A 69-year-old Caucasian woman comes to the clinic for a routine physical examination.

While introducing yourself and getting to know the patient, you notice that she has a nodular lesion on her lower eyelid. When this is pointed out to her, she admits that it has been there at least a month or two, but states that she is not ery concerned about it, as it doesn!t hurt and is not affecting her ision. "he is a little annoyed, howe er, that the lesion seems to be getting slowly larger. A close examination of the lid lesion re eals a #-cm, firm, painless, pearly, indurated nodule on the lower lid margin, with loss of eyelashes directly abo e the lesion. $he central indentation seems to be mildly crusted with some degree of ulceration. $he rest of the eyelid seems normal, aside from some mild telangiectasias spreading outward from the lesion. $he eye itself is unin ol ed. Which of the following is the most appropriate management% A.&iopsy and resection of nodule and fro'en section examination of surgical margins &.(ot compresses and topical antibiotic ointment applied to lesion three times daily C.)ncision and drainage of nodule, hot compresses, return to the clinic in # week *.)ntralesional in+ection of long-acting corticosteroid, followup in # month ,.-o further inter ention, pro ide reassurance that lesion is not dangerous $he correct answer is A. $his patient has a basal cell carcinoma .&CC/. &asal cell carcinoma is the most common form of skin cancer and also accounts for approximately 901 of all malignant tumors of the eyelid. When it in ol es the eyelid, it most commonly occurs on the lower lid margin. )t often is described as pearly, with surrounding telangiectasia, and may ha e a central area of ulceration, gi ing it the description of a 2rodent ulcer,3 as if a rodent had gnawed away at the lesion. $he treatment, particularly in a location like the eye, in ol es 4oh!s microsurgery, with examination of the margins to make sure all of the tumor cells ha e been remo ed. (ot compresses and topical antibiotics .choice &/ can be used to treat a stye. $his lesion is not painful or warm, howe er, and has more of an insidious onset and prolonged time course than a stye. (ot compresses and topical antibiotics will not help this malignant lesion. 5or styes or chala'ions that do not resol e, an ophthalmologist may perform an incision and drainage .choice C/. $his techni6ue is not appropriate for solid tumors. )ntralesional in+ections of corticosteroids .choice */ are used for a ariety of eyelid lesions, including persistent chala'ions and keloid scars. $his is not the treatment for basal cell carcinoma, howe er, which needs to be surgically remo ed. $he patient should be ad ised that the lesion, though curable, is dangerous, and that further inter ention is necessary. $o do otherwise .choice ,/ is medical malpractice.

A 79-year-old woman comes to your office complaining of a skin rash that appeared while she was on acation in the Caribbean. )t started as a bad sunburn, but new lesions are now forming on her scalp, as well as her face, e en though she has not been in the sun since her acation. "he has no other complaints. (er past medical history is unremarkable. $he family history is significant for heart disease in her father and rheumatoid arthritis in her sister. "he has two healthy children of school age. 8e iew of systems is negati e for respiratory, gastrointestinal, genitourinary, and musculoskeletal complaints. 9n physical examination, the patient is in no acute distress. (er ital signs are within normal limits. )nspection of the skin re eals fi e discrete lesions located on the

scalp, lateral cheeks, and arms .shown in photograph/. $he oral and con+uncti al mucosae are unremarkable.

Which of the following is most likely to be associated with this patient!s skin lesions% A.)g: antibodies to desmoglein 7 &.:uaiac-positi e stool C.;ositi e rheumatoid factor *.;ositi e "chirmer test ,."carring alopecia

$he correct answer is ,. $his patient has discoid lupus erythematosus and she is most likely to de elop scarring alopecia as a conse6uence of discrete lesions located in the scalp. *iscoid lupus erythematous is a chronic, scarring, photosensiti e autoimmune connecti e tissue disease. )n approximately <1 of these patients, o er time, symptoms and signs of systemic lupus erythematosus will de elop. $herefore, the typical skin lesions may be seen in the context of systemic disease, as well. $he male-to-female ratio is #=> and it most often de elops in the third or fourth decade .mean age of onset= 7? years/. *iscoid lupus erythematosus is slightly more common in African American patients than in Caucasians or Asians. $ypical skin lesions of discoid lupus erythematosus are well-demarcated, erythematous pla6ues that de elop adherent scale and central atrophy. As the lesions age, patulous follicular openings with hyperkeratotic plugs are seen. 8esolution of an acti e lesion results in atrophy and scar formation. *iscoid lupus erythematosus most commonly affects sun-exposed areas. $he scalp, face, concha of the ear, and arms are fre6uently affected. 9ral mucosa may also be in ol ed. Approximately >01 will ha e antinuclear antibodies, and # to 71 may ha e anti-8o antibodies. Clinical diagnosis is confirmed with histopathologic and immunopathologic e aluation of lesional skin. "tandard treatment in ol es topical or intralesional corticosteroids and systemic antimalarials. )g: antibodies to desmoglein 7 .choice A/ are present in pemphigus ulgaris, a blistering autoimmune skin disease often seen in middle-aged patients of 4editerranean descent. :uaiac-positi e stool .choice &/ is not associated with discoid or systemic lupus erythematosus. $he gastrointestinal system is usually not in ol ed in the context of this disorder. ;ositi e rheumatoid factor .choice C/ is infre6uently detected in patients with discoid lupus erythematosus and should prompt a workup for rheumatoid disease. )n a "chirmer test .choice */, a bent piece of Whatman -o. @# filter paper is placed in the lower con+uncti ae, and the amount of tearing on the filter paper is recorded. -ormal wetting is greater than #< mm after < minutes, whereas a definiti e positi e result is less than < mm after < minutes. $his test can be useful to help exclude or confirm significant dryness of the eyes and is often helpful in the diagnosis of xerophthalmia associated with sicca syndrome .part of "+Agren syndrome/. )t is also positi e in up to one-third of elderly patients and is not disease-specific. *iscoid lupus erythematosus is not associated with xerophthalmia.

A @7-year-old man comes to the office complaining of his skin darkening in the body folds. (e

states that it started about > years earlier and is progressi ely worsening. (e is otherwise in good health, except that he gained weight recentlyB his new +ob takes him to many business-associated luncheons and dinners. $he family history is significant for hypertension, heart disease, diabetes, and genitourinary cancer, all in his mother!s family. (is medications include a daily baby aspirin and a multi itamin preparation. 9n physical examination, the patient is in no acute distress. (is ital signs are within normal limits. (e is 6 feet tall and weighs >>0 pounds. )nspection of the skin shows el ety pla6ues present periorbitally, on the lateral and posterior neck .see photograph/, in the axillary, and in the inguinal folds. $he remainder of the examination is within normal limits.

Which of the following diseases is most commonly associated with these cutaneous findings% A.Addison disease &.*iabetes insipidus C.*iabetes mellitus *.4alignant melanoma ,.9chronosis

$he correct answer is C. $his patient has acanthosis nigricans, a cutaneous disease most likely caused by factors that stimulate epidermal keratinocyte and dermal fibroblast proliferation. )n the benign form of acanthosis nigricans, the inducing factor is thought to be insulin or an insulinlike growth factor that alters epidermal proliferations and leads to typical skin changes. )n the malignant form, which is most commonly associated with adenocarcinoma of the gastrointestinal tract, it is hypothesi'ed that the tumor secretes a substance with similar effects, such as transforming growth factor alpha. 8emission of the skin lesions occurs with remo al of the tumor. )t can also be induced by medications, niacin being the most commonly implicated. ;atients with benign acanthosis nigricans often ha e an underlying insulin-resistant state. $he se erity of the insulin resistance is highly ariable and ranges from an incidental finding on routine blood studies to o ert diabetes mellitus. $he se erity of skin findings may parallel the degree of insulin resistance, and a partial resolution may occur with treatment of the insulin-resistant state. Addison disease .choice A/ is associated with increased 2bron'e3 pigmentation of the entire skin .not +ust the skin in the body folds/ and mucous membranes and accentuation of the palmar lines. )t is caused by se ere adrenocortical insufficiency due to destruction or dysfunction of the adrenal cortex. *iabetes insipidus .choice &/ is caused by decreased secretion or renal resistance to antidiuretic hormone that results in polyuria and polydipsia by reducing the patient!s ability to concentrate urine. $he only cutaneous signs associated with diabetes insipidus are those of dehydration, when present. 4alignant melanoma .choice */, when metastatic, may cause diffuse melanosis of the skin or areas of depigmentation associated with tumor regression. Alternati ely, metastatic nodules of arious colors may be seen. 9chronosis .choice ,/ presents as blue-black discoloration of ear cartilage and ocular tissue. )t is seen in alkaptonuria, a rare autosomal recessi e metabolic disorder caused by deficiency of homogentisic acid oxidase.

An #?-year-old college student is referred to your office for an employment health screen. "he has no complaints. (er past medical history is unremarkable. $he family history is significant for hypertension. 9n physical examination, the patient is a well-de eloped, well-nourished woman. "he is < ft 6 in tall and weighs #60 lb. (er blood pressure is #>0C?< mm (g, pulse is 6<Cmin, and respiratory rate is #6Cmin. )nspection of the skin re eals multiple disseminated skin lesions as shown in the photograph. 9n palpation, these lesions are soft and compressible. "he also has multiple cafD-au-lait spots on the trunk and extremities. Which of the following findings is necessary to confirm the suspected diagnosis of her skin disorder% A first-degree relati e with the same disease &.(ypertriglyceridemia C.)E less than 90 *.;osterior subcapsular cataract on ophthalmologic examination ,."coliosis $he correct answer is A. $his patient has neurofibromatosis type ) . on 8ecklinghausen disease/. $he photograph shows multiple neurofibromas, which are one of the diagnostic criteria. $he diagnosis of type ) neurofibromatosis re6uires two or more of the following criteria=

4utation of the -5# gene on chromosome #F causes on 8ecklinghausen disease. $he -5# gene is a tumor suppressor geneB it encodes a protein, neurofibromin, which modulates signal transduction through the ras :$;ase pathway. ;atients with -5# are at increased risk of de eloping ner ous-system neoplasms, including plexiform neurofibromas, optic gliomas, ependymomas, meningiomas, astrocytomas, and pheochromocytomas. -eurofibromas may undergo secondary malignant degeneration and become sarcomas. (ypertriglyceridemia .choice &/ is not found with increased fre6uency in patients with neurofibromatosis. )n fact, neurofibromatosis does not ha e any associated laboratory abnormalities. An )E of less than 90 .choice C/ would signify mental retardation, a condition that has not been associated with neurofibromatosis. A few of the genodermatosis that may be associated with mental retardation include tuberous sclerosis .&ourne ille disease/, focal dermal hypoplasia .:olt' syndrome/, and basal cell ne us syndrome .:orlin syndrome/. ;osterior subcapsular cataract on ophthalmologic examination .choice */ is not associated with neurofibromatosis. A common skin disorder associated with formation of posterior subcapsular cataract in long-standing disease is atopic dermatitis. "coliosis .choice ,/ may be associated with neurofibromatosis and often is first noted in schoolage children with this disorder, but it is not a diagnostic criterion.

An #?-year-old woman comes to the clinic for a routine followup isit. "he has se ere acne that

has been unresponsi e to a ariety of treatments, including topical ben'oyl peroxide, topical retinoic acid, and topical antibiotics. "he recently was started on systemic minocycline and had her oral contracepti e changed. $his has pro ided little impro ement, howe er, and the patient remains distressed and embarrassed about her acne. ;hysical examination re eals persistent acne with numerous comedones and occasional papules, pustules, and nodules. $he rest of the physical examination is unremarkable. After discussion of the risks and benefits of treatment with the patient, it is decided to start the patient on systemic isotretinoin. When prescribing this medication, it is necessary to monitor which of the following%

A.;regnancy test &.;regnancy test and C&C C.;regnancy test, C&C, and li er tests *.;regnancy test, C&C, li er tests, and lipid panel ,.;regnancy test, C&C, li er tests, lipid panel, and psychiatric symptoms

$he correct answer is ,. )sotretinoin re6uires close monitoring. As the drug is highly teratogenic, two pregnancy tests are re6uired before starting the medication. A C&C is recommended as a baseline and e ery @-6 weeks after starting therapy, as the medication can cause bone marrow suppression. Gi er tests are necessary to monitor for hepatotoxicity. A lipid panel , particularly serum triglycerides, is needed on a routine basis, as hypertriglyceridemia and pancreatitis can occur. 5inally, the prescribing physician should screen for psychiatric symptoms as depression and suicide .and associated law suits/ ha e been linked to isotretinoin. All of these need to be monitored, therefore choices A, &, C and * are incorrect.

A @9-year-old woman comes to the office complaining of an itchy rash that appeared 7 weeks earlier and has been worsening. "he tried using o er-the-counter cortisone cream but that pro ided minimal relief of the itch. ;ast medical history is significant for hypertension, diabetes mellitus, arthralgias, and a recent urinary tract infection. (er current medications were all introduced in the > months before rash onset and include captopril, hydrochlorothia'ide, ibuprofen, and insulin. "he was also taking trimethoprim-sulfamethoxa'ole for > weeks, with the last dose approximately @ weeks ago. 9n physical examination, she is in no acute distress and her ital signs are within normal limits. )nspection of the skin re eals that the trunk and proximal extremities are affected by multiple discrete and confluent skin lesions as shown in the photograph. $he oral, ocular, and genital mucosa is unremarkable. 9n the basis of the history and physical examination you conclude that the most likely etiology of her skin lesions is drug related and propose discontinuation of the culprit medication. Which of the following medications is the most likely cause of this patient!s skin lesions% A.Captopril

&.(ydrochlorothia'ide C.)buprofen *.)nsulin ,.$rimethoprim-sulfamethoxa'ole $he correct answer is A. $his patient has de eloped a lichenoid drug eruption and the most likely cause among her medications is captopril. Gichenoid drug eruptions are similar to lichen planus in appearance. Hiolaceous, polygonal, flat-topped papules may be widespread and confluent into pla6ues. "cale is often more abundant than in idiopathic lichen planus and the pruritus may be ery se ere. $he mucosa are most commonly not affected, as distinguished from idiopathic disease, which is characteri'ed by fre6uent presence of reticulated white or gray lesions on the buccal and genital mucosa. *rugs known to produce lichenoid eruptions include antimalarials, beta-blockers, captopril, diflunisal, furosemide, gold, le amisole, penicillamine, phenothia'ine, tetracycline, and thia'ides. (ydroxyurea and tegafur are chemotherapeutic agents that may cause a lichenoid drug eruption. *iscontinuing the offending agent leads to slow resolution of the skin lesion commonly with pronounced postinflammatory hyperpigmentation that may take many months to resol e. (ydrochlorothia'ide .choice &/ use has been associated with the following cutaneous reactions= purpura, photosensiti ity, rash, urticaria, necroti'ing angitis, asculitis, cutaneous asculitis, alopecia, exfoliati e dermatitis, toxic epidermal necrolysis, erythema multiforme, "te ensIohnson syndrome and drug-induced "G,. )buprofen .choice C/ is a member of the nonsteroidal antiinflammatory drugs that are known to fre6uently induce a ariety of drug eruptions. 4aculopapular exanthema is common while "te ens-Iohnson syndrome occurs in less than #1 of patients. )nsulin .choice */ is highly unlikely to cause cutaneous drug eruptions. $rimethoprim-sulfamethoxa'ole .choice ,/ is a common cause of cutaneous drug eruptions such as maculopapular exanthems, "te ens-Iohnson syndrome, or toxic epidermal necrolysis.

A <7-year-old man is hospitali'ed for acute onset of fe er, headache, muscle pain, and +oint pain of 7 days! duration. (e had +ust reco ered from an upper respiratory infection a week earlier that was treated symptomatically. )n addition, multiple tender skin lesions de eloped o er his back and arms the pre ious day. (is past medical history is significant for mild hypertension and chronic emphysema. $he family history is unremarkable and no other family members ha e been ill in the pre ious weeks. (is current medications include a daily baby aspirin and daily nebuli'er treatments. 8e iew of symptoms is positi e for headache, diffuse muscle pain, and arthralgia. 9n physical examination, he is in mild distress, with a temperature of 7?.F C, pulse of 90Cmin, and respiratory rate of >0Cmin. )nspection of the skin re eals tender, +uicy, erythematous papules and pla6ues on the trunk and proximal extremities .see photograph/. $he oral and con+uncti al mucosae are unaffected. ;alpation of muscles and +oints re eals diffuse tenderness with unaffected strength or range of motion. Gaboratory studies show an absolute neutrophilia and ele ated erythrocyte sedimentation rate. &lood cultures are negati e.

Which of the following is the treatment of choice for this patient% A.Acetaminophen &.:ranulocyte colony-stimulating factor C.;rednisone *.$erbinafine ,.Hancomycin $he correct answer is C. $his patient has the classic presentation of acute febrile neutrophilic dermatosis, or "weet syndrome. "weet syndrome is a reacti e inflammatory disease characteri'ed by the abrupt onset of tender red circinate pla6ues on the head, neck, trunk, and extremities typically preceded by fe er and peripheral neutrophilia. )t may be accompanied by headache, myalgia, and arthralgia. 8ange of disease includes the classic idiopathic form .often precipitated by immuni'ations or upper respiratory or gastrointestinal infections/, as well as forms associated with inflammatory diseases or malignancies. )t is also seen as a drug reaction, particularly to granulocyte colony-stimulating factor. "weet syndrome typically responds dramatically to systemic steroids and resol es without scarring. 8ecurrences, howe er, are common. 8arely, it may persist indefinitely. Cases associated with malignancy are often clinically bullous or ulcerati e and may be recalcitrant to treatment. Acetaminophen .choice A/ may be used to symptomatically treat fe er in patients with "weet syndrome, but it has no effect on the course of the disease :ranulocyte colony-stimulating factor .choice &/ is the prototypical drug associated with the appearance of "weet syndrome, most commonly in patients with acute myelogenous leukemia. 9ther drugs known to induce this disorder are trimethoprim-sulfamethoxa'ole, all-trans retinoic acid, and minocycline. $erbinafine .choice */ is an allylamine antifungal medication used in the treatment of dermatophyte infections of the skin, hair, or nails. )t is not indicated in the treatment of "weet syndrome. Hancomycin .choice ,/ is an antibiotic used for intra enous treatment of serious systemic infections, especially those caused by methicillin-resistant "taphylococcus aureus. )t is not indicated in the treatment of idiopathic "weet syndrome.

A @7-year-old woman comes to your office interested in treatment options for the aricose eins on her legs. "he tells you that they started appearing when she was an adolescent, but significantly worsened with each of her three pregnancies. -ot only are they unsightly, but she often feels that her legs are tired and she has trouble standing for prolonged periods of time. $his is ery disrupti e to her acti e lifestyle and her +ob that in ol es standing for hours at a time. 8ecently she also has noticed an increased incidence of 2Charlie horses.3 "he is otherwise in good health and takes only a multi itamin. "he denies a history of deep enous thrombosis or pulmonary

embolism. $he family history is positi e for aricose eins. 9n physical examination, you note a long and tortuous aricose essel, shown in the photograph, along the inner aspect of her leg. An in-depth e aluation of the lower extremity enous system re eals no anatomic anomalies or signs of obstruction.

Which of the following treatment options is the most appropriate% A.Chemical sclerosis &.Compression stockings C.Cutaneous electrodesiccation *.;ulse-dye laser ablation ,."urgical extirpation $he correct answer is ,. $his patient has a markedly aricose greater saphenous ein. Henous insufficiency caused by a refluxing circuit that results from failure of the primary al es at the saphenofemoral +unction typically leads to superficial aricose eins. $he typical signs and symptoms of enous insufficiency, including ankle edema, stasis dermatitis, and possibly ulceration, may occur when aricose eins are untreated. $he most appropriate treatment that produces long-lasting results with the smallest chance of recurrence is surgical extirpation. 5or this location, radical surgery is superior to sclerotherapy because of a significantly higher rate of cure and impro ement. Chemical sclerosis .choice A/, often called sclerotherapy, is the most widely used medical procedure for ablation of aricose eins and spider eins. A thorough diagnostic e aluation is essential before treatment. )nad ertent in+ection of concentrated sclerosants into the deep system can cause deep enous thrombosis, pulmonary embolism, and death. )t is used more commonly for superficial aricose eins of small caliber and spider eins. Compression stockings .choice &/ with a 70- to @0-mm (g gradient are indicated after treatment of large aricose eins by any method and patients are instructed to maintain or increase their normal acti ity le els. )n the absence of another, destructi e method of treatment, compression stockings may offer only partial and temporary relief of symptoms with prompt recurrence on their remo al. ,lectrodesiccation .choice C/ rarely is used by experts because it usually leads to disfiguring scars with no real impro ement in enous disease. )t has no place in treating large essels. ;ulse-dye laser ablation .choice */ is used for the treatment of spider eins and has no use in the aricose ein treatment. With a wa elength of <?<-<9< nm, the depth of penetration of the laser beam is a couple of millimeters.

A >@-year-old man comes to your clinic complaining of a rash and +oint pain. 5or the past @ months he has had a scaly rash o er his elbows, fingers, and scalp, and has had pain in his right index finger. $he pain is mild and he is concerned because he is a guitar player and is ha ing increasing difficulty playing music. Aside from these complaints, he has been in good health. 8e iew of symptoms and past medical history are unremarkable. Hital signs are= temperature 7F.0 C .9?.6 5/, blood pressure #>>CF? mm (g, pulse F>Cmin, and respirations >0Cmin. "kin

examination shows palpable, ele ated lesions approximately 7 cm in diameter on both elbows. $he lesions are well demarcated and brightly erythematous with loosely adherent sil ery white scale. 8emo ing the scale lea es multiple punctate bleeding points. ,xamination of the nails re eal small, multiple pits. $he right index finger distal interphalangeal +oint is mildly painful and warm. Which of the following is an appropriate way to describe the lesions on this patient!s elbows% A.&ulla &.4acule C.4aculopapular *.-odule ,.;apule 5.;la6ue :.;urpura (.;ustule ).Jlcer I.Hesicle $he correct answer is 5. $his patient has psoriatic arthritis with classic features, such as an Auspit' sign .punctate bleeding with scale remo al/, pitted nails, and large scaly pla6ues on the elbows. When discussing a rash, it is essential to characteri'e the lesions according to a defined ocabulary. A palpable, ele ated skin lesion greater than # cm in diameter is called a pla6ue. A bulla .choice A/ is a esicle that is greater than # cm in diameter. A macule .choice &/ is a nonpalpable, circumscribed lesion that is flat and less than # cm in diameter. 4aculopapular .choice C/ rashes are confluent, erythematous lesions made up of macular and papular lesions. -odules .choice */ are deep, roundish lesions less than #.< cm in diameter that can in ol e the epidermal, dermal, and subcutaneous tissue. ;apules .choice ,/ are palpable lesions that are solid, ele ated, and less than # cm in diameter. ;urpura .choice :/ describes papular or macular nonblanching lesions that are caused by extra asation of blood. ;ustules .choice (/ are esicles that contain pus. Jlcers .choice )/ are depressed skin lesions resulting from the loss of the epidermis and upper layer of the dermis. Hesicles .choice I/ are distinct, ele ated skin lesions that contain fluid and are less than # cm in diameter.

A >>-year-old woman comes to the office complaining of disfiguring acne of 7 year!s duration. "he constantly breaks out with painful lesions that lea e unsightly scars. 9 er the past year she has been on oral and topical antibiotics, ben'oyl peroxide preparations, and topical retinoids with little impro ement. (er past medical history is unremarkable. "he has regular menstrual periods. Current medications include minocycline #00 mg ;9 bid, ben'oyl peroxide 91 topically 6d, and tretinoin 0.0>1 topically 6d. $he family history is significant for se ere acne on the father!s side.

9n physical examination, the patient is in no acute distress. Hital signs are within normal limits. $he patient has multiple comedones, inflammatory papules and pustules on the face, chest and upper back. "he also has multiple tender, fluctuant nodules on the back. )nterspersed with these acute lesions are many atrophic, rolled and punched-out scars. 9therwise, the examination is within normal limits. "he should be told which of the following%

A. A topical antibiotic should be added to the regimen

&. , aluation for isotretinoin treatment is indicated at this time

C. "he has polycystic o ary disease

*. )ntralesional steroids added to the regimen

,. $he dose of minocycline should be increased

$he correct answer is &. Acne ulgaris is an inflammatory disease of the pilosebaceous follicle characteri'ed by noninflammatory follicular papules or comedones, inflammatory papules, pustules, and nodules in its most se ere forms. )t is ery common and affects up to #001 of people at some time during their li es. )t is strongly influenced by genetic factors, although certain cosmetic agents, medications, and endocrine disorders .congenital adrenal hyperplasia, polycystic

o ary disease/ may trigger the de elopment of acne. $reatment includes topical and oral antibiotics, topical ben'oyl peroxide, topical and oral retinoids, and hormonal therapy. )sotretinoin is a systemic retinoid that is highly effecti e in the treatment of se ere, recalcitrant acne, or disfiguring scarring acne. )sotretinoin is a teratogen, and pregnancy must be a oided during its use and for # month following cessation of use. Contraception counseling is mandatory, and two negati e pregnancy tests are re6uired prior to initiation of therapy. &aseline laboratory tests should also include a complete blood count and fasting lipid profile. 9ther potential ad erse effects of isotretinoin include pseudotumor cerebri, ision impairment, headaches, myalgias, arthralgias, and depressionB dry skin and cheilitis are nearly uni ersal ad erse effects )t is not recommended to use an oral and topical antibiotic at the same time because of a high risk of de eloping resistant bacteria. $herefore, it is incorrect that a topical antibiotic should be added to the regimen .choice A/. ;olycystic o ary disease is characteri'ed by hirsutism, obesity, oligomenorrhea, and se ere acne. $his patient has normal periods and no indication of hirsutism or obesity. )t is highly unlikely that she has polycystic o ary disease .choice C/. )ntralesional steroids .choice */ may expedite resolution of treated nodules and cysts in patients with acneB howe er, they ha e no influence on untreated lesions and do not affect further outbreaks. )n a patient with se ere acne, they are not ery helpful. $he maximum dose of minocycline used in the treatment of acne is #00 mg gi e twice a day for a total daily dose of >00 milligrams .choice ,/. (igher doses than this are fre6uently associated with undesirable andCor detrimental side effects. )f the patent does not respond to a reasonably long course of minocycline at this dose, it should be substituted with either a different systemic antibiotic or consideration for isotretinoin therapy.

A #9-year-old African American woman comes to see you for treatment of a large scar on the back of her left arm. While trying to replace a mirror in her bathroom last month, the mirror slipped and the broken glass cut her arm. $he wound was sutured in the emergency department and originally healed well. "ince then, howe er, the scar has become large, disfiguring, and painful. "he had a similar problem at age #6 years. At that time she had both her ears pierced and had to ha e scar tissue surgically remo ed 6 months later. Aside from an appendectomy at age #@ years, her past medical history is unremarkable. Hital signs are= temperature 7F.0 C .9?.6 5/, blood pressure ##?CF0 mm (g, pulse 6>Cmin, and respirations >0Cmin. ,xamination of her skin shows a @-cm scar on her left arm with heaped-up margins approximately # cm abo e the skin. ,xamination of her abdomen shows an additional hypertrophic scar with margins approximately 0.< cm abo e the surface of the abdomen. Which of the following is the most appropriate first-line treatment for this patient%

A. Cryosurgery

&. ,mpiric antibiotics

C. )ntralesional corticosteroids

*. 8adiation therapy

,. "urgical resection

$he correct choice is C. $his patient has a keloid. Keloids are benign fibrous growths present in scar tissue that form because of altered wound healing. Jp to F01 of patients respond to intralesional steroids. 5or patients who do not respond or in whom the lesions recur, combination therapy with steroids and surgical resection is an appropriate strategy. Cryosurgery .choice A/ is an effecti e treatment for keloids, with a response rate of <01 when used alone. )ts ma+or usefulness is as combination therapy with another treatment modality. )n dark skinned patients, howe er, cryotherapy creates patchy areas of hypopigmentation and should not be considered a first-line agent. $here is no role in this patient for empiric antibiotics .choice &/. An infectious agent does not cause keloids. 8adiation therapy .choice */ is highly effecti e in reducing keloid lesions and can be combined with surgery to treat se ere cases. :i en the risks associated with radiation therapy, howe er .internal fibrosis, malignancy/, it is not a good first choice for the treatment of keloids. "urgical resection .choice ,/ alone is likely to cause more scar formation. )f intralesional steroids fail, surgery as combination therapy is a good strategy. 8eferral to a plastic surgeon or dermatologist with experience remo ing keloids is indicated, as surgical resection has a high rate of recurrence.

A >6-year-old woman with widespread psoriasis comes to the office for a followup isit. "he is concerned that the topical medications prescribed # month earlier are not working. "he has dealt with the disease since she was #? years of age and is 6uite frustrated with the efficacy of a ailable treatments. 9 er the years she has been on methotrexate, ultra iolet light therapy, and cyclosporine, with ariable results. *uring the isit she in6uires if any new treatment alternati es ha e become a ailable. 9therwise she is in good health and has no complaints. (er current medications include topical clobetasol dipropionate and topical calcipotriol. $he family history is unremarkable. 9n physical examination, she is in no acute distress and her ital signs are within normal limits. A recent complete blood count, li er function test, and fasting lipid profile were all within the normal range. )nspection of the skin re eals generali'ed discrete and confluent erythematous pla6ues with sil ery scale in ol ing greater than 701 body surface area. $here is prominent nail pitting and onycholysis. Lou tell her that there is a new class of biologic drugs that ha e become a ailable recently for the treatment of moderate to se ere psoriasis. Lou prescribe alefacept and explain that she will need to ha e weekly blood tests to monitor which of the following%

A. C*@M $ cell count

&. Complete blood count

C. 5asting lipids

*. Gi er function tests

,. ;latelet count

$he correct answer is A. An increased understanding of the immunologic basis of psoriasis, combined with ma+or ad ances in arious scientific disciplines, is enabling the de elopment of new biologic therapies that selecti ely target the underlying cause of the disease. &iologic therapies are drugs that target the acti ity of $ lymphocytes and cytokines responsible for the inflammatory nature of psoriasis. Alefacept is a dimeric fusion protein that binds to C*> on memory-effector $ cells, resulting in the inhibition of $ cell acti ation and a reduced number of memory-effector $ lymphocytes. &ecause it in ariably causes apoptosis of $ cells, a weekly C*@M $ cell count is mandatory to ensure patient safety. )f the C*@M count is ><0 cellsCmG or less, a dose of alefacept is deferred. )f a week later the count remains at ><0 cellsCmG or less, the drug is discontinued altogether. A complete blood count .choice &/ is re6uired at baseline and then initially weekly for monitoring of patients on methotrexate. Anemia and thrombocytopenia may de elop soon after the drug is initiated and may re6uire lowering the dose or complete discontinuation of the medication. 5asting lipids .choice C/ are mandatory at baseline and then on a monthly basis in all patients treated with systemic retinoids .acitretin or isotretinoin/. 8e ersible ele ation of the triglycerides may occur and treatment with lipid-lowering agents or discontinuation of the medication may be re6uired. Gi er function tests .choice */ are performed on a monthly basis in patients with psoriasis treated with methotrexate and retinoids, as they may de elop ele ated transaminases. $hese changes are usually re ersible on discontinuation of the medication. A platelet count .choice ,/ is mandatory at baseline and then weekly for patients with psoriasis on methotrexate until the dose is stable. "ubse6uently, monitoring fre6uency can be reduced to biweekly or monthly for as long as the patient is on the same dose.

A >7-year old woman comes to the office because of a nonhealing sore that appeared on her leg se eral weeks earlier. "he remembers in+uring her leg in that general area before the appearance of the skin lesion when she fell off her bicycle. 5irst, a tender pimple resembling an insect bite appeared that enlarged o er se eral days and then broke down to form a painful sore that has been expanding slowly e er since. "he has applied topical antibiotics daily without impro ement. (er past medical history is significant for en ironmental allergies and occasional +oint pains. $he family history is unremarkable. 9n physical examination, the patient does not seem to be in distress and her ital signs are within normal limits. )nspection of the skin re eals a <N <-cm ulcer on the left lateral thigh as shown in the photograph. 9therwise the examination is within normal limits. Lou order a panel of blood tests, including serologic studies and cultures, chest x-ray, and an upper gastrointestinal series. Lou also perform a skin biopsy for histopathologic examination and tissue culture.

Which of the following is the most likely finding in this patient%

A. Air-fluid le els in the colon

&. ,le ated blood glucose le el

C. -umerous eosinophils on skin biopsy

*. ;ositi e blood and tissue cultures of ;seudomonas aeruginosa

,. ;ulmonary infiltrates on chest x-ray

$he correct answer is ,. $his patient has pyoderma gangrenosum, an uncommon ulcerati e skin disease of uncertain etiology. )t is associated with systemic diseases in more than <01 of the patients. 4ost fre6uent associations include inflammatory bowel disease .either ulcerati e colitis or Crohn disease/, polyarthritis, and hematologic diseases. Classic skin lesions are deep ulcerations with undermined, iolaceous borders that may ha e isible pustules at the acti e edge. $hey are seen most commonly on the legs. $he diagnosis is made by excluding other causes of similar skin ulcers and the histopathologic finding of diffuse neutrophilic abscesses in the skin.

Gesions of pyoderma gangrenosum may occur after trauma or in+ury of the skin, a process called pathergy that is not specific to the disease but that may aid in making the correct diagnosis. ;atients may ha e in ol ement of other organ systems with sterile neutrophilic infiltrates, such as the lungs, heart, central ner ous system, gastrointestinal tract, eye, li er, spleen, bone, and lymph nodes. "terile pulmonary infiltrates are the most common extracutaneous manifestation. $he prognosis is generally good, but recurrences are common and the lesions lea e unsightly scars. Air-fluid le els in the colon .choice A/ of an adult are obser ed in large bowel obstruction. Causes of this surgical problem include neoplasms, strictures, incarcerated hernia, ol ulus, intussusception, and impaction. Clinically, the patient complains of failure to pass stool or flatus. An ele ated blood glucose le el .choice &/ is associated with diabetes mellitus, which is not typically associated with pyoderma gangrenosum. -umerous eosinophils on skin biopsy .choice C/ would not be found in pyoderma gangrenosum. $ypically, tissue infiltrates are composed almost entirely of neutrophils that form diffuse, ery marked infiltration in the form of widespread abscesses. ;ositi e blood and tissue cultures of ;seudomonas aeruginosa .choice */ are seen with ecthyma gangrenosum, a disease of infants and se erely ill patients. $he characteristic skin lesion is a friable, undermined ulceration co ered by a thick, adherent, black eschar. $he patients are se erely ill.

A 6>-year-old man comes to the clinic concerned that he might ha e skin cancer. (e is worried about two 2bumps3 on the back of his neck. $he bumps ha e been present for at least 6 months and may be growing slowly, though he is not certain. (e points out that he is a commercial fisherman and is often in the sun, ha ing had countless sunburns o er the years. Aside from his anxiety o er the bumps on his neck, he reports feeling healthy. (e denies any other lesions, and a re iew of symptoms is unremarkable. ;hysical examination re eals two firm, well marginated, reddish, #.<-cm papules that ha e a rough feel and some surrounding erythema. A biopsy is performed that re eals a clonal proliferation of atypical but well differentiated keratinocytes. $his patient should be told which of the following%

A. A small number of these lesions de elop into s6uamous cell skin cancer

&. -o further treatment is necessary, though suntan lotion should be used regularly

C.

;rolonged sun exposure on this type of skin lesion increases the risk for melanoma

*. $he biopsy and physical findings are consistent with the most common skin cancer

,. $his lesion likely represents skin cancerB an operation is necessary immediately

$he correct answer is A. $his patient has actinic keratoses, which are proliferations of atypical keratinocytes in sun-exposed areas. $hese lesions are considered premalignant, and approximately # in #000 progresses to s6uamous cell carcinoma, not malignant melanoma .choice C/. )t is ad ised that the lesions be remo ed, commonly with cryosurgery, topical <-5J, or electrocautery. 5urther treatment is definitely beneficial, as it reduces the risk for malignant transformation, and should be ad ised, in addition to using suntan lotion .choice &/. $he most common form of skin cancer is basal cell carcinoma .&CC/. "uperficial &CC can mimic the presentation of an actinic keratosis, but more commonly is described as a pale, 2pearly3 papule with surrounding telangiectasia and central depression or ulceration. Crusting and superficial bleeding are common. 5urther, the findings on biopsy show basal cell layer abnormalities and peripheral palisading, not +ust abnormal keratinocytes. )t would be incorrect to suggest that this patient!s biopsy and physical findings are consistent with the most common skin cancer .choice */. $his is a premalignant lesion with some cellular atypia. )t does not represent skin cancer and, although it should be remo ed, does not necessitate an immediate operation .choice ,/.

A >?-year-old man comes to your office complaining of a se ere outbreak of pimples that started a week earlier. Lou ha e been treating him for acne for the past se eral months with a combination of oral doxycycline, topical clindamycin, and a salicylic acid cleanser. (e was doing well, with a reduction in inflammatory lesions at his most recent isit three weeks earlier. $he patient tells you that he had stopped taking the doxycycline because he was doing so well, and within days, de eloped hundreds of new lesions. (e has no other complaints and is in good health. (is current medications are topical clindamycin and a multi itamin. 9n physical examination, the patient is in no acute distress, and his ital signs are normal. )nspection of the skin re eals hundreds of

uniform, follicle-centered erythematous papules with central pustules on the face, neck, chest, back, and shoulders. Which of the following pathogens is most likely responsible for this patientOs skin lesions%

A. *emodex folliculorum

&. ,scherichia coli

C. ;ityrosporum o ale

*. ;ropionibacterium acnes

,. "taphylococcus aureus

$he correct answer is &. $his patient has de eloped gram-negati e folliculitis, an infectious complication that de elops in patients with acne ulgaris or rosacea treated withP systemic antibiotics for a prolonged time. :ram-negati e folliculitis should be considered in patients with acne who ha e a flare of pustular or cystic lesions or if the acne is resistant to treatment. "ystemic antibiotics alter the nasal flora with resultant o ergrowth of gram-negati e bacteria leading to folliculitis. $he gram-negati e microorganisms responsible include ,scherichia coli, Klebsiella species, "erratia species, ;roteus species, and, rarely, ;seudomonas aeruginosa. $reatment of

choice is with isotretinoin and systemic antibiotics chosen according to results of culture and sensiti ity studies. *emodex folliculorum .choice A/ is a mite normally found to inhabit the follicular infundibula of adults. )t has been implicated in the pathogenesis of rosacea in the past, but no studies ha e been able to pro e a causal relationship. ;ityrosporum o ale .choice C/ is a yeast that is normally present in the scalp of adults. 9 ergrowth causes the clinical picture of tinea ersicolor, where slightly pink, scaly macules and patches appear on the neck, shoulders and back of young adults who sweat profusely. ;ropionibacterium acnes .choice */ is a bacterium normally found to inhabit the pilosebaceous follicle of adults. )t is important in the pathogenesis of acne because it hydrolyses lipids to free fatty acids, which cause inflammation and rupture of the hair follicle, leading to de elopment of inflammatory lesions. "taphylococcus aureus .choice ,/ is a bacterium that commonly causes impetigo of the skin, especially in children. ,rythematous, ill-defined patches co ered with honey-colored, sticky crusts de elop at sites of infection. Autoinoculation with ad+acent spread is ery common. *iagnosis is based on clinical examination and skin cultures. $reatment is with topical and oral antibiotics.

A <@-year-old man of "candina ian descent comes to the office for a persistent rash of > years! duration. (e has used multiple topical medications, including topical corticosteroids and topical immunomodulators, to no a ail. (is past medical history is significant for essential hypertension and gout, which are well controlled with oral medication. $he family history is unremarkable. 9n physical examination, he is no acute distress and his ital signs are within normal limits. 4ultiple discrete lesions are present on the face, trunk, and proximal extremities, as shown in the photograph. A skin biopsy performed se eral months earlier showed well-formed epithelioid cell granulomas with scant lymphocytes and giant cells.

Which of the following tests is the most appropriate next step in management%

A. &lood glucose le el

&. *ental ;anorex

C.

,rythrocyte sedimentation rate

*. $otal body scintigraphy with gallium 6F

,. $uberculin skin test

$he correct answer is *. $his patient has sarcoidosis, a multisystem disorder of unknown origin. )t most commonly affects young adults, and has the highest pre alence in "candina ians and African Americans. (istologically, it is characteri'ed by a noncaseating epithelioid cell granuloma. )t can in ol e any organ of the bodyB howe er, the sites of predilection are lungs, lymph nodes, skin, and eyes. "kin manifestations appear in about >0 to 7<1 of patients with systemic sarcoidosis, but cutaneous sarcoidosis can also occur without systemic disease. $he extent of cutaneous lesions does not correlate with the extent of systemic disease. $he criteria for establishing the diagnosis of sarcoidosis include= #/ a compatible clinical andCor radiologic pictureB >/ histologic e idence of noncaseating granulomataB and 7/ negati e special stains and cultures for microorganisms. "cintigraphy with gallium 6F represents a specific, nonin asi e diagnostic in estigation for systemic in ol ement, but a definiti e diagnosis for cutaneous sarcoidosis re6uires the demonstration of noncaseating granulomas in the lesional skin. $wo common findings seen in sarcoidosis with gallium scintigraphy are the lambda and panda patterns. Gambda pattern is produced by uptake of right paratracheal and bilateral hilar lymph nodes. 2;anda image3 is produced by symmetric uptake by lacrimal and parotid glands. &lood glucose le els .choice A/ are not affected by sarcoidosis, and this patient has no personal or family history of diabetes. $herefore, this test is not indicated as the most appropriate next step. A dental ;anorex .choice &/ is performed for suspected lesions in ol ing the maxilla and mandible as well as teeth. "arcoidosis does not affect bones, but is likely to affect the sali ary glands and the parotid. $hese may show up as soft-tissue swelling on a dental ;anorex, but the test is not specific or sensiti e enough for the diagnosis of sarcoidosis. ,rythrocyte sedimentation rate .choice C/ is not altered in sarcoidosis. , en if it were abnormal, this is only a nonspecific indicator of inflammation and would not aid in making the diagnosis. A tuberculin skin test .choice ,/ is performed for suspected 4ycobacterium tuberculosis infection. (owe er, it may also be used to e aluate delayed-type immune reactions. ;atients with

sarcoidosis may be anergic, but this is not a specific diagnostic test.

Lou ha e +ust accepted a new position that includes taking care of patients in a nearby nursing home. While examining a F0-year-old patient with chronic obstructi e pulmonary disease and coronary artery disease, you notice a >.7-cm skin lesion on his left cheek .see photograph/. (e tells you that it started as a pimple approximately a year earlier and +ust kept growing. (is health had significantly deteriorated lately and his family did not ha e time to ha e that examined on top of all the other appointments he needed. )t does not bother him at all, but makes sha ing a bit of a challenge. ;ast medical history is as noted. Current medications include albuterol, theophylline, alsartan, baby aspirin, hydrochlorothia'ide, and a daily multi itamin. ;hysical examination of the remaining skin is unremarkable except for chronic actinic damage of the sun-exposed areas. ;reauricular and cer ical lymph nodes are not enlarged.

Which of the following treatment modalities is the best choice for this patient%

A. Con entional excision with @-mm margin

&. Cryosurgery

C. 4ohs micrographic surgery

*. $opical <-fluorouracil

,. $opical imi6uimod

$he correct answer is C. $his patient has a large basal cell carcinoma, a malignant epithelial neoplasm comprised of cells that resemble hair follicle undifferentiated matrix cells. )t is the single most common cancer in humans. $he etiology has been linked to excessi e sunlight exposure, chemical carcinogens, radiation, and genetic determinants. Clinically, se eral types are recogni'ed= classic or nodular, superficial, and morpheaform. $he nodular type presents as a pink pearly papule or nodule with a rolled border and telangiectasias. )t often ulcerates centrally. $he course is one of local destruction, and only ery large, neglected, and ulcerated basal cell carcinomas ha e been known to metastasi'e. $he treatment of choice for this patient is 4ohs micrographic surgery. )n 4ohs micrographic surgery, the excision is performed in layers, and during the surgery, fro'en sections are prepared that allow iewing of #001 of the margins of excised tissue. )f the tumor is iewed close to or near the specially prepared margins, another layer of tissue is excised and fro'en sections prepared in the same manner. $his procedure is repeated until the margins are clear. ,xcision of basal cell carcinoma with 4ohs micrographic surgery has a recurrence rate of approximately #1, compared to ?-91 with con entional surgery. )t is preferred for lesions that are recurrent, in a high-risk location, are large and ill defined, and in areas where maximal tissue conser ation is critical. Con entional excision with a @-mm margin .choice A/ carries a high risk for 2missing3 parts of the neoplastic tissue when the lesion is large. )n addition, excising with a bigger yet still arbitrary margin on the face, where conser ation of tissue is so important, is not practical and makes reconstruction difficult. Cryosurgery .choice &/ is not a good choice for a basal cell carcinoma of such large si'e because of the lack of margin control and probability that it would cause excessi e destruction of the surrounding facial tissue and lea e a considerable scar. )t is performed by inserting a thermocouple into the central part of the tumor down to subcutaneous tissue, after appropriate local anesthesia is administered, and free'ing the area with li6uid nitrogen or other cryogens. $he depth and length of free'ing ary considerably among surgeons and are largely based on experience. $opical <-fluorouracil .choice */ is a chemotherapeutic agent that is used for topical treatment of the superficial type of basal cell carcinoma in certain circumstances in which other, more aggressi e types of treatment are not indicated, either because of the poor o erall health of the patient and associated risk for surgery or because the patient refuses other treatment modalities. )t is applied twice daily for a period of @-6 weeks, leading to ulceration of the tumor and inflammation of the surrounding skin. )t is not indicated for treatment of nodular basal cell carcinomas such as the one described. )mi6uimod cream .choice ,/ is an immune modulator that is 5*A appro ed for the treatment of genital warts. $here ha e been multiple publications of case reports in which it was successfully used for the treatment of superficial basal cell carcinoma in patients in whom more aggressi e surgical treatment was not an option. )t is not con entional treatment for basal cell carcinoma.

A >7-year-old man comes to the Jni ersity (ealth Center because of a new onset skin rash that he noticed the pre ious day. ,xcept for the appearance of the rash, he has no symptoms. Lou had +ust seen him a week earlier for a urinary tract infection and exacerbation of asthma and had prescribed multiple medications. (e is now feeling much better and has returned to his normal class schedule. (e thinks that > years ago similar lesions had appeared in almost the exact same spots, but he cannot remember what the diagnosis was. ;ast medical history is significant for asthma and atopic dermatitis. Current medications include trimethoprim-sulfamethoxa'ole, albuterol, fexofenadine, steroid inhaler, and acetaminophen. (e has no known allergies to medication. $he family history is significant for atopic disease. 9n physical examination, the patient is in no acute distress and does not seem systemically ill. $he skin lesions are shown in the photograph. -o other abnormalities are noted. Lou suspect that the skin lesions are drug-induced.

Which of this patient!s medications should you discontinue%

A. Acetaminophen

&. Albuterol

C. 5exofenadine

*. "teroid inhaler

,. $rimethoprim-sulfamethoxa'ole

$he correct answer is ,. $his patient has de eloped a fixed drug eruption, al reaction in which skin lesions typically recur in the same area e ery time the patient takes the offending drug. 8ound and o al, well demarcated, slightly edematous, iolaceous pla6ues with a dusky hue appear 70 minutes to ? hours after drug administration. 4ost commonly, one or a few discrete lesions appear on the hands, feet, or genitalia, but multiple and bullous lesions are seen also. $hey resol e with pronounced postinflammatory hyperpigmentation that may take many months to disappear. $he most common offenders are sulfonamides, anticon ulsants, nonsteroidal antiinflammatory drugs,, phenolphthalein, and tetracyclines Acetaminophen .choice A/ is a less likely cause of a skin drug reaction. Ad erse effects may manifest as drug fe er, rare instances of blood dyscrasias, renal tubular necrosis and renal failure, and hypoglycemic coma. 9 erdose may result in centrilobular hepatic necrosis. Albuterol .choice &/ may cause tremor and tachyarrhythmia as a side effect, but almost ne er is associated with skin reactions. 5exofenadine .choice C/ is a peripherally selecti e (#-receptor antagonist. Ad erse effects are mainly limited to gastrointestinal upset and low incidence of drowsiness. "kin drug reactions are highly unlikely. A steroid inhaler .choice */ is most likely to cause local ad erse effects in the form of nasal congestion, epistaxis and sore throat. 9thers effects are glaucoma, septal perforation, loss of sense of taste, and impaired wound healing may be seen. Gong-term use may result in systemic absorption and systemic side effects.

While you are making rounds at a local nursing home, one of the nurses asks you to e aluate a patient about whom she is concerned. $he patient is an elderly wheelchair-bound woman. 9n her right buttock is an area of nonblanching erythema that in ol es the dermis. "ome small superficial erosions of the skin appear to be forming, but subcutaneous and deeper structures do not appear to be in ol ed and the skin is for the most part intact, if markedly erythematous. Concerned about a de eloping pressure ulcer, you ad ise increased mobility as well as techni6ues and de ices to relie e pressure. Which of the following is an appropriate additional therapy for this wound%

A. *ry gau'e dressings, changed regularly

&.

,mpiric antibiotics, applied topically to the wound

C. "urgical consultation for debridement and 2 ac-pack3

*. Wet dressings, changed when still moist

,. Wet to dry dressings, changed regularly

$he correct answer is *. )mmobile patients, particularly the elderly, are at risk for pressure ulcer formation. "tages ) and )) pressure ulcers, which do not in ol e subcutaneous tissue, are best treated with relief of pressure, good nutrition and hygiene, and wound care. )n general, the wound should be kept clean and moist with wet saline dressings, which should be changed when still moist. Wet to dry dressings .choice ,/, which are often used for wounds re6uiring microdebridement, are not as useful as keeping the pressure site moist. Gikewise, dry gau'e .choice A/ will further dry and macerate the area and may delay healing. ,mpiric topical antibiotics .choice &/ should be started if the wound has not healed in > weeks or if the site appears grossly infected .pus/. (owe er, routine use of empiric antibiotics is not necessary, and has not been pro en to impro e outcomes. "urgical debridement .choice C/ and wound management may be necessary for stage ))) and )H pressure ulcers, which in ol e subcutaneous tissue and bone. "tage ) and )) pressure sores, by definition, do not ha e a large amount of necrotic tissue that would benefit from debridement.

A F7-year-old man of )rish descent is brought to the office by his daughter who recently noticed an enlarging dark spot on his back. $he patient was a construction worker all his life and sustained multiple sunburns and chronic sun exposure throughout his adult years. (e is in rather good health with only mild hypertension and arthritis. 9 er the pre ious #0 years, he has had multiple actinic

keratoses and two basal cell carcinomas treated. (is current medications include hydrochlorothia'ide and naproxen. $he family history is positi e for nonmelanoma skin cancer. 9n physical examination, the patient is in no acute distress and his ital signs are within normal limits. 9n the right upper shoulder, there is a > x 7-cm dark brown patch with scalloped borders and se eral black macules at the periphery. Lou perform an excisional sha e biopsy that re eals single cells and nests of atypical melanocytes with pagetoid spread throughout the epidermis and in the epidermis with a &reslow thickness of # mm. A thorough examination of lymph nodes is unremarkable. Complete blood counts, metabolic panel, li er function tests, alkaline phosphatase le els, and a chest x-ray are all within normal limits. )n addition to performing a re-excision, which of the following procedures should be offered to the patient%

A. &one scintigraphy

&. -eedle aspiration of the regional lymph node

C. "entinel lymph node biopsy

*. 8adical lymph node dissection

,. $otal body 48)

$he correct answer is C. $his patient has malignant melanoma. , en with melanomas that appear locali'ed to the epidermis .melanoma in situ/, a ailable data suggests that #-71 of these melanomas can e entuate in metastatic disease. $his is most likely the result of rare neoplastic cells or nests present in the dermis at the time of diagnosis that are not detected with routine histopathologic e aluation. Current standard of care dictates that each patient diagnosed with a malignant melanoma # mm or greater in thickness should be offered sentinel lymph node biopsy. $he alue of this procedure for thin melanomas .Q# mm/ is under debate. "entinel lymph node biopsy with selecti e lymph node dissection has been de eloped as an alternati e to electi e lymphadenectomy or obser ation for patients with clinically negati e regional lymph nodes who are at high risk for nodal metastasis. &one scintigraphy .choice A/ is indicated in patients with bone pain or an ele ated alkaline phosphatase le el. )t would be indicated if the sentinel lymph node biopsy confirms nodal in ol ement that implies metastatic disease. -eedle aspiration of the regional lymph node .choice &/ is not used in the diagnostic and staging workup of melanoma because of low yield of positi e results. 8adical lymph node dissection .choice */ is a procedure with high morbidity and no longer is performed in patients with melanoma in the absence of palpable lymph nodes. $otal body magnetic resonance imaging .choice ,/ may be done in patients with suspected or pro en metastatic disease. )n this case, a sentinel lymph node biopsy is the next appropriate step in management.

A @0-year-old man with a long-standing history of pemphigus ulgaris is seen for a routine follow-up isit. (e is currently fairly well controlled with 70 mg prednisone e ery other day and #<0 mg a'athioprine daily. )n addition to that, he takes glyburide, hydrochlorothia'ide, nifedipine, a daily multi itamin, and occasional acetaminophen for headaches. (is family history is significant for hypertension and diabetes. 9n physical examination the patient is in mild distress due to oral lesions that are painful when he talks or eats. (is ital signs are within normal limits, and a complete blood count and electrolyte panel show no abnormal alues. )nspection of the oral mucosa re eals multiple ulcers in arious stages of healing. $he skin has no acti e bullous lesions, but you note the appearance of the lesions shown in the photograph, which were not present at his last checkup.

(e should be told which of the following%

A. *aily topical steroid application is indicated to hasten resolution of these skin lesions

&.

Gosing weight will most likely result in the disappearance of these skin lesions

C. $hese skin lesions will resol e once he is weaned off prednisone

*. (e will not get any new skin lesions unless the dose of prednisone is increased

,. $he skin lesions are permanent and their number will most likely increase with time if he continues his current treatment regimen

$he correct answer is ,. $his patient has de eloped striae distensae, or 2stretch marks.3 $hey represent linear dermal scars accompanied by epidermal atrophy. "triae distensae appear on skin that is sub+ected to continuous and progressi e stretching, such as the abdomen and breasts in pregnancy, shoulders in bodybuilders, back and thighs in adolescents going through a growth spurt, and arious body areas in o erweight people. ;rolonged use of oral or topical steroids, as well as CushingOs syndrome, will lead to de elopment of striae. )t is hypothesi'ed that skin distension causes mast cells to degranulate, with subse6uent destruction of collagen and elastin. $he changes are irre ersible, although the appearance of striae distensae does impro e with time as their original iolaceous color fades to become whiter. "triae distensae induced by prolonged systemic steroid administration, such as in pemphigus ulgaris, are usually larger and wider than other phenotypes of striae, and may include widespread areas of the body, including the face. "ome cosmetic impro ement of their isual appearance may be achie ed with topical trichloroacetic acid peels or the flashlamp pulsed-dye laser. 4ultiple treatments are necessary. *aily topical steroid application .choice A/ would only worsen the already existing striae distensae and may cause de elopment of new ones. $herefore, topical steroids are contraindicated in the treatment of striae distensae. Gosing weight .choice &/ will not affect the course of the existing lesions because they, in fact, represent scars and are irre ersible. (owe er, weight loss may reduce the appearance of new

lesions. )t is incorrect to say that these lesions will resol e once the patient is weaned off prednisone .choice C/, because they present irre ersible dermal and epidermal scars. "topping the systemic prednisone would decrease the likelihood of new striae de eloping. )t is highly likely that additional new lesions would de elop whether the dose of prednisone is increased or not .choice */. "ystemic steroid administration is a ma+or risk factor for the occurrence of striae distensae.

A <>-year-old man comes to your office for a new-patient isit. (e has recently mo ed to the area and needs continuous medical care for pemphigus ulgaris, a chronic blistering autoimmune disease of #0 years! duration. With him, he brings extensi e medical records from his pre ious physician. $hey include multiple hospitali'ations and complicated treatment regimens used in the attempt to keep his skin disorder under control. 8e iew of the records re eals multiple long courses of prednisone, mycophenolate mofetil, a'athioprine, and cyclophosphamide. (e has also undergone four courses of plasmapheresis in the past > years. *espite all that, the disease keeps recurring as soon as his medication is tapered. (is medical history includes hypertension and adult onset diabetes mellitus. $he family history is positi e for hypertension and heart disease. 9n physical examination, the patient is in no acute distress. (e weighs #9? lb and is < ft ? in tall. (is blood pressure is #@0C?< mm (g, pulse is F<Cmin, and respiratory rate is #6Cmin. Lou note that he has disproportionate body fat distribution and musculoskeletal changes .see photograph/. $here are multiple purple striae on his abdomen and proximal extremities.

Which of the following treatments is the most likely culprit for these changes%

A. A'athioprine

&. Cyclophosphamide

C. 4ycophenolate mofetil

*.

;lasmapheresis

,. ;rednisone

$he correct answer is ,. $his patient exhibits the typical changes of Cushing syndrome induced by long-term systemic steroid administration. 4ore than 991 of cases of Cushing syndrome are due to administration of excessi e amounts of glucocorticoids. As a result of multiple ad erse effects of chronic glucocorticoid excess, Cushing syndrome is associated with significant morbidity. Jntreated, it is also associated with an increased risk of premature death. All patients recei ing glucocorticoid treatment de elop Cushingoid features if exposed to a high enough dose for long enough. $hese include moon facies .broad cheeks with temporal muscle wasting/, facial plethora, generali'ed and truncal obesity, supracla icular fat collection, buffalo hump .posterior cer ical fat deposition/, thin and fragile skin, iolaceous striae, and steroid acne. Cardio ascular effects include hypertension and congesti e heart failure. $he patients may ha e osteoporosis, spontaneous fractures, a ascular necrosis of the femoral head, and myopathy. )mmune function is suppressed, resulting in fre6uent infections. 9phthalmologic changes are the formation of posterior subcapsular cataracts and ele ated intraocular pressure or o ert glaucoma. Commonly, insulin resistance, diabetes mellitus, and suppression of the hypothalamus-pituitary-adrenal axis de elop. ;atients may also de elop gastric irritation or a peptic ulcer, acute pancreatitis, and fatty infiltration of the li er. 4ultiple hematopoietic and central ner ous system changes are seen in addition to those named abo e. Although some of these ad erse effects are re ersible upon discontinuation of systemic steroids, many are not, resulting in significant morbidity. A'athioprine .choice A/ is a purine analogRacti e metabolite often used as a steroid-sparing agent for the treatment of autoimmune blistering disease. "ide effects include ele ated transaminases, bone marrow suppression, and increased risk of lymphoproliferati e diseases. Cyclophosphamide .choice &/ is an alkylating agent used primarily for the treatment of mediumsi'e essel asculitis and autoimmune disorders. "ide effects most commonly encountered include diarrhea, hemorrhagic cystitis, transitional cell bladder carcinoma, and leukopenia. 4ycophenolate mofetil .choice C/ is a purine synthesis inhibitor that is usually ery well tolerated by the patient. :astrointestinal side effects are most common and include nausea, omiting, diarrhea, cramps and anorexia. $he most common ad erse effect of plasmapheresis .choice */ is hypotension during the procedure. 9ccasionally, bleeding or allergic reactions may occur. Also, temporary excessi e

immune suppression may re6uire prophylactic antiinfectious measures.