differentiating dermatological diagnosis and treatment - podiatry

be used to describe the rash appro-priately, both in the chart and incorrespondence to other physi-cians. When looking at the shapeof the lesions, it is helpful to deter-mine if they were self-induced bythe patient (excoriation by a finger-nail) or naturally caused (a plantarheel fissure). One should documentif the lesions are plantar foot, dor-sal foot, or proximal on the lowerleg. Nail involvement should benoted. Finally, the fingernails anddorsum and palmar aspects of thehands should be examined as manyskin dermatoses mirror the pedalinvolvement there.

Continued on page 176

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APRIL/MAY 2010 • PODIATRY MANAGEMENTwww.podiatrym.com 175

tice the color, shape, and size in ad-dition to laterality of the lesions on

the lower extremity. Primary andsecondary lesions (Table 1) should

By Tracey C. Vlahovic, DPM, FAPWCAand Michelle Oliver, BA

Apatient first presenting witha red, scaly, itchy foot or legcan prove to be a challenge

to diagnose and manage. Whenfaced with a patient with an in-flammatory skin condition in theoffice, the podiatric physicianshould have a systematic approachto arrive at a baseline differentialdiagnosis: observe, ask, and applyan algorithm.

ObserveUpon entering the treatment

room, the practitioner should no-

Objectives

1) To provide asystematic approachto examining andtreating inflamma-tory skin conditions

2) To discuss themost common skinconditions seen inthe podiatric practi-tioner’s office

3) To discuss thefirst line treatmentfor inflammatoryskin disorders

Continuing

Medical Education

Plaque psoriasis

presents as

an erythematous

plaque with a

silvery scale.

The authors present a systematic approach toexamining and treating inflammatory skinconditions.

DifferentiatingDermatologicalDiagnosis andTreatment

C O N T I N U I N G M E D I C A L E D U C AT I O NC O N T I N U I N G M E D I C A L E D U C AT I O N

the dermis from a pathology per-spective.

Other questions to consider ask-ing patients are the color of socksthey wear (azo dyes in blue sockscan be a potential allergen), occu-pation, and any associated dailyhazards. Also, oneshould ask aboutboth over-the-counter andhomeopathic ornatural treatmentoptions they havetried. In order toplan for a possi-ble in-office biop-sy during thatvisit, it is impor-tant to ask whatthe natural pro-gression of the le-sions has beenand where thenewest crops oflesions are.

Now thatbasic observationand questioninghave occurred,it’s important todelve more deeply into the chiefcomplaint and examine the skinfully. Common skin signs of in-flammation are calor (heat), rubor(redness), tumor (swelling) and pru-ritis (itching), which ultimatelypoint to skin barrier dysfunction.The skin barrier, which is stratumcorneum with the lipid-enrichedextracellular matrix surroundingthe corneocytes, is the body’s pro-tective wall and regulates home-

ostasis, trans-epidermal water loss,and prevents entry of foreign parti-cles and pathogens into the body.Trans-epidermal water loss is thenewest target in the dermatologicalpharmaceutical armamentarium inorder to reduce skin flares and com-

fort the patientwith an inflam-matory skin der-matosis.

Apply anAlgorithm

To begin for-mulating a differ-ential diagnosis,there is a basic al-gorithm to followfor treating themost commonskin disorders en-countered in theoffice: is it aplaque, scale, orzebra? (Table 2) Awell-defined andgeometric shapedplaque is oftenpsoriasis, buteczema and

lichen planus also must be consid-ered. Circular, serpiginous scales aremost often tinea but xerosis shouldbe ruled out. Remember that tineapedis is KOH positive and may in-volve both the interspaces and theplantar foot. Any papules, vesiclesor other skin markings are consid-ered “zebras” for this algorithm’spurpose.

Following the above algorithm,the most common inflammatory

skin conditions thepodiatric practition-er will encounter areas follows:

PlaquePlaque psoria-

sis presents as anerythematous plaquewith a silvery scale.These lesions are ge-ographic, bilateral,and symmetrical,and typically occuron the extensor sur-faces. The plaquescan also be pruriticand affect joints aswell as the nails dur-


176 www.podiatrym.comPODIATRY MANAGEMENT • APRIL/MAY 2010

Differentiating...

AskQuestions that will help form

differential diagnoses should beasked while completing the physi-

cal exam of the skin. Often, the pa-tient will answer a question thatwill help direct the diagnosis. Be-yond asking the history of presentillness, past medical history andfamily history, the podiatric physi-cian should consider asking if thereis a personal or family history of al-lergic rhinitis, sensitive skin, asth-ma or skin cancer. The patientshould be asked if he has ever seena dermatologist before and if he hasany skin lesions or “rashes” any-where else on the body that may ormay not be similar to what is seenon the feet.

Unfortunately, most patients donot correlate what is happening onthe rest of the body to what is man-ifesting on the plantar aspect of thefeet. It is the physician’s responsi-bility to ask the questions in orderto make that connection. It is help-ful to ask if the skin has ever beenbiopsied (for example, “did youhave a piece of skin removed andthen have stitches?”). A skin scrap-ing for KOH that was completed byanother physician does not countas a proper biopsy to base the diag-nosis on, as a biopsy of inflamma-tory skin disorders should include

Continuing

MedicalEducation

TABLE 1

Primary Skin Lesions:MaculePatchPlaqueNoduleVesicleBullaeWhealTelangiectasia

Secondary Skin Lesions:UlcerAtrophyScaleCrustErosionExcoriationScarLichenification

TABLE 2Algorithm

Plaque—� Consider psoriasis, lichen planus,eczema

Scale—� Consider xerosis, tinea pedis,ichythosis, non-inflamed to mildly inflamedpsoriasis and eczema

Zebra—� Blisters? Bullous diabeticorum,pemphigus, drug reaction

Target lesions? Erythema multiformeminor, drug reaction

Trans-epidermal water

loss is the newest

target in the

dermatological

pharmaceutical

armamentarium in

order to reduce skin

flares and comfort the

patient with an

inflammatory skin

dermatosis.

Wickham’s stri-ae, which is the finewhite lacy overlay onthe plaques, may also beseen. This skin condition canbe so pruritic that activities ofdaily living may be compromised.It may also affect the toenails, ap-pearing anywhere from a proximalsubungual onychomycosis-like pre-sentation to a thinning of the nailwith a ‘wing’ of skin or pteryigiumpointing distally (Figure 4).1 Nailinvolvement should be treated im-

mediately as it can irreversibly scarthe nail unit. Lichen planus canalso form lesions in the mouth.2

Case Example #2A young male presented with

numerous small plaques andpapules that wereextremely pruritic(Figure 5). He hadbeen diagnosedwith tinea pedis,and had triedover-the-counterantifungals withno improvement.During his officevisit, the extent ofinvolvement ofthe nails and oralcavity were notedand a diagnosis oflichen planus wasmade.

In addition topsoriasis and

lichen planus, a scaly erythematousrash with fissures could also be aneczematous reaction pattern. De-fined plaques may or may not bepresent, but eczema should be a dif-ferential diagnosis when consider-ing psoriasis. An eczematous reac-tion that is often seen is atopic der-matitis. This is usually inherited, as


arthritic component of psoriasiswhich may manifest in dactylitis ofthe digits (sausage toes), enthesitisof the Achilles tendon, and distalinterphalangeal joint involvement.

Case Example #1A young male patient presented

to the clinic with a pruritic andscaly plantar rash (Figures 2-3) thatwas mis-diagnosed as tinea pedis atthe emergency department. He hadpresented there for painful fissureson his feet that prevented himfrom walking properly. He wasgiven oral ketoconazole at the EDand then presented to the office. Apunch biopsy was taken confirmingthe clinical suspicion of psoriasis,and topical corticosteroid therapywas implemented. The patienthealed unevent-fully from theacute flare andpresents periodi-cally for mainte-nance treatment.

If the patientpresents with cir-cular papules orplaques with little

or nos c a l et h a textendproxi-ma l l yf r o mt h ef o o t ,the differential diagno-sis of psoriasis thatshould be considered islichen planus. Lichenplanus is characteristicof the “P’s”: plentiful,pruritic, purple, pol-ished, popular and pla-nar lesions that are bi-lateral and symmetrical.

ing the progression of the disease.Psoriasis can develop either inchildhood or as an adult. Besidesplaque psoriasis, pustular psoriasisappears as sterile pustules on theplantar foot.

P l a n t a rplaque andpustular pso-riasis are fre-quently mis-diagnosed aseither vesicu-lar or moc-casin tineapedis. Due tothe fissuring

that often accompanies psoriaticplaques, it has also been misdiag-nosed as xerosis. If the patient’scurrent treatment consists of eitheran oral or topical antifungal, andisn’t improving the skin conditionwithin the appropriate time frame,a biopsy of the skin, in order to de-termine if a topical steroid shouldbe used, is warranted. Upon exami-nation of one patient, the handswere also involved. A skin biopsy ofthe plantar foot lesion revealed pso-riasis, and the patient was started

on first-line therapy:topical corticosteroids.

Also, if the patientonly presents with ony-chomycosis-like nail in-volvement and has notresponded to oral anti-fungals, a diagnosis ofpsoriatic nail diseaseshould be considered.Another clue to aid inthe diagnosis of psoriat-ic nails includes exam-ining for the presence oferythema peri-ungually,onycholysis, and pitting(Figure 1).1 Patients mayalso present with the

Differentiating...


Continuing

Medical Education

Figure 2: Psoriasis upon first presenta-tion

Figure 3: Psoriasis uponone month of using topi-cal steroid therapy

Figure 1: Nail diseasein psoriasis

Figure 4: Nail involvement in lichenplanus

Figure 5: Pedal lichen planus

Lichen planus

is characteristic of

the “P’s”: plentiful,

pruritic, purple,

polished, popular and

planar lesions that

are bilateral

and symmetrical.

plantar feet and doesn’t have to bebilateral and symmetrical.

Patch TestThe patch test

done in an aller-gist’s or dermatol-ogist’s office willassist in pin-point-ing the allergencausing the reac-tion. When pa-tients have a his-tory of chronic ve-nous insufficiencywith skin that be-comes indurated,inflamed, andpruritic, venous stasis dermatitis isthe standard diagnosis. Since stasisdermatitis is the most commoncause of an id reaction on thepalmar aspect of the hand, it isimportant for the physician toexamine the hands to aid inthe diagnosis. L a s t l y ,dyshidrotic eczema is a specificcondition that should not bean overall term applied to anyinflamed skin condition. Con-trary to its name, it is not

linked tosweat glanddysfunction.D y s h i d r o t i ceczema (pom-pholyx) character-istically has prurit-ic tapioca pud-ding-like blisterson the palmar as-pect of the handswith minimal footinvolvement.4 Thiscan be a self-limit-ing condition;however, most pa-tients have debili-tating pain and fis-suring that can bedifficult to treat.

Case Example #3A female patient presented with

denuded and inflamed skin on theanterior tibia (Figure 6). She report-ed that this began after the use oftriple antibiotic ointment. Uponfurther history and examination ofthe patient, a working diagnosis ofallergic contact dermatitis to thepreservatives in triple antibioticointment was made. The drug was

removed from the patient’s regi-men, and topical steroids weregiven. The patient’s inflamed skin

resolved in fourweeks.

ScaleXerotic, or

dry skin, shouldhave scales pre-sent within theskin lines on theplantar foot. Moc-casin tinea pedis,on the otherhand, usually pre-sents with smallserpiginous scales

plantarly. The most common formof dry skin that is KOH negative en-countered on the lower extremity is

termed asteatotic or xerotic eczema.It can also be termed erythemacraquele. This is commonly knownas “winter itch” due to its increasedseverity especially during the win-ter months in the northern part ofthe United States.

Asteatotic eczema commonlypresents on the anterior aspect of the

leg as pruritic, annular, scalingpatches. This condition is frequentlymisdiagnosed as tinea corporis, but is



Differentiating...

patients will present with apersonal or family history of

asthma, hay fever, and skin rashappropriate for their age. It is oftendescribed as an “itch that gets arash” and can’t be described as hav-ing a primary lesion as is the casewith psoriasis and lichen planus.3

Atopic dermatitis, like the otherforms of eczema, can be describedas having an acute, sub-acute, andchronic stage of the disease. Duringthe acute phase, patients experi-ence intense pruritus with an ery-thematous scaling and oozing skinrash. Clinically, this can also ap-pear as dry skin eczema, contactdermatitis, stasis dermatitis or evena dermatophyte infection. Sub-acute forms of atopic dermatitispresent with less pruritus, erythe-ma, scaling, and fissured skin rash.

Chronic eczema presents withpruritus, hyper- and hypopigmentedplaques of previous inflamed skin,scaly and lichenified skin. Due to thesevere skin barrier disruption in allforms of atopic dermatitis, these pa-tients are susceptible to secondarybacterial infec-tions and thisshould be consid-ered in the treat-ment plan. Over-all, differential di-agnosis for atopicdermatitis include:tinea pedis, con-tact dermatitis,lichen simplexchronicus (chron-ic form of atopic)and dyshidrosi-form eczema.

If the patientdoesn’t fit intohaving the“triad” of atopicdermatitis, othertypes of eczemashould be considered. Allergic con-tact dermatitis can occur when apatient has developed sensitivity toa product (detergent, soap, glue,dye) after using it for a length oftime. Allergic contact dermatitis is aresult of an antigen-antibody reac-tion that presents eight to twenty-eight days after initial introductionto the allergen. Contrary to belief, acontact dermatitis can occur on the

Continuing

MedicalEducation

Since stasis dermatitis

is the most common

cause of an id reaction

on the palmar aspect

of the hand, it is

important for the

physician to examine

the hands to aid in

the diagnosis.

Figure 6: Allergic contact dermatitis

Figure 7: keratoderma climacterum

Asteatotic eczema

is also seen in

patients with

dementia who

bathe frequently.


arch with no underlying erythema(Figure 8). A biopsy helped to diag-nose her with psoriasis and the ap-propriate therapy commenced.

ZebraIf vesicles, bulla, or other skin le-

sions are present,the podiatricphysician shouldconsider severalother diagnoses. Adiabetic patientwho presents withtense blisters thatseem to appearovernight, mostlikely has bullosisd i abe t i co rum. 5

Bullosis diabetico-rum may have lit-tle inflammationpresent and mayheal uneventfullyif the patient does-n’t pop or scratch

them. Bullous pemphigoid, com-monly seen in older adults in nurs-ing homes, will present with subepi-dermal blistersthat originallywere urticarialplaques thatturned into tensebullae. These le-sions are locatedw i d e s p r e a dthroughout thebody on flexuralsurfaces.

N i k o l s k y ’ ssign, or exfolia-tion of the upperlayers of epider-mis upon rubbingof the skin, isnegative andthese lesions cancrust, pigment,but not scar un-less excoriatedinto an ulcer.Pemphigus vul-garis is a chronicdisease affectingadults which canbe life-threaten-ing due to its le-sions beginningin the mouth and affecting the oro-pharyngeal area. Flacid bullae thenprogress to the face, neck, chest,groin and intertriginous areas.

KOH negative. Asteatotic eczema isalso seen in patients with dementiawho bathe frequently. Patients canalso develop dry, cracked heels plan-tarly which is known as keratodermaclimacterum (Fig-ure 7).

In addition tothese environ-mental causes ofdry skin, themost common in-herited form isichthyosis vul-garis. These pa-tients presentwith fish scale-like dryness thatmay improvewith age.Ichthyosis vul-garis can also beacquired and maybe associatedwith diabetes, renal disease, andvarious types of cancer.

Circular scales with serpiginous

borders are often diagnosed as tineapedis, but other skin conditionsthat present as small circular, scalyrimmed lesions are pityriasis roseaand secondary syphilis. There havealso been instances of plantar psori-asis presenting as scaly skin with noerythema.

Case Example #4A female patient presented to

the clinic for a second opinion. Shehad been previously diagnosed ashaving xerosis, but continued tohave extreme pruritus that was notcontrolled by any topical medica-tion. Her plantar feet had a local-ized plaque with scale in the medial

Differentiating... These are tender lesionsand are usually Nikolsky’ssign positive.

If patients have target lesionswith three zones of color (center le-sion surrounded by a clear zone,and followed by a red border) asso-ciated with circular papules and/orplaques with mild scaling; onemust consider erythema multi-forme minor. This is associatedafter a manifestation of herpes sim-plex (recent cold sore or genital le-sion) and the target lesions maypresent on the feet.6 Drug reactionsmay also present as target-like le-sions with less defined target zonesof color on the lower extremity.

First-Line Treatment OptionsWhen treating a condition that

is fungal, bacterial, or inflammato-ry in nature, the podiatric practi-tioner should use the appropriatedrug, but if one is unsure of thecause, a biopsy of the skin lesionshould be completed. Inflammato-ry skin conditions often warranttopical corticosteroid therapy as a

first line methodin treatment.

It is useful toavoid combina-tion steroid-anti-fungal drugs orm e t h y l p r e d -nisolone dosepacks as thesemay create aquick fix, but ulti-mately can causefrustration for thedermatologica lpatient. The re-bound effect fromthe dose pack canbe potentially de-bilitating by caus-ing a dermatitisthat is worse thanthe original reac-tion, and the dosepack itself isn’tthe same as pre-scribing a trueprednisone taper.

When indoubt, the first linetherapy for an in-

flammatory skin dermatosis should be atopical steroid and a skin moisturizer orkeratolytic (such as urea or lactic acid).


Continuing

Medical Education

Dyshidrotic eczema

(pompholyx) charac-

teristically has pruritic

tapioca pudding-like

blisters on the palmar

aspect of the hands

with minimal foot

involvement.

Figure 8: Psoriatic Scale plantarly

A diabetic patient who

presents with tense

blisters that seem to

appear overnight,

most likely has

bullosis diabeticorum.

Pemphigus vulgaris is

a chronic disease

affecting adults which

can be life-threatening

due to its lesions

beginning in the

mouth and affecting

the oro-pharyngeal

area.

should be added to decrease trans-epidermal water loss and decreaseflares.7 If the patient is in the sub-

acute or chronic stage and a topicalsteroid is warranted for the level ofirritation and pruritus present, thepractitioner should prescribe theappropriate steroid class (Table 3).

The goal in treating inflamma-tory conditions is to ultimatelyhave the patient use little to notopical steroid, and use the previ-ously mentioned skin moisturizersas maintenance, if possible. If thepatient does not respond to the

topical steroid aspredicted, furtherconsideration ofother diagnosesshould be givenand a biopsyshould beplanned. If this isnot within thecomfort zone ofthe practitioner,he should thenrefer the patientfor a dermatologyconsult.

Overall, in-flammatory skindermatoses can bechallenging andfrustrating forboth the practi-

tioner and patient. By doing a thor-ough history and skin exam, the as-tute practitioner can create a work-ing list of differential diagnosesthat can be further changed byboth reaction to treatment and, ofcourse, a biopsy result. �

References1 Zaiac MN and Daniel CR: “Nails in

Systemic Disease,” Dermatol Ther, vol15, 2002, pg 99-106.

2 Bolognia JL, Jorizzo JL, Rapini RP.Dermatology. Volumes 1 and 2, 1st edi-tion, 2003.

3 Brenninkmeijer EE, Schram ME,Leeflang MM, Bos JD, Spuls PI. Diagnos-tic criteria for atopic dermatitis: a sys-tematic review. Br J Dermatol. Apr2008;158(4):754-65.

4 Lofgren SM, Warshaw EM.Dyshidrosis: epidemiology, clinicalcharacteristics, and therapy. Dermatitis.Dec 2006;17(4):165-81

5 Cantwell AR Jr, Martz W. Idiopathicbullae in diabetics. Bullosis diabeticorum.Arch Dermatol. Jul 1967;96(1):42-4.

6 Huff JC. Erythema multiforme andlatent herpes simplex infection. SeminDermatol. Sep 1992;11(3):207-10.

7 Cork MJ, Danby S. Skin barrierbreakdown: a renaissance in emollienttherapy. Br J Nurs. Jul 23-Aug 122009;18(14):872, 874, 876-7.


Differentiating...

The stage (acute, sub-acute,a n d

ch ron -ic) ofthe skindisorderand thel e n g t hof timethe con-d i t i o npresentswill aidin thelevel oftop i c a ls t e ro idw h i c hs h ou l dbe used.

F o rthe severe, acute inflammatory skinconcerns, Class 1 drugs should beused for two weeks consecutively.Some examples of Class 1 steroidsinclude: clobetasol (Clobex, Olux,Temovate), betamethasone (Dipro-lene), diflorasone (Psorcon), halobe-tasol (Ultravate), fluocinonide(Vanos).

In the author’s experience, norefills are given due to the side-ef-fects of using a Class I steroid forlonger than four-teen days. Side-effects includeskin thinning oratrophy whichcan lead tostretch marks,telangiectasias,and hypopig-mentation, toname a few. It ishelpful to titratedown from aClass 1 steroid toa mid-potencypreparation afterthat initial twoweek period.

For example,one could havethe patient use aClass 1 steroid on Monday,Wednesday, and Friday with themid-potency topical steroid for thedays in between.

The fairly new skin barrier pro-tection emollient moisturizers (Im-pruv lotion, Mimyx, Atopiclair)

Continuing

MedicalEducation

Dr. Vlahovic is an Associate Profes-sor at Temple University School of Podi-atric Medicine.

Ms. Oliver is a fourth year student atTemple University School of PodiatricMedicine, Philadelphia, PA.

TABLE 3Topical Steroid Classes

Class I: Ultra potentClass II: PotentClass III: Upper mid-strengthClass IV: Mid-strengthClass V: Lower-mid strengthClass VI: MildClass VII: Least potent (hydrocortisone)

Adapted from the National Psoriasis Foundation Topical Steroids PotencyChart

Side-effects of using a

Class I steroid for

longer than fourteen

days include skin

thinning or atrophy

which can lead to

stretch marks,

telangiectasias, and

hypopigmentation.

When in doubt,

the first line therapy

for an inflammatory

skin dermatosis

should be a topical

steroid and a skin

moisturizer or

keratolytic

(such as urea

or lactic acid).


an ID reaction is:

A) Atopic dermatitis

(eczema)

B) Irritant contact dermatitis

C) Stasis dermatitis

D) Lichen simplex chronicus

7) Which of the following

doesn’t the patient need to have

to diagnose of atopic dermatitis

(eczema)?

A) paronychia of great toe

B) personal history of

asthma, runny nose, skin rash

C) pruritis

D) chronic relapsing course

8) Asteatotic Eczema (Eczema

craquele) is associated with:

A) children

B) high humidity

C) frequent bathing

D) hyperhidrosis

9) Bullosa diabeticorum

(diabetic bullae) usually appear

as ____ blisters on the lower

extremity.

A) tense

B) flaccid

C) pus-filled

D) hemorrhagic

10) Pemphigus vulgaris lesions

most commonly begin in this

location:

A) Pretibial

B) Soles

C) Thighs

D) Mouth

1) All of the following are

primary lesions EXCEPT:

A) macule

B) bulla

C) tumor

D) scale

2) In plaque psoriasis, which of

the following best describes the

lesion?:

A) plaque with silver scale

B) plaque with yellow scale

C) plaque with pustules

D) plaque with peeling inside

edge

3) The pustules in palmar/

plantar psoriasis are filled

with:

A) sterile fluid

B) staph aureus

C) pseudomonas

D) strep

4) Lichen planus can be

described by all of the following

EXCEPT:

A) Peachy

B) Pruritic

C) Purple

D) Papular

5) The best differential diagnosis

for plantar psoriasis is:

A) atopic dermatitis

B) herpes simplex

C) erythema multiforme

D) neurotic excoriations

6) The most common cause of

11) Which of the following is a

Class 1 steroid?:

A) Psorcon (diflorasone)

B) Cortaid (hydrocortisone)

C) Aclovate (aclometasone)

D) Kenalog (triamcinolone)

12) Contact dermatitis:

A) is bilateral and

symmetrical

B) intensity varies on each

limb

C) only involves vesicles

D) never itches

13) Dyshidrosic eczema

(pompholyx):

A) is linked to sweat

glands

B) occurs mostly on the

hands

C) first appears as pustules

D) is a drug reaction

14) One of the side-effects of

using a Class 1 topical steroid

consecutively over the initial

two-week period is:

A) lichenification

B) scar formation

C) atrophy

D) hyperkeratosis

15) Which of the following is a

secondary skin lesion?

A) telangiectasia

B) scale

C) papule

D) patch

Continuing

Medical Education

E X A M I N A T I O N

See answer sheet on page 183.


182 PODIATRY MANAGEMENT

16) The new skin barrier moisturizers help to

reduce flare by:

A) decreasing trans-epidermal water loss

B) increasing trans-epidermal water loss

C) decreasing T-cell lymphocyte

involvement

D) increasing T-cell lymphocyte

involvement

17) The target lesion in erythema multiforme

minor has __ zone(s) of color:

A) 1

B) 2

C) 3

D) 4

18) A differential diagnosis for tinea pedis

would be:

A) pityriasis rosea

B) erythema multiforme minor

C) nevi

D) stretch mark

19) Dyshidrotic eczema has vesicles that can

be described as:

A) grapefruit-like

B) tapioca-like

C) peau d’orange-like

D) raspberry-like

20) The latest treatment for inflammatory skin

dermatoses involves prescribing:

A) a topical steroid and a moisturizer

B) a topical steroid and an NSAID

C) a topical steroid and sunscreen

D) a topical steroid and diphenhydramine

E X A M I N A T I O N

(cont’d)

See answer sheet on page 183.

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Please call (631) 563-1604 if you have any ques-tions. A personal operator will be happy to assist you.

Each of the 10 lessons will count as 1.5 credits;thus a maximum of 15 CME credits may beearned during any 12-month period. You may se-lect any 10 in a 24-month period.

The Podiatry Management Magazine CMEprogram is approved by the Council on PodiatricEducation in all states where credits in instruction-al media are accepted. This article is approved for1.5 Continuing Education Contact Hours (or 0.15CEU’s) for each examination successfully completed.

www.podiatrym.com

Home Study CME credits nowaccepted in Pennsylvania

Over, please

Please print clearly...Certificate will be issued from information below.

Name _______________________________________________________________________Soc. Sec. #______________________________Please Print: FIRST MI LAST

Address_____________________________________________________________________________________________________________

City__________________________________________________State_______________________Zip________________________________

Charge to: _____Visa _____ MasterCard _____ American Express

Card #________________________________________________Exp. Date____________________

Note: Credit card is the only method of payment. Checks are no longer accepted.

Signature__________________________________Soc. Sec.#______________________Daytime Phone_____________________________

State License(s)___________________________Is this a new address? Yes________ No________

Check one: ______ I am currently enrolled. (If faxing or phoning in your answer form please note that $2.50 will be chargedto your credit card.)

______ I am not enrolled. Enclosed is my credit card information. Please charge my credit card $20.00 for each examsubmitted. (plus $2.50 for each exam if submitting by fax or phone).

______ I am not enrolled and I wish to enroll for 10 courses at $139.00 (thus saving me $61 over the cost of 10 individualexam fees). I understand there will be an additional fee of $2.50 for any exam I wish to submit via fax or phone.

Note: If you are mailing your answer sheet, you must completeall info. on the front and back of this page and mail with yourcredit card information to: Podiatry Management, P.O. Box490, East Islip, NY 11730.

TESTING, GRADING AND PAYMENT INSTRUCTIONS(1) Each participant achieving a passing grade of 70% or

higher on any examination will receive an official computer formstating the number of CE credits earned. This form should be safe-guarded andmay be used as documentation of credits earned.

(2) Participants receiving a failing grade on any exam will benotified and permitted to take one re-examination at no extra cost.

(3) All answers should be recorded on the answer formbelow. For each question, decide which choice is the best an-swer, and circle the letter representing your choice.

(4) Complete all other information on the front and back ofthis page.

(5) Choose one out of the 3 options for testgrading: mail-in,fax, or phone. To select the type of service that best suits yourneeds, please read the following section, “Test Grading Options”.

TEST GRADING OPTIONSMail-In GradingTo receive your CME certificate, complete all information

and mail with your credit card information to:Podiatry Management

P.O. Box 490, East Islip, NY 11730There is no charge for the mail-in service if you have already

enrolled in the annual exam CPME program, and we receive this

ENROL LMENT FORM & ANSWER SH E E T

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183

Continuing

Medical Education

exam during your current enrollment period. If you are not en-rolled, please send $20.00 per exam, or $139 to cover all 10 exams(thus saving $61* over the cost of 10 individual exam fees).

Facsimile GradingTo receive your CPME certificate, complete all information and

fax 24 hours a day to 1-631-563-1907. Your CPME certificate willbe dated and mailed within 48 hours. This service is available for$2.50 per exam if you are currently enrolled in the annual 10-examCPME program (and this exam falls within your enrollment period),and can be charged to your Visa, MasterCard, or American Express.

If you are not enrolled in the annual 10-exam CPME pro-gram, the fee is $20 per exam.

Phone-In GradingYou may also complete your exam by using the toll-free ser-

vice. Call 1-800-232-4422 from 10 a.m. to 5 p.m. EST, Mondaythrough Friday. Your CPME certificate will be dated the same dayyou call and mailed within 48 hours. There is a $2.50 charge forthis service if you are currently enrolled in the annual 10-examCPME program (and this exam falls within your enrollment peri-od), and this fee can be charged to your Visa, Mastercard, Ameri-can Express, or Discover. If you are not currently enrolled, the feeis $20 per exam. When you call, please have ready:

1. Program number (Month and Year)2. The answers to the test3. Your social security number4. Credit card information

In the event you require additional CPME information,please contact PMS, Inc., at 1-631-563-1604.

Enrollment/Testing Informationand Answer Sheet

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ENROL LMENT FORM & ANSWER SH E E T (cont’d)Continuing

MedicalEducation

LESSON EVALUATION

Please indicate the date you completed this exam

_____________________________

How much time did it take you to complete the lesson?

______ hours ______minutes

How well did this lesson achieve its educationalobjectives?

_______Very well _________Well

________Somewhat __________Not at all

What overall grade would you assign this lesson?

A B C D

Degree____________________________

Additional comments and suggestions for future exams:

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

1. A B C D

2. A B C D

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D

12. A B C D

13. A B C D

14. A B C D

15. A B C D

16. A B C D

17. A B C D

18. A B C D

19. A B C D

20. A B C D

Circle:

EXAM #4/10Differentiating Dermatological Diagnosis

and Treatment(Vlahovic and Oliver)

differentiating dermatological diagnosis and treatment - podiatry

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