Pruritus, topical

therapy and
inflammation
MCQs

101
 Lymphocytes:

A. Recognize antigens attached to MHC molecules on the surface of antigen-presenting

cells.
B. Contain receptors for the Fc portion of immunoglobulins.

C. Secrete cytokines.
D. Contain CD3 cell markers.

E. All of the above are true.

You CORRECTLY answered E

Human T cells are composed of helper, cytotoxic, and suppressor cells. They have
distinct cell surface receptors that enable them to recognize processed antigens on the
surface of antigen-presenting cells in association with major histocompatibility complex
(MHC) molecules. They secrete numerous cytokines which are involved in cell–cell
communication. CD3 is a pan-T-cell marker and is part of the T-cell receptor complex. T
cells contain receptors for immunoglobulins that enable them to induce immune
responses to foreign antigens.

2. Which of the following molecules are directly involved in cell adhesion?

A. Integrins.

B. Immunoglobulin superfamily.

C. Cadherins.
D. Selectins.

E. All of the above.

The CORRECT answer is E

A great deal of information has been obtained in recent years regarding mechanisms of
leukocyte homing and migration in acute inflammation. Much of our understanding of
these processes stems from work on cellular adhesion molecules involved in cell–cell and
cell–matrix interactions. There are currently four families of cell adhesion molecules that
have been classified: cadherins, immunoglobulin superfamily, selectins, and integrins.
During acute inflammation, endothelial cells are induced to express P-selectin.
Neutrophils attach to P-selectin at sites of inflammation and are caused to roll along the
vascular endothelium. Later expression of E-selectin by vascular endothelium contributes
to this process. Full adhesion and extravasation of neutrophils at vascular endothelium
requires the expression of a VLA-4 integrin by leukocytes that binds to ICAM-1 (an
immunoglobulin superfamily member) on endothelial cells. VLA-4 is expressed by
leukocytes, not by endothelial cells.
3. Which form of steroid is generally most potent?

A. Cream.

B. Lotion.
C. Ointment.

D. Foam.
E. Gel.

You CORRECTLY answered C

The ointment form of a topical corticosteroid is generally more potent than other forms of
the same drug. This is largely related to the occlusive effects of ointments, which tend to
prevent water evaporation from the skin surface and enhance drug absorption.

4. The classic complement cascade is initiated primarily by which ONE of the following
molecules?

A. Oligosaccharides.
B. Antibody-antigen complexes.

C. Bacterial cell walls.

D. Nucleic acids.
E. Radiographic contrast medium.

You CORRECTLY answered B

The classic complement cascade is activated by many factors, including IgG, IgM,
antigen-antibody complexes, proteolytic enzymes, C-reactive protein, and RNA viruses.
In contrast, the alternative complement cascade is activated by bacterial cell walls,
endotoxic polysaccharides, aggregated immunoglobulins, and radiographic contrast
medium
5. Tincture

A. Oil-in-water

B. Water-in-oil
C. Alcohol-based

D. Propylene glycol-based
E. Powder in ointment

The CORRECT answer is C

6. Lotion

A. Oil-in-water

B. Water-in-oil
C. Alcohol-based
D. Propylene glycol-based

E. Powder in ointment

. The CORRECT answer is A

7. Cream

A. Oil-in-water

B. Water-in-oil
C. Alcohol-based

D. Propylene glycol-based
E. Powder in ointment

You CORRECTLY answered A

8. Paste

A. Oil-in-water
B. Water-in-oil

C. Alcohol-based
D. Propylene glycol-based
E. Powder in ointment

The CORRECT answer is E

9. Gel

A. Oil-in-water

B. Water-in-oil
C. Alcohol-based

D. Propylene glycol-based
E. Powder in ointment

You CORRECTLY answered D

Ointments are generally considered water-in-oil formulations, whereas creams and lotions
are oil-in-water formulations. Solutions and tinctures are alcohol-based with solutions
containing variable amounts of propylene glycol. Gels are propylene glycol-based agents.
Pastes are creams or ointments to which powder has been added.

10. All of the following are true regarding natural killer (NK) cells EXCEPT:

A. They possess T-cell and B-cell markers.

B. They are CD16-positive.

C. They are able to lyse tumor cells.

D. They are able to lyse virally infected cells.
E. They constitute 20% of peripheral blood lymphocytes.

. The CORRECT answer is A

Natural killer cells are CD16-positive cells capable of natural killer (NK) and antibody-
dependent cell cytotoxicity (ADCC). They are important cells in host defense against viral
infections and tumors. They constitute 20% of peripheral blood lymphocytes; however,
they lack T-cell and B-cell markers.
11. In acute inflammation, leukocytes are induced to roll on vascular endothelium by
increased endothelial cell expression of all of the following EXCEPT:

A. P-selectin.
B. E-selectin.

C. lntercellular adhesion molecules (ICAM-1).

D. Very late activation antigen-4 (VLA-4).

You CORRECTLY answered D

A great deal of information has been obtained in recent years regarding mechanisms of
leukocyte homing and migration in acute inflammation. Much of our understanding of
these processes stems from work on cellular adhesion molecules involved in cell–cell and
cell–matrix interactions. There are currently four families of cell adhesion molecules that
have been classified: cadherins, immunoglobulin superfamily, selectins, and integrins.
During acute inflammation, endothelial cells are induced to express P-selectin.
Neutrophils attach to P-selectin at sites of inflammation and are caused to roll along the
vascular endothelium. Later expression of E-selectin by vascular endothelium contributes
to this process. Full adhesion and extravasation of neutrophils at vascular endothelium
requires the expression of a VLA-4 integrin by leukocytes that binds to ICAM-1 (an
immunoglobulin superfamily member) on endothelial cells. VLA-4 is expressed by
leukocytes, not by endothelial cells.

12. Which of the following are FALSE regarding integrins?

A. They mediate cell-cell interactions.

B. They mediate cell-matrix interactions.

C. Most cells express a single integrin.

D. They are adhesion molecules.

. The CORRECT answer is C

lntegrins are adhesion receptors on cells that mediate cell–cell and cell–matrix
interactions. They possess distinct ligand specificity. lntegrin receptor families are
classified according to their eight subunits. A multitude of integrins may be expressed by
leukocytes or fibroblasts and show specificity for binding to collagens, laminin, and
fibronectin. Most cells express several integrins and can therefore bind to several
extracellular matrix proteins.
13. Lipophilic topical steroid agents are generally more effective than hydrophilic agents
because of all of the following EXCEPT:

A. Increased absorption across the stratum corneum.

B. Increased receptor binding of such agents within the cytoplasm of viable

epidermal cell.

C. Increased active transport across cell membranes of epidermal cells.

D. Increased penetration across viable cells within the epidermis.

The CORRECT answer is C

The stratum corneum favors increased absorption of lipophilic agents. Increased

absorption of lipophilic agents is seen within the viable cell layers of the epidermis. In
addition, there is increased cytoplasmic binding of such lipophilic steroid molecules within
viable epidermal cells. There is no appreciable active transport of these molecules across
cell membranes.

14. What is the major barrier to drug absorption in human skin?

A. The stratum corneum.

B. The granular layer.

C. The basal layer.
D. The papillary dermis.
E. Dermal vessel walls.

You CORRECTLY answered A

In stratified squamous epithelium, the major barrier to drug absorption is the stratum
corneum. There is no active transport across the stratum corneum; therefore, drug
transport across this skin layer is dependent on Fick law of diffusion.

15. All of the following substances have been shown to mediate pruritus EXCEPT:

A. Histamine.

B. Interleukins.

C. Opioids.
D. Temperature.
E. Substance P.

The CORRECT answer is B

Histamine, opioids, thermal stimuli, and substance P have all been demonstrated to
mediate pruritus either by direct effects on itch receptors or through effects on mast cells.
While interleukins are known products of keratinocytes and are mediators of the
inflammatory response, they have not been demonstrated to induce pruritus.
16. Characteristics of ointments include all EXCEPT:

A. Lipophilic preparations.

B. Usually water-in-oil emulsions.

C. Composed of microcrystalline hydrocarbons.

D. Ability to absorb water.

You CORRECTLY answered D

Ointments are lipophilic preparations that, if pre pared as an emulsion, are usually water-
in-oil mixtures. They are often composed of a petrolatum base containing a complex
mixture of various hydrocarbons, including microcrystalline hydrocarbons. Because of the
hydrophobic nature of ointments, they tend to repel, not absorb, water unless an
emulsifying agent is present to form an absorption base.

17. Topical steroids can be used for all of the following EXCEPT:

A. Inflammatory lesions.

B. Hyperplastic lesions.
C. Infiltrative lesions.

D. Infectious lesions.
E. Pruritic lesions.

You CORRECTLY answered D

Topical steroids possess both an anti-inflammatory effect and an antimitotic effect.

Pruritic lesions, depending on their cause, can often be relieved by topical steroids.
Topical steroids have no antimicrobial effects; rather, because they affect various
cytokines, they may make persons MORE prone to infections.

18. Adverse effects of long-term use of superpotent topical steroids include which of the
following?

A. Epidermal atrophy.
B. Striae.

C. Rosacea.

D. Suppression of the hypothalamic-pituitary-adrenal axis.

E. All of the above.

You CORRECTLY answered E

Superpotent topical steroids, when used daily for as short as several weeks (depending
on the surface area, site, and patient age), may have serious and lasting side effects.
Among the more commonly encountered side effects are steroid-induced rosacea,
epidermal atrophy, and subsequent striae. Rarely is suppression of the hypothalamic-
pituitary-adrenal axis seen with topical steroid treatment, although this may occur,
especially in children and infants.
19. The effect of a particular topical agent on a specific cutaneous disorder depends on
what?

A. The availability of the drug for absorption.

B. The penetration of the drug through the skin.

C. The interaction of the drug with target receptors.

D. Degradation of the active ingredient in the topically applied agent.

E. All of the above.

You CORRECTLY answered E

The effect of any topically applied agent depends on drug availability from the vehicle in
which it is prepared, penetration of the agent through the skin, interactions of the agent
with various cellular receptors, and its degradation in the skin.

20. In order to combine two immiscible liquids it is necessary to do all of the following
EXCEPT:

A. Emulsify one product into the other.

B. Add a surfactant to the two agents.

C. Reduce the surface tension at the interface between the two agents.
D. Have an excess of the hydrophobic agent.

The CORRECT answer is D

Emulsions are composed of two immiscible liquids—usually oil and water. When forming
a vehicle for a particular topical therapeutic agent oftentimes a water-in-oil or oil-in-water
emulsion is used. The internal phase is said to be dispersed in the external or continuous
phase. This can only occur with the use of a surfactant (detergent) to reduce surface
tension at the interface of the two phases. Whether the emulsion is oil-in-water or water-
in-oil is determined by the amount of oil and water in the compound and the surfactant
used. Most creams are oil-in-water-based. It is not necessary to have excess of either the
hydrophilic or hydrophobic phase in order to form an emulsion.
21. All of the following regarding intralesional steroid therapy are true EXCEPT:

A. It achieves high-dose local treatment with rare systemic effects.

B. It is useful for treating keloids.

C. It may result in local skin atrophy.

D. It is useful for generalized pruritic eruptions.

E. It is useful for treating acne cysts.

The CORRECT answer is D

Intralesional steroid therapy is useful for treating well-circumscribed, localized,

inflammatory, or hyperplastic lesions. It rarely produces systemic effects if used correctly.
Local side effects of this treatment include atrophy, hypopigmentation, localized
increased hair growth, infection, and ulceration of treated lesions.

Choose the ONE BEST answer to the following question:

22. All of the following statements are true regarding human T cells EXCEPT:

A. They induce graft rejection.;

B. They mediate delayed-type hypersensitivity reactions.;
C. They provide defense against viral and fungal infections.;"
D. They possess immunologic ""memory.""";
E. They mediate the development of serum sickness.

The CORRECT answer is E

T cells are responsible for recognizing non-self-antigens as a function of an organism's

immune surveillance capacities. They must recognize foreign antigens in the context of
cellular MHC molecules in order to function appropriately. Although B cells are primarily
responsible for antibody production and immune defense against bacterial infections, T
cells are primarily involved in defense against mycobacterial, fungal, intracellular viral,
and protozoal infections. T cells are the primary mediators of delayed-type
hypersensitivity reactions, which involve "memory" T cells. T cells also mediate graft
rejection and graft-versus-host disease. B cells and subsequent antibody production with
antigen-antibody complex formation and tissue deposition are responsible for the
development of serum sick- ness reactions.
23. Increased cutaneous penetration of topical steroid therapies is achieved by:

A. Increasing skin temperature.

B. Stripping the stratum corneum.

C. Wetting the skin before using the medication.

D. Occluding the steroid treatment with an airtight dressing.

E. All of the above.

You CORRECTLY answered E

Increased skin temperature, wetting the skin, and occlusive therapy all contribute to
increased permeability of the stratum corneum to topical medications. Stripping the skin
of the stratum corneum increases penetration by topical steroids through elimination of
the largest barrier to skin absorption.
Questions 24 - 28 of 75

For each numbered item, choose the most likely associated lettered item. Each
numbered item has ONLY ONE correct answer. Within each group, each lettered
item may be the answer to one, more than one, or none of the numbered items.

A. UVB therapy pruritus;B. Cholestyramine;C. Topical or intralesional steroids;D.

Antihistamines;E. Dialysis

24. Cholestasis-related

You CORRECTLY answered B

25. Uremic pruritus

You CORRECTLY answered A

26. Dermographism

You CORRECTLY answered D

27. Prurigo nodularis

You CORRECTLY answered C

28. Lichen simplex chronicus

You CORRECTLY answered C

Multiple therapies have been tried for cholestasis pruritus. Although there is no correlation
between the levels of serum conjugated bile acids and pruritus, substantial relief has
been obtained with bile acid-sequestering agents, e.g., cholestyramine. Uremic pruritus
appears to be best controlled by ultraviolet B (UVB) therapy. There is no correlation
between level of uremia or serum creatinine and pruritus; furthermore, dialysis has not
been shown to substantially reduce pruritus in these patients. Dermatographism involves
an accentuated wheal and flare response to stroking the skin. It is primarily histamine-
mediated and is therefore responsive to antihistamine therapy. Prurigo nodularis and
lichen simplex chronicus are both types of neurodermatitides. Often times, these
disorders are associated with habitual rubbing at times of stress. The pruritus here is
often severe. Once systemic causes for the pruritus have been ruled out, successful
treatment of these lesions usually requires potent topical or intralesional steroids. A
consideration of mild systemic anxiolytic therapy or improved stress management
techniques might also be useful in this situation.
29. Drug absorption across the stratum corneum is calculated using which law?

A. Murphy.

B. Fitzpatrick.
C. Fick.

D. Koebner.
E. Mother-in-law.

You CORRECTLY answered C

Because there is no active transport across the stratum corneum, transport across it is
dependent on passive diffusion, or Fick law. In Fick law, J = flux, or flow of diffusing drug,
K = partition coefficient between the stratum corneum and the vehicle; D = diffusion
coefficient of the stratum corneum; ΔC = concentration gradient between the skin surface
and the epidermis, and d = the thickness of the stratum corneum.

30. Dermal effects of long-term topical steroid use include which of the following?

A. Reduced collagen synthesis.

B. Increased ground substance.
C. Increased elastin synthesis.

D. Inhibition of melanogenesis.
E. Vasoconstriction.

You CORRECTLY answered A

Dermal effects of long-term topical steroid use include decreased collagen synthesis with
reduction in ground substance, which leads to decreased vascular support and
subsequent striae. Although immediate effects of topical steroids include
vasoconstriction, long-term use promotes vasodilation, often as a rebound phenomenon.
Inhibition of melanocyte function is an effect of topical steroid use on the epidermis.
31. Cytokines synthesized and expressed in skin include which of the following?

A. GM-CSF.
B. TNF-α.
C. TGF-β.

D. IL-1.
E. Choices A, B, and D.
F. All of the above.

You CORRECTLY answered F

Interleukins (IL-1, -3, -6, -8); colony-stimulating factors, including granulocyte-

macrophage colony-stimulating factor (GM-CSF), granulocyte colony-stimulating factor
(G-CSF), macrophage colony-stimulating factor (M-CSF); tumor necrosis factor (TNF);
and nerve, tumor, and fibroblast growth factors have all been localized to skin.

32. The rate of topical drug absorption depends on which of the following?

A. Concentration of drug in the vehicle.

B. The lag phase of drug absorption.

C. The steady-state phase of drug absorption.

D. The vehicle used.

E. All of the above.

You CORRECTLY answered E

The rate of topical drug absorption is related to Fick law as previously described. The rate
of absorption depends on the concentration gradient from the stratum corneum to the
dermal vasculature. Initially, the absorption of a topically applied agent as the drug moves
from the vehicle to the stratum corneum through the epidermis to the dermal vessels is
slow. This initial phase of absorption is the lag phase. Once the amount of drug
absorption per unit of time is constant, we have reached the steady-state phase of
absorption. The vehicle used is also important for drug absorption, more water-
impermeable (i.e., hydrophobic) vehicles allowing more absorption of drug through a
hydrated stratum corneum. In addition, the vehicle used is important in determining the
partition coefficient of a particular drug as relates to Fick law.
Choose the ONE BEST answer to each of the following questions:

33. The average amount of ointment required to cover an entire adult skin surface is
which of the following?

A. 1 gram.
B. 10 grams.

C. 45 grams.
D. 75 grams.

E. 100 grams.

You CORRECTLY answered C

The average adult individual requires 30 to 60 grams of ointment to cover the entire
cutaneous surface area.

34. Tachyphylaxis against a potent topical steroid may occur when?

A. Within a day of initiating treatment.

B. Within a week of initiating treatment.

C. Only years after initiating treatment.

D. It never occurs.

E. It is rarely reversible.

The CORRECT answer is B

Tachyphylaxis may begin within one week of initiating treatment with a potent topical
steroid. The ability to fully respond to the same medication usually returns within a week
of stopping the topical therapy. It is therefore best to treat disorders with potent agents
over a short period of time with "rest" periods, either without steroid treatment or with use
of a substantially weaker steroid.
35. Which one of the following is true regarding cytokines?

A. They include interleukins, interferons, and antibodies.

B. They are long acting.

C. They mediate cell–cell communication in an autocrine and paracrine manner.

D. They are of high molecular weight.

E. They possess unique functions.

E. All of the above are true.

The CORRECT answer is C

Cytokines are low-molecular-weight nonantibody mediators of cell–cell interactions.
Included in this group of molecules are interleukins, interferons, and growth factors. They
are short-acting mediators that function in an autocrine or paracrine manner. Cytokines
possess multiple overlapping functions.

36. The free nerve endings that serve as the point of initiation of itch sensation are:

A. Located in the lower dermis.

B. Formed into an epidermal nerve net.

C. Formed from nerve termini of myelinated cutaneous nerves.

D. Composed mainly of type A sensory fibers.

E. Found to project into the granular layer of the epidermis.

The CORRECT answer is E

The free nerve endings that serve as points of initiation of itch sensation are located
primarily in the upper dermis. They form a subepidermal nerve network. These free nerve
endings are terminals of unmyelinated cutaneous nerves that are composed mainly of
type C fibers. Free nerve endings that project into the epidermis reach the granular layer
and then spread laterally.

37. All of the following are true regarding prostaglandins EXCEPT:

A. PGE2, PGD2, and PG12 are potent proinflammatory agents in the skin.
B. They are formed by cyclooxygenase conversion of arachidonic acid.

C. Nonsteroidal anti-inflammatory agents inhibit their formation.

D. Their levels in skin are increased by ultraviolet radiation.

E. Their levels are decreased in the physical urticarias.

. The CORRECT answer is E

PGE2, PGD2, and PG12 are highly potent proinflammatory agents in skin, causing
erythema, edema, and pain in nanomolar concentrations. NSAIDS inhibit formation of
prostaglandins by direct inhibition of cyclooxygenase and, therefore, conversion of
arachidonic acid to prostaglandins. Increased levels of prostaglandins in skin are seen in
response to UV irradiation, in allergic contact dermatitis, and in the physical urticarias.
Questions 38 - 42 of 75

For the following questions the set of lettered headings accompanies a list of
numbered words or phrases. For each numbered word or phrase, choose:
A. If the item is associated with A only
B. If the item is associated with B only
C. If the item is associated with both A and B
D. If the item is associated with neither A nor B

38. Composed of kappa or lambda light chains

A. IgG

B. IgM
C. Both

D. Neither

You CORRECTLY answered C

39. Contains a J-region

A. IgG

B. IgM

C. Both
D. Neither

The CORRECT answer is B

40. Able to fix complement

A. IgG

B. IgM
C. Both

D. Neither

The CORRECT answer is C

41. Can be transferred transplacentally

A. IgG
B. IgM
C. Both
D. Neither

You CORRECTLY answered A

42. Responsible for immediate hypersensitivity reactions

A. IgG

B. IgM
C. Both

D. Neither

The CORRECT answer is D

There are five distinct classes of immunoglobulins: IgG, IgM, IgA, IgD, and IgE. IgM and
IgA can exist as multimers that are joined by J regions. All immunoglobulins are
composed of two heavy chains and two light chains that contain variable and constant
regions. Only IgG and IgM antibodies are able to fix complement, and only IgG antibodies
can be transferred across the placenta. Immediate hypersensitivity reactions are
mediated by IgE binding to mast cells.

43. Human cutaneous mast cells release histamine in response to which of the following?

A. C3a.

B. CSa.

C. IgE.
D. Substance P.

E. All of the above.

You CORRECTLY answered E

Human mast cells release histamine in response to numerous stimuli. Mast cells possess
receptors for the Fc portion of IgE and for the anaphylatoxins C3a, C4a, and C5a.
Additionally, numerous hormones and endogenous opiate peptides can cause mast cell
degranulation. Known mast cell activators include IgE, C3.a, C5a, opiates, and substance
P.

44. Class 1 topical steroids should be limited to how long?

A. One day of therapy.

B. One week of therapy.

C. Two weeks of therapy.

D. One month of therapy.

E. Six months of therapy.

You CORRECTLY answered C

Because of the superpotent nature of class 1 steroids, their use should generally be
limited to 2 weeks of continuous therapy with a subsequent rest period to reduce the
likelihood of side effects and tachyphylaxis of the agent used. Generally, a 1- to 2-week
rest period is sufficient to avoid severe side effects of the stronger topical steroid
therapies. Retreatment with more potent topical steroids should then be initiated for
exacerbation of the disease process being treated.
 45. Traditional methods for determining topical steroid potency include which of the
following?

A Thermal measurements.
B. Epidermal thickness changes.

C. Vasodilator assay.
D. Vasoconstrictor assay.

The CORRECT answer is D

In 1962, the vasoconstrictor assay was presented as a novel method for determining
percutaneous absorption of topical steroids. Since that time, the assay has undergone
some modifications but has essentially remained the "gold standard" for determining
topical steroid potency.
For each of the following numbered items, choose the most likely associated
lettered. Each numbered item has ONLY ONE correct answer. Within each group,
each lettered item may be the answer to one, more than one, or none of the
numbered items.

A. CD1a;B. CD3;C. CD4;D. CD6;E. CD8

46. Cytotoxic/suppressor T cells

You CORRECTLY answered E

47. Pan-T-cell marker

You INCORRECTLY answered A. The CORRECT answer is B

48. T helper cells

You CORRECTLY answered C

49. Langerhans cells

You CORRECTLY answered A

50. Part of T-cell receptor complex

You CORRECTLY answered B

The current designation of T-cell markers is based on the CD designation. CDla is a

marker for Langerhans cells. It is particularly useful in evaluating the histiocytoses; CD3 is
a constituent a part of the T-cell receptor and therefore is a pan-T-cell marker; CD30 is a
marker for malignant T cells; CD8 is present on cytotoxic and suppressor T cells.
51. The main cyclooxygenase product of human skin mast cells is which of the following?

A. PGE2.

B. PGD2.
C. PG12.

D. LTB4.
E. 5-HPETE.

The CORRECT answer is B

The main cyclooxygenase product of human skin mast cells is PGD2, which along with
histamine is responsible for much of the inflammatory response of mast cells. PGE2 and
PG12 are found in skin but at lower concentrations than PGD2. LTB4 and 5-HPETE are
products of the lipoxygenase pathway in human skin.

52. Long-term topical steroid use that results in subsequent decreased efficacy over time
is termed what?

A. Anaphylaxis.
B. Tachyphylaxis.

C. Habituation.

D. Tachydermia.
E. Koebnerization.

You CORRECTLY answered B

Long-term continuous use of topical steroid agents results in tachyphylaxis and

decreased efficacy. It is thought that intermittent application of topical steroid agents may
decrease the incidence of tachyphylaxis to a particular agent.

53. Phenotypic characteristics of Langerhans cells include which of the following?

A. HLA-DR.

B. OKT6.
C. Vimentin.

D. S-100.

E. All of the above.

You CORRECTLY answered E

Langerhans cells are responsible for suprabasal antigen presentation in skin. They
contain numerous phenotypic markers, including HLA-DR, CDla, HLA- DS, OKT6,
vimentin, S-100, Fc receptors, and C3 receptors. These cells are mesenchymal and are
derived from bone marrow precursor cells.
For the following questions the set of lettered headings accompanies a list of
numbered words or phrases. For each numbered word or phrase, choose:

A. PGD2;B. Histamine;C. Both;D. Neither

54. Found preformed in mast cells

You CORRECTLY answered B

55. Increases vascular permeability

. The CORRECT answer is C

56. Contracts smooth muscle

The CORRECT answer is C

57. Promotes platelet aggregation

The CORRECT answer is D

Mast cells contain preformed and newly formed mediators that are released during
degranulation and subsequent activation. Preformed mediators contained within mast cell
granules include histamine, heparin, trypsin, chymotrypsin, and arylsulfatases.
Arachidonic acid metabolites, including the prostaglandins, thromboxanes, and
leukotrienes, are synthesized following mast cell activation. Both histamine and PGD2
cause increased vascular permeability and smooth muscle contraction. Neither histamine
nor PGD2 are involved in promoting platelet aggregation. PGD2 is an inhibitor of platelet
aggregation. Platelet-aggregating factor, an additional mast cell product, is responsible
for mast cell-induced platelet aggregation.
58. Substance P has which of the following properties?

A. It is a potent degranulator of mast cells.

B. It is naturally derived from chili peppers.

C. It is an endonucleotide.

D. It is a potent neutrophil chemokine.

. The CORRECT answer is A

Substance P is a neuropeptide that is localized to sensory nerve terminals. It is a potent

degranulator of cutaneous mast cells. Substance P is released in association with
cutaneous sensory nerve action signaling and is involved in generation of the sensation
of cutaneous pain. Capsaicin, a derivative of chili peppers, depletes sensory nerves of
neuropeptides and prevents their reaccumulation. It has been used clinically to treat the
cutaneous pain of postherpetic neuralgia. Substance P is not derived from chili peppers,
nor does it possess neutrophil chemoattractant properties.
For each of the following numbered items, choose the most likely associated
lettered. Each numbered item has ONLY ONE correct answer. Within each group,
each lettered item may be the answer to one, more than one, or none of the
numbered items.

A. IL-1;B. IL-2;C. IL-4;D. IL-8;E. Tumor necrosis

59. Induces fever, activates resting T-cells, induces B-cell proliferation

You CORRECTLY answered A

60. Growth factor for activated T cells, induces factor (TNF) lymphocyte-activated
killer (LAK) cells

. The CORRECT answer is B

61. Activates macrophages, growth factor for mast cells

The CORRECT answer is C

62. Induces granulocytosis

You CORRECTLY answered D

63. Endogenous pyrogen, activates coagulation system, induces cachexia

. The CORRECT answer is E

Cytokines are nonantibody soluble molecular mediators of cell–cell communication. They

include interleukins, interferons, and growth factors. These molecules are generally of low
molecular weight, produced transiently by the body, act by binding to specific receptors,
function in immune-mediated processes, and have overlapping functions. IL-1 induces
fever, activates resting T cells, and induces B-cell proliferation. IL-2 is a growth factor for
activated T cells and induces LAK cells. IL-4 activates macrophages and is a growth
factor for mast cells. IL-8 induces granulocytes. Tumor necrosis factor (TNF) is referred to
as endogenous pyrogen; it also activates the coagulation system and induces cachexia.
64. All of the following are true regarding IL-1 EXCEPT:

A. It is a constitutive product of the epidermis.

B. The bioactive form in skin is IL-1β.

C. There is only one receptor for IL-lα and IL-1β.

D. It is partly responsible for fever associated with sunburns.

You CORRECTLY answered B

Interleukin-1 (IL-1) is a cytokine produced constitutively by the epidermis. There are two
forms of IL-1, alpha and beta. Both forms bind to the same receptor; however, the
bioactive form in skin is IL-1α. Elevated levels of IL-1 are associated with fevers following
increased UV exposure of skin.

65. Hydration of the stratum corneum results in which of the following?

A. Increased permeability of lipophilic molecules only.

B. Increased permeability of hydrophilic molecules only.

C. Increased permeability of hydrophilic and lipophilic molecules.

D. Increased permeability of charged molecules only.

E. Decreased permeability of lipophilic molecules.

The CORRECT answer is C

Water in the stratum corneum may be "bound' or "free." As the stratum corneum becomes
hydrated, more free water is available, allowing water molecules to move more freely
through the skin. This increased water content of the stratum corneum gives it a larger
diffusion constant in Fick law as a result of increased movement of molecules across a
fixed concentration gradient.

66. In order for corticosteroids to exert their physiologic effects, they must bind to what?

A. Specific receptors on cell membranes.

B. Specific receptors within target cell cytoplasm .
C. Specific nuclear membrane receptors.
D. Ribosomes.

E. Mitochondria.

The CORRECT answer is B

Corticosteroids exert their effects by diffusing through cell membranes, binding to specific
cytosolic receptors, and subsequently migrating to the cell nucleus, where the steroid-
receptor complex binds to cellular DNA to initiate transcription of various effector
molecules.
67. Which of the following factors significantly and positively influence absorption of
topically applied drugs?

A. Hydrophilic molecule.
B. Increased frequency of application greater than three times per day.

C. Increased hydration of skin.

D. Increased density of hair follicles.

You CORRECTLY answered C

Increased absorption of topically applied agents is achieved by lipophilic substances and

a hydrated skin surface. Increased frequency of topical application does not significantly
influence transcutaneous drug absorption beyond three times a day treatment, since
maximal flux is reached by most drugs at one to three times daily applications. The
transfollicular route of drug absorption is not very significant, and density of hair follicles in
a given region does not influence absorption to a great extent.

68. Which ONE of the following statements is true regarding histamine?

A. There are three types of histamine receptors in the body.

B. Dermal blood vessels contain only H1 receptors.

C. Itch is mediated by H2 receptors.
D. H1 receptors are found only in the skin.
E. H2 receptors are found primarily in the brain.

You CORRECTLY answered A

There are three types of histamine receptors in the human body: H1 receptors are found
in the skin and brain; H2 receptors mediate gastric acid secretion; and H3 receptors are
found in brain, lung, and other tissue. Dermal blood vessels contain both H1 and H2
receptors, which cause vasodilation when stimulated. Itch is mediated through the H1
receptor.

69. Which ONE of the following is true regarding antigen presentation by macrophages?

A. la (class II) antigen expression is not necessary for antigen presentation.

B. Foreign antigens are processed extracellularly.

C. IL-1 is secreted by macrophages.

D. IL-2 is secreted by macrophages.
E. Processed antigen is presented to B cells.

. The CORRECT answer is C

Macrophages take up and internalize foreign antigens, which are then processed
internally. Macrophages then secrete IL-1, which induces T-cell recognition of the foreign
antigen only in association with la (Class II MHC) antigens. IL-2 is secreted by activated T
cells following recognition of processed antigens on macrophage cell surfaces.
70. Which one of the following is TRUE regarding pruritus?

A. Pruritus is produced primarily within the subcutaneous tissues.

B. Itch and pain sensations are carried to the central nervous system via the same
sensory afferents.
C. The reflex response to itch is the same as the reflex response to pain.

D. Itch cannot be elicited when the dermis and epidermis have been removed.
E. Itch and pain cannot be experienced in the same site simultaneously.

The CORRECT answer is D

Pruritus is produced primarily at the dermal-epidermal junction; consequently, itch cannot

be elicited without an intact dermis and epidermis. The sensory fibers transmitting pain
and itch sensation from the skin to the central nervous system are unique and are
composed of two distinct populations of primary sensory afferents. Because there are two
unique sensory afferents for itch and pain, these two sensations can be experienced at
the same site simultaneously. The reflex response to itch is scratching, whereas the
reflex response to pain is withdrawal.

71. Changes in the structure of the basic steroid moiety (Figure 3–1) that have led to
increased potency include which of the following?

A. Fluorination at the 9 position of the steroid ring.

B. Introduction of a double bond between carbons 1 and 2 of the steroid ring.

C. Alteration of the side chains at C-21.
D. Alkylation at position 6 of the steroid ring.

E. All of the above.

. The CORRECT answer is E

Increased steroid glucocorticoid potency is achieved by halogenation at the 6 or 9

positions of the steroid ring, introduction of a double bond between carbons 1 and 2 of the
steroid ring, alteration of the side chains at C-21, and alkylation at position 6 or 16 of the
steroid ring.
72. Which of the following diseases has been associated with systemic pruritus?

A. Biliary cirrhosis.

B. Anemia.
C. Uremia.

D. Polycythemia vera.
E. All of the above.

You CORRECTLY answered E

Pruritus may be a prominent feature of several systemic disease processes. Frequent

causes include malignancies (especially lymphoma), uremia, obstructive biliary disease,
polycythemia vera, hypo/hyperthyroidism, carcinoid, and anemia. A work-up for chronic
generalized pruritus includes a complete history and physical examination, CBC with
differential, thyroid, liver, and renal function, laboratory studies; fasting blood sugar, and a
chest x ray.