay patenesalatraty m 8m gentocrural creases. There are similar bu smaller patches inte alae anc n fourth ‘nfrsigtal space onthe feet. Woods ott examination shows coral-edfuoresconce in a3 locations. Vitich of folowing isthe most key diagnosis? OA Enfasima O Bint O Ciirwerse psoriasis ‘©. sebonmeic dermatts (OE Tings cre Tuo correct answoris A. This paonthas the teal cinica presentation oferinrema, which Is characirznd by sharply delineated, ‘e¢-bronn, stanty seating patcnes inte interginous stess, especialy he alse, ne gentocural ceases, anc me interigtal weD ‘paces. The most common site otinvoWement 1s Between he fourth and Tah toes, where the disease presents 2s a macerated whte ‘plaque. Entrrasma i bpicalyasimnptomaic ut grain lesions can burn orien. The causative micvorganisr is the orapostive roo [Connebacterium minutssimum. Woods ight exsmination 's the diagnostic test of choice for patients who have enrasms, oecause pathognomic crated fuorescenceis seen, which resuls fom he presence of coproporphiyin Il inthe stratum comeum, Eecive ‘weatrienis include oral enthromysin and topical eindarycin ane benzo! petonae, Inteige (choice B) Is an itant contact detmatts that appeais in Iletiginous teas fom nea, moisture, and ficton. Wis most ‘common betwoan layers of pannus in obesoinaiduals. Shiny and mois pink patches are seen witin th creases and oon nave oop, nemoragi, and paintul fesutes. Stnging, butning and pain te common symptoms. Dring measures, use of gone ‘cleansers, and avclaance of potential ntants are me mainstays ofestrent. topical antungalis also etecve, Inverse psonasis (choice C) appecrs in itersginous areas such asthe axtla suommmar folds, and intergutea anc gentocural regions in theform of bight re, shiny, well demarcated slaques tpicsly wih no scale. Sometimes there ste ty pustules atthe 092s ofthese plaques, and there may be psonasis slaques on other ody ses, nverse psoriasis Nas a chronc course marked by remissions and exacerbations Woods ight examination willnct show flucrescence inimerse psoriasis. Seborhetc dermatiis (choice D) ypically occurs onthe scale, midface, and chest Redpnkpaiches wih evanescent borders covered wth a yellowish, greasy scale characerze this eruption In instiutionalzed paints or hose who have poor hygiene, the scale ean accumulate, mimicsing keratoses. ‘Tinea cuts (choice E) ie 2 common tnfaction tat may be caused by any ofthe datmatophytee mat infect ckin pidermapnston, ‘wirosporum, and Trenopmton). oy, pink-reg, se, annular, and poWacle patches appearin the groin and spread centugaly. In the toe wens, cermatopntesis usually presents wn Tick. white, macetate,Kerstolc skin anda ceep-sestednssufe atte botom ot ‘he crease, Woods light examination of fines cruns and'inea ped does not show fusrescence, [Enmrrasma ts a supemial pater inecton of me sien caused by Conmebacterum minuteimum Wafects imentiainous sites and ‘ata! woo szacos win wel demarcate rec-trovm patches and maceratod plaques, resnecwvey. Woods Hon axaminaion i “agnostic shows a corabed" Muorescenee caused by coproparpiin il depastion inthe sum corneum.‘A2,ear-olo man comes to he physican because of wcespreac prin coimshaped lesions on his snfor2 months. The lesions begin as chy patches of vesicles and papules tha ler ooze sur and cust over. He sales that some ofthe lesions have appeared lo heal and en resppdar at tio samo sts. The paflon nas 2 history of conical cy skin. Physical examinaton shows usted fenfnemateus patches and plaques on the extensor surfaces ofthe extremities and onthe buttocks. Which ofthe folowing isthe most ely diagnosis? (© A.Nummutarsermabis OB Fomehoine Oc. Poonssis (0D. Sebortheic dermatitis OE stasis dermatitis ‘Te correct answeris A. This ratent most ikelynas nummula dermatts,s common and chronic sien clsease ct unenown etoloay ‘hat manifests win eoi-e (nummular lesions of eccemstous derratts. The presenfaton Hlustatedin tre question stems ‘pil ‘Thehead strncaly spared n patents who have nummuar dermis. Ths conciton shouldbe inthe diferental lagnosis whenever ‘3. cueston uses the tems ‘con-shapedt of “isco to describe a patent's skin lesions Microscopically, the cominant features 3 localized spongiosis(coresponding ts edema) ofthe epidermis Patients are ical rested wis high-potency topical caricosteroids ‘rcaleaurn inhibitors and re insriced fo avoid possinle stants Pompholy (choice B} rele io an acte-onset pratt, deep-seated vesicular detmatlis ofthe palms and soles. Psoriasis (choice C) can produce coin-shaped lesions, but psoriasis is also usualy characerized y a sivan scale andwell cematcated plaques. Smal, round, wel dstoued lesions of psoas ae Wplcal efeved to as qulte psolasis and are lassieaty associated win rocont srstocaccal infections. Sobor dormetits (choice D) procuces erynama and scaling on no seap, misface, and micnost ‘Sissis dermatitis (choice E) can produce ennema. scaling, dark alscoloraton, erosions, and gczng. Rypicalycesuts inte lower ‘eqs near he anises in patents who neve chronic yencus Insumteno, |Nummular dormattis Is charactorzod oy grunt, coin-staped, eczomatous plaques on me tunkand extensor sunaeos ofthe ‘etierities The headis Npically spared Trestentis ofen accomplished wih fopicalstarcis or calcineurin inhisitrs.'A38-year-ld woman comes fo Bie physician uecause ofa progres, Rey rash on nor elbows, kno9s, and bucks for 3 mons. Hor racical bison is unremarkable and she takes no mecicalions oer than viamins, Examination shows grouped vesicles on an ‘eninematous nase wih exconanons on me elbows, knees, ano buTocks.Ant-tesue vansglitaminase sntoody assay e pose. A Biopsy “specimen wi dec immunofurescence of the lesion shows ly post. This patients al greatest isk or which ofthe folowing ‘conaons? OA.cotac azease OB.cionn asease OC enetier disease (OD Uicerative colts OE vancela zoster ‘To correct answor's A. This catentnas dormatts nerpebtormic (DH}-DH Ie an sutsimmune clseaso characte canis oy ‘tremely ruc, groupesvesicles on an enreratous base (herpetform’) symmeticallydsticuted on ypical sites, nclucing the ‘elbows, knees, sacum, and buttocks (see image), alhough eter locations are possitle. The pathophysiology of DH has not been ‘leat delineated, butthe mecrianism s beleved to late tothe depositon of ant-ransoutarinase od immune complexes nthe play dermis. These IgA immune compleves atract neutrogms anc nate an immune resgonse, causing local Infamrraton and Dapilary dermal microabscesses. The ant-ransphtaminase anicodies are mostly produce folowing an napoteniae immune. tesponse to gliadin, a component of gluten, within the smalinlestine following consumiion ofglier-contaning foods suchas baley ‘and hea. This pathophysiology is sirilar to tal of celiac disease (clulen-sensiive enteropathy), in wich ingestion of gluten causes ‘an inaporenntao immune responce inthe small dowel mucosa, oacing to enacoment ct sal intestnal wil and maiapsorcton, Bon [DH and celiac cisease are associated vith the KLA-DQ2 alee, and neat al patents have atleast some form of gutersenstive Ccronn disease (enoice B} and ulcerative calls (cnolce 0) are formes ofinfammatay bonel csoas9. Classic cutanaous fnings in these condtions include pyoderma ganotenosum anc enanema necosum. Acdtonaly,gatents wno rave Cronn disease may ‘experince “cutanecus’ Conn sisease with penanal ules ulcerations around stoma stes, and oral ulcers. neti disease (choice C), or pralzn-iesing enteropathy, is characetizedby excessive protein loss rom the gut leading to \oplotion of plasma proteins. Cutanoous fhings include edema, which may become severe enough to cause anasatea.Avaroly of ‘lseases ote gut may cause tis conction, Varicella zoster (choice ) is the c2USe of chicken pox anchempes zoster (shingles) in shingles, aera prostomalilness of pain and paresthesias,enfhematcus macules and papules develop and progress to vesicles wihin 24 hours. The vesicles eventually crust and rasow, Dermatitis nerpetfornis (OH) is charactered by severely pric nespeliorm lesions symmeticaly onthe elbows, knees, and ‘buttocks. OH is associated wit coizc cisease, a glutor-sensive enteropathy wi antiransclutaminase antbocies, Histologically. DH is cheracteizec by rapilay dermal nevtroohil collectons and lad complexesreer) 'A.20-ar-oldcolape studint comes to sudert neath senfces bocause ofan iy rash for 6 dae Mat Dogan a¢ large rod mark and ‘han spreadte ner back upper arms. and ions. She had a sore tvoat2 weoks ago Matlacled 4 cays. Se dios foe, vaginal ‘dscharge, abdominal pain, back pan crisint psn. Curent mecicatonsinclice orl conracepves She is semua schve snd ane anc her paneruse condoms inconsistent: Eraminaton ¢ shown ‘Tore ‘10 multpo ink ol patches on the back, proximal upper eames, and praia lowor edema. TeI0 Is no Iymphadsrpatny, Which ofthe follwing isthe most sly agnosis? (OA. Acts Hav reacton 08 cutate psoriasis OC Herpes zoster OD.Lyme disease © E.Pamasis 0502 © F.Pamasis versteolar 06. secondary syenits‘The correct answer's E, This i acassicdesenpton of pitrasis rosea. This dermatologic conatton dsssicalybepins with the “development ane or more herald patches "A neal patch is alarge, ed, oval-shaped and scaly patch or lacie that ically precedes the more generalized ewurtion by approdmatay 2 weeks. usualy appeats onthe bunk (see image). Subsequenty, = ‘suidon etuoton of pnt, oval pales ocaurs an te unk, upper aims, and thighs. The lesions of pris rosea tango lay wi tele {ong aes in the skin tension ines sweeping rom the ace tote Front on he unk. The arienation and ston ofthese lesions ‘ypicaliooks ikea Christmas tee onthe back This eruption typically asyrpiomatc The scale on the sutace cf each esion ibis 2 tendency to peel fom the inside toward the edge, esulng in so-aled “peripheral colaete”The rash Wpicallresches ‘vortie couree of few wooks, andtocimant is usualy unnecessary. Paste rosea is most oten a manifestation of nuran Inerpeswus 7; ima al30 be associated wim HHV-6, and recent, possible assoeatons win HHV-8 andine 2008-2010 pancemic [HIN inusnza Avs have also been reported [An acute HIV reaction (choice A) is possible, especially wit 3 histor of unoolacted intercourse, The mast common cutaneous fruptions assoastea win acute HV conversion ate puféc and do not exibt scales. The rash of acute HIV reseton usualy iS assocttea win fever, chanyngts, and mai CGultate psoriasis (choice 8) presents as srl wall demarcated scaling lesions affecng the ttso, most commonk fllowing 3 ‘sbeplococcalinfecton. The main distrguishing features, however, te that gulale psoriasis demonstrates hypereraoic lesions with ‘stver scales and cepilan-point nemormage wth removal ct te seale(Alspit sign). Gate psoriasis does not nave the classic “Christmas tee" appearance and the lesions are ound, whereas thay are oval in pitiasis rosea, The rash ofherpes zoster (choice C) is usual unaeral ina detmatoma pall. does nolcioss the midline except in Immunosuppressod rations, who may experonce isceminatogzostor. Adcionaly, te lesions ornarpes zocor roacwaton sro vesicular and are assocatec win paresinesias and neurogaruic pan “The rash assocaled with Lyme disease (choice D) is known as enema migrans, which is # smal red macule occuring a he site lof alck bite that slowly spreads outward ina centifugafaston to Fem an enghematous rng (annular erythema). Dryrasis versicolor (choice) Is causes by Malsesezia species, which are normal skin Tors presertin plosenaceousrolices. On fair sin the lesions are less notizeable, but on darker pigmented sin me lcal apDearance 1s patcny hypopigmentsion wih overvng scale ‘Secondary syphilis (choice G) can presentin avail fashions andis regatded as he grea imitator” Most commonly it manifests weeks ale resolution of te primary sypiliicchancre with enjheralous maculesinvohing the unk, palms ofthe hands, ‘and sole ofthefeet, which are sparedin the present case. Pynacis rosea Ie cnaractenzed by an entmomatous scaling eruption often preceded by 9 soltary fargo losion on the trunk known a6 a “heralcipatn” Th orupton et prytaste rosea characenctcal nas losions ononted inte flayed sn tension ines on tne back, (hing a ypical"Ciustras tee" appearance. Piylasisroseais associated win human NeipesMius-7 (and), is set-imted, ands ‘ost often asymptomaticoe ‘Az t-yearold woman comes fo fe physician Because ofan eh rash on her hands for? weeks. She has had aft sleeping at right Decauso orintaton and sertenng. sho Nas be9n applying over tne-counterhydocorUsone cam wit minimal improvement. Sho nas had no fever, fatigue, shortness of breath, wheezing, or cough. She has ahistr of aletgic hints, chlahood asthma, and = conic ash a8 a crs Current mesiestions inte tesarenacine ana an orl eorraceptve pl sne has ten fore past’ years. She has no alerpies to medications Her brothernad 3 similar rash on his face. Her temperature 's 387% (90°), Examination shows palmar ershera ana weeping. crusting plaques ontne hands anarngers. There are sesteredvesices and edematous papules win esenratons. Vihch ote follwing isthe most appropriate recommendation fr his paint rash? (OA.Chronicuse ot anthistamines tomnimze aopieresponse © B.Freauont use of soap © ¢.Lomnumvaty ondrcnmonts (OD. Regular use of overthe-courter land emaliens (© E-shower tequenty mth warm waterto remove pacer! deers “The correct answer is D. This pallet nas atopic dermis, actuonic infamy disease ofthe skin wih chrome vetapsing course, Key olomonts ofthe lagnosts include arictory of atop, cimicaly cezomatous lesions, and prurus. other totures tat Supporttie clagnastsincuce family history ora personal nistory of atopy. young age of onset, chronierelapsing course, ana a Aistnbuton consistent wth atic dermatts in children and adults (1. fecal surtaces of the arms; see image) Steric ointments can help wih severe symptoms, sttrough mid steroids need to be usesin thin-skinned areas, suena the face gro, anc intertiginous ses. Keeping the skin moist with ovarthe-countar bland emalients such as patoatum is one efthe mainstays of Thorapy. Such emotion patteutay important medially afar cating, oreventng water loss tom the skin ang iia exposure ‘Civonleanthistarines (cholce A} should nct be used, because hey have nol Deen proven Io have lonodeim efectneness. They are Incieated, ower, for ie management of allergic inl. n acute eczema sedating aistarines may be used at night fo nelp 2 Datont steep, put oy sto generaly nolovedto work cocauso otetr sodstve efect.notiairant-tn properis.. Frequent use of scaps (choice &) should to ayelded, pecauso hose wll emove ie natura ids ne san tat prone a ptaectve barerto the endronment Standard scans oten also predispose te futher atopic fares. Noisturing non-soap cleansers should be used ia cleansers required ata Humility can help reduce symptorn fates. Lov-humity ersranments (choice C) thus should be avoied Low humid, which laads te xerosis (dry skin), can be countered wih a huride ‘Regular bahing (choice E) is permissible bu is nol required as an adjunct te teatrent of toric dermal ‘Nopic dermatis causes prttus and eczematous lesions over te texural urfses, cheeks, or scalp I typieally folows 8 retapsing ‘course, athough ita fade oy late cildneod Maintsining skin hyraton with cvershe-couter emollient is a mainstay ofiestment for atopic dermatisoer ‘A s7-jenrald toy comes tothe physician ecause ofa Lear istry of facial lasons. He says thatsome lesions begin as painul “eum,” wneress eters look ke “pmpies" ena arg pares. 19 medical ristor Ie unremarksbe and e takes no meicatons. HE thinks oecasional/on waskends. He denies lic rug use. He is seal ache and he uses condoms consistent His tempera is 38.0°C (@8.4°F). Examination i show, ‘Tare ae open and dosed comedones, numetous de9p iarnmatoy nodules, andicw pik-ika searing. Wich of tho following I the ‘most appropriate pharmacotheapy fr this patents condtion? OA.ora aatreon 0B oral isobetingin 06.012! minosjcine ©. ora prednisone © E.orl spironolactone (© F. Topical taztotonemenzon peroido ‘Tne correct answoris &. This patente sutenng tom nogulceysic aero vin scaring. Ic pck-tKe seaming i commonly xsorved in ‘severe cases of acne: tis characterized by 2 sharply demarcated scar that fazers to pont within the dermis. Acne can also cause atopic and rypertophie scaring When scaringis prominent and he disease is stil acive, as inte presen patet, cal einic rmadicafons ae required io auch reat the acne anc halthe formato of new scas, The most commonly used ofl rnold for acne is iobstinoin, Because of ts polertal for adverse efecs, including severe dying ofthe skin, hells, pseudetumor cere. ‘eupidemia,skoletl nyporostoes, anc tratogenatyIotstnoin is note trst.ine modicstonforloss soveretorms otacno dssote ‘ts etcao, ny iscretnoinprescipton for 3 woman of clcbesning age must be precedes oy a pregnancy test ana accomeaniea by 2 forms of bch can Aciretin (choice A) is an oral einid usedin he testment cfpsariasis. Because of ts ong halfife and abiyto be converted te he Jonget-tved evetnate on excosure fo alcohol, is nol used In women of cildbeating 292 Ninocyeine {onolce C) 1s tevacysine-cass antbitc used i Teat acne. is he most Upopnllc ote teracrcnes, ana Ms se Iely cause ors Increased eriany over te other ttracyctines (donojaIne anc tevaqjcie).R can cause verigo ancpigment Clepostion inthe legs and face as well as within sca, se close montoring is required when using his medication. Pradrisone (choice D) is mast commonly associate with steoidnduced acne, hich teically manifests wih comedones alli the ‘same stage of dovelopmont(menomorphous} It can alco Be used as an nial Ueatmont ofa severe frm of aone known as acne fulminans, wien Ie charactewed by ne acute onset earge Intammator and ulceratingnodulss onthe fac, chast and back wh systemic symptoms such 8 fever Spironolactone (choice E) is an antaldosterone duretc uses toteat acne in women because ofits antiandrogen capaniites, Under normal crcumstancas, the fistine tesiments for uncomplicated acne are topical preparations consisting of retnsids, such 25 tazatolene(patto choice F),adapalene, or teincin, and antimicrobials, suchas benzoyl peroxide (also part of choice F)cindanven, ‘and gapcone, Isovednoinis an ofl retnotd agent indiested inpatients who nave ace scaring. Adverse eects of orl isoetnoin include teratogericiy, pseudotumor estebtxeosis, cli, and dyslipidemia, amang ohers. Women who ate prescribed isobstinon require ‘pregnancy est porto preseibing and atleast 2oums of bi cont'A36-year-ld woman comes to Me phsiclan because of 2 od lesion on ner ndexngor tat dovlopod afar a minor un 2 woaks 200. ‘The woman pods thatthe lesion isnot uncomfortable, aficugh ts cosmetic appearance is bothersome. Examinalion shows a ‘-cm red, vascular fale papule win thin colaete of scale The lesion leeas easiy anc does not blanch wh pressure. There are no changes {in ne suounding skin, Which oft rooming isthe most Healy agnosie? OA. Dermatoforoma OB keloid (OG keratoacentioma (0 D.Progente granuloma Oe war ‘The correct answers D. This patent most kena a pyoventc grnuloma (PG). PGs most commonly develop st tes of prenous minor inuries. Classical, these lesions manest as fable, reply enlarging enthematous, vascularappesting papules wth @

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