Pharmacology

1. A patient with ocular cicatricial pemphigoid on cyclophosphamide develops dysuria. Which of the following
interventions would have likely prevented this patient's complication?
A. Proper hydration
B. mesna
C. Phenazopyridine
D. A, B
E. A, B, C

Correct answer: (D) A, B. Proper hydration and mesna.

Explanation: Both proper hydration and mesna are interventions shown to prevent hemorrhagic cystitis. mesna is a
cytoprotective agent useful in reducing the risk of bladder damage related to chemotherapy drugs ifosfamide and
cyclophosphamide.
(C) Cyclophosphamide, in conjunction with systemic steroids, is the primary treatment for moderate to severe ocular
cicatricial pemphigoid. A major side effect of cyclophosamide is hemorrhagic cystitis, related to the metabolic product
acrolein. Although phenazopyridine may help with topical anagelsia, it would not prevent the development of
hemorrhagic cystitis.

2. How does adalimumab function?

A. Binds EGFR
B. Binds CD45RO
C. Binds p40 subunit of IL-12 and IL-23
D. Binds CD20- on B cells
E. Binds TNF-alpha

Correct answer: (E) Binds TNF-alpha.

Explanation: Binds TNF-alpha.
(A) Binds EGFR - Cetuximab.
(B) Binds CD45RO – Alefacept.
(C) Binds p40 subunit of IL-12 and IL-23 – Ustekinumab.
(D) Binds CD20- on B cells – Rituximab.

3. An 18 year old female with hormonally exacerbated acne vulgaris is started on combination oral contraceptives.
Which of the following is true regarding oral contraceptives therapy in acne patients?
A. Physicians need to check free testosterone levels prior to initiation
B. Some combination oral contraceptives do not carry an increased risk of venous thrombosis
C. Oral contraceptives decrease free testosterone levels by competitively binding to testosterone
receptors
D. Oral contraceptives increase hormone binding globulins in serum
E. Oral contraceptives directly inhibit sebaceous gland activity

Correct answer: (D) Oral contraceptives increase hormone binding globulins in serum.
Explanation: OCPs induce sex hormone binding globulin production, which then bind to free testosterone in the blood,
reducing availability.
(A) There are no consensus recommendations recommending checking testosterone levels outside of suspected polycystic
ovarian syndrome in the setting of hormonal acne vulgaris.
(B) All combination OCPs carry a small risk of venous thrombosis. Progestin-only contraceptives do not carry a risk of
venous thrombosis.

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 (C) OCPs reduce free testosterone, but not by binding testosterone receptor.
(E) Spironolactone, not OCPs, has been shown to decrease androgen-stimulated sebocyte proliferation in vitro and
inhibits sebaceous activity in mice.

4. A 45 year old female with systemic lupus erythematosus (SLE) is being counseled about a steroid taper which
includes alternate day dosing. Which of the potential adverse effects is not minimized by alternate day dosing?
A. Cataracts
B. Weight changes
C. Opportunistic infections
D. Growth retardation
E. Myopathy

Correct answer: (A) Cataracts.

Explanation: The key factors for the development of subcapsular cataracts in patients on glucocorticosteroids are the
dose and duration of steroid therapy.
(B) Long-term weight changes are affected by alternate day dosing.
(C) Opportunistic infections are reduced by alternate morning doses of glucocorticosteroids and if doses remain less than
the equivalent of 10 mg/day.
(D) Alternate morning therapy of glucocorticosteroids may minimize growth retardation, but does not eliminate it.
Compensatory growth spurt occurs with normal development of height once the steroids are discontinued. This
compensatory growth may not occur if chronic glucocorticosteroids are given before age 2 years and at puberty. Closure
of the epiphyses may occur if glucocorticosteroids are given just prior to puberty.
(E) Myopathy may begin weeks to months after glucocorticosteroid doses over 40 mg/day of prednisone. Alternate day
dosing may decrease the onset of myopathy.

5. You are seeing a patient with photosensitivity. Wearing a broad spectrum sunscreen is emphasized while counseling
the patient. Which of the following chemical sunscreens is strictly considered a UVB absorber?
A. Dibenzoylmethanes
B. Benzophenones
C. Methyl Anthranilate
D. Oxybenzone
E. Padimate O

Correct answer: (E) Padimate O.

Explanation: Sunscreens are categorized as either chemical absorbers or physical blockers. Titanium dioxide and zinc
oxide are physical blockers. Padimate O (PABA ester), octylmethoxycinnamate and octyl salicylate are the most common
UVB chemical sunscreen absorbers.
(A) Benzophenones, dibenzoylmethanes, and methyl anthranilate are UVA chemical sunscreen absorbers. Avobenzone is
a dibenzoylmethane that absorbs UVA I.
(B) (C) Benzophenones, dibenzoylmethanes, and methyl anthranilate are UVA chemical sunscreen absorbers.
(D) Benzophenones, oxybenzone and dioxybenzone have a broad spectrum of UVB and UVA II absorption.

6. Which of the following is the least likely medication associated with periungual pyogenic granulomas?
A. Isotretinoin

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 B. Indinavir
C. Minocycline
D. Zidovudine
E. Lamivudine

Correct answer: (C) Minocycline.

Explanation: Minocycline is not associated with periungual pyogenic granulomas.
(A) Painful periungual pyogenic granulomas have been associated with HIV medications such as indinavir, zidovudine
and lamivudine. Also, periungual pyogenic granulomas have been reported with isotretinoin, anti-CD20 monoclonal
antibody (Rituximab), Paclitaxel and others.
(B) Indinavir has a reported association with painful periungual pyogenic granulomas.
(D) Zidovudine has a reported association with painful periungual pyogenic granulomas.
(E) Lamivudine has a reported association with painful periungual pyogenic granulomas.

7. Which chemotherapy drug below has a mechanism of action that is not cell cycle specific?
A. Cyclophosphamide
B. Methotrexate
C. Hydroxyurea
D. 5-fluorouracil
E. Azathioprine

Correct answer: (A) Cyclophosphamide.

Explanation: Cyclophosphamide cross-links DNA at any point in the cell.
(B) Methotrexate specifically acts at the S-phase.
(C) Hydroxyurea specifically acts at the S-phase.
(D) 5-fluoruracil specifically acts at the S-phase. (E) Azathioprine specifically acts at the S-phase.

8. A patient with delusions of parasitosis is being started on pimozide. The patient should be aware that all of the
following potential side effects may emerge, except?
A. Prolactinemia
B. Weight gain
C. Extrapyramidal side effects
D. QT prolongations
E. Arthralgia

Correct answer: (E) Arthralgia (All of the others are potential side effects).
Explanation: All of the below are potential side effects of pimozide. The most common side effects include somnolence,
hyperhidrosis, nocturia, and dizziness.
(A) Prolactinemia is a potential side effect of pimozide.
(B) Weight gain is a potential side effect of pimozide.
(C) Extrapyramidal (pseudo-Parkinsonian) side effects are associated with pimozide use.
(D) QT prolongation is a major potential side effect of pimozide. Newer atypical antipsychotics, like risperdal, with more
favorable side effect profiles are now used more routinely.

9. A 37 year old female with cystic acne develops arthritis, myalgias and pericarditis. There are minimal cutaneous
findings. All of the following medications have been associated with drug-induced SLE except:

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 A. Isoniazid
B. Gold
C. Minocycline
D. Hydralazine
E. Procainamide

Correct answer: (B) Gold.

Explanation: Gold is not associated with drug induced SLE, but may cause lichenoid drug eruptions. Drug induced SLE
may occur due to drugs including minocycline, procainamide, hydralazine, isoniazid, chlorpromazine, phenytoin and
methyldopa. Unlike idiopathic SLE, drug induced SLE often causes only minimal cutaneous findings.
(A) Isoniazid is associated with drug induced SLE. Anti-histone antibody is found in patients with drug induced SLE.
(C) Minocycline is associated with drug induced SLE and also may cause blue-black pigmentation of the skin (shins
classically), nails, sclera and scars.
(D) Hydralazine is associated with drug induced SLE.
(E) Procainamide is associated with drug induced SLE.

10. What drug below is most likely to cause the non-pigmented variant of fixed drug eruption?
A. Naproxen
B. Sulfonamides
C. Erythromycin
D. Tetracycline
E. Pseudoephedrine

Correct answer: (E) Pseudoephedrine.

Explanation: Pseudoephedrine may cause fixed drug eruption and is the most likely drug listed to cause the non-
pigmenting variant.
(A) Naproxen may cause fixed drug eruption but is not the most likely to cause the non-pigmenting variant.
(B) Sulfonamides may cause fixed drug eruption but is not the most likely to cause the non-pigmenting variant.
(C) Erythromycin may cause fixed drug eruption but is not the most likely to cause the non-pigmenting variant.
(D) Tetracycline may cause fixed drug eruption but is not the most likely to cause the non-pigmenting variant.

11. A 54-year-old female with recalcitrant psoriasis has “been on everything”. She is quite frustrated with her current
management and is inquiring into alternative options. Approximately what percentage of dermatology patients uses
Complementary and Alternative Medicine in their lifetime?
A. 5%
B. 15%
C. 30%
D. 50%
E. 75%

Correct answer: (D) 50%.

Explanation: 35–69% of patients with skin disease have used complementary and alternative medicine as some point in
their lives. Further, a 2009 study found that 49.4% of patients with skin problems had used complementary and
alternative medicine within the previous year, and 6% had used it specifically for their skin disease.

12. Which of the following drugs may cause penile erosions?

A. Acyclovir

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 B. Valacyclovir
C. Zidovudine
D. Foscarnet
E. Gancyclovir

Correct answer: (D) Foscarnet.

Explanation: Foscarnet is associated with penile erosions. (A) Acyclovir does not cause penile erosions, but intravenous
infusions may cause phlebitis and reversible nephropathy. (B) Valacyclovir does not cause penile erosions, but high doses
may cause thrombotic thrombocytopenia and hemolytic uremic syndrome. (C) Zidovudine does not cause penile erosions,
but may cause hyperpigmented nail streaks. (E) Gancyclovir does not cause penile erosions, but may cause bone marrow
suppression.

13. A 55 year old male’s pemphigus vulgaris has become treatment resistant. He inquires about the availability of any
new treatment options. You explain that a medication, Rituximab, is approved for PV. The black box warnings for
rituximab include all of the following except:
A. Anaphylaxis
B. Methemoglobinemia
C. Hepatitis B reactivation
D. Progressive multifocal leukoencephalopathy
E. Mucocutaneous reactions

Correct answer: (B) Methemoglobinemia.

Explanation: Methemoglobinemia and hemolytic anemia are dose-related potential side effects of dapsone, not
Rituximab. Rituximab is a monoclonal antibody that depletes CD 20+ normal and malignant B cells. It is approved for the
treatment of B-cell non-Hodgkin’s lymphoma, CD 20+ chronic lymphocytic leukemia, rheumatoid arthritis, and
pemphigus vulgaris. It is being used off label to treat conditions such as pemphigus foliaceous, paraneoplastic
pemphigus, epidermolysis bullosa acquisita, bullous pemphigoid, mucous membrane pemphigoid, dermatomyositis,
cutaneous lupus erythematosus, acute graft-versus-host disease and vasculitis.
(A) (C) (D) (E) The black box warning for Rituximab includes anaphylaxis, Hepatitis B reactivation, mucocutaneous
reactions and progressive multifocal leukoencephalopathy.

14. Which of the following medications causes trichomegaly?

A. Bimatoprost
B. Latanoprost
C. Cyclosporine
D. Interferon
E. All of the above

Correct answer: (E) All of the above.

Explanation: Trichomegaly (enlargement of the eyelashes) can be seen with many medications. Known associations
include prostaglandin analogues (bimatoprost, latanoprost), HIV, EGFR inhibitors, cyclosporine, topiramate, tacrolimus,
interferon.

15. A patient is started on dapsone for dermatitis herpetiformis. What underlying condition will increase the likelihood of
developing methemoglobinemia?
A. Iron deficiency

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 B. Glucose-6-phosphate dehydrogenase deficiency
C. Vitamin B6 deficiency
D. Aplastic Anemia
E. Thrombocytopenia

Correct answer: (B) Glucose-6-phosphate dehydrogenase deficiency.

Explanation: Glucose-6-phosphate dehydrogenase deficiency (G6PD) is most common among those of African, Middle
Eastern and Asian descent. People with G6PD deficiency are more susceptible to oxidative stresses and dapsone
metabolites.
(A) Methemoglobinemia is not associated with iron deficiency.
(C) Methemoglobinemia is not associated with Vitamin B6 deficiency.
(D) Methemoglobinemia is not associated with Aplastic Anemia.
(E) Methemoglobinemia is not associated with Thrombocytopenia.

16. An 80 year old male with BCC of the scaphoid fossa of the ear is being prepped for Mohs surgery. Which antiseptic
agent should be used with caution when cleaning around the ear?
A. Povidone iodine
B. Chlorhexidine
C. Hydrogen peroxide
D. Hexachlorophene
E. Isopropyl alcohol

Correct answer: (B) Chlorhexidine.

Explanation: Chlorhexidine is ototoxic. It may also cause ocular conjunctivitis and keratitis.
(A) Povidone iodine is a skin irritant and may cause contact dermatitis.
(C) Although, Hydrogen Peroxide is sometimes grouped with antiseptics, it really has no significant antiseptic properties.
(D) Hexachlorophene is a teratogen and can also cause neurotoxicity in infants.
(E) Isopropyl alcohol is a skin irritant. It is flammable in the setting of cautery.

17. A 28 year old female being treated for rheumatoid arthritis develops worsening of her rheumatoid nodules. Which
drug may be responsible for this?
A. Methotrexate
B. Corticosteroids
C. Hydroxychloroquine
D. Gold

Correct answer: (A) Methotrexate.

Explanation: Methotrexate induced accelerated nodulosis (MIAN) is a rare side effect of methotrexate. Methotrexate
may cause activation of adenosine A1 receptors, enhanced cellular fusion and production of multinucleated giant cells.

18. Which of the following medications exerts its anti-inflammatory effect by binding to cyclophilin?
A. Topical tacrolimus
B. Topical pimecrolimus
C. Dapsone
D. Cyclosporine
E. Colchicine

Correct answer: (D) Cyclosporine.

Explanation: Cyclosporine binds to cyclophilin in the cytoplasm of cells and blocks the dephosphorylation of a protein
called NFAT inhibiting the production of interleukin-2. Interleukin 2 is a potent pro-inflammatory stimulant that leads to

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 the recruitment and activation of components of the cell-mediated immunity including CD4+ and CD8+ T-cells.
Cyclosporine decreases the recruitment of T-cells in the epidermis. Topical tacrolimus and pimecrolimus belong to the
family of calcineurin inhibitors.
(A) (B) These medications bind to a protein called FK506 and through downstream interactions, have a similar effect on
inhibiting the dephosporylation of NFAT and decrease nuclear transcription that would eventuate in increased levels of
IL-2.
(C) Dapsone works by inhibiting the respiratory burst that takes place in neutrophils. It also prevents chemotaxis of
neutrophils to sites of inflammation.
(E) Colchicine exerts its anti-inflammatory effect by arresting cells in the metaphase portion of the cell cycle preventing
replication. It does so by preventing microtubule assembly. It also inhibits inflammatory cell motility out of the
vasculature by preventing adhesion and chemotaxis. Finally, it is also thought that colchicine can inhibit the
degranulation of neutrophils.

19. A 17-year-old patient with severe acne arrives to your office 4 months into isotretinoin therapy. The patient is at a
cumulative dose of 100mg/kg and tolerating the medication well. His recent lab work, however, reveals a
hypertriglyceridemia of 479mg/dL. Patient is otherwise asymptomatic. What is the best next step?
A. History and physical examination
B. Start gemfibrozil
C. Discontinue isotretinoin
D. Start simvastatin
E. Start fenofibrate

Correct answer: (A) History and physical examination.

Explanation: Up to 25% of isotretinoin patients can develop a reversible hypertriglyceridemia while on therapy. However,
lifestyle modifications (eg, diet, exercise, weight reduction) are initiated before any pharmacologic therapy in the
treatment of primary and secondary dyslipidemia, particularly in patients who are asymptomatic. In this case, one
important historical item must be determined prior to discussing potential interventions; namely, if the patient was
fasting prior to their most recent lab work. Following failure diet and lifestyle modifications, it would still be appropriate
to start a fibrate (gemfibrozil, fenofibrate) rather then discontinuing isotretinoin, as the patient is asymptomatic and
near the target cumulative dose of 120-150mg/kg.

20. A patient you are treating for pustular psoriasis has been taking cyclosporine for the past three weeks. As part of his
follow-up exam, you order several lab tests to monitor for side effects. You notice an increase from his baseline serum
creatinine from 0.8 to 1.1 mg/dL. The next best step in his management would be which of the following?
A. Recheck his levels in 2 weeks
B. Reduce his dose of cyclosporine by 10%
C. Reduce his dose of cyclosporine by 25%
D. Reduce his dose of cyclosporine by 50%
E. Discontinue his use of cyclosporine

Correct answer: (A) Recheck his levels in 2 weeks

Explanation: Cyclosporine is a potent immunomodulator that works as an anti-inflammatory medication by decreasing
interleukin 2 stimulation of CD4 and CD8 positive T-cells. It exerts its mechanism of action by binding to cyclophilin within
the cellular cytoplasm. Despite its proven efficacy as a first line therapy for several conditions including but not limited to
pustular psoriasis, cyclosporine has a significant side effect profile and requires frequent lab testing to screen for end-
organ damage. Renal disease is monitored by the frequent evaluation of BUN/Creatinine levels, magnesium, potassium,
and uric acid levels. An elevation in 25% of a patient’s BUN/Cr from baseline should alert physicians for potential renal
disease. The first step in approaching this would be to re-check BUN/Cr levels in 2 weeks. If the levels of BUN/Cr decrease
to less than 25% of baseline, cyclosporine can be continued at the current dose. Should the elevation persist after the

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 two-week re-check it is then advised to decrease the dose of cyclosporine to 25-50% of the original dose and re-check
BUN/Cr in one month. If the elevation is greater then 50% of the baseline BUN/Cr at the initial 2-week re-check, it is
advised to decrease the cyclosporine levels to 50% of the original dose and re-check after one month. If after one month,
regardless of the dose reduction (25-50% or 50%), no change in the BUN/Cr or improvement warrants cessation of the
medication. Looking at the numbers in this case, moving from 0.8 to 1.2 is a 50% increase. Anything above 1.2 in this
situation warrants holding cyclosporine. If however, the raise was anything >30% BUT less than 50%, the correct answer
would be to re-check the level at 2 weeks.

21. A patient on dapsone recently noted increased fatigue and pallor. Laboratory evaluations reveal a hemolytic anemia.
Which of the following vitamins may have helped prevent prevent dapsone-related hematologic side effects?
A. Vitamin A
B. Vitamin C
C. Riboflavin
D. Niacin
E. Vitamin E

Correct answer: (E) Vitamin E.

Explanation: Partial protection against dapsone-induced hemolysis was exhibited in a clinical trial by orally administered
vitamin E, but not vitamin C. Vitamin E is a fat-soluble vitamin with a variety of cellular membrane stabilizing-
antioxidant and non-antioxidant functions. Vitamin E has been suggested to prevent the oxidation of polyunsaturated
fatty acids in red blood cell (RBC) membrane, thus inhibiting the premature erythrocytelysis. Several clinical trials have
indicated that vitamin E might be used therapeutically as a potential erythropoietic agent for decreasing the premature
erythrocyte hemolysis by reducing the fragility of erythrocytes.

22. In the treatment of oral HSV infections, the mechanism of action for antivirals that may be used include all of the
following EXCEPT:
A. Conversion to monophosphates by virus-specific thymidine kinase
B. Conversion to triphosphates by cellular enzymes
C. Inhibition of DNA synthesis
D. Competitive inhibitor of viral DNA-dependent DNA polymerase
E. Inhibition of viral RNA-dependent DNA polymerase

ANSWER: E.
EXPLANATION:
E. This statement is correct: The ability to inhibit RNA-dependent DNA polymerase is only seen in antiretrovirals, often
involved in the treatment of HIV. Acyclovir, the primary drug in the treatment of oral lesions of HSV, does not inhibit
RNA-dependent DNA polymerase.
In the treatment of acute external oral HSV lesions, topical acyclovir may be used. Additionally, for primary infections,
extensive oral infections, or immunosuppressed patients, IV or oral acyclovir may be given. This antiviral’s mechanism of
action involves conversion to monophosphates by virus-specific thymidine kinase. It is then converted to triphosphates by
cellular enzymes. This triphosphate product inhibits DNA synthesis via inhibition of viral DNA-dependent DNA
polymerase.

23. A patient with other medical problems develops a patch of scalp alopecia with black dots and occipital lymph-
adenopathy. Tinea capitis is suspected. Griseofulvin may adversely interact with all of the following drugs except
A. Phenobarbital
B. Drospirenone/ ethinyl estradiol combination pill

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 C. Rifampin
D. warfarin
E. butalbital

Correct answer: (C) Rifampin.

Explanation: Rifampin does not have any drug interactions with griseofulvin.
(A) Phenobarbital is commonly utilized for it’s anti-seizure properties. When barbiturates are taken with griseofulvin,
there is decreased gastrointestinal absorption of griseofulvin and increased metabolism. This causes decreased plasma
levels of griseofulvin.
(B) Drospirenone/ Ethinyl estradiol combination pill and other oral contraceptives may lose effectiveness when taken in
conjunction with griseofulvin due to increased metabolism.
(D) When griseofulvin is taken with warfarin, the anticoagulant activity of warfarin decreases.
(E) Patients with chronic tension headaches may be taking a medication that contains butalbital, a barbiturate. When
barbiturates are taken with griseofulvin, there is decreased gastrointestinal absorption of griseofulvin and increased
metabolism. This causes decreased plasma levels of griseofulvin.

24. You are treating a patient with atopic dermatitis. A different class of steroid is applied for the face and body folds.
You explain your rationale to the medical student. Which body site has the highest level of drug penetration?
A. Eyelid
B. Back
C. Mucous Membranes
D. Scrotum
E. Face

Correct answer: (C) Mucous Membranes.

Explanation: Topical medication penetration: mucous membranes > scrotum > eyelids > face > chest and back > upper
arms and legs > dorsal hands and feet > palms and soles > nails.

25. You prescribe doxepin to a 37-year-old woman to treat neurotic excorations on her arms. The patient is concerned
about the side effects of this drug. Which of the following is not a side effect of doxepin?
A. Xerostomia
B. Liver toxicity
C. Somnolence
D. Urinary retention
E. Constipation

Correct answer: (B) Liver toxicity.

Explanation: Although extensively metabolized by the liver and excreted by the kidney, liver toxicity is very rare.
Nephrotoxicity, on the other hand, is a well-known serious adverse effect of long term doxepin use. (A) (C) (D) (E)
Doxepin is a tricyclic antidepressant with H1 and H2 antihistamine activity. Side effects include sedation and
anticholinergic effects (dry mouth, urinary retention, and constipation).

26. Which of the following is the longest acting systemic corticosteroid?

A. Cortisone
B. Prednisone
C. Methylprednisone

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 D. Dexamethasone
E. Triamcinolone

Correct answer: (D) Dexamethasone.

Explanation: Dexamethasone and Betamethasone have the longest half-life of 36-54 hours.
(A) Cortisone and Cortisol (hydrocortisone) are the short acting systemic corticosteroids with a half-life of 8-12 hours.
(B) Prednisone, Prednisolone, Methylprednisolone, and Triamcinolone have an intermediate half-life 24-36 hours.
(C) Methylprednisolone has an intermediate half-life of 24-36 hours.
(E) Triamcinolone has an intermediate half-life of 24-36 hours.

27. A 30 year old male with condyloma accuminatum is being treated with imiquimod. Which of the following is false
regarding imiquimod?
A. Activates Toll-like receptor-7
B. Induces secretion of cytokine tumor necrosis factor α
C. Induces secretion of cytokines interferon α and interferon γ
D. Induces secretion of cytokine interleukin 12
E. Exhibits direct antiviral activity

Correct answer: (E) Exhibits direct antiviral activity.

Explanation: Imiquimod acts via immunomodulation and does not have direct antiviral activity. It induces a cell-
mediated response by stimulating the secretion of TNF-α, IFN-γ, IFN-α, IL-6, IL-1α, IL-1β, IL-8, IL-12, GM-CSF and G-CSF.

28. A 32-year-old female’s pemphigus foliaceous has become treatment resistant. She inquires about the availability of
any new treatment options. You explain that a medication, rituximab, used off-label for pemphigus foliaceous has
been successful in some cases. Potential side effects for rituximab include all of the following except:
A. Late onset neutropenia
B. Formation of antibodies to rituximab
C. Severe cardiac ventricular arrhythmia
D. Reactivation of JC virus
E. Delayed onset skin cancers

Correct answer: (E) Delayed onset skin cancers.

Explanation: There have been reports of rapid onset, not delayed onset, cutaneous squamous cell carcinoma and Merkel
cell carcinoma.
(A) Late onset neutropenia usually occurs after 2-6 months on the treatment and is self-limited.
(B) Autoantibodies to rituximab may occur, but the clinical significance is uncertain.
(C) Patients with a history of arrhythmias, ischemic heart disease or angina should be placed on cardiac monitoring
because rituximab may induce cardiac ventricular arrhythmia.
(D) Reactivation of the JC virus may lead to progressive multifocal leukoencephalopathy (PML). PML remains a risk even
after the drug is discontinued. New onset neurologic changes should prompt an evaluation.

29. What is the wavelength of narrowband UVB?

A. 259nm
B. 304nm
C. 312nm

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 D. 332nm
E. 378nm

Correct answer: (C) 312nm.

Explanation: (A) (B) (D) (E) Currently, phototherapy encompasses irradiations with broadband UVB (290-320 nm),
narrowband UVB (311-313 nm), UVA-1 (340-400 nm) and UVA plus psoralens (PUVA).

30. Which of the following drugs shares the same mechanism of action as Clindamycin?
A. Azithromycin
B. Doxycycline
C. Ciprofloxacin
D. Rifampin
E. Penicillin

Correct answer: (A) Azithromycin.

Explanation: Azithromycin and Clindamycin inhibit the 50S ribosomal subunit during protein synthesis.
(B) Doxycycline binds to the 30 S ribosomal subunit to inhibit protein synthesis.
(C) Ciprofloxacin inhibits DNA gyrase.
(D) Rifampin inhibits the DNA dependent RNA polymerase thereby inhibiting RNA synthesis.
(E) Penicillin inhibits the synthesis of the bacteria’s cell wall.

31. What is the most common location of the gene defect in hereditary hemochromatosis?
A. C282Y
B. H63D
C. P53
D. P14
E. P16

Correct answer: (A) C282Y.

Explanation: A homozygous defect in C282Y is the most common cause of hereditary hemochromatosis. The second most
common cause is a defect in H63D. Both genes causes the genetic loss of hepcidin, the iron hormone produced in the
liver. This leads to an increase in iron in the bloodstream and as it accumulates it causes toxic effects in other organs.
There are 4 types of hereditary hemochromatosis, types 1-3 are inherited in an autosomal recessive manner, while type 4
is inherited autosomal dominant manner. All types present with a triad of bronze skin, diabetes, and arthralgias.

32. A 42 year old housekeeper has a chronic hand dermatitis and is complaining of severe pruritus. You want to
prescribe a strong topical corticosteroid. All of the following are Class I corticosteroids, except:
A. Halobetasol 0.05% cream
B. Fluocinonide 0.1% cream
C. Clobetasol 0.05% lotion
D. Diflorasone diacetate 0.05% ointment
E. Mometasone 0.1% cream

Correct answer: (E) Mometasone 0.1% cream.

Explanation: Mometasone 0.1% cream and lotion are Class IV medium potency corticosteroids while Mometasone 0.1%
ointment is a Class II high potency corticosteroid.
(A) Halobetasol 0.05% cream and Halobetasol 0.05% ointment are both Class I (highest potency) corticosteroids.
(B) Fluocinonide 0.1% cream is a Class I corticosteroid, while the Fluocinonide 0.05% cream, gel and ointment
formulations are Class II corticosteroids.
(C) Clobetasol 0.05% cream, foam, gel, lotion, spray and ointment formulations are Class I corticosteroids.

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 (D) Diflorasone diacetate 0.05% ointment is a Class I corticosteroid.

33. A 48-year-old Ukrainian male patient presents to the emergency room with a several month history of burning eyes,
tender mouth angles, and groin dermatitis. Patient endorses a history of excessive alcohol intake. On physical exam,
the patient is also found to have bright, red tongue and photophobia. CBC reveals a low hemoglobin level. What
treatment would likely provide the patient complete resolution?

A. Systemic steroids
B. Mycophenolate mofetil
C. Isotretinoin
D. Vitamin B1
E. Vitamin B2

Correct answer: (E) Vitamin B2.

Explanation: Replacement therapy typically includes riboflavin 3-10mg/day orally, with intramuscular treatment
reserved for severe cases. (A) (B) (C) (D) This is a case of Oculo-orogenital syndrome. This is primarily due to vitamin B2
(riboflavin) deficiency, although is typically occurs in the setting of co-existent vitamin B deficiency. Oculo-orogenital
syndrome is characterized by angular cheilitis, glossitis, conjunctivitis, and seborrheic dermatitis-like lesions in the
groin. Other abnormalities include photophobia, anemia and iris pigment changes.

34. What is an effective treatment for angiofibromas associated with tuberous sclerosis?
A. Acitretin
B. Rapamycin
C. Bexarotene
D. Imantinib
E. Pimecrolimus

Correct answer: (B) Rapamycin.

Explanation: Rapamycin is an mTOR inhibitor that can help with the appearance of facial angiofibromas. Improvement
has been reported with either oral or topical rapamycin. It can also reduce the size of renal angiomyolipomas and
improve lung lymphangioleiomyomatosis.

35. Which of the following medications have been shown to be efficacious in treating the following condition?

A. Topical alpha-antagonists
B. Topical alpha-1 agonist
C. Topical alpha-2 agonist
D. Topical vitamin D analogs
E. Oral antimalarials
F. Both B and C are correct

Correct answer: (F) Both B and C are correct

Explanation: Topical brimonidine is an alpha-2 agonist that has recently been shown to reduce the non-transient facial
erythema of rosacea. The FDA has approved an alpha-1A agonist, topical oxymetazoline [Rhofade] for
erythematotelangiectatic rosacea

12
 (A) Topical alpha-antagonists have not been shown to be beneficial in the treatment of rosacea.
(D) Topical vitamin D analogs have not been shown to he beneficial in the treatment of rosacea.

36. If a patient taking azathioprine has genetically low levels of this enzyme, they are at increased risk for bone marrow
suppression.
A. Dihydrofolate reductase
B. Thiopurine methyltransferase
C. Myeloperoxidase
D. Inosine monophosphate dehydrogenase
E. Epoxide hydroxylase

Correct answer: (B) Thiopurine methyltransferase.

Explanation: Thiopurine methyltransferase (TMPT), xanthine oxidase and hypoxanthine-guanine
phosphoribosyltransferase (HGPRT) are the enzymes responsible for metabolizing azathioprine. If TMPT has decreased
activity, the HGPRT pathway leads to more of the active metabolite 6-thioguanine. The potential toxicity increases
including the risk of bone marrow suppression.
(A) Methotrexate is a dihydrofolate reductase inhibitor.
(C) Dapsone and sulfapyridine inhibit myeloperoxidase activity of polymorphonuclear neutrophils.
(D) Mycophenolate mofetil inhibits inosine monophosphate dehydrogenase. This inhibits de novo purine synthesis.
(E) Epoxide hydroxylase deficiency may increase the risk of anticonvulsant syndrome.

37. An obstetrician calls you about a patient she is sending to your office. In anticipation, you review the pregnancy
categories of some common medications. All of the following are pregnancy category B except:
A. Nystatin
B. Permethrin
C. Lidocaine
D. Etanercept
E. Azeleic Acid

Correct answer: (A) Nystatin.

Explanation: Nystatin is category C, as are other medications including sulfa, allegra, interferon, sudafed, diamox, and
dapsone.
(B) Permethrin is pregnancy category B.
(C) Lidocaine is pregnancy category B. However, lidocaine with epinephrine is pregnancy category C.
(D) Most biologics currently used in dermatology are pregnancy category B, including etanercept, adalimumab,
ustekinumab, and infliximab.
(E) Azeleic acid is pregnancy category B, while topical tretinoin and topical adapalene are pregnancy category C.

38. Which of the following medications inhibits squalene epoxidase, thereby blocking the conversion of squalene to
lanosterol?
A. Ketoconazole
B. Fluconazole
C. Terbinafine
D. Itraconazole
E. Voriconazole
Correct answer: (C) Terbinafine.
Explanation: Terbinafine is an allylamine that inhibits squalene epoxidase resulting in accumulation of squalene and a
deficiency of ergosterol. The low levels of ergosterol contribute to the fungistatic properties of terbenafine, while the
accumulation of squalene may contribute to the fungicidal action.

13
 (A) Ketoconazole is an imidazole that inhibits the lanosterol 14-α dimethylase and prevents lanosterol’s conversion into
ergosterol.
(B) Fluconazole is a triazole that inhibits the lanosterol 14-α dimethylase and prevents lanosterol’s conversion into
ergosterol.
(D) Itraconazole is a triazole that inhibits the lanosterol 14-α dimethylase and prevents lanosterol’s conversion into
ergosterol.
(E) Voriconazole is a triazole that inhibits the lanosterol 14-α dimethylase and prevents lanosterol’s conversion into
ergosterol.

39. A 26-year-old female patient with psoriasis and psoriatic arthritis has recently initiated methotrexate therapy. CBC
reveals a pancytopenia. Which of the following drugs likely contributed to this pancytopenia?
A. Systemic steroids
B. Acetaminophen
C. Isotretinoin
D. Vitamin B9
E. NSAIDs

Correct answer: (E) NSAIDs.

Explanation: NSAIDs can increase hematologic toxicity when used concomitantly with methotrexate.
(A) (B) (C) (D) This is a case of methotrexate-related bone marrow suppression. This is can be exacerbated by certain
medications that affect folate metabolism, including trimethoprim-sulfamethoxazole, dapsone, and NSAIDs. Further,
NSAIDs reduce glomerular filtration of methotrexate by reduced renal blood flow as a result of prostaglandin inhibition.
Vitamin B9 is folic acid, which would actually reduce the risk of bone marrow suppression.

40. A 34-year-old male with severe atopic dermatitis is well controlled on cyclosporine and topical steroids. At follow-up,
the patient notes a new onset of weakness, muscle cramping, and occasional tremors. What lab abnormality is the
most likely to cause these side effects?
A. Hyperuricemia
B. Hypomagnesemia
C. Hypokalemia
D. Hypocalcemia
E. Hypernatremia

Correct answer: (B) Hypomagnesemia.

Explanation: These symptoms are most likely related to hypomagnesemia as a result of cyclosporine toxicity.
Cyclosporine causes multiple electrolyte abnormalities, likely related to its nephrotoxicity, including HYPOmagnesemia,
HYPERkalemia, and HYPERuricemia. Gout flares and liver toxicity would be less likely to cause a triad of weakness,
cramping, and tremors given this clinical scenario.

41. A patient with multibacillary leprosy is receiving dapsone, clofazimine, and rifampin. Which of the following
statements is true regarding the mechanism of action of these medications?
A. Dapsone is bacteriostatic because of its inhibitory effects on dihydrofolate reductase.
B. Clofazimine is bactericidal by directly inhibiting bacterial DNA polymerase.
C. Rifampin is bacteriostatic by inhibiting RNA synthesis by blocking DNA-dependent RNA
polymerase.
D. Rifampin is bactericidal by inhibiting RNA synthesis via blocking DNA-dependent RNA polymerase.
ANSWER: D.
EXPLANATIONS:
C/D. TRUE: Rifampin is bactericidal by inhibiting RNA synthesis via blocking DNA-dependent RNA polymerase.

14
 A . FALSE: Dapsone inhibits bacterial synthesis of dihydrofolic acid via competition with para-aminobenzoate for the
active site of dihydropteroate synthetase. Dapsone is both bacteriostatic and weakly bactericidal against M. leprae.
Neither of the listed mechanisms is the cause of these effects.
B. FALSE: As a substance with both anti-leprosy and anti-inflammatory activity, clofazimine is weakly bactericidal against
M. leprae by binding to the guanine bases of bacterial DNA, not DNA polymerase directly.

42. Which of the following medications is least likely to cause the reaction represented by the histology shown?

A. Levetiracetam
B. Phenobarbital
C. Amoxicillin
D. Captopril
E. Nifedipine

Correct answer: (A) Levetiracetam.

Explanation: The figure displays the histologic appearance of pemphigus vulgaris/drug-induced pemphigus, which are
indistinguishable by H&E stain. There are no reported caes of levetiracetam-induced pemphigus at this time. As the other
drugs listed are well known causes of drug-induced pemphigus, levetiracetam should be chosen by process of
elimination. (B) (C) (D) (E) Each of these are well known causes of drug-induced pemphigus.

43. In a patient who has had allergic reactions to hair dyes and henna tattoos, which of the following local anesthetics
would be most appropriate to use?
A. Prilocaine
B. Benzocaine
C. Procaine
D. Tetracaine
E. Chlorprocaine hydrochloride

Correct answer: (A) Prilocaine.

Explanation: Most true local allergic reactions to local anesthetics have been reported in the ester anesthetic sub-group.
In most cases this is secondary to cross-reaction with contact sensitizers such as para-aminobenzoic acid (PABA), para-
amino salicylic acid, and para-phenylenediamine (PPD). The patient in this question has ad allergic contact dermatitis
secondary to contact sensitization to PPD which is found in hair dyes and henna tattoos and should therefore avoid ester
anesthetics such as those listed in Choices B-E. Prilocaine is an amide anesthetic and would not increase the potential for
cross-reactivity in this patient.

44. Which of the following enzymes is necessary for the conversion of 6-mercaptopurine to 6-thioguanine?
A. Thymidylate synthetase
B. Dihydrofolate reductase
C. Xanthine oxidase
D. Thiopurine methyltransferase
E. Hypoxanthine guanine phsosphoribosyl transferase
Correct answer: (E) Hypoxanthine guanine phososphoribosyl transferase.
Explanation: Hypoxanthine guanine phososphoribosyl transferase (HGPRT) is the enzyme responsible for converting 6-
mercaptopurine (6-MP) to its active metabolite 6-thioguanine (6-TG). This purine analogue is similar in structure to

15
 adenine and guanine, and because of this characteristic, is incorporated into DNA and RNA which leads to the inhibition
of purine metabolism.
Incorrect answers:
(A) Thymidylate synthetase is the enzyme required for the conversion of dUMP to dTMP, a function required for RNA
synthesis. It is inhibited by the pyrimidine analog 5-fluorouracil.
(B) Dihdydrofolate reductase is an enzyme that converts dihydrofolate to tetrahydrofolate. Tetrahydrofolate is required
for the synthesis of thymidylate and the purine nucleotides necessary for DNA and RNA synthesis. Inhibition of
dihydrofolate reductase is the mechanism of action of methotrexate.
(C), (D) Xanthine oxidase (XO) and thiopurine methyltransferase (TPMT) are enzymes that share the substrate 6-
mercaptopurine, however, their activity once bound to 6-MP results in the production of inactive metabolites. The
presence and function of TPMT as well as XO is crucial for the appropriate metabolism of 6-MP into 6-TG. Should either
metabolic pathway be blocked, excess 6-MP is converted into 6-TG creating an over abundance of active metabolites.

45. A 49-year-old female presents for outpatient follow-up 5 weeks after a lengthy inpatient admission for DRESS
syndrome. The patient notes no residual rash, however has noted worsening dry skin and mild diffuse hair loss. What
is the best next step?
A. Check a CBC and ferritin
B. Check TSH
C. Check HHV-7 reactivation
D. Reassure the patient that telogen effluvium is normal following a stressful event
E. Educate patient on dry skin care and biotin supplementation for hair loss

Correct answer: (B) Check TSH.

Explanation: A small percentage of DRESS patients may develop an autoimmune thyroiditis (as well as lupus
erythematosus and myocarditis) several weeks to months following DRESS syndrome.
(A) Although iron-deficiency anemia is a cause of diffuse hair loss, given the clinical context, thyroid function studies
would be more important for this patient.
(C) HHV-6 reactivation, not HHV-7, has been associated with DRESS syndrome and subsequent thyroiditis in case reports.
(D) Telogen effluvium is also on the differential for this patient, but should be considered a diagnosis of exclusion given
this patient’s history.
(E) Assuming all lab studies are negative, this would be appropriate advice for the patient, however, not the best next
step.

46. A patient presents with lesion noted in the photograph. The lesion reappears when in the same location when the
patient takes a specific medication. A biopsy is performed which revealed interface dermatitis, necrotic keratinocytes
and eosinophils. Which of the following drugs is most likely the culprit of this reaction?
47.

A. Antifungals
B. Penicillin
C. Albuterol
D. Trimethoprim-Sulfamethoxazole
E. Bleomycin

Correct answer: (D) Trimethoprim-Sulfamethoxazole.

Explanation: Trimethoprim-Sulfamethoxazole is among the most common drugs that can cause a fixed drug eruption.
Fixed drug eruptions happen at the same skin site with each exposure to the offending medication. Usually there is only

16
 one lesion, but multifocal eruptions may occur. Fixed drug eruptions can happen anywhere on the body, but 50% occur on
the oral and genital mucosa. The photograph is a classic image of the target-like lesion that develops. Prolonged post-
inflammatory hyperpigmentation often follows fixed drug eruption, but there is a non-pigmented variant as well.
(A) Any drug can cause a fixed drug eruption, but antifungals are not among the most common culprits.
(B) Any drug can cause a fixed drug eruption, but Penicillin is not among the most common culprits.
(C) Any drug can cause a fixed drug eruption, but Albuterol is not among the most common culprits.
(E) Any drug can cause a fixed drug eruption, but Bleomycin is not among the most common culprits. Some of the
characteristic adverse effects induced by Bleomycin include flagellate or linear hyperpigmentation and pulmonary fibrosis.

48. A 42 year old female complains of painful ears bilaterally. Her review of systems is positive for nose bleeds and
migratory arthralgias. Which of the following is the most appropriate treatment?

A. Isotretinoin
B. Doxycycline
C. Itraconazole
D. Dapsone
E. Intravenous Immunoglobulin G

Correct answer: (D) Dapsone.

Explanation: Treatment options for relapsing polychondritis include dapsone, corticosteroids, indomethacin,
methotrexate, azathioprine, cyclophosphamide, cyclosporine A, biologics and colchicine. Three of the following
symptoms are needed to make the diagnosis of relapsing polychondritis: bilateral auricular chondritis, nasal chondritis,
respiratory chondritis, non-erosive seronegative inflammatory polyarthritis, ocular inflammation, audiovestibular
damage. The image demonstrates one of the characteristic features of relapsing polychondritis. The earlobe does not
contain cartilage and is spared.

49. A 50 year old male patient presents to clinic with extensive psoriasis and joint pain. A decision is made to begin
treatment with infliximab. In addition to screening for tuberculosis, prior to beginning therapy with infliximab,
which test for latent infection should be performed to avoid viral reactivation?
A. Hepatitis A serology
B. Hepatitis B serology
C. Hepatitis C serology
D. HLTV-1 antibody
E. HIV serology

Correct answer: (B) Hepatitis B serology.

Explanation: Infliximab (Remicade) is a chimeric IgG monoclonal antibody against TNF-α. Inhibition of TNF can lead to
reactivation of hepatitis B, which can result in fulminant hepatic failure. In a retrospective study of more than 250
patients treated with infliximab 40% of hepatitis B carriers developed hepatitis B reactivation, compared to 5% of
patients positive for hepatitis C antibody.
(A) (D) Screening for hepatitis A and HTLV-1 are not currently recommended by the AAD or FDA. During a 2 year
observation period of HTLV-1 positive patients with rheumatoid arthritis on anti TNF therapy, no patients developed
adult t-cell leukemia.
(C) Screening for hepatitis C is recommended by the AAD prior to starting biologic therapy, however the impact of TNF on
hepatitis C is not well understood. Therapy with anti TNF agents is thought to be safe in the management of psoriatic

17
 arthritis patients with concomitant HCV infection. In a review of 216 patients with HCV treated with anti–TNF-α agents,
there were only 3 cases of drug withdrawal because of suspicion of worsening HCV.
(E) There is insufficient evidence of screening for HIV prior to initiation of TNF inhibition therapy. Among the available
reports evaluating the risk of HIV progression during biologic treatment, there were no notable increases in viral load,
decreases in CD4 T cell counts, or opportunistic infections while being treated with anti–TNF-α therapy.

50. Each of the following symptoms should be concerning for early signs of lidocaine toxicity EXCEPT?
A. Digital paresthesias
B. Euphoria
C. Lightheadedness
D. Restlessness
E. Psychosis

Correct answer: (E) Psychosis.

Explanation: In addition to choices A-D, circumoral paresthesias as well as drowsiness are also initial indicators of
lidocaine overdose. Symptoms of lidocaine overdose are directly correlated to the serum blood level of lidocaine and
progressive CNS and cardiovascular signs and symptoms correspond to specific serum levels. The above choices, except
for E, will occur when lidocaine levels exceed 1-6 mcg/ml. Psychosis, along with nausea, vomiting, muscle twitching,
blurred vision, tinnitus and confusion occur with lidocaine levels exceeding 6 mcg/ml. The most severe side effects of
lidocaine toxicity, including coma and cardiopulmonary arrest occur at lidocaine serum levels > 12 mcg/ml. The
maximum recommended dose for lidocaine without epinephrine is 5 mg/kg and with epinephrine it is 7 mg/kg, both are
at standard 1-2% concentrations.

51. Rituximab functions via which of the following?

A. TLR7
B. Treg cells
C. B cells
D. T Cells
E. TNFalpha

Correct answer: (C) B cells.

Explanation: Rituximab is a B cell anti-CD20 monoclonal antibody used in non-Hodgkin B-cell lymphoma, chronic
lymphocytic leukemia, rheumatoid arthritis, microscopic polyangiitis, and cutaneous B-cell lymphoma. In addition, it is
used to treat pemphigus vulgaris, bullous pemphigoid, lupus, and dermatomyositis.

52. All of the following are causes of pseudoporphyria except:

A. Phenytoin
B. Naproxen
C. Dapsone
D. Tetracycline
E. Furosemide

Correct answer: (A) Phenytoin.

Explanation: Phenytoin is not associated with pseudoporphyria. However, phenytoin may cause pseudolymphoma and
drug hypersensitivity disorder.
(B) Pseudoporphyria results in photodistributed cutaneous findings (vesicles, bullae, ulcerations) identical to porphyria.
However the patients do not have metabolic porphyrin abnormalities. Naproxen is the most common cause of

18
 pseudoporphyria. Other examples of causes include nalidixic acid, NSAIDS, tetracycline, furosemide, thiazide diuretics,
retinoids, piridoxime, dapsone, amiodarone and cyclosporine.
(C) Dapsone may cause pseudoporphyria.
(D) Tetracycline may cause pseudoporphyria.
(E) Furosemide may cause pseudoporphyria.

53. A 25 year old patient with nodulocystic acne is being counseled about isotretinoin. She is counseled about
discontinuing oral doxycycline before beginning isotretinoin. What potential complication is lessened if tetracyclines
are discontinued during isotretinoin therapy?

A. Pseudotumor cerebri
B. Hepatotoxicity
C. Myalgias
D. Angular chelitis
E. Triglyceridemia

Correct answer: (A) Pseudotumor cerebri.

Explanation: The risk of pseudotumor cerebri increases when patients take isotretinoin in combination with tetracyclines.
Isotretinoin has potential adverse events including xerosis, cheilitis, photosensitivity, pyogenic granuloma-like lesions,
myalgias, arthralgias, hypertriglyceridemia and hyperlipidemia. Rare side effects include hepatitis, alopecia and
hypercalcemia. Controversial side effects include depression and inflammatory bowel disease.
(B) Hepatotoxicity is a potential side effect of isotretinoin.
(C) Myalgias and arthralgias are a potential side effect of isotretinoin.
(D) Angular chelitis is a potential side effect of isotretinoin.
(E) Triglyceridemia is a potential side effect of isotretinoin.

54. A patient you have been evaluating for palmar-plantar pustular psoriasis returns to your clinic frustrated after
failing several topical and oral medications. You initiate a discussion with her about initiating cyclosporine. She
questions you about common side effects she should look out for. Which of the following is the most common side
effect of cyclosporine?
A. Acute Renal Failure
B. Hypertension
C. Gingival Hyperplasia
D. Hypertrichosis
E. Paresthesias

Correct answer: (B) Hypertension

Explanation: While all of the listed choices, (A) (C) (D) (E), are side effects associated with cyclosporine, hypertension is
the most common. It is recommended that patients taking cyclosporine have baseline blood pressure measurements
prior to starting the medication, and at every office visit afterwards while on the medication.

55. Pimecrolimus functions by which of the following?

A. Binds TNF-alpha
B. Binds high-affinity IL-2 receptor on T cells
C. Binds CTLA-4
D. Forms complex with FK506 binding protein
E. Forms complex with cyclophilin

19
 Correct answer: (D) Forms complex with FK506 binding protein.
Explanation: Forms complex with FK506 binding protein – Pimecrolimus and Tacrolimus inhibit calcineurin activity by
forming a complex with FK506 binding protein.
(A) Binds TNF-alpha – TNF inhibitors such as infliximab, adalimumab, and entanercept.
(B) Binds high-affinity IL-2 receptor on T cells – Denileukin Diftitox.
(C) Binds CTLA-4 – Ipilimumab.
(E) Forms complex with cyclophilin – Cyclosporine inhibits calcineurin activity by forming a complex with cyclophilin.

56. A patient with pruritus from the condition displayed reports decreased nighttime awakenings from pruritus when she
takes hydroxyzine. She was just hired for a job and would like to take a less sedating antihistamine during the day.
Which of the following medications is metabolite of hydroxyzine?

A. Loratadine
B. Cetirizine
C. Desloratadine
D. Cyproheptadine
E. Fexofenadine

Correct answer: (B) Cetirizine.

Explanation: First generation H1antagonists like chlorpheniramine, hydroxyzine, diphenhydramine and doxepin cross the
blood brain barrier and are sedating. Cetirizine, a second generation H1 antagonist, is a metabolite of hydroxyzine and is
much less sedating/non-sedating. The second generation H1 antagonists like cetirizine, loratadine, desloratadine,
acrivastine, mizolastine and fexofenadine and levocetirizine cross the blood-brain barrier very poorly and thus result in
less drowsiness. H2 antagonist antihistamines include cimetidine and ranitidine and may be used in combination with
other antihistamines.
(A) Loratadine is a second generation H1 antagonist and is non-sedating.
(C) Desloratadine, a second generation H1 antagonist, is a metabolic derivative of loratadine.
(D) Cyproheptadine is an antihistamine particularly effective for cold urticaria. ketotifen, a leukotriene receptor
antagonist is also helpful with severe cold urticaria.
(E) Fexofenadine, a second generation H1 antagonist is non-sedating.

57. A 26-year-old male patient with severe nodulocystic acne develops a femur fracture while playing soccer with his
family. Which of the following medications that have been taken by this patient is the most likely contributor to this
patient’s fracture?
A. This is to be expected in a high impact sport
B. Minocycline
C. Isotretinoin
D. Prednisolone
E. Dapsone

Correct answer: (D) Prednisolone.

Explanation: Systemic steroids are used to prevent flares during isotretinoin initiation. Risks with systemic steroid use
include aseptic necrosis of femoral and humeral heads and pathologic fracture of long bones. This may be prevented
with oral vitamin D and calcium supplementation.

20
 (A) This is the case of a pathologic fracture due to corticosteroid use. A femur fracture is typically the result of a high
impact injury of significant force directly to the thigh. It is unlikely that playing soccer with his family would, in itself,
produce such an impact. This should raise suspicion for a pathologic fracture.
(B) (C) (E) Minocycline, isotretinoin, and dapsone have not been shown to increase fracture risk.

58. An intubated patient in the intensive care unit has a suspected hypersensitivity reaction. The patient’s family reveals
that the patient has a known penicillin allergy. While reviewing the list of the patient’s current medications, the
clinician notes that no penicillins are listed, but the patient is receiving a cephalosporin. Which of the following is a
fourth-generation cephalosporin?
A. Cefepime
B. Cephalexin
C. Cefaclor
D. Cefotaxime
E. Ceftriaxone

ANSWER: A.
EXPLANATIONS:
A. TRUE: Cefepime is a fourth-generation cephalosporin. Fifteen percent of people with penicillin allergy have cross-
reactivity to cephalosporins. Also, 2% of people with a cephalosporin allergy have cross-reactivity to penicillins.
Cephalosporins and penicillins may cause similar cutaneous findings, including morbilliform eruption, urticaria, drug
fever, eosinophilia, and acute generalized exanthematous pustulosis.
B. FALSE: Cephalexin is a first-generation cephalosporin, along with cefadroxil and cefazolin.
C. FALSE: Cefaclor is a second-generation cephalosporin along with cefprozil, cefuroxime axetil, cefuroxime, cefotetan,
and cefoxitin.
D. FALSE: Cefotaxime is a third-generation cephalosporin along with cefixime, cefdinir, cefpodoxime, ceftazidime,
ceftibuten, cefditoren, and ceftriaxone.
E. FALSE: Ceftriaxone is a third-generation cephalosporin.

59. Which of the following medications are contraindicated in pregnancy (Category X)?
A. Acitretin
B. 5-fluorouracil
C. Tazarotene
D. Finasteride
E. All of the above

Correct answer: (E) All of the above.

Explanation: All of the above medications are contraindicated in pregnancy.
(A) Acitretin is pregnancy category X.
(B) 5-fluorouracial is pregnancy category X.
(C) Tazarotene is pregnancy category X.
(D) Finasteride is pregnancy category X.

60. What chemotherapeutic agent can cause yellow-brown callus-like hyperkeratotic plaques?
A. Sorafenib
B. Tamoxifen
C. Cyclophosphamide
D. Bleomycin

21
 Correct answer: (A) Sorafenib.
Explanation: Sorafenib is a tyrosine kinase inhibitor that has many side effects including palmoplantar hyperkeratosis,
keratoacanthomas, SCCs, angioedema, and Stevens Johnson syndrome. Hyperkeratotic hand–foot skin reaction is a
painful complication seen most frequently during the early weeks of use with sorafenib, sunitinib and pazopanib.
Hyperkeratotic plaques develop predominantly over sites of pressure or friction.

61. A patient presents with a bleeding nodule periungually. Pathology reveals a lobular proliferation of capillaries within
granulation tissue. What medication is associated with increased prevalence of this lesion?
A. Methotrexate
B. Indomethacin
C. Penicillins
D. Isotretinoin
E. Doxycycline

Correct answer: (D) Isotretinoin.

Explanation: Development of periungual and subunugual pyogenic granulomas have been reported as a rare side-effect
of systemic isotretinoin treatment. Other medications reported to cause this include: topical retinoids, antiretrovirals
(mostly in the great toe), epidermal growth factor receptor inhibitor therapy, 5-fluorouracil, capecitabine, mitoxantrone,
the taxanes, erlotinib, cyclosporine, erythropoietin, and anti-CD 20 monoclonal antibody therapy.

62. A patient presents with a bleeding nodule periungually. Pathology reveals a lobular proliferation of capillaries within
granulation tissue. What medication is associated with increased prevalence of this lesion?

A. Gold
B. Captopril
C. Hydrochlorothiazide
D. Penicillamine
E. Terbinafine

Correct answer: (E) Terbinafine.

Explanation: Sawtooth rete ridges, destruction of the basal layer, a band-like lichenoid lymphocytic infiltrate, civatte
bodies and eosinophils describes a classic lichenoid interface dermatitis. The differential diagnosis for lichenoid interface
dermatitis with eosinophils or parakeratosis includes benign lichenoid keratosis, lichenoid drug, lichenoid graft-versus-
host disease, lichenoid regression of melanoma and hypertrophic lupus. Terbinafine is not associated with lichenoid drug
eruption. In addition to the drugs listed in answers (A), (B), (C), and (D), other common causes of lichenoid drug eruption
include antimalarials and NSAIDS.
(A) Gold can cause lichenoid drug eruptions.
(B) Captopril can cause lichenoid drug eruptions.
(C) Hydrochlorothiazide can cause lichenoid drug eruptions.
(D) Penicillamine can cause lichenoid drug eruptions.

22
63. Which of the following medications can cause white tongue in a patient undergoing hematopoietic stem cell
transplantation?
A. Palifermin
B. Indinavir
C. Azathioprine
D. Fluconazole
E. Foscarnet

Correct answer: (A) Palifermin.

Explanation: Palifermin is a keratinocyte growth factor that is used to prevent mucositis caused by cytotoxic therapy in
patients undergoing hematopoietic stem cell transplantation. It stimulates epidermal proliferation and differentiation. It
causes white tongue which is attributed to protective mucosal thickening.

64. A 27 year old pregnant woman presents complaining of severe pruritus. The pruritus involves the abdomen, back,
chest and extremities. Erythematous papules with excoriation are noted on exam including the lesions displayed in the
photograph. How should this patient be treated?

A. Permethrin 5% Cream
B. Ivermectin
C. Topical corticosteroids and reassurance
D. Precipitated Sulfur 6%
E. Lindane 1%
F. Both A & D are therapeutic options during
pregnancy

Correct answer: (F) Both A & D are therapeutic options during pregnancy.
Explanation:
(A) Permethrin cream is pregnancy category B. Precipitated sulfur is the first line treatment for pregnant women with
scabies, but permethrin is also considered, by some, as a relatively safe option in pregnant women.
(B) Ivermectin is pregnancy category C. Safer alternative treatments are available.
(C) Topical corticosteroids and reassurance is an appropriate treatment plan for pregnant women with pruritic urticarial
papules and plaques of pregnancy (PUPPP), but not for scabies.
(D) Precipitated sulfur 6% compounded in petrolatum is the treatment of choice for this pregnant patient. It is safe,
effective and appropriate for infants under 2 months, pregnant women and lactating women.
(E) Lindane should not be used in pregnant or nursing women, young children or those with seizure disorders or other
neurologic conditions. Lindane is pregnancy category C, and carries a black box warning due to its potential neurotoxicity
with repeated or prolonged use.

65. A 65-year-old male presents with new onset skin yellowing and blue-black blotching on his gums. Which of the
following medications is most likely to cause the symptoms listed?
A. Amiodarone
B. Quinacrine
C. Clofazimine
D. Minocycline
E. Mercury

23
 Correct answer: (B) Quinacrine.
Explanation: Not uncommonly, patient can develop diffuse yellow to yellow–brown discoloration with quinacrine.
Further, there have been multiple reports of ochronosis-like hyperpigmentation with quinacrine use.
(A) Amiodarone typically causes a slate-gray to violaceous discoloration of sun-exposed skin, especially the face.
(C) Clofazimine causes a diffuse red to red–brown discoloration of skin and conjunctivae.
(D) Minocycline has 3 forms of blue-black hyperpigmentation: 1) within sites of inflammation and scars (iron-related
pigment) 2) on shins (iron- and melanin-related pigment) 3) diffuse “muddy brown” discoloration (melanin-related
pigment)
(E) Mercury causes slate-grey discoloration that is accentuated at skin folds.

66. Which of the following drugs inhibits de novo purine synthesis through the non-competitive inhibition of inosine
monophosphate dehydrogenase as a mechanism of action?
A. Azathioprine
B. Mycophenolate Mofetil
C. Cyclosporine
D. Cyclophosphamide
E. Methotrexate

Correct answer: (B) Mycophenolate Mofetil.

Explanation: Mycophenolate Mofetil inhibits de novo purine synthesis by non-competitively inhibiting inosine
monophosphate dehydrogenase. Cells like B cells and T cells that lack a purine salvage pathway, depend on the de novo
purine synthesis pathway and are thus selectively inhibited.
(A) Azathioprine is metabolized to a purine analog (adenine and guanine) which inhibits DNA and RNA synthesis.
Azathioprine is converted into 6-mercaptopurine. Azathioprine is also catabolized into inactive metabolites via xanthine
oxidase and thiopurine methyltransferase (TPMT) activity.
(C) Cyclosporine inhibits calcineurin by binding to cyclophilin. Calcineurin is unable to dephosphorylate NFAT-1
transcription factor. NFAT-1 is unable to initiate IL-2 which, when, stimulates CD4 and CD8 T cell proliferation.
(D) Cyclophosphamide is derived from nitrogen mustard. It is cell cycle non-specific. It causes more B cell dysfunction
than T cell dysfunction.
(E) Methotrexate competitively and irreversibly binds dihydrofolate reductase. It, therefore, prevents the formation of
tetrahydrofolate, a key to the synthesis of thymidylate and purine nucleotides.

67. During a recent dental procedure, your patient had a delayed type IV allergy to an amide anesthetic. You are
preparing to do a skin biopsy. Which amide anesthetic below should be avoided?
A. Lidocaine
B. Tetracaine
C. Benzocaine
D. Cocaine
E. Procaine

Correct answer: (A) Lidocaine.

Explanation: Lidocaine is the only amide anesthetic listed. Amides have “two i’s” in the spelling of their names. Patients
who experience a type IV delayed sensitivity to either esters or amides are not commonly allergic to anesthetics in the
other group. An exception are those with para-aminobenzoic acid (PABA) allergy which can cross-react with the ester
group of anesthetics. Esters and PABA are more likely associated with immediate type I hypersensitivity reactions.
(B) Tetracaine is an ester.
(C) Benzocaine is an ester.
(D) Cocaine is an ester.
(E) Procaine is an ester.

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68. You receive a phone call from a parent who has questions about a topical anesthetic that was prescribed for their 9
month-old child’s port-wine stain prior to undergoing pulsed dye laser therapy. You review his chart and note that
the vascular lesion extends from his right anterior shoulder down to his right hand. A eutectic mixture of 2.5%
lidocaine and 2.5% prilocaine hydrochloride was prescribed. What is the maximum recommended area that this
topical anesthetic can be applied to in this patient without risking methemoglobinemia?
A. 10 cm^2
B. 20 cm^2
C. 50 cm^2
D. 100 cm^2
E. 200 cm^2

Correct answer: (B) 20 cm^2.

Explanation: In a child 3-12 months of age, the maximum total dose of eutectic mixture of 2.5% lidocaine and 2.5%
prilocaine hydrochloride should not exceed 2 grams or cover an area greater than 20 cm^2. Doses above this amount or
covering an area greater than recommended, increase the risk of prilocaine hydrochloride induced methemoglobinemia.
It is important to know that these dose and surface areas can be overestimated if there are breaks in the skin, or if a
particular patient is susceptible to methemoglobinemia. In children less than 3 months old, the total dose should not
exceed 1 gram or an area greater than 10 cm ^2 (Choice A). Children 1-6 years of age should not receive doses greater
than 10 grams or exceed an area greater than 100 cm^2 (Choice D). Children 7-12 years of age should not receive doses
greater than 20 grams or exceed an area greater than 200 cm^2. An easy way to remember this is the maximum area in
cm^2 should not be greater than ten times the maximum total dose of cream.

69. A 6 month old male is diagnosed with atopic dermatitis. You are educating his parents about the importance of
moisturizing the child’s skin. Which of the following vehicles has as its end result the greatest hydration for the skin?
A. Solution
B. Gel
C. Lotion
D. Ointment
E. Cream

Correct answer: (D) Ointment.

Explanation: Ointments are highly viscous, semi-solid mixtures of large amount of oil with a small amount of water. The
greasiness of the ointment traps moisture, aiding in the skin barrier function. This results in it being the most hydrating
for the skin.
Incorrect answers:
(A) Solutions have low viscosity and usually have water or alcohol as a base.
(B) Gels often have an alcohol base and have the consistency of a semisolid.
(C) Lotions include mixtures of oil, water and less alcohol than solutions.
(E) Cream is a combination oil and water emulsion.

70. A 35 year old man with the disease pictured has tried multiple treatments including topical corticosteroids, and
calcipotriene. His skin disease has worsened and he is open to discussing the use of biologic medications. He prefers
biologic medications that he can self-administer at home for convenience. All of the following may be a treatment
option, except for what biologic that has to be given via intravenous infusion?
A. Efalizumab
B. Etanercept
C. Adalimuab
D. Infliximab
E. Ustekinumab

25
 Correct answer: (D) Infliximab.
Explanation: Infliximab, a TNF alpha inhibitor, must be infused intravenously.
(A) Efalizumab is a monoclonal antibody that is delivered subcutaneously, but is no longer available in the United States.
Efalizumab imparts immunosuppression by binding to the CD11a subunit of lymphocyte function-associated antigen 1
(LFA-1) integrin.
(B) Etanercept inhibits the cytokine TNF alpha, and is given by subcutaneous injection.
(C) Adalimuab inhibits the cytokine TNF alpha, and is given by subcutaneous injection.
(E) Ustekinumab is a monoclonal antibody direct against IL 12 and IL 23. It is given by subcutaneous injection. Initially it
was only administered by healthcare professionals, but it is now available for patient self-injection.

71. A young adult female is an avid soccer player, but needs a tetracycline prescription. Which tetracycline is the least
phototoxic?
A. Tetracycline
B. Doxycycline
C. Demeclocycline
D. Minocycline
E. Oxytetracycline

Correct answer: (D) Minocycline.

Explanation: Minocycline has negligible phototoxicity.
(A) Tetracycline is phototoxic.
(B) (C) Doxycycline and Demeclocycline are highly phototoxic.
(E) Oxytetracycline is phototoxic.

72. A 30-year-old HIV+ male is admitted for disseminated herpes simplex infection. Empiric acyclovir is started, however
cultures show HSV-2 resistant to acyclovir, so therapy is switched to IV foscarnet. The patient seems to be improving
on therapy; however, he soon develops well-demarcated erythematous erosions surrounding the urethral meatus
extending to the ventral shaft. No other new mucocutaneous lesions are noted. What is the most likely cause of the
penile erosions?
A. Medication-induced penile erosions
B. Early Stevens-Johnson syndrome
C. New primary herpes simplex infection with HSV-1
D. The patient has worsening disease of multi-drug resistant HSV-2 that is also resistant to foscarnet
E. Patient has a new primary chancroid

Correct answer: (A) Medication-induced penile erosions.

Explanation: There have been multiple reports of foscarnet-induced penile erosions. These are not thought to be related
to HSV reactivation, but rather directly drug-induced.
(B) Although consideration for early SJS must be considered, the lack of other mucocutaneous lesions makes this less
likely. Continued monitoring of this patient for progression should be considered.
(C) New primary herpes simplex while on foscarnet is highly unlikely.
(D) There are cases of multi-drug resistant herpes simplex, however, this would likely present as a recurrence of
disseminated herpes rather than penile erosions.
(E) About half of male chancroid patients have only a single ulcer, described as a “hard chancre”, with associated
inguinal lymphadenopathy (“buboes”).

26
73. A patient with metastatic melanoma is begun on therapy with ipilimumab. Which of the following describes the
mechanism of action of ipilimumab?
A. Inhibition of PD-1
B. Inhibition of CTLA-4
C. Inhibition of MAP kinase
D. Inhibition of MEK
E. Inhibition of KIT

Correct answer: (B) Inhibition of CTLA-4.

Explanation: Recently there have been a host of new agents available for treatment of advanced melanoma. Ipilimumab
inhibits CTLA4, a negative regulator of T-cell activation that competes with CD28 for binding of B7 on antigen presenting
cells. By “cutting the breaks” with an immune checkpoint inhibitor, T-cells are able to detect and destroy cancerous cells.
(A) Pembrolizumab and nivolumab are anti PD1 antibodies. Programmed cell death 1 is a molecule expressed on T-cells
that when bound to its ligand on tumor cells prevents apoptosis of the tumor cell. Combination therapy of anti PD1 and
anti CTLA4 resulted in increased survival compared to monotherapy.
(C) Vemurafenib and dabrafenib are inhibitors of BRAF, which activates the MAP kinase pathway. Roughly ½ of
melanomas have the V600 mutation in BRAF which would be amenable to therapy with vemurafenib.
(D) Trametinib works downstream of vemurafenib to inhibit MEK activation directly. Combination therapy of a BRAF and
MEK inhibitor was shown to have improved survival compared to monotherapy.
(E) Imantinib is a tyrosine kinase inhibitor which inhibits c-KIT. 25% of mucosal or acral melanomas contain mutations in
KIT, however not all are responsive to therapy with inhibition of KIT.

74. A 52-year-old man with history of dermatitis herpetiformis (on dapsone) presents to clinic with 3-day history of
cough, sore throat, sinus congestion, and oxygen saturation levels of 87% on room air. On exam, the patient exhibits a
mild bluish hue to his skin. What diagnostic test would be most useful in this patient?
A. Repeat pulse oximetry as this is likely a transient finding
B. Co-oximetry
C. Chest x-ray
D. Sputum cultures
E. CT of the chest

Correct answer: (B) Co-oximetry.

Explanation: Co-oximetry is the most useful test for diagnosing methemoglobinemia as it is able to differentiate
methemoglobin from other forms of hemoglobin, making it essential for diagnosis.
(A) This case represents a case concerning for methemoglobinemia. Upper respiratory symptoms may cause respiratory
discomfort, however, cyanosis and low oxygen saturation in a patient on dapsone should alert the provider to the
potential presence of methemoglobinemia. Repeat pulse oximetry would likely continue to show hypoxia.
(C) (D) (E) Chest x-ray, sputum cultures and a CT of the chest would not be useful for diagnosing methemoglobinemia.

75. A patient with discoid lupus is taking chloroquine, using sunscreen and practicing sun avoidance habits. The discoid
lupus is worsening. What topic should be discussed with this patient?
A. If the medication is being taken on an empty stomach
B. If the medication is being taken with a meal
C. How many cups of coffee the patient drinks daily
D. Whether the patient smokes
E. If the patient is exercising right after taking the medication

Correct answer: (D) Whether the patient smokes.

Explanation: People who smoke cigarettes respond less to chloroquine than to those who are non-smokers.
(A) Food intake does not affect the activity of chloroquine.

27
 (B) Food intake does not affect the activity of chloroquine.
(C) Caffeine intake does not affect the activity of chloroquine.
(E) Exercising does not affect the activity of chloroquine. However, some physicians instruct patients taking ketoconazole
for cutaneous fungal diseases to work up a sweat after taking the medication due to its secretion in eccrine sweat.

76. A patient with a long history of onychomycosis recently completed a 3-month course of terbinafine. He has yet to see
significant improvement and is wondering how terbinafine works. What is the mechanism of action for terbinafine?
A. Preventing ergosterol synthesis by inhibiting 14-alpha-demethylase
B. Direct membrane damaging effects
C. Inhibits fungal cell mitosis by causing disruption of the mitotic spindle structure
D. Inhibiting DNA transcription by interacting with histone deacetylase
E. Preventing ergosterol synthesis by inhibiting squalene 2,3-epoxidase

Correct answer: (E) Preventing ergosterol synthesis by inhibiting squalene 2,3-epoxidase.

Explanation: This is the mechanism for terbinafine. (Squalene monooxygenase is also called Squalene epoxidase).
(A) This is the mechanism of action for ketoconazole.
(B) Some recent reports have suggested direct damage of fungal cell membrane (i.e. sertaconazole), however, this has
not been reported with terbinafine.
(C) This is the mechanism of action for Griseofulvin.
(D) This is not a mechanism for any anti-fungal agents.

77. Which medication is most likely to cause the Mazzotti reaction?

A. Bleomycin
B. Diethylcarbamazine
C. Dapsone
D. Adalimumab
E. Infliximab

Correct answer: (B) Diethylcarbamazine.

Explanation: Diethylcarbamazine may cause the Mazzotti reaction. When patients are treated with Diethylcarbamazine
for onchocerciasis, they may develop lymphadenopathy, edema, exacerbation of pruritus, joint pains, fever, chills, fever,
urticaria, abdominal pain. These symptoms are likely due to the sudden release of antigen by dying parasites or due to
Wolbachia organisms within the worms.
(A) Bleomycin is associated with linear or flagellate hyperpigmentation. Bleomycin is not associated with the Mazzotti
reaction.
(C) Dapsone is not associated with the Mazzotti reaction.
(D) Adalimumab is not associated with the Mazzotti reaction.
(E) Infliximab is not associated with the Mazzotti reaction.

78. A 23 year old female with erythrodermic psoriasis has failed to improve with conventional medications and is
resistant to other treatments. Due to the severity of this condition you suggest acitretin as the next treatment option.
What contraceptive period is advised after completing the acitretin course?
A. 3 months
B. 2 months
C. 3 years
D. 2 years

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 Correct answer: (C) 3 years.
Explanation: Acitretin is a retinoid and is the main metabolite of etretinate. They are equally effective, but acitretin is
cleared more rapidly. Etretinate is 50 times more lipophilic than acitretin. Etretinate has a half-life of 120 days. In the
presence of alcohol, acitretin may convert to etretinate. Therefore, the FDA advises a contraceptive period of 3 years to
avoid teratogenicity. Etretinate is no longer available in the US.

79. A 24-year-old patient with moderate-severe psoriasis was recently started on a new oral medication and has noted
that his clothes have been frequently clinging to his body, even when minimally damp. Which of the following
medications is the likely cause of these symptoms?
A. Dexamethasone
B. Vitamin D3
C. Acitretin
D. Methotrexate
E. Mycophenolate mofetil

Correct answer: (C) Acitretin.

Explanation: Of the medications listed, Acitretin is the only reported cause of sticky skin.
(A) (B) (D) (E) This case is typical for “sticky skin syndrome” (also known as acquired cutaneous adherence), a rare side
effect of retinoids, ketoconazole, and doxorubicin.

80. A patient develops herpetiform vesiculobullous lesions. Immunofluorescence revealed linear deposition of IgA at the
basement membrane. Which of the following drugs does not cause a linear IgA dermatosis?
A. Finasteride
B. Vancomycin
C. Lithium
D. Amiodarone
E. Captopril

Correct answer: (A) Finasteride.

Explanation: Finasteride does not cause linear IgA dermatosis.
(B) Vancomycin may cause linear IgA dermatosis.
(C) Lithium may cause linear IgA dermatosis.
(D) Amiodarone may cause linear IgA dermatosis.
(E) Captopril may cause linear IgA dermatosis.

81. A 5 year old boy, followed by a pediatric dermatologist for molluscum contagiosum, presents with an accidental first
degree burn. His only medication is cimetidine. He received a prescription for silver sulfadiazine cream from the local
emergency room. Which of the following is true?
A. The use of silver sulfadiazine cream is contraindicated due to the child’s age
B. The use of silver sulfadiazine is contraindicated in patients with molluscum contagiosum
C. When topical silver sulfadiazine is used in conjunction with cimetidine, there is increased risk of
leukopenia
D. Silver sulfadiazine should only be used for third degree burns.
E. None of the above are true

Correct answer: (C) When topical silver sulfadiazine is used in conjunction with cimetidine, there is increased risk of
leukopenia.
Explanation: Topical silver sulfadiazine has a potential adverse effect of leukopenia. The risk of leukopenia is increased
when patients are also taking cimetidine.
(A) Silver sulfadiazine, a topical antimicrobial, can be used in those over 2 months of age.

29
 (B) Silver sulfadiazine is not contraindicated in patients with molluscum contagiosum.
(D) Silver sulfadiazine may be used for first, second and third degree burns.

82. If a patient takes ketoconazole and doxorubicin, what potential reaction may occur?
A. Capillary leak syndrome
B. Flagellate hyperpigmentation
C. Acneiform eruption
D. Sticky skin
E. Leg ulcers

Correct answer: (D) Sticky skin.

Explanation: Sticky skin may result from the combination of a retinoid or ketoconazole with doxorubicin.
(A) Capillary leak syndrome may be induced by interleukins.
(B) Bleomycin may induce linear or flagellate hyperpigmentation.
(C) Acneiform eruptions are common with epidermal growth factor receptor inhibitors.
(E) Hydroxyurea may cause leg ulcers and dermatomyositis-like reactions.

83. A 40 year old female with moderate-severe eczema since childhood received multiple courses of corticosteroids as a
child. She was recently diagnosed with osteoporosis. All of the following are responsible for systemic corticosteroid
induced osteoporosis except:
A. Secondary hyperparathyroidism and bone resorption
B. Increased gastrointestinal absorption of calcium
C. Increased osteoclast activity
D. Decreased osteoblast activity
E. Increased renal excretion of calcium

Correct answer: (B) Increased gastrointestinal absorption of calcium.

Explanation: Systemic corticosteroids cause decreased gastrointestinal absorption of calcium. All of the other answer
choices summarize the key factors responsible of system corticosteroid induced osteoporosis. The most bone resorption
occurs in the ribs, vertebral bodies and flat bones of the pelvis.

84. Which of the following lab abnormalities would you LEAST expect in a patient taking cyclosporine?
A. Hyperkalemia
B. Hyperuricemia
C. Hypermagnesimia
D. Hypertension
E. All of the above are side effects of cyclosporine treatment

Correct answer: (C) Hypermagnesimia.

Explanation: Hypermagnesemia is not a side effect associated with the treatment of cyclosporine. Low levels of
magnesium, hypomagnesemia, are a side effect of cyclosporine. Low levels of this element contribute to and exacerbate
additional side effects associated with cyclosporine including paresthesias and hyperesthesia. The remaining choices,
hyperkalemia, hyperuricemia, and hypertension are all potential laboratory abnormalities associated with cyclosporine
and should be monitored throughout the treatment regimen.

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85. A patient with ocular cicatricial pemphigoid on cyclophosphamide develops hematuria. Which of the following
statements most likely explains this patient’s symptoms?
A. This patient has undergone pelvic radiation
B. This is likely due to an arteriovenous malformation
C. This is related to acrolein-mediated organ damage
D. This is due to the patient’s high risk of nephrolithiasis
E. This is a result of phosphoramide mustard-related apoptosis of bladder cells

Correct answer: (C) This is related to acrolein-mediated organ damage.

Explanation: Acrolein is directly toxic to bladder epithelium. This can lead to bladder scarring and possible
carcinogenesis. (A (B) (D) (E) Cyclophosphamide, in conjunction with systemic steroids, is the primary treatment for
moderate to severe ocular cicatricial pemphigoid. A major side effect of cyclophosphamide is hemorrhagic cystitis. There
are many other causes of hemorrhagic cystitis, including previous radiation, AV malformations and nephrolithiasis,
however, it is not the mechanism for cyclophosphamide-related cystitis. Metabolism of cyclophosphamide results in
production of phosphoramide mustard and acrolein. Phosphoramide mustard forms DNA crosslinks that leads to cell
apoptosis, however it is also not the cause of cystitis.

86. After a patient is started on one of the medications below, his dose of Cyclosporine A needed to be increased. Which
of the medications below prompted the Cyclosporine A dose adjustment?
A. Ciprofloxacin
B. Ketoconazole
C. Carbamazepine
D. Gemfibrozil
E. Furosemide

Correct answer: (C) Carbamazepine.

Explanation: Cyclosporine A is metabolized by the hepatic cytochrome P-450 3A4. Carbamazepine induces cytochrome P-
450 3A4 thereby decreasing the levels of Cyclosporine A, which prompted the dose adjustment.
(A) Ciprofloxacin is a cytochrome p-450 3A4 inhibitor and in turn increases the level of Cyclosporine A.
(B) Ketoconazole is a cytochrome p-450 3A4 inhibitor and in turn increases the level of Cyclosporine A.
(D) Gemfibrozil is a cytochrome p-450 3A4 inhibitor and in turn increases the level of Cyclosporine A.
(E) Furosemide is a cytochrome p-450 3A4 inhibitor and in turn increases the level of Cyclosporine A.

87. Your patient has a 6mm dark brown nevus on the posterior lower leg. The nevus has grown in size and has an
irregular shape. You discuss performing a skin biopsy to rule out a dysplastic nevus. When asking about anesthetic
allergies, the patient reports a positive patch test to para-aminobenzoic acid in the past. Which local anesthetic
ingredient should be avoided in this patient?
A. Bupivacaine
B. Benzocaine
C. Lidocaine
D. Sodium Bicarbonate
E. Prilocaine

Correct answer: (B) Benzocaine.

Explanation: Benzocaine is an ester anesthetic. Esters are hydrolyzed by plasma pseudocholinesterases. PABA is a
metabolite of ester anesthetics and may cause allergic sensitivity reaction in those with PABA allergy. Patients who
experience a type IV delayed sensitivity to either esters or amides are not commonly allergic to anesthetics in the other
group. An exception are those with para-aminobenzoic acid (PABA) allergy which can cross-react with the ester group of
anesthetics. Esters and PABA are more likely associated with immediate type I hypersensitivity reactions.
(A) Bupivacaine is an amide anesthetic and is safe to use in patients with para-aminobenzoic acid (PABA) allergy.

31
 (C) Lidocaine is an amide anesthetic and is safe to use in patients with para-aminobenzoic acid (PABA) allergy.
(D) Sodium Bicarbonate use is not contraindicated in those with PABA allergy.
(E) Prilocaine is an amide anesthetic and is safe to use in patients with para-aminobenzoic acid (PABA) allergy. The
easiest way to distinguish between an amide and an ester anesthetic is the following: amides have two i's in their name
(e.g. bupivacaine, lidocaine, prilocaine), whereas esters only have one i (e.g. benzocaine).

88. All of the following retinoids are excreted in the urine except:
A. Tretinoin
B. Isotretinoin
C. Acitretin
D. Bexarotene
E. Etretinate

Correct answer: (D) Bexarotene.

Explanation: Bexarotene is metabolized by the liver and is excreted via the hepatobiliary system.
(A) Tretinoin is metabolized by the liver and is excreted via bile and urine.
(B) Isotretinoin is metabolized by the liver and is excreted via bile and urine.
(C) Acitretin is metabolized by the liver and is excreted via bile and urine.
(E) Etretinate is metabolized by the liver and is excreted via bile and urine.

89. A 25 year old patient with atopic dermatitis reports no improvement with topical steroids. Despite strict adherence he
believes his disease is getting worse since starting therapy. Patch testing reveals allergy to tixocortol-21-pivalate and
budesonide. Which of the following topical steroids would be an appropriate therapy for this patient?
A. Hydrocortisone
B. Methylprednisolone
C. Triamcinolone
D. Desonide
E. Desoximetasone

Correct answer: (E) Desoximetasone.

Explanation: Steroid allergy should be suspected if a patient’s dermatitis does not improve or worsens during therapy
with topical steroids. A classification has been created to determine patterns of cross reactivity.
Desoximetasone is in group C, of which allergy is very rare.
(A) (B) Tixocortol-21-pivalate is the patch test substance for group A steroids, which includes hydrocortisone and
methylprednisolone.
(C) (D) A positive patch test to budesonide characterizes allergy to group B steroids, which includes triamcinolone and
desonide.

90. Which drug may cause serpentine supravenous hyperpigmentation?

A. Bleomycin
B. Fluorouracil
C. Daunorubicin
D. Zidovudine
E. Methotrexate

Correct answer: (B) Fluorouracil.

Explanation: Fluorouracil may cause serpentine supravenous hyperpigmentation tracing the vein near the site of drug
administration.

32
 (A) Bleomycin may cause flagellate linear hyperpigmentation.
(C) Daunorubicin may cause polycyclic bands on the scalp overlapping circular, hyperpigmented bands.
(D) Zidovudine is associated with blue lunula and may induce brown nail hyperpigmentation.
(E) Methotrexate may cause horizontal hyperpigmented bands along the hair shaft known as the “flag sign.” These
hyperpigmented bands alternate with normal appearing hair.

91. A 28-year-old female with a history of epilepsy presents to clinic for treatment of moderate atopic dermatitis. Which
of these potential medications’ risk likely outweighs the benefits in this patient?
A. Cyclosporine
B. Omalizumab
C. Methotrexate
D. Topical steroids
E. Azathioprine

Correct answer: (A) Cyclosporine.

Explanation: Cyclosporine lowers the seizure threshold. (B) (C) (D) (E) All of these medications have not been reported to
lower seizure threshold.

33