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1

What structure is most likely to have a different appearance in axillary skin?

Structue number 6 - this is an eccrine sweat gland.

In the axilla you would see apocrine sweat glands

 

2

Spongiosis seen in eczematous dermatitis develops in which area?

#2 - stratum spinosum

 

3

What is the cause/pathogenesis of allergic contact dermatitis?

Topically applied antigens

 

4

What will the histologic findings look like in the following...

Allergic contact dermatitis

Atopic dermatitis

Spongiotic dermatitis in both cases

 

5

Drug related eczematous dermatitis arises d/t systemically administered antigens or haptens (e.g. penicillin).  What will the histologic findings look like?

Spongiotic dermatitis with deeper infiltrate and abundant eosinophils

 

6

Photoeczematous eruptions occur with UV light exposure and may require associated exposure to systemic or topical antigens.  

What will the histologic findings be?

What manner of testing may help in dx?

Spongiotic dermatitis; infiltrate that diminishes gradually with depth.

Photopatch testing may help with DX

 

7

Eczematous insect bite reaction arise d/t locally injected antigen or toxins from arthropods and may appear with papules, nodules, plaques, and vesicles.  They may be linear when multiple.  

What does the spongiotic dermatitis found on histology look like?

Wedge-shaped infiltrate with many eosinophils

 

8

A 25 y/o female has been using lip balm continuously for months and the changes seen in the image are not improving.  What is the presumptive dx?

Allergic or irritant contact exfoliative cheilitis

9

What should a patient with Allergic or irritant contact exfoliative cheilitis do?

What might you test for?

  • Patient should: Stop using the lip balm and substitute moisturizer with limited ingredients and/or topical corticosteroid.
  • Could consider cultures for S. aureus or C. albicans.

10

A 34 year old female developed a pruritic rash that involved the skin.  Her dentist also noted bluish and reddish white lesions in the mouth.

 What is the name of the oral lesion?

What is the presumptive diagnosis?

  • Wickham striae
  • lichen planus

11

What are the 6 P's of lichen planus?

  • Pruritic
  • Purple
  • Polygonal
  • Planar
  • Papules
  • Plaques

12

What are the clinical entities associated with lichen planus? (one bold and 7 not bold)

  1. Hepatitis C,
  2. ulcerative colitis
  3. alopecia areata 
  4. vitiligo
  5. dermatomyositis 
  6. morphea
  7. lichen sclerosis
  8. myasthenia gravis

13

Atrophy of which structure leads to “dry skin”?

5 - Sebaceous gland 

14

What are the changes shown here d/t?

Aging and chronic actinic skin damage (UV)

 

15

What is this condition?

What are some of the consequences?

Sunburn 

  1. acute inflammation with pain
  2. desquamation
  3. blistering with secondary infections
  4. chronic actinic skin damage including wrinkles
  5.  solar elastosis
  6. solar lentigos
  7. actinic keratoses
  8. squamous cell carcinomas
  9. basal cell carcinomas
  10. melanomas

16

A 52 year old male presents with a new skin rash not responding to topical cortisone and moisturizers.   During the physical examination the rash is diffuse and there is also axillary and cervical lymphadenopathy.

Presumptive dx?

Ichtyosis

 

17

Newborn with blistering skin disease.  What is the presumptive dx?

Epidermolysis  bullosa

18

How would you definitively dx epidermolysis bullosa?

Skin biopsy to exclude other blistering disorders and EM to subclassify.

 

19

What is the mutation involved in the simplex type of epidermolysis bullosa?

keratin 14 of 5 mutation

 

20

What type of blisters are seen in the simplex type epidermolysis bullosa?

Intraepidermal (suprabasilar) blisters

21

What is the defect in the junctional type epidermolysis bullosa?

I.Junctional type:  defect at lamina lucida (laminin or BPAG2 defects)

22

Where are the blisters in the junctional type epidermolysis bullosa?

Intra-lamina lucida subepidermal blisters

23

What is shown here?

Eczema

24

What is described by the following?

–food, insect, light, drug, allergen testing

–humoral mediation type I

–eosinophils prominent in inflammation

–responds to topical steroids

–history to differentiate from allergic contact

Allergic atopic

 

25

What is shown in this case?

Allergic contact

 

26

What is described here?

–poison ivy, nickel, other metals, rubber compounds

–T-cell mediated type IV

–lymphocyte rich inflammation

–Will not respond to topical steroids

–no inflammation until 2nd exposure; > 24 hr delay

Allergic Contact

 

27

What is described here?

–chemicals

–no prior exposure as direct damage to epidermis

–necrosis and ulceration with neutrophil response

Primary irritant

 

28

Into what subtype would you place this ichthyosis?

A 52 year old male presents with a new skin rash not responding to topical cortisone and moisturizers.   During the physical examination the rash is diffuse and there is also axillary and cervical lymphadenopathy

Based on the lymphadenopathy probably Icthyosis vulgaris, associated with lymphoma.

 

29

Icthyosis vulgaris is associated with what conditions?

  1. Lymphoma
  2. hypothyroidism
  3. sarcoidosis
  4. visceral or generalized cancers
  5. HIV
  6. medications (nicotinic acid and hydroxyurea)

 

30

What are the four types of Icthyosis?

  1. Ichthyosis vulgaris (autosomal dominant or acquired)
  2. Congenital ichthyosiform  erythroderma (recessive)
  3. Lamellar ichthyosis (recessive)
  4. X-linked ichthyosis

31

What is this tumor on the back of the ladies neck?

What number indicated the origin of this tumor?

Epidermermal inclusion cyst

7 - follicular origin

 

32

If this cyst lining had no granular layer, what would the diagnosis be?

What would it be arising from in this case?

Trichilemmal/pilar cyst

Still number 7

 

 

33

What is this tumor?

What is the cell of origin? 

Trichoepithelioma - note the location it is arising in

#7 - follicular

34

What is presumptive dx?

Treatment?

Acne vulgaris

1.Benzoyl peroxide

2.Erythromycin or clindamycin

3.Topical retinoids

35

In what patients should you be careful with using topical retinoids for acne?

Why?

- Be careful with retinoids in child-bearing age females as they may be potentially teratogenic in topical forms and definitely teratogenic in oral forms (affects HOX gene expression leading to neural crest migration craniofacial defects and also increased abortions)

36

What should you be sure to check periodically in a patient taking retinoic acid?

Liver enzymes, vitamin A toxicity is possible.

37

What are the structures involved in acne?

Pilosebaceous gland

38

What are four factors that are important in the development of acne?

  1. Plugging of the hair follicle with desquamated cells
  2. Sebaceous gland hyperactivity (begins at puberty with influence of testosterone)
  3. Proliferation of bacteria (especially Propionibacterium acnes)
  4. Inflammatory response to bacteria & entrapped keratin

39

What is the difference in comedo in whitehead vs. black head?

Oxidation of melanin - if the pore is closed there will be no oxidation and you get a white head.  If the pore is open you get oxidation and a blackhead.

 

 

40

What is the difference in presentation of a papule vs a pustule and what occurs in the pilosebaceous unit to lead to a pustule?

Papule is dome shaped skin elevation that can occur in blackheads or whiteheads without pus.

Pustule occurs when skin pore is blocked and accumulated infected debris is accompanied by purulent material.

41

What is the tumor type shown here?

What is the cell of origin?

Turban Tumor (cylindroma)

#6 - Eccrine sweat gland

42

Tumor type?

Cell of origin?

 

Basal cell carcinoma

#3

43

5 year prognosis for basal cell carcinoma?

What is the tx?

~100% survival with treatment.  Tx with excision

 

44

Tumor type and cell of origin?

 

Squamous cell carcinoma

#3

 

45

Classify the differentiation of this squamous cell carcinoma.

Well differentiated - can see squamous characteristics

 

 

46

What is the tumor type and cell of origin?

Seborrheic keratosis

#3

 

47

What is this lesion?

How do you know?

Seborrheic keratosis - note the keratin sprouts indicated with the arrow

 

48

What is the tumor type?

Cell of origin?

Melanoma

#4

 

49

What are the four gross clinical criteria for melanoma?

  1. Asymmetry
  2. Borders
  3. Color
  4. Diameter >6mm

50

What are poor prognostic indicators in melanoma and which  factor is the #1 prognostic indicator?

•1 Breslow level (thickness)

–Mitotic activity and Clark (anatomic) level for tumors <1mm

•Tumor ulceration

•Nodal metastases (sentinel node biopsy)

•Distant metastases (visceral mets are worse)

•Lactate dehydrogenase elevation

•Location (head and neck worst, palmar and plantar bad)

•High mitotic activity

•Lack of tumor infiltrating lymphocytes

•Older age (>65 worse)

•Male sex (for younger people)

•High tumoral vascularity (angiogenesis)

•Satellitosis

•Tumor regression

51

Likely dx?

Compound nevus

 

52

Probable dx?

Prognosis?

Seborrheic keratosis - prognosis depends on the cancer setting it off.

 

 

53

What is this most likely?

Ephelis - freckle

 

54

This appeared recently and has enlarged.

What is the likely dx?

Do you need a biopsy?

Solar lentigo

Yes biopsy needed, solar lentigo is benign but must differentiate from lentigo maligna.

 

55

What are some possibilities for this?

  1. Amalgam tatoo
  2. graphite tatoo
  3. nevus
  4. melanoma
  5. smokers melanosis

56

What have we here?

Is a biopsy warranted?

Giant congenital nevus.  Only biopsy if rapid changes occur as melanoma can arise in these.

 

 

57

This appeared on sun exposed skin and has telangiectasia.  

What is the probable dx?

Biopsy needed?

Lentigo maligna (based only on appearance can't tell from melanoma though)

Remove the lesion and test

58

What is this?

Do you need to biopsy?

How is the prognosis?

Acral lentiginous melanoma

Must biopsy.

Prognosis is terrible

 

59

Probable diagnosis? 
Biopsy needed? 
Natural history and prognosis?

Birthmark hemangioma

No biopsy

prognosis excellent

 

60

What is described here?

DNA repair after radiation injury/ataxia, dyskenesia and vascular telangiectasias of conjunctiva and skin

Ataxia-telangiectasia

61

What is this?

Developmental patterning gene/multiple basal cell carcinomas; odontogenic keratocysts, palmar and plantar pits, medulloblastomas and ovarian fibromas, calcification of falx cerebri

Nevoid basal cell carcinoma (Gorlin) syndrome

62

What is described here?

Lipid phosphatase/macrocephaly, benign follicular appendage (trichilemmomas) tumors; hamartomatous colon polyps; internal adenocarcinoma (often breast/endometrium); cerebellar dysplastic gangliocytoma

Cowden syndrome

63

What is this?

Involved in DNA mismatch repair/sebaceous adenoma, sebaceous epithelioma, or sebaceous carcinoma and a visceral malignancy (usually gastrointestinal or genitourinary carcinomas)

Muir-Torre  syndrome

 

64

What is this?

Negatively regulates RAS signaling/neurofibromas (plexiform and solitary), optic nerve gliomas, Lisch nodules on iris, café au lait spots

Neurofibromatosis I

65

What is this?

Integrates cytoskeletal signaling/neurofibromas; meningiomas and bilateral acoustic neuromas; spinal cord ependymomas

Neurofibromatosis II

66

A 71 year old male with multiple yellowish nodules on the scalp and forehead. The patient has a history of adenocarcinoma of the colon.

Dx?

 

Sebaceous tumor - Muir torre syndrome

 

67

A 66-year-old male patient presented with multiple asymptomatic skin lesions and a history of recurrent basal cell carcinoma. Also present are exophthalmos and numerous pits over the palms and soles. Surgical procedures for the basal cell carcinoma took place 12 and 6 years ago.  Biopsy of the mass and a lung nodule demonstrated basaloid squamous cells.

Dx?

Syndrome?

Nevoid basal cell (Gorlin) syndrome with recurrent and metastatic basal cell carcinoma

68

What is the mutated gene in gorlin syndrome?

What else could be present in a patient with gorlin syndrome?

PTCH or SMO

Ovarian fibromas and cerebellar medulloblastomas also seen in this syndrome

 

69

Random basal-cell tumors have mutations in the hedgehog signaling pathway that do either one of what two things?

1- inactivate PTCH1 [7-9] (loss-of-function mutation)

2- constitutively activate SMO15 (gain-of-function mutation)

70

Basal cell carcinoma incidence is increased in what 6 genetic syndromes?

  1. –Albinism
  2. –Xeroderma pigmentosa
  3. –Nevoid basal cell carcinoma syndrome (Gorlin syndrome)
  4. –Bazex syndrome
  5. –Ramussen syndrome
  6. –Rombo syndrome

71

34 year old male presents to your office with a long history of pigmented skin lesions but one has been changing.  

Dx?

Melanoma arising in dysplastic nevus syndrome

72

42 year old from North Carolina who likes to bird hunt presents with fever, rash and abdominal pain for a few days.  Felt fine previously.  His hunting dogs also not feeling well and he has been treating them for ticks.

Dx?

 

Rocky mountain spotted fever - acuired from a dog tick

 

73

How would you definitively dx rocky mountain spotted fever?

indirect immunofluorescence assay (IFA) with Rickettsia rickettsii antigen immediately and in 2-4 weeks

74

42 year old from Maryland who likes to garden presents with fever, chills, headache and a rash present for a few days.  Felt fine previously.  

Dx?

Test to confirm?

Erythema migrans of Lyme Disease

enzyme-linked immunosorbent assay (ELISA) or immunofluorescence assay (IFA)  with Borrelia burgdorferi antigen

75

What should you use to treat lyme or rocky mountain spotted fever?

Doxycycline

 

76

What is the vector for lyme disease?

Deer tick

 

77

What is this likely from?

Either a bee or a wasp

 

 

78

What drugs would you use for anaphylaxis?

Epi

Steroids

Antihistamine

H2 blocker (spill over effect on H1 also)

 

79

What is this most likely?

Lice/pediculosis

 

80

Likely cause?

Bedbugs/cimicosis

 

81

Likely culprit?

Aedes aegypti bites primarily ankles and elbows during the day (mosquitos)

 

82

What is this most likely?

Fleas

83

What most likely caused this?

 

Trombiculosis = chiggers

84

Most likely organism?

Scabies

Sarcoptes scabiei (var hominis)

85

What is the most likely culprit heere?

Cutaneous larva migrans - dog and cat hookworms

 

86