jeopardy!

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Click Once to BeginJEOPARDY!

IM-Derm Board ReviewNita Kohli, MD, MPH

PGY-4, Derm


JEOPARDY!

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tumah”Derma-what?


Question 1-100• 49-y/o woman several-day hx

of pruritic lesions on the abdomen. Noticed upon return from business trip to a large northeastern city. Didn't see any bugs in the hotel.

• Husband not itching and has no visible lesions, although he shared the same room and bed.

• No new meds or exposures to other persons with similar rashes.

• Medical hx unremarkable, takes no meds.


• Which of the following is the most appropriate treatment?

A. Oral doxycyclineB. Oral ivermectinC. Topical permethrin creamD. Topical triamcinolone acetonide cream

Question 1-100


D. Topical triamcinolone acetonide creamDx: Bed Bugs (Cimex lectularius)

• Itch: topical TAC, antihistamines. Spont resolution in days.

• Characteristic grouping linear pattern; series of bites close together. Small punctum or bite mark in center.

• May be bitten while visiting infested locations; may unknowingly bring the bedbugs home in their luggage. Varied response in different individuals; possible for different persons sharing the same room to have reactions ranging from no visible marks to larger, urticarial wheals.

• Bugs do not actively infest the skin, pediculicides not indicated. Can become secondarily infected if scratched.


Question 1-200• 82-y/o man w/ 6-wk hx

of intensely itchy rash on trunk and extremities, worse at night.

• No new exposures or meds.

• PMH: Alzheimer’s, lives in assisted care facility.

• Meds—donepezil, MVI.• PE: scratching

intermittently; lesions in finger webs, wrists, torso, umbilicus. Fine linear scale in a few areas.


• Which of the following is the most appropriate diagnostic test to perform next?

• A. Complete blood count• B. Microscopic evaluation of skin scrapings• C. Serum tissue transglutaminase level• D. Skin biopsy for direct immunofluorescence

microscopy

Question 1-200


B. microscopic eval of skin scrapingsDx: scabies

• Dx by microscopic identification of the mite, feces, or eggs.

• Scrape many lesions.

• Unexplained itch, rash; institutionalized pt.


Question 1-300• 35-y/o man sores on

lips following trip to Caribbean 1 week ago, where he sustained a sunburn followed by painful blisters on the back, face, and especially the lips.

• Blisters on lips crusted.

• Otherwise well except for recurrent herpes labialis.

• Meds: intermittent oral acyclovir.


• Which of the following is the most likely diagnosis?

• A. Actinic cheilitis• B. Allergic contact dermatitis• C. Coxsackievirus infection• D. Reactivation of herpes simplex virus

Question 1-300


D. Reactivation of HSV• Herpes labialis can be reactivated by UV.

• Actinic cheilitis--premalignant condition occurring in persons who have spent a significant time outdoors. It usually affects the lower lips.

• Contact dermatitis to sunscreen can occur on the lips, but it is usually pruritic (a hallmark of contact dermatitis) or irritating.

• Coxsackievirus—hand, foot, mouth dz primarily in kids. Intraoral and palmar/plantar lesions. Oral aphthae, fever, sore throat. Spares lips, gingiva (HSV does not).


Question 1-400• 20-y/o man single

erythematous macule on L arm that rapidly changed to fluid-filled lesions, some of which were cloudy.

• PE: vitals normal


• Which of the following is the most appropriate topical treatment?

• A. Bacitracin• B. Clotrimazole• C. Hydrocortisone• D. Mupirocin

Question 1-400


D. MupirocinDx: Impetigo

• Staphylococci or streptococci.– Tx: cleansing, wet dressings to remove crust, mupirocin

treatment of choice.

• Bullous impetigo--always S. aureus. Systemic spread of the same toxins causes staphylococcal scalded skin syndrome. Most impetigo is nonbullous.

• Nonbullous impetigo--direct person-to-person contact, spreads rapidly. S. aureus or Streptococcus pyogenes.

• This pt: localized infection, afebrile; systemic Abx not indicated as first-line tx.

• Bacitracin--high rate of allergic contact dermatitis. Anaphylaxis reported with prior contact sensitization.


Question 1-50035 y/o woman w/recurrent salmoncolored oval lesions onchest, upper back,occasionally itchy.

• Tried OTC selenium sulfide- shampoo with modest improvement.

• Lesions reappear every year during hot, humid weather.

• KOH : “spaghetti and meatballs” pattern


Question 1-500

• Which of the following is the most appropriate next step in treatment?

• A. Oral ketoconazole, single dose• B. Topical corticosteroids• C. Topical ketoconazole• D. No treatment


C.Topical ketoconazoleDx. Tinea versicolor

• aka pityriasis versicolor, a common superficial fungal infection caused by yeast Malassezia furfur (aka Pityrosporum ovale or Pityrosporum orbiculare).


Question 2-100• 30-y/o man w/ nail

changes. Induction chemo for AML 1 mth ago.

• Afebrile, no systemic complaints.

• Kidney, liver chemistry studies normal.



• A. Beau lines• B. Lichen planus• C. Median nail dystrophy• D. Psoriasis

Question 2-100


A. Beau linesChemo induced

• Transverse linear depressions in nails from significant systemic stress such as chemo, sepsis.

• Temporary disruption of nail production in nail matrix. Typically, all nails are involved.

• Harmless; atypical portion will grow out, be clipped off as nail growth returns to normal.


Lichen Planus


Median Nail Dystrophy• Longitudinal

depression or canal in center of nail, down entire length.

• Typically 1-2 nails; thumb nails prone to this condition

• Cause: trauma.


Psoriatic nails


Question 2-200• 25-y/o man

w/persistent discoloration on a single nail x 1 yr.

• Enlarged slowly.• No hx trauma. • No other nails are

affected



• A. Longitudinal melanonychia• B.Hematoma• C. Onychomycosis• D.Subungual melanoma

Question 2-200


D. Subungual melanoma

• Pigmentation extending onto proximal nail fold or other adjacent skin (Hutchinson sign) and a wider diameter of the pigmented area at the proximal area of the lesion, indicating an expanding lesion.


Question 2-300• 65-y/o man 10-year hx

of painful thickened fingernails. Started on L hand with two nails, gradually spread to all fingernails.

• Not improved after 3 mths of po terbinafine.

• PMH: DM2 treated with metformin and glyburide.


• Which of the following is the most appropriate next step in management?

• A. Begin fluconazole• B. Begin itraconazole• C. Obtain nail clipping for histology and

culture• D. Repeat a second course of oral

terbinafine

Question 2-300


C. Nail clipping for path, cx• Up to 50% of all nail dystrophies are caused

by conditions other than fungal infection, the dx should be confirmed before tx initiated. – Oral antifungal agents are not without toxicities– KOH, cx, PAS of clipping

• Causes: dermatophytes, yeasts, molds, trauma, lichen planus, psoriasis


Question 2-400• 53-y/o woman rash gradual

onset x 2 mths. Scalp pruritus, redness of face, pruritic rash on chest, arms.

• Started after baseball game where she sat in sun for hours.

• More fatigued lately, DOE.

• PE: Violaceous erythema of periorbital face, malar area, nasolabial folds.

• Difficulty abducting arms above 90 degrees or rising from a chair without using her arms to help.

• DTRs nl, no obvious joint abnormalities.



• A. Dermatomyositis• B. Psoriasis with psoriatic arthritis• C. Rheumatoid arthritis• D. Systemic lupus erythematosus

Question 2-400


A. Dermatomyositis

• Heliotrope rash, Gottron papules.

• Psoriasis--pink plaques with silvery scale, elbows, sites of trauma or pressure. No muscle weakness, malar rash, or V-neck erythema. Improved by UV.

• RA--rheumatoid nodules over extensor joints. No muscle weakness, photosensitivity, malar or V-neck erythema.

• SLE--malar erythema, can follow sun exposure; rare muscle weakness. No Gottron’s papules.


Question 2-500• 46 y/o woman 4-day hx intensely pruritic rash

on face, neck. Started using new facial moisturizer 1 week prior to onset.

• Stopped using moisturizer, rash persisted. Tried calamine lotion, no improvement.

• PMH—neg; takes no meds.• PE: poorly defined, red, weepy, eczematous

patches on cheeks, neck. Few fine vesicles, some serous crusting.


• Which of the following is the most appropriate corticosteroid cream for this rash?

• A. Betamethasone dipropionate• B. Clobetasol propionate• C. Desoximetasone• D. Hydrocortisone valerate

Question 2-500


D. Hydrocortisone valerateDx: Allergic contact dermatitis to moisturizer

• High-potency topical steroids cause thinning of skin, avoid on face, periorbital, occluded areas (intertriginous folds, axillae, under breasts, pannus), and on atrophic skin where absorption may be enhanced use low potency.

• Patient's rash involves face, neck lower potency steroid safest.

• Adverse effects: thin skin, striae, hypopigmentation, telangiectasia.

• Clobetasol propionate--ultrapotent corticosteroid• Betamethasone dipropionate, desoximetasone--high-

potency


Question 3-100• 54-y/o woman

w/enlarging, painful ulcer medial leg x 3-4 mths.

• Unresponsive to several courses of po cephalexin. Remote hx DVT L leg.

• BLE skin feels somewhat thickened. Sensation in feet normal. Toes warm.

• ABI of left leg is 0.9.


• Which of the following is the most appropriate treatment?

A. Arterial revascularizationB. Contact castingC. Intravenous vancomycinD. Unna boot compression

Question 3-100


D. Unna Boot CompressionDx: venous stasis ulcer

• Compression minimizes vascular HTN, edema.

• Risk factors: chronic venous HTN, hx of DVT, trauma in affected limb. Classically medial malleolus, surrounding skin thickened with chronic hemosiderin deposition. May be assoc w/ venous stasis dermatitis, which causes affected skin to become red, warm, and possibly tender and mimics cellulitis.

• Contact casting--to redistribute pressure on plantar feet in neuropathic ulcers.

• Venous stasis dermatitis vs cellulitis:– presence of chronic erythema in both lower legs, the

absence of fever or leukocytosis, lack of response to appropriate Abx tx favor non-infectious.


Arterial ulcers

•bony prominences, posterior calf. “Punched-out”, painful, limb may be cool to touch, poor capillary refill. Distal pulses may not be palpable. ABI < than 0.9.


Question 3-200• 35 y/o man pain,

increased warmth, erythema, swelling on RLE x 2 d. No pruritus.

• Hx tinea pedis, chronic lymphedema in RLE.

• No meds; NKDA.• PE: T100.1 °F; other

vital. BMI 30.



• A. Bullous tinea• B. Cellulitis• C. Contact dermatitis• D. Stasis dermatitis

Question 3-200


B. Cellulitis • Rapidly spreading, deep, SQ-based infection, w/ well-

demarcated area of warmth, swelling, tenderness, erythema, may have lymphatic streaking, fever, chills.

• Often secondary to streptococcal or staph infection. On legs, almost never bilateral.

• Risk factors: hx of cellulitis in same location, chronic leg ulceration, varicose veins, thrombophlebitis, DM2, heart failure, lymphedema, obesity, onychomycosis, tinea pedis.

• Contact dermatitis--swelling, erythema, warmth, but almost always accompanied by pruritus; vesicles, bullae if severe.


Bullous Tinea

• Also inflammatory, erythematous; usually localized to foot, occ spreads to lower ankle. Clues: scales in a “moccasin” distribution.


Stasis Dermatitis

• Looks similar to cellulitis when inflammatory, can become secondarily infected;

• Almost always bilateral and usually not tender.


Question 3-300• 27-y/o man w/ rapidly

progressive ulcer on leg, extremely tender, expanding x 1 week.

• Started 10 -14 days ago. Initial lesion a “pimple.”

• 2 mths abdominal pain, frequent BMs, watery stools, occ bloody.

• PE: afebrile, other vitals nl. No streaking erythema, fluctuance, purulent discharge, expressible pus, or sinus tracts.



• A. Calciphylaxis• B. Ecthyma gangrenosum• C. Necrotizing fasciitis• D. Pyoderma gangrenosum

Question 3-300


D. Pyoderma gangrenosum

• Uncommon, neutrophilic, ulcerative skin disease assoc w:– inflammatory bowel disease, – RA, – seronegative spondyloarthritis, – hematologic dz or malignancy, most

commonly AML.


Calciphylaxis

• Painful ulcerative process due to ectopic calcification of the arteries feeding the skin.

• Nearly always in pts w/ ESRD in setting of very high Ca-P products;

• Reticulated, dusky erythema then ulcerates due to cutaneous ischemia.


Ecthyma gangrenosum• From perivascular

bacterial invasion of blood vessel walls with secondary ischemic necrosis.

• Multiple lesions may be present at different stages of development.

• Pseudomonas aeruginosa

• Almost always occurs in a significantly immunocompromised pt who is clinically ill.


Necrotizing fasciitis• Rapidly progressive

infection of subcutis, often streptococcal or polymicrobial.

• Critically ill, disease progresses over hours.

• Extreme pain, dull or dusky skin, potentially with crepitus, and a clinical picture of sepsis.


Question 3-400• 31-y/o woman 2-wk hx

slightly tender lesions on anterior shins. Appeared suddenly.

• No joint pain, fevers, cough, ocular symptoms, GI problems.

• Recently started OCPs.• PE: vitals normal. 6-7 bilateral

reddish-brown SQ nodules are present on anterior shins. No fluctuance.

• Rest of exam normal• CXR normal.


• Which of the following is the most appropriate next step in management?

• A. Discontinue oral contraceptives• B. Initiate oral acyclovir• C. Initiate oral cephalexin• D. Initiate oral fluconazole

Question 3-400


A. D/C OCPsDx: drug induced erythema nodosum

• Septal panniculitis w/ sudden onset of tender, erythematous nodules on the anterior legs

• Associated with infections, systemic diseases, or adverse drug reactions, particularly to Abx, OCPs, and hormone therapy.


Question 3-500•68-y/o man slightly pruritic, occ painful plaques on arms x 1 yr. Skin is now very tight, constant discomfort. •1 yr ago, had MRI w/ gadolinium to eval spinal stenosis and back pain. •On hemodialysis for ESRD.

•Meds: Epo-A, lisinopril, nifedipine, sevelamer, ASA.

•PE: vital nl. Skin indurated, tight, woody, bound-down texture.

•Labs: SPEP wnl; ANA neg. Anticentromere Ab neg. •Scl-70 antibody Neg


Question 3-500

Most likely diagnosis?• A. Lipodermatosclerosis• B. Nephrogenic systemic fibrosis• C. Scleroderma• D. Scleromyxedema


B. Nephrogenic Systemic Fibrosis

• Gadolinium contrast agents identified as potential cause of NSF in pts w/ CKD.

• Scleroderma is unlikely given the localization of the skin changes to the arms, lack of sclerosis of the face and perioral region, the lack of involvement of the fingers, and neg labs.


Lipodermatosclerosis

• Pts w/ sig. venous insufficiency--can develop a severe fibrosing panniculitis.

• Darkly pigmented, indurated skin , bound down to subQ.

• Inverted champagne bottle legs


Scleromyxedema

• Rare. Widespread erythematous, indurated skin w/near-confluent fleshy papules;

• Face, fingers, extremities. • Usually assoc w/ a serum

paraprotein.


Question 4-100• 65-y/o woman prodrome of

pain on tip of nose followed by a painful eruption involving the right periorbital tissue.

• PE: vitals nl.• Grouped vesicles on an

erythematous base on the tip of the nose and about the right eye.

• Which of the following is the most appropriate first step in management of this patient?

• A. Warm compresses• B. Begin ophthalmic

corticosteroids• C. Begin valacyclovir and

obtain urgent ophthalmology consultation

• D. Bacterial cx and start cephalexin


C. Begin valacyclovir, consult ophthoDx: Ocular Herpes zoster

• Medical emergency, requires prompt referral ophthalmology, initiation of antiviral tx. If not tx’d promptly, can cause blindness.

• Eye redness, rash in the supratrochlear nerve distribution assoc w/ clinically relevant eye dz.

• DFA or PCR confirm dx; however decision to start antivirals based on H&P, rather than wait for lab testing.


Question 4-200

• 22-y/o man w/ lip erosions and new rash on the palms.


• Which of the following infections is most commonly associated with this skin finding?

• A. Herpes simplex virus• B. Parvovirus B19• C. Streptococcus, group A• D. Varicella zoster

Question 4-200


A. HSVDx: erythema multiforme

• Erythema multiforme is an acute dermatosis of the skin and mucosae that can be triggered by infections, most commonly herpes simplex virus.

• Tx: symptomatic, prophylactic antiviral tx.


Question 4-300• 64-y/o man in ER for rash x 3d, rapidly spread to most of

body. Skin is painful. • PMH: psoriasis and asthma. • Meds: topical corticosteroids prn, inhaled corticosteroid,

salmeterol, albuterol. 1 wk ago, completed 10-day course of oral corticosteroids for an acute exacerbation of asthma.

• PE: appears ill. T102.0 °F, BP 118/78 mm Hg, P 112/min. • > 90% BSA erythematous, widespread coalescing

erythematous patches and plaques, with pinpoint pustules coalescing into lakes of pus. Mucous membranes are normal.


Question 4-300


• A. Candida albicans infection

• B. Pustular psoriasis• C. Sweet syndrome• D. Toxic shock

syndrome


A. Pustular psoriasis

• Pts w/ hx of psoriasis txd w/ systemic corticosteroids may develop an acute pustular erythrodermic flare after the systemic corticosteroids are discontinued.

• Tx: underlying dz (psoriasis in this patient), supportive care.

• Most common causes of erythroderma: drug eruptions, psoriasis, atopic dermatitis, CTCL


Sweet’s syndrome(Acute febrile neutrophilic dermatosis)• More common in adults

than children. Majority (50%-80%) of pts have a fever.

• Arthralgia, myalgia, and arthritis are seen in 30% to 60% of patients.

• Often considered a reactive syndrome, assoc. with a preceding URI, GI illness;

• Assoc. w/malignancy in about 10% of pts.

• First-line tx: systemic corticosteroids.


Question 4-400• 37-y/o woman 24-hour hx

of peeling skin. Recently treated for UTI w/ bactrim. Developed fever , red, itchy papules on her torso and extremities. She continued the Abx, rash worsened, skin became painful.

• No other meds, NKDA.

• PE: acutely ill, pain. T102.9 °F, BP 100/60 mm Hg, P106, RR20.

• Skin shears. Erythema, crusting around eyes, lips, open erosions in mouth, vulva


Patient is admitted to the ICU and aggressiveIVF replacement is begun. • Which of the following should be done

next?• A. Begin intravenous corticosteroids• B. Begin topical corticosteroids• C. Begin vancomycin• D. Obtain a skin biopsy

Question 4-400


D. skin biopsyDx: Toxic epidermal necrolysis

• Most important step is stopping the suspected causative medication and initiating supportive care in an ICU or burn unit.

• Emergent derm consult for evaluation, skin biopsy to ensure appropriate dx and mgmt.


Question 4-50079- y/o woman pruritic blisters on chest, abdomen, and lower extremities x 3 -4 weeks' duration. The blisters arise in crops, drain clear yellow fluid, and crust over before healing.

No recent illness, feels well. Cannot identify precipitating causes. Takes no new meds, no new topicals, no new exposures to plants.

No sick contacts.

PMH: Hashimoto thyroiditis;

Meds: levothyroxine.


Question 4-500What is the best

next step?• A. Bacterial cx• B. PCR from

blister fluid• C. Skin biopsy

and DIF• D. Tzanck prep


C. Skin biopsy and DIFDx: Bullous Pemphigoid

•Chronic, vesiculobullous eruption, mainly involves nonmucosal surfaces. Subepidermal tense blisters.

• Widespread: lower abdomen, inner thighs, groin, axillae, flexural aspects arms and legs.

• Has been assoc. w/ psoriasis, DM, SLE, pernicious anemia, thyroiditis, polymyositis, RA.

•Path: Subepidermal blister, DIF + IgG, C3 at BMZ


Question 5-100• 75 y/o man asymptomatic, dark brown, irregularly

pigmented patch on cheek x 7 yrs; enlarging slowly.


• Which of the following is the most appropriate next step?

• A. Broad shave biopsy• B. Cryotherapy• C. Single punch biopsy• D. Topical 5-fluorouracil

Question 5-100


A. Broad shave biopsyDx: Lentigo maligna

• Uniformly pigmented, light-brown patch on face or upper trunk in sun-damaged skin, enlarges slowly, variegated in color.

• Preferred method of bx for most atypical pigmented lesions worrisome for melanoma is excisional biopsy with 2-mm margins. This allows determination of both atypia and depth.

• 3 reasons why broad shave bx preferred for LM: (1) most in situ or minimally invasive; little risk of transecting base; (2) the atypical cells are not distributed homogenously throughout the lesion; performing a small punch biopsy carries a significant risk of a false-negative result; and (3) cosmetic result superior compared with more invasive techniques.


Question 5-200• 78-y/o man several-year hx of increasing number of irregularly pigmented

“moles” on the back. Mostly asymptomatic, some itch, some getting larger. • Concerned for melanoma, asking for removal of all.• FHX: sister with melanoma at 55 y/o.


• Which of the following is the mostly likely diagnosis?

• A. Atypical nevi• B. Melanomas• C. Seborrheic keratoses• D. Solar lentigines

Question 5-200


C. Seborrheic keratoses

• Benign waxy, verrucous papules ranging in color from flesh colored, to yellow, to tan, may be irregularly pigmented.

• Torso, back, btwn breasts, face, scalp. • Rare: rapid development of multiple SKs--sign

of Leser-Trélat--assoc with malignancy


Question 5-300• 75-y/o man w/

asymptomatic smooth papule on his face x 7 mths.

• Enlarging steadily and periodically bleeds when traumatized.



• A. Actinic keratosis• B. Basal cell carcinoma• C. Epidermal inclusion cyst• D. Melanoma• E. Squamous cell carcinoma

Question 5-300


B. Basal cell

• Smooth, pearly, asymptomatic telangiectatic papules that grow slowly, but may eventually cause substantial local tissue destruction if not removed.


Question 5-400• 45-y/o kidney

transplant recipient w/ asymptomatic lesion below his right ear x 4-6 wks. Unsure if it changed in size.

• Does not itch or bleed, but is occasionally painful.

• Med: tacrolimus, lisinopril, atenolol, and trimethoprim-sulfamethoxazole.


Which of the following is the most likely diagnosis?

• A. Fixed drug reaction secondary to trimethoprim-sulfamethoxazole

• B. Nummular eczema• C. Psoriasis• D. Squamous cell carcinoma• E. Tinea corporis

Question 5-400


D. Squamous cell

• Transplant recipients are at increased risk for the development of skin cancer.– Immunosuppressive agents increase the risk of

malignancy. – These skin cancers are more likely to be

multiple, occur at a younger age, behave more aggressively with a significantly increased risk of metastasis and death.


Question 5-500• 57-y/o man sore on lip x

3 mths.• Former smoker; quit 10

yrs ago.


• A. Actinic cheilitis• B.Herpes simplex

infection• C. Impetigo• D. Lichen planus• E. Squamous cell

carcinoma


E. Squamous cell carcinoma

• Most common type of oral malignancy, generally consists of red plaques or nodules that may be covered with scale, crust, and erosions.

• Risk factors: smoking, alcohol, sun exposure.• Biopsy


Question 6-100• 27-y/o woman w/ 4-wk hx

of wheals, burning sensation w/o pruritus. Each lesion persists x 48 hrs, slowly resolves, leaving a bruise.

• Meds-- diphenhydramine, hydroxyzine, cetirizine, and oral contraceptives.

• Mom—SLE. • PE: vitals nl. Scattered

ecchymoses at sites of fading lesions. No facial lesions, mucous membranes nl. No joint swelling or tenderness.

• Which of the following is the most appropriate management?

• A. Discontinue oral contraceptives

• B. Radioallergosorbent testing

• C. Skin biopsy• D. Thyroid function testing


C. Skin biopsyDx: urticarial vasculitis

• Lesions persist > 24 hours and resolve with bruising should be biopsied to evaluate for urticarial vasculitis.

• 50% of pts have underlying autoimmune disease such as SLE.

• Less frequently caused by meds; has not been associated with OCPs.


Question 6-200• 34-y/o man

progressive thickening of neck, axillae. Asymptomatic, but concerned about the cosmetic appearance.

• Has DM2, HTN, HLD• Meds: metformin,

lisinopril, simvastatin.• BMI 32. • No nail changes. No

lesions elsewhere.



• A. Acanthosis nigricans• B. Allergic contact dermatitis• C. Inverse psoriasis• D. Lichen simplex chronicus• E. Tinea corporis

Question 6-200


A. Acanthosis nigricans

• Skin thickening, velvety hyperpigmentation of intertriginous areas, particularly the axillae and the neck, in obese patients with hyperinsulinemia.

• Often develop multiple skin tags. • Weight loss and improved control of

hyperinsulinemia are primary interventions.• Some cases associated with malignancy.


Question 6-300• 22-y/o woman

evaluated for acne, had since her teens. Now 2 mths pregnant, acne worsening.

• Using OTC benzoyl peroxide, no improvement.

• PMH: neg. Meds: PNV.

• Which of the following topical drugs is contraindicated in this patient?

• A. Azelaic acid• B. Clindamycin• C. Tazarotene• D. Tretinoin


C. Tazarotene

• Tazarotene is rated pregnancy category X and is contraindicated during pregnancy.

• Tretinoin: topical cat. C; oral cat. D• Clindamycin, azelaic acid: cat. B


Question 6-40059 y/o man 3 mo hx intermittent itching on forearms, described as deep, with burning, tingling sensation.

Scratching helps, OTC topical corticosteroids have not. Cooling soothes. Did not notice a rash until he started scratching. Itch worse after being in the sun, but sun exposure does not cause redness or rash.

PE: chronic sun damage, hyperpigmentation, solar lentigines. Few excoriations on the forearms, but no significant dermatitis. Sensation normal. DTR normal.


Question 6-400• Which of the following is the most likely

diagnosis?• A. Brachioradial pruritus• B. Polymorphous light eruption• C. Prurigo nodularis• D. Solar urticaria


A. Brachioradial pruritis “itch without a rash”

• Neuropathic itch linked to abnormalities in C-spine

• Deep, crawling, or tingling sensation on the forearms, shoulders, and upper back; no visible skin findings.

• Evaluation of the spine may reveal evidence of osteoarthritis or other structural abnormalities; however, in absence of gross neurologic deficits, surgery unlikely to benefit.

•Tx: short term: pramoxine, topical analgesics; long term: gabapentin, pregabalin.


Notalgia paresthetica

• neuropathic itch on the mid, medial back.


Question 6-50050-y/o man w/ asymptomatic pink-brown rash in axillae x 3 mo. unresponsive to OTC topical corticosteroids. Meds: none.

Coral-pink fluorescence under Wood lamp.

Diagnosis?A.CandidiasisB.ErythrasmaC.Inverse psoriasisD.Tinea


B. Erythrasma• Well-defined, pink-brown patches w/ fine scale, in moist, occluded skin folds.

• G+ bacterium Corynebacterium minutissimum. Porphyrins produced by bacteria illuminate bright coral-pink fluorescence

• Asymptomatic or mild pruritus.

• Tx: topical abx such as erythromycin or clindamycin.


Cutaneous Candidiasis• Red, itchy, inflamed.

Sites of skin-to-skin contact, glazed, shiny, eroded.

• May be characterized by burning more than pruritus.

• Satellite pustules.


Inverse Psoriasis

•Intertriginous areas, sharp demarcation.

•Often mistaken for fungal or bacterial infection b/c no scaling.

•Improves w/ topical corticosteroids.

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