1. What are the two most important prognostic indicators when predicting melanoma survival for tumors less than or equal to 1 mm in thickness?
a. Clark's level and Breslow depth
b. Mitotic rate and Breslow depth
c. Ulceration and Breslow depth
d. Mitotic rate and Clark's level
2. Which of the following is not an expected manifestation of Bazex syndrome?
a. Palmoplantar keratoderma
b. Acral psoriasiform lesions
c. Alopecia
d. Enlargement of distal phalanges
3. When evaluating prepubertal children for Neurofibromatosis type 1, one of the diagnostic criteria is the presence of _________ cafe-au-lait macules of more than 5 mm in greatest diameter.
a. Three or more
b. Four or more
c. Five or more
d. Six or more
4. In the United States, which dermatophyte is the most common cause of onychomycosis?
a. Trichophyton tonsurans
b. Trichophyton rubrum
c. Microsporum canis
d. Microsporum audouinii
5. A young woman presents with multiple, asymptomatic, yellowish outpouchings on the lateral aspect of her heels. Which diagnosis best fits her clinical presentation?
a. Papular acrodermatitis
b. Necrobiosis lipoidica
c. Piezogenic papules
d. Eruptive xanthomas
6. Which of the following nail conditions results in the appearance of multiple longitudinal hollows within a thickened nail plate?
a. Onychomatricoma
b. Keratoacanthoma
c. Glomus tumor
d. Subungual exostosis
7. The development of a pilomatricoma is most common among which age group?
a. Infants
b. Children
c. Middle-aged adults
d. Elderly adults
8. In which of the following conditions would spongiosis not be an expected histopathologic finding?
a. Pityriasis alba
b. Contact dermatitis
c. Tinea pedis
d. Keratosis pilaris
9. How long does it take for the first incidence of a fixed drug eruption to appear after exposure to the responsible medication?
a. 12-24 hours
b. 48-72 hours
c. 1-2 weeks
d. 3-5 days
10. Which of the following autoantibodies has the highest disease specificity for systemic lupus erythematosus?
a. Double-stranded DNA
b. Sjogren-syndrome-related antigen A
c. Single-stranded DNA
d. Sjogren-syndrome-related antigen B
Answers
1. b. Mitotic rate and Breslow depth. Since the last publication of the guidelines of care for primary cutaneous melanoma by the American Academy of Dermatology in 2001, the most significant changes in the management of primary melanoma are a result of the acknowledgment of the dermal mitotic rate as an important prognostic parameter. This change is reflected in the seventh edition of the American Joint Committee on Cancer staging system for melanoma, effective January 1, 2010. In the new staging system, mitotic rate has replaced Clark's level of invasion as the second factor predicting melanoma survival in addition to tumor thickness (Breslow depth) for tumors less than or equal to 1 mm in thickness.
Bichakjian, C. K., Halpern, A. C., Johnson, T. M., Foote Hood, A., Grichnik, J. M., Swetter, S. M., [horizontal ellipsis] American Academy of Dermatology. (2011). Guidelines of care for the management of primary cutaneous melanoma. American Academy of Dermatology. Journal of the American Academy of Dermatology, 65(5), 1032-1047.
2. c. Alopecia. Bazex syndrome (also known as acrokeratosis paraneoplastica) is a rare, acral psoriasiform dermatosis that is associated with internal malignancy. Classic dermatologic findings include well-defined erythematous to violaceous plaques covered by a fine-to-thick adherent psoriasiform-like scales that are symmetrically distributed on the acral areas, ear helices, and nasal and malar surfaces. In later stages, the limbs and trunk become involved. Other cutaneous findings include hyperpigmentation, palmoplantar keratoderma, and paronychia. Involved nails show ridging, thickening, yellowish discoloration, and onycholysis. Bulbous enlargement of distal phalanges with nail dystrophy is another characteristic finding. The appearance of psoriasiform lesions precedes the diagnosis of the associated malignancy in 65%-70% of patients. Treatment is aimed at eradication of the underlying malignancy, and in 90%-95% of patients, the cutaneous manifestations improve with successful treatment of the underlying malignancy. Systemic retinoid therapy should be considered if the tumor is unresectable or treatment resistant.
Shah, K. R., Boland, C. R., Patel, M., Thrash, B., & Menter, A. (2013). Cutaneous manifestations of gastrointestinal disease: Part I. Journal of the American Academy of Dermatology, 68(2), 189.e1-189.21.
3.d. Six or more. Neurofibromatosis is an autosomal-dominantly inherited syndrome manifested by developmental changes in the nervous system, bones, and skin. The diagnosis of Neurofibromatosis type 1 (which encompasses more than 85% of cases) requires two or more of the following criteria: (a) six or more cafe-au-lait macules of more than 5 mm in greatest diameter in prepubertal individuals or more than 15 mm in greatest diameter in postpubertal individuals, (b) two or more neurofibromas of any type or one plexiform neurofibroma, (c) freckling in the axillary or inguinal regions, (d) optic glioma, (e) two or more Lisch nodules, (f) a distinctive osseous lesion, and (g) a first-degree relative with the disease.
James, W. D., Berger, T. G., & Elston, D. M. (2011). Andrews' diseases of the skin: Clinical dermatology (11th ed.). Philadelphia, PA: Saunders/Elsevier.
4. b. Trichophyton rubrum. Most onychomycosis cases in the United States are caused by dermatophytes, most commonly Trichophyton rubrum, which is also the most common cause of tinea pedis. Trichophyton mentagrophytes is less commonly identified as the causative organism, followed by Trichophyton tonsurans, Microsporum canis, and Epidermophyton floccosum. When yeast is the cause of onychomycosis, Candida parapsilosis is the most commonly identified organism, followed by Candida albicans. Among the nondermatophyte molds that are responsible for onychomycosis in the United States, Acremonium and Fusarium species are most commonly responsible, followed by Scopulariopsis species.
Jellinek, N. J., Rich, P., & Pariser, D. M. (2015). Understanding onychomycosis treatment: Mechanisms of action and formulation. Retrieved from http://www.globalacademycme.com/fileadmin/pdf/supplement_pdf/DERM_3S_6-15_Onycho
5. c. Piezogenic papules. Piezogenic papules are yellowish outpouchings on the heel that represent herniation of subcutaneous fat through small tears in the plantar fascia. This condition may be asymptomatic or tender and is often associated with distance running or high-impact sports. Papular acrodermatitis (also referred to as papular acrodermatitis of childhood or Gianotti-Crosti syndrome) is a self-limited cutaneous eruption that manifests with skin-colored to pink-red, edematous papules that are symmetrically distributed on the face, buttocks, and extensor surfaces of the extremities. Necrobiosis lipoidica presents with yellow-brown, atrophic, telangiectatic plaques in the pretibial region that are surrounded by raised, violaceous rims. Eruptive xanthomas are erythematous to yellowish papules that are usually 1-4 mm and distributed on the extensor surfaces of the extremities, buttocks, and hands. They are often associated with hypertriglyceridemia.
Bolognia, J. L., Jorizzo, J. L., & Rapini, R. P. (2012). Dermatology (2nd ed.). St. Louis, MO: Elsevier/Mosby.
6. a. Onychomatricoma. Onychomatricoma is a rare neoplasm that produces localized or diffuse thickening of the nail plate with perforations consisting of multiple longitudinal hollows that contain the digitating tumor. A frontal view of the nail typically reveals multiple holes in the thickened free margin, and there is usually transverse overcurvature. The affected nail is yellow-white in color with multiple splinter hemorrhages. Keratoacanthoma presents as a painful, subungual keratotic nodule; glomus tumor is a painful, red-bluish nail bed macule; subungual exostosis is a tender, benign bony proliferation.
Bolognia, J. L., Jorizzo, J. L., & Rapini, R. P. (2012). Dermatology (2nd ed.). St. Louis, MO: Elsevier/Mosby.
7. b. Children. Pilomatricoma is a benign adnexal neoplasm typified by cornification of follicular material that usually presents as a solitary, firm, skin-colored to faint-blue nodule. These lesions most commonly develop on the head or upper trunk and usually occur during childhood or adolescence. Treatment is generally accomplished with simple enucleation, although if multiple recurrences are observed, complete excision is advised to exclude the possibility of pilomatrical carcinoma.
Bolognia, J. L., Jorizzo, J. L., & Rapini, R. P. (2012). Dermatology (2nd ed.). St. Louis, MO: Elsevier/Mosby.
8. d. Keratosis pilaris. Spongiosis is not an expected histologic finding in keratosis pilaris. Spongiosis is mainly an extracellular edema between keratinocytes in the epidermis. The edema may cause the keratinocytes to become elongated and stretched, eventually producing spongiotic intraepidermal vesicles. Spongiosis is the hallmark of eczema, although it may not be present in all stages. It also commonly appears nonspecifically in many rashes and irritated neoplasms, including pityriasis rosea, erythema multiforme, candidiasis, tinea, contact dermatitis, lichen striatus, pityriasis alba, Gianotti-Crosti syndrome, pityriasis lichenoides acuta, and arthropod bites.
Bolognia, J. L., Jorizzo, J. L., & Rapini, R. P. (2012). Dermatology (2nd ed.). St. Louis, MO: Elsevier/Mosby.
9. c. 1-2 weeks. The first incidence of fixed drug eruption (FDE) generally develops 1-2 weeks after exposure to the responsible medication. With subsequent exposures, the eruption occurs in the same site within 24 hours. Classic FDE appears in the form of one or a few round, sharply demarcated erythematous and edematous plaques, sometimes with a dusky violaceous hue, central blister, or detached epidermis. The lesions can arise anywhere on the body but favor the lips, face, hands, feet, and genitalia. The lesions fade over several days and often leave a postinflammatory brown pigmentation. In the nonpigmenting variant of FDE, erythematous and edematous plaques appear, often in the girdle region, that are characteristically quite large in diameter (>10 cm) and heal with no residual. There is also a rare linear variant of FDE that may be confused with linear lichen planus.
Bolognia, J. L., Jorizzo, J. L., & Schaffer, J. V. (2012). Dermatology (3rd ed.). St. Louis, MO: Elsevier/Mosby.
10. a. Double-stranded DNA. Double-stranded DNA is frequently (60%) detected in patients with systemic lupus erythematosus (SLE) and also has a high disease specificity for this condition. Smith antibodies, ribosomal ribonucleoprotein, and proliferating cell nuclear antigen also have high disease specificity for SLE but are not as commonly elevated. Single-stranded DNA, histones, and Sjogren-syndrome-related antigen A are commonly found in patients with SLE (50%-60%) but have a low disease specificity for SLE. Other less frequently detected autoantibodies with a low specificity for SLE include U1 ribonucleoprotein, Sjogren-syndrome-related antigen B, and Ku.
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.