Questions

Question 1

Differentiate between papulosquams and eczema

Answer 1

Eczema: Itch, ill defined, epidermal disruption, vesication, weeping, crusting, lichenification. Distribution. History
Papulosquam: Well demarcated with scale as the predominant secondary lesion. Distribution. History
Both: Eryhtematous plaques.

Question 2

Differentiate Eczema

Answer 2

-First differentiate whether it is exogenous or endogenous. History and exposures and distribution can aid. 4 criteria for contact are presence with contact, absence without, assymetry, and involvment of eyes, ears, hands, feet, etc.
Among exogenous irritants can tend to be more chronic and fissured, patch testing can also identify an allergen.
Atopic is defined by chronic itch + (Dry skin, less than 2, ich locatin, eczema location, atopy)
Nummular-middle age discrete lesions
Seborrheic-

Question 3

Acne

Answer 3

Genes, Hormones, environment including cosmetics contribute to epithelial and cosmetic occlusion of follicular opening and incresed sebum production
-This leads to bacterial overhrwoth and breakdown of TG potential rupture of sebaceous gland leading to inflammation via TLR2 genreating a type 4 immune reaction. ROS and inflamatory cell infiltarate along with local edema contibute to lesions.

Question 4

Pemphigus Vs Bullous Pemphigoid

Answer 4

Pemphigus: Ag is desomiglein 1,3 which are intercellular adhesion molecules between corneocytes. Leads to intraepidermal bullae which are easily ruptured. There is extensive mucosal involvment as well as trunkal. Patients tend to be a little younger. The severity is worse in pemphigus and requires a stronger treatment.

Associated with penicilamine and paraneoplastic. Genetic component related to HLA2

Pemphigoid: Ag is in the basement memnrane BP230, 180 which lead to linear deposits and disruption of BM leading to subepidermal blister formation. These tend to be less likely to rupture, generally spare mucous membranes and often involve flexures. Tend to be older patients and the prognpsis is better, treatment can often be accomplished with less steoid and even topical.

Eosinophils and ithcing are common symptoms.

Question 5

Photoallergy vs Phototox

Answer 5

Allergy: Occurs when sun causes a normal nonimmunogenic drug or self antigen to become immunogenic. Delayed onset 3-14 days. Itch is the predoinatnt symptoms. Patient will be photopatch test positive. Not all patients will have a photoallergy. Steroids and immunosupressants can help

Can be inherited and genetic, seen in downsyndrome. HLA.

Toxicity: Caused by the accumulation of molecule that causes local inflammation when it accumulates to a certain level and is exposed to sun. Everyone will have toxicity with enough. Photopatch negative. Symptom is pain and is more immediate. lasts 3-5 days. Steroids don’t help.

Both: Require UV and are often precipitated by drugs.

Question 6

AA and Telogen Effluvium

Answer 6

AA: Caused by inflammatory infiltrate at hair bulbs that leads to destruction of hair usually mm above scalp. The lesions are well circumscribed and patchy. They can occur on the scalp and elsewhere. Their recurrence is spordic and unpredictable. Treatment with steroids may be helpful

Telogen: Non immunogenic caused by insult in the form of stress, hemorrhage, fever, childbirth etc. Hairs syndhronize in catagen and then fall out togethre. There is diffuse hair loss that is only present in the scalp. Hairs will show a club and will not leave any hair exposed above the scalp.

Both alopecia that are potentially reversible.

Question 7

Nails and systemic disesae

Answer 7

• Koilonychia: Fe def anemia
• Pitting: Psoriasis or AA
• Changes in Lichen Planus 10%
• Splinter hemorrhages show endocarditis
• Half and half show renal disease
• White nails show liver disease
• Beau lines show an insult
• Telangectasia are seen in CT
• Clubbing can be seen in hypoxia
• Yellownail is associated with pleural effusion
• Nail patella
• Periungal fibromas are seen inTSC
• Eczema often has polished nails
• Dystrophic EB may also show lost nails

Question 8

Sun screen

Answer 8

• Seek shade
• Only be out in mornins and evening avoid 10-4
• apply sunscreen when out
• Wear protective clothing including wide brimmed hat
• Sunscreen should be applied twice, once 20 mins before
• Use SPF 30+ broadband coverage
• Reapply frequently 2 hours or 80 mins if swimming/sweating
• Golf ball size amount should be used, go through 8 oz per week
• Make it part of routine and apply daily,
• Have someone help reach areas you cannot
• Avoid sunburns, tanning, and artifical tanning booths
• Keep kids and children out of the sun

Question 9

Steroid Selection

Answer 9

• Always use the least potent steroid necessary
• Consider the extent and type of the lesion
• Consider the duration of therapy
• Consider the surface area that will be treated and size of the patient
• Consider the location and absorption
• Consider the vehicle
• Consider the integrity of the patients skin
• Consider the patients compliance
• Monitoring

Question 10

Describe lesinons

Answer 10

Psoriasis: Pink to red plaques with adherent silvery scale. Disributed symmetrically and commonly on the extensor surface and buttock. Often involvment of scalp.

Seborrheic Dermatitis: Red papules with greasy yellow scale that are distributed on the face and scalp, chest, and intertriginous areas. Often associated with itch.

Herpes Zoster: Grouped vesicles on an eryhtematous base in a dermatomal pattern that may show crust and erosion. Often preceded by burning pain. unilateral clear vesicle to purpulent to scab to erosion

Leukocytoclastic Vasculitis: Painful purpuric papules located in dependent areas of body including lower legs and buttock. There may be black center from necrosis of the overlying tissu. There are subtypes including HSP and urticarial forms with urticaria lasting more than 24 hours.

infected Eczema: Patient has a history of itchy poorly defined weeping lesions that have recently began to develop large amount of yellow crust. There may be bullae

Question 11

Chronic Leg Ulcer

Answer 11

Pyoderma Gangrenosum
Necrobiosis Lipoidica
Venous Ulcer, Arterial Ulcer
SCC
Embolism
Trauma
PAN
Beurgers disease
Vasculitis
Sweets
Pressure ulcer
Bacterial infection
Lupus
Systemic Sclerosis
Diabetic ulcer
Sickle Cell
Cryoglobulins
Syphilis
Mycobacteria
Fungal
Ulcerating Melanoma
BCC
Lymphoma
CTCL

Question 12

Clark 3, 1,4 MM

Answer 12

Means it has invaded the reticular dermis to a depth of 1.4 mm. A sentinal lymph node biopsy is indicated to determine the extent of spread. The 5 year survivial is 85% are you are at TNM stage 1 and AJCC stage 1b. Wide local excision is indicated with 2 mm margins. You will need to have follow up every 6 months in the near future. Sun protection will continue to be important. Alert your family as family history of melanoma increases risk.

Question 13

Mohs

Answer 13

2012 AAD guidlines

Indicated for BCC that extends to the margins of biopsy

• Aggressive BCC
• BCC in sensitive area
• Recurrent BCC
• Cicatricial or scarring BCC
• BCC on areas prone to recurrence (Nose, glabella, nasolabial folds)
• Aggressive SCC
• SCC extending to margins
• Recurrent SCC
• AFX, merkel Cell and other non BCC and SCC cancers
• Immunocompromised
• Leiomyosarcoma, Apendage tumor

Question 14

CTCL Diagnosis

Answer 14

• CTCL presents as eryhtematous patch with scale. Distinguishin features are bizzare shape and assymetry. Along with atrophy, poikiloderma, telangectasia, and wrinkling.
• Patch stage
• Then can progess to plaque stage in which there may be ulceration and the presence of nodules. It may eventially invade nodes and can go to the blood when called sezeary.
• Folliculoptropic type can cause odd hairloss and follicular erythema
• Lymphoma papulomatosis can also occur
• Testing for clonality using TCR gene rearangement can help secure diagnosis
• Histologically will show atypical lymphocytes in the superficial dermis along with peaturier micorabcesses/