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Select the ONE answer that is BEST in each case.
A 19-year-old man develops new lesions at the sites of skin trauma. The lesions appear as sharply marginated erythematous papules with silvery-white scales.
Koebner phenomenon is typically seen in psoriasis. The kind of injury eliciting the phenomenon is usually mechanical, but ultraviolet light or allergic damage to the skin may be provocative. Koebner phenomenon can also occur in lichen planus, lichen nitidus, keratosis follicularis, and pemphigoid. The Koebner phenomenon has been used to study early skin changes in these diseases.
A 32-year-old man with human immunodeficiency virus (HIV) infection develops skin tumors and patches on the legs with some on the face. They are palpable, firm, and appear violaceous with some nodules appearing purple brownish.
Kaposi sarcoma often manifests as multiple blue dermal plaques. Lesions have two prominent features: accumulation of spindle cells and presence of vascular elements. Classical Kaposi sarcoma is an indolent disease of later life and is much more common in men than women. Kaposi sarcoma in association with HIV infection is a much more aggressive disorder. In all types of Kaposi the deoxyribonucleic acid (DNA) of human herpes virus 8 has been identified.
A 43-year-old woman develops a rash on her arms and hands after starting a new job in a factory. The lesions have well-demarcated erythema and edema with superimposed closely spaced vesicles and papules. Findings might include
The history should not reveal worsening eruption during the weekend. Allergy, acne, diabetes, psoriasis, xeroderma, or seborrheic dermatitis may all be mistaken for occupational disorders. The list of possible occupational skin hazards is long. At times, a site visit to the workplace is required to confirm the diagnosis. First aid in the workplace often involves sensitizing agents that worsen the situation. Skin problems can be severe and permanent. Relatively few patients are malingerers.
A 19-year-old woman with asthma has a chronic rash with distribution on her hands, neck, and elbow creases. It is very itchy, and the skin appears thickened with increased skin markings. There are some areas of fissures in the skin at the elbow creases and hands. Which of the following is the most appropriate advice?
A change of environment is among the best treatments for atopic dermatitis. The patient should be kept in as dust-free an environment as possible and should not wear rough garments. Maintenance of adequate humidity is also important.
A 74-year-old man develops a new single 1.5 cm lesion on his face. It is firm and nodular with a dome shape and central keratotic plug. Excisional biopsy confirms keratoacanthoma. Which of the following best characterizes this lesion?
This tumor as a rule occurs on exposed, hairy skin. It grows rapidly but involutes slowly, occasionally up to 1 year. It is more common in white-skinned males. The lesion starts as a small, rounded, flesh-colored or reddish papule. It grows rapidly and may reach 10–20 mm in a few weeks. There are telangiectasias just below the surface and the center contains a horny plug or is covered by a crust concealing a keratin-filled crater. Histology can be difficult to differentiate from squamous cell cancer.
A 85-year-old woman has large blistering lesions on the abdomen and thighs that come and go without therapy. Nikolsky’s sign is negative. Which of the following is the most likely diagnosis?
There are antibodies to skin basement membrane, but unlike pemphigus, antibody levels do not correlate with disease activity. Bullous pemphigoid is most common in the elderly, and the disease often starts with urticaria-like and pruritic erythematous lesions, before classic blisters occur. The blisters arise from inflamed and normal skin, unlike in pemphigus where they arise from normal skin. As well, unlike pemphigus, mucosal lesions are minimal or absent.
A 69-year-old woman develops dark, velvety pigmentation in her axillae. She has noticed 10 lb weight loss over the past 3 months with heartburn and early satiety. She notices no other symptoms. Which of the following conditions should she be studied for?
Patients with acanthosis nigricans should be studied for a visceral carcinoma. There are hereditary, drug-induced, and benign forms of acanthosis nigricans as well. Given this patient’s symptoms a gastric malignancy should be ruled out. Diabetics get a benign form of the disorder. Other dermatoses associated with malignancy include dermatomyositis, flushing, acquired ichthyosis, and thrombophlebitis migrans.
A 22-year-old woman develops an acute contact dermatitis to a household-cleaning agent. Which of the following treatments is most appropriate during the bullous, oozing stage?
Ointments are not used, but wet dressings are applied several times a day, using Burow’s solution or boric acid, and baths are also included in the treatment. The key aspect of care is prevention. When contamination does occur, washing the affected area is the first mode of treatment. Oral corticosteroids are only used in severe cases. In less severe cases, topical class I glucocorticoid preparations can be helpful.
Which of the following is a characteristic of ringworm of the scalp as compared with other dermatophytoses?
Ringworm of the skin is most common in children because of their intimacy with animals and other children. The lesions are round or oval scaly patches. Secondary bacterial infection is common with certain fungi.
A 27-year-old man develops warts on his hand. Which of the following is a correct statement concerning these skin lesions?
Verrucae are viral in etiology. The human papillomavirus is a DNA-containing virus of the papovavirus group that includes animal tumor viruses. Although most warts are not felt to be premalignant; there is evidence to show that genital warts are correlated with malignancy.
A 27-year-old man develops a painless 1 cm sore on his penis. It appears ulcerated with a raised margin and minimal serous exudates. Which of the following is the most appropriate next step in the diagnosis?
This is likely a case of primary syphilis. Serology is the most appropriate test; it can remain negative for a period up to 1 month after the infection is contracted. The serologic test for syphilis usually is positive within 1 week after the chancre appears. With therapy the chancre heals rapidly, but will heal in 4–6 weeks even without treatment. Genital chancres are usually painless, unless superinfected, but extragenital chancres (e.g., fingers) can be quite painful. Biopsy is usually not necessary for diagnosis, and the spirochetes are seen with dark-field examination, not with Gram stain.
A 64-year-old woman notices bullous-type lesions over her thighs and axilla. They are itchy, but not painful, and she has no other symptoms. On examination, there are large tense, serous-filled bullae on the affected areas. A biopsy confirms the diagnosis of bullous pemphigoid. Which of the following histologic features is typical of this condition?
In bullous pemphigoid, biopsy reveals immunoglobulin G (IgG) deposits in the basement membrane area. In pemphigus vulgaris, the immune deposition and damage is withinthe lower zone of the epidermis. IgA deposits are seen in dermatitis herpetiformis.
A 27-year-old woman has a 1-year history of loosely formed bowel movements associated with some blood and abdominal pain. She develops multiple painful erythematous nodules on her lower legs. Which of the following is the most likely diagnosis?
About 15% of patients with ulcerative colitis will develop skin manifestations. Typical lesions include erythema nodosum, pyoderma gangrenosum (painless, but can heal with scarring), aphthous ulcers, and ocular inflammation (episcleritis, iritis, uveitis). The activity of the skin manifestations typically parallels the severity of the colonic disease.
Which of the following best describes mycosis fungoides?
Mycosis fungoides is best described as a cutaneous T-cell lymphoma. Lesions may remain confined to the skin for years, and internal organ involvement occurs when the disease advances into late stages. It is a disorder involving T lymphocytes. Treatment is usually palliative rather than curative.
A 58-year-old man complains of an enlarged, pitted nose, and a facial rash that “flushes” in response to drinking hot liquids or alcohol. The rash is on both cheeks, and it is red and flushed in appearance, with some telangiectatica and small papules. Which of the following is the most likely diagnosis?
Rhinophyma is a complication of rosacea. It can be treated surgically by shaving off the excessive tissue with a scalpel, but regrowth occurs in time. There is very little evidence to support the association between alcoholism and rhinophyma. The other conditions do not cause flushing or blushing-type appearance. Psoriasis and seborrheic dermatitis have lesions that have white dry scales.
A 81-year-old man presents with pallor, glossitis, cheilitis, and vitiligo. Which of the following is the most likely diagnosis?
Glossitis and cheilitis result from the vitamin deficiency affecting rapidly turning over tissues. Patients may complain of a “burning” tongue, and examination reveals atrophy of papillae, a deep red mucosa, and a “cobblestone” appearance. Vitamin B 12 administration rapidly relieves these symptoms. The vitiligo is caused by an associated autoimmune disorder.
A 70-year-old man develops multiple pruritic skin lesions and bullae mostly in the axillae and around the medial aspects of his groin and thighs. There are some lesions on his forearms and on his lower legs (first appeared in this location), and moderately painful oral lesions. Nikolsky’s sign is negative. There is no eye involvement. Which of the following is the most likely diagnosis?
The description and age range (60–80) is typical of bullous pemphigoid. PV is usually associated with a positive Nikolsky’s sign (pressure on blister leads to lateral extension), and very severe oral lesions. Cicatricial pemphigoid is also a disease of the elderly, but is rare and usually involves the eyes as well. EB is an inherited disorder that usually presents in earlier life. DH does not usually affect mucous membranes, and the lesions are grouped in clusters. However, it can mimic early bullous pemphigoid, and biopsy is needed for confirmation. Permanent remission is frequent, and continued therapy would not be required.
A man presents with bullous lesions on his face, armpit, and chest. He initially had them only in his mouth. They appear round and oval with serous fluid and some are “flabby.” When pressure is applied to the lesion the fluid spreads laterally. A clinical diagnosis of pemphigus vulgaris (PV) is made. Which of the following is the usual age of onset for this condition?
PV is most common from 40 to 60 years of age, whereas bullous pemphigoid is seen most frequently after the age of 80. Dermatitis herpetiformis is most common in the age group from 30 to 40, but has a wide age range.
Which of the following is the most likely drug to cause pemphigus vulgaris (PV)?
Captopril and other drugs can cause PV, but D-penicillamine is the most likely to cause the disease. Drug-induced PV usually, but not invariably, remits when the offending agent is withdrawn.
Malignant, but does not metastasize beyond the skin
Basal cell tumors have a substantial capacity for local destruction but metastasize very rarely.