JEOPARDY!

1. JEOPARDY! Click Once to Begin IM-Derm Board Review Nita Kohli, MD, MPH PGY-4, Derm

2. JEOPARDY! Stop bugging me Nail it Sexy legs Bubble- rap “It’s not a tumah” Derma-what? 100 100 100 100 100 100 200 200 200 200 200 200 300 300 300 300 300 300 400 400 400 400 400 400 500 500 500 500 500 500

3. 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. Question 1-100

4. Question 1-100 • Which of the following is the most appropriate treatment? A. Oral doxycycline B. Oral ivermectin C. Topical permethrin cream D. Topical triamcinolone acetonide cream

5. 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.

6. 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. Question 1-200

7. Question 1-200 • 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

8. Dx by microscopic identification of the mite, feces, or eggs. Scrape many lesions. Unexplained itch, rash; institutionalized pt. B. microscopic eval of skin scrapingsDx: scabies

9. 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. Question 1-300

10. Question 1-300 • 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

11. 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).

12. 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 Question 1-400

13. Question 1-400 • Which of the following is the most appropriate topical treatment? • A. Bacitracin • B. Clotrimazole • C. Hydrocortisone • D. Mupirocin

14. 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.

15. 35 y/o woman w/ recurrent salmon colored oval lesions on chest, 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

16. 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

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

18. 30-y/o man w/ nail changes. Induction chemo for AML 1 mth ago. Afebrile, no systemic complaints. Kidney, liver chemistry studies normal. Question 2-100

19. Question 2-100 • Which of the following is the most likely diagnosis? • A. Beau lines • B. Lichen planus • C. Median nail dystrophy • D. Psoriasis

20. 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. A. Beau linesChemo induced

21. Lichen Planus

22. Longitudinal depression or canal in center of nail, down entire length. Typically 1-2 nails; thumb nails prone to this condition Cause: trauma. Median Nail Dystrophy

23. Psoriatic nails

24. 25-y/o man w/persistent discoloration on a single nail x 1 yr. Enlarged slowly. No hx trauma. No other nails are affected Question 2-200

25. Question 2-200 • Which of the following is the most likely diagnosis? • A. Longitudinal melanonychia • B.Hematoma • C. Onychomycosis • D.Subungual melanoma

26. 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.

27. 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. Question 2-300

28. Question 2-300 • 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

29. 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

30. 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. Question 2-400

31. Question 2-400 • Which of the following is the most likely diagnosis? • A. Dermatomyositis • B. Psoriasis with psoriatic arthritis • C. Rheumatoid arthritis • D. Systemic lupus erythematosus

32. 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.

33. 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.

34. Question 2-500 • Which of the following is the most appropriate corticosteroid cream for this rash? • A. Betamethasone dipropionate • B. Clobetasol propionate • C. Desoximetasone • D. Hydrocortisone valerate

35. 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

36. 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. Question 3-100

37. Question 3-100 • Which of the following is the most appropriate treatment? A. Arterial revascularization B. Contact casting C. Intravenous vancomycin D. Unna boot compression

38. 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.

39. 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.

40. 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. Question 3-200

41. Question 3-200 • Which of the following is the most likely diagnosis? • A. Bullous tinea • B. Cellulitis • C. Contact dermatitis • D. Stasis dermatitis

42. 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.

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

44. Looks similar to cellulitis when inflammatory, can become secondarily infected; Almost always bilateral and usually not tender. Stasis Dermatitis

45. 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. Question 3-300

46. Question 3-300 • Which of the following is the most likely diagnosis? • A. Calciphylaxis • B. Ecthyma gangrenosum • C. Necrotizing fasciitis • D. Pyoderma gangrenosum

47. D. Pyoderma gangrenosum • Uncommon, neutrophilic, ulcerative skin disease assoc w: • inflammatory bowel disease, • RA, • seronegative spondyloarthritis, • hematologic dz or malignancy, most commonly AML.

48. 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. Calciphylaxis

49. 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. Ecthyma gangrenosum

50. 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. Necrotizing fasciitis