1. The development of Sweet's syndrome is most commonly associated with which of the following conditions?
a. Upper respiratory infection
b. Hematologic malignancies
c. Pregnancy
d. Inflammatory bowel disease
2. Which of the following terms is used to describe the patches of white hair that can occur in individuals with vitiligo?
a. Ophiasis
b. Schizotrichia
c. Poliosis
d. Madarosis
3. In normal skin, how long does it take for a keratinocyte to migrate from the basal cell layer to the surface of the stratum corneum?
a. 10 days
b. 14 days
c. 20 days
d. 28 days
4. All of the following conditions are typically caused by a herpetic viral strain except _________
a. Roseola infantum.
b. Hand-foot-and-mouth disease.
c. Kaposi sarcoma.
d. Infectious mononucleosis.
5. In which of the following conditions would you expect histologic evaluation to reveal cornoid lamella?
a. Porokeratosis
b. Superficial erythema annulare centrifugum
c. Parapsoriasis
d. Pityriasis lichenoides chronica
6. Notalgia paresthetica characteristically occurs in which anatomic location?
a. Base of the skull
b. Lateral, posterior thigh
c. Ulnar wrist
d. Border of the scapula
7. A 54-year-old man explains that when his feet get too warm, they turn bright red and feel like they are burning. What is the most likely diagnosis?
a. Erythema ab igne
b. Erythromelalgia
c. Erythema marginatum
d. Erythroderma
8. Which of the following diagnostic maneuvers is utilized to test for Asboe-Hansen sign?
a. The skin is stroked firmly with a blunt object.
b. A pencil eraser is twisted against the skin.
c. Firm pressure is applied to a flaccid bulla.
d. The skin is pricked with a sterile needle.
9. Freckles are also known as __________________
a. Maculae ceruleae.
b. Rhytides.
c. Perleche.
d. Ephelides.
10. Which of the following statements is not true regarding the use of prednisone during pregnancy and lactation?
a. Use in the first trimester is linked to an increased risk of oral-facial clefts.
b. Approximately 30% of the maternal dose is transferred to her breast milk.
c. Use during pregnancy may cause premature delivery, intrauterine growth retardation, and preeclampsia.
d. Peak levels are found in breast milk within 1 hour of maternal ingestion.
Answers
1. a. Upper respiratory infection. Most Sweet's syndrome cases are preceded by an upper respiratory infection. Other documented associations include nonrespiratory infections, inflammatory bowel disease, hematologic malignancies or solid tumors, pregnancy, and certain medications. The primary lesion of Sweet's syndrome is a sharply marginated, rapidly extending, tender, erythematous or violaceous, painful, elevated plaques 2-10 cm in diameter. Lesions may appear indurated or intensely edematous and typically involve the face, neck, upper trunk, and extremities. More than three quarters of affected individuals have systemic symptoms such as fever, arthritis, arthralgias, myalgias, conjunctivitis, episcleritis, or oral lesions. Many also have an elevated sedimentation rate, neutrophilia, leukocytosis, and a left shift. The standard treatment is systemic corticosteroids. When associated with an upper respiratory infection, Sweet's syndrome generally lasts 3-6 weeks and then resolves. Persistent cases have been reported to last several years. Because of the association with internal malignancies, attempts should be made to identify the underlying cause, especially in persons over the age of 50 years and those with anemia, thrombocytopenia, or lesions that are bullous or necrotic.
James, W. D., Berger, T. G., & Elston, D. M. (2011). Andrews' diseases of the skin: Clinical dermatology (11th ed.). Philadelphia, PA: Saunders/Elsevier.
2. c. Poliosis. The term "poliosis" refers to circumscribed patches of white or gray hair. These patches may be associated with several syndromes including vitiligo, regressing melanoma, and alopecia areata. Migrating patches without hair loss may represent a forme fruste presentation of alopecia areata. The term "ophiasis" is used to describe confluent hair loss along the temporal and occipital scalp and is usually a feature of alopecia areata. Madarosis refers to a loss of eyelashes and/or eyebrows, and schizotrichia is used to describe hairs that are splitting at their distal ends.
Linton, C. P. (2012). Describing the hair and related abnormalities. Journal of the Dermatology Nurses' Association, 4(3), 207-208.
3. d. 28 days. The migration of keratinocytes from the basal layer to the cornified layer of the epidermis takes at least 14 days, and the transit through the cornified layer to the surface of the stratum corneum requires another 14 days. During this journey to the surface, the keratinocytes proceed through a synthetic and then degradative differentiation process called keratinization.Kolarsick, P. A. J., Kolarsick, M. A., & Goodwin, C. (2011). Anatomy and physiology of the skin. Journal of the Dermatology Nurses' Association, 3(4), 203-213.
4. b. Hand-foot-and-mouth disease. Hand-foot-and-mouth disease has been linked to several nonpolio enteroviruses, although the most commonly identified cause is coxsackievirus A or B. Affected individuals are generally 1-4 years old and present with fever, malaise, and a characteristic exanthema, which consists of gray-white vesicular lesions on the palms and soles. In addition, painful vesicles and erosions are typically present on the buccal surfaces, palate, tongue, uvula, gingivae, and anterior tonsillar pillars that may cause anorexia or dehydration. The course of hand-foot-and-mouth disease is generally benign, and treatment is supportive. Roseola infantum is a common cause of sudden, unexplained high fever in children 6-36 months old that is associated with human herpesvirus-6 and human herpesvirus-7. The fever remains consistently high, with morning remission, until the fourth day, when it falls precipitously to normal, coincident with the appearance of a morbilliform eruption consisting of small blanchable pink macules and papules, 1-5 mm in diameter, on the trunk and neck that may remain discrete or become confluent. The buttocks, face, and extremities may be affected, and often, there is a blanched halo around the lesions. The course is self-limited, and resolution occurs within 1-2 days with only symptomatic management. Kaposi sarcoma is a multifocal, systemic tumor of endothelial origin caused by human herpes virus-8. The routes of human herpes virus-8 transmission are not completely known, although it has been confirmed that transmission occurs during sexual activities, and it is widely assumed that contact with saliva and blood or blood products can also transmit the infection. The early lesions of classic Kaposi sarcoma appear most commonly on the toes or soles as reddish, violaceous, or bluish-black macules and patches that spread and coalesce to form rubbery nodules or plaques. The course is slowly progressive, and the lesions generally respond well to chemotherapy and radiation. Infectious mononucleosis is caused by the Epstein-Barr virus, which is a gamma herpesvirus. This viral strain infects human mucosal cells and B-lymphocytes. The infection persists for the life of the host, often transitioning between latent and productive phases many times. Initial exposure generally occurs through contact with oral secretions during childhood or early adulthood, and about 95% of the population has been infected by their early 20s. Cutaneous and mucous membrane lesions are present in about 10% of patients, and exanthems occur in 15%-30% of affected children. Treatment is generally supportive.Goldsmith, L. A., Katz, S. I., Gilchrest, B. A., Paller, A. S., Leffell, D. J., & Wolff, K. (2012). Fitzpatrick's dermatology in general medicine (8th ed.). New York, NY: McGraw-Hill Medical.James, W. D., Berger, T. G., & Elston, D. M. (2011). Andrews' diseases of the skin: Clinical dermatology (11th ed.). Philadelphia, PA: Saunders/Elsevier.
5. a. Porokeratosis. Porokeratosis is a chronic, progressive disorder of keratinization characterized clinically by hyperkeratotic papules or plaques surrounded by a thread-like, elevated border that expands centrifugally. This border corresponds to the cornoid lamella, which is a distinctive histopathologic feature. Several variants have been described, some with overlapping features. Superficial erythema annulare centrifugum presents with one or more lesions that begin as erythematous macules or urticarial papules that enlarge by peripheral extension to form ringed, arcuate, or polycyclic figures with an indistinct border and trailing scale. Parapsoriasis generally occurs as oval or irregularly shaped patches or very thin plaques that are usually discrete and occur mainly on the trunk. These lesions are light red-brown or salmon pink, asymptomatic, or mildly pruritic and may persist for years with little change in clinical appearance. Pityriasis lichenoides chronica is characterized by recurrent crops of erythematous scaly papules that spontaneously regress over several weeks to months.Wolff, K., Goldsmith, L. A., Katz, S. I., Gilchrest, B. A., Paller, A. S., & Leffell, D. J. (2008). Fitzpatrick's dermatology in general medicine (7th ed.). New York, NY: McGraw-Hill Medical.
6. d. Border of the scapula. Notalgia paresthetica is characterized by focal, intense pruritus over the medical scapular borders. It can occasionally be accompanied by pain, paresthesias, or hyperesthesias. This condition is thought to be a sensory neuropathy that may involve spinal nerve impingement. The overlying skin is often unaffected, although there may be hyperpigmentation or lichenification because of chronic rubbing of the area.Bolognia, J. L., Jorizzo, J. L., & Schaffer, J. V. (2012). Dermatology (3rd ed.). St. Louis, MO: Elsevier/Mosby.
7. b. Erythromelalgia. Erythromelalgia is a rare form of paroxysmal vasodilation of the feet that is usually triggered by an increase in environmental temperature. Episodes can last for a few minutes or several days and manifest with burning, localized pain, redness, and high skin temperature. This can be a primary condition or secondary to diseases such as polycythemia vera, thrombotic thrombocytopenic purpura, thrombocytopenia, peripheral neuritis, myelitis, multiple sclerosis, systemic lupus erythematosus, hypertension, or diabetes mellitus. Childhood erythromelalgia often appears without an underlying cause, and an autosomal dominant inheritance has been identified. Symptoms can be relieved by supportive measures such as elevation of the extremity or immersion in cold water. Erythema ab igne is a persistent condition produced by long exposure to direct, moderate heat such as fireplaces, space heaters, heating pads, and laptop computers. Erythema ab igne begins as a mottling caused by local hemostasis and progresses into a reticulated erythema. Multiple colors are simultaneously present in an active patch, varying from pale pink to old rose or dark purplish-brown. After the cause is removed, the pigment tends to disappear gradually, although in some cases, it may be permanent. Erythema marginatum is an indicator of rheumatic fever that manifests with a spreading patchy erythema that migrates peripherally and often forms polycyclic configurations that appear for only a few hours or days on the trunk or proximal extremities. Erythroderma, also known as exfoliative dermatitis, presents with extensive erythema and scaling, which progresses until the entire body surface is dull scarlet and covered by small, laminated scales that exfoliate profusely. Erythroderma usually occurs because of a preexisting generalized dermatosis such as psoriasis or atopic dermatitis, certain medications, internal malignancy, erythrodermic mycosis fungoides, or Sezary syndrome.James, W. D., Berger, T. G., & Elston, D. M. (2011). Andrews' diseases of the skin: Clinical dermatology (11th ed.). Philadelphia, PA: Saunders/Elsevier.
8. c. Firm pressure is applied to a flaccid bulla. Asboe-Hansen sign refers to the extension of a blister to adjacent unblistered skin when firm pressure is applied to the surface of a flaccid bulla. Nikolsky sign is present when the twisting or rubbing of unblistered skin causes intact epidermis to shear away from the underlying dermis. Both of these signs show that the extent of microscopic vesiculation can be more significant than is evident by simple inspection. They are useful when evaluating the severity of pemphigus vulgaris and severe bullous drug reactions. A positive Darier's sign is elicited when skin that is firmly stroked with a blunt object becomes erythematous, edematous, and pruritic. This urticarial reaction is indicative of cutaneous mastocytosis. Pathergy testing is a nonspecific diagnostic tool that is not commonly utilized in clinical settings. It is performed by pricking the skin with a sterile needle and observing the area over the next few days for the appearance of a papule, pustule, or ulceration at the site of the injury. Pathergy testing is often positive in Behcet disease, pyoderma gangrenosum, and Sweet's syndrome.James, W. D., Berger, T. G., & Elston, D. M. (2011). Andrews' diseases of the skin: Clinical dermatology (11th ed.). Philadelphia, PA: Saunders/Elsevier.New Zealand Dermatological Society Incorporated. (2011). Pathergy. Retrieved from http://www.dermnetnz.org/reactions/pathergy.html
9. d. Ephelides. Freckles are also known as ephelides. They are small, well-circumscribed pigmented macules found only on the sun-exposed skin of individuals with fair skin. Rhytides is another name for wrinkles, and perleche is another name for angular cheilitis. Maculae ceruleae are blue- or slate-colored macules that can appear on the sides of the trunk and inner thighs of individuals with pediculosis pubis.Bolognia, J. L., Jorizzo, J. L., & Schaffer, J. V. (2012). Dermatology (3rd ed.). St. Louis, MO: Elsevier/Mosby.James, W. D., Berger, T. G., & Elston, D. M. (2011). Andrews' diseases of the skin: Clinical dermatology (11th ed.). Philadelphia, PA: Saunders/Elsevier.
10. b. Approximately 30% of the maternal dose is transferred to her breast milk. Of the systemic corticosteroids, prednisone is the preferred choice because placental enzymes limit passage to the embryo. Prednisone use during pregnancy has been associated with a three-fold increase in the risk of orofacial clefts when it is taken during the 4 weeks before conception or up to 12 weeks after conception. However, the absolute risk still remains low as the baseline risk is only 1 in 1,000 live births. Prednisone also may result in premature delivery, premature membrane rupture, intrauterine growth retardation, gestational diabetes, hypertension, preeclampsia, and eclampsia. For these reasons, many clinicians recommend that prolonged use be limited to 7.5 mg/day and that doses of 20 mg/day or higher be avoided. The American Academy of Pediatrics considers systemic corticosteroids "usually compatible" with lactation and recommends prednisone or prednisolone over other options. One study found that, for mothers with doses between 10 and 80 mg, relative infant doses ranged from 0.002 to 0.059 mg, which represents <10% of the infant's endogenous cortisol level. The published literature fails to show adverse effects in lactating infants, although these studies include modest maternal doses (between 5 and 10 mg daily). In an effort to minimize exposure and avoid the peak levels that occur 1 hour after maternal ingestion, it is recommended that mothers do not breastfeed for at least 4 hours after taking prednisone.Murase, J. E., Heller, M. M., & Butler, D. C. (2014). Safety of dermatologic medications in pregnancy and lactation: Part I. Pregnancy. Journal of the American Academy of Dermatology, 70(3), 401.e1-401.e14.Murase, J. E., Heller, M. M., & Butler, D. C. (2014). Safety of dermatologic medications in pregnancy and lactation: Part II. Lactation. Journal of the American Academy of Dermatology, 70(3), 417.e1-417.e10.