Transcript Schoofs - Missouri Dermatological Society

Self Assessment (MOC)
Kimberly Schoofs, MD, FAAD
Missouri Dermatological Society Meeting
September, 2016
A 26 year old Asian male presents with a 7 year history of these progressive,
asymptomatic, non-scaly discolored patches over the trunk and proximal
extremities. Wood’s lamp examination reveals follicular red fluorescence in
the hypopigmented areas. Which of the following is the best treatment?
A. Careful sun protection
and avoidance
B. Triamcinolone 0.1%
cream
C. Ketoconazole
shampoo
D. Benzoyl peroxide and
clindamycin gel
E. Hydroquinone cream
A 26 year old Asian male presents with a 7 year history of these progressive,
asymptomatic, non-scaly discolored patches over the trunk and proximal
extremities. Wood’s lamp examination reveals follicular red fluorescence in
the hypopigmented areas. Which of the following is the best treatment?
A. Careful sun protection
and avoidance
B. Triamcinolone 0.1%
cream
C. Ketoconazole
shampoo
D. Benzoyl peroxide and
clindamycin gel
E. Hydroquinone cream
A 26 year old Asian male presents with a 7 year history of these progressive,
asymptomatic, non-scaly discolored patches over the trunk and proximal
extremities. Wood’s lamp examination reveals follicular red fluorescence in
the hypopigmented areas. Which of the following is the best treatment?
A. Careful sun protection
and avoidance
B. Triamcinolone 0.1%
cream
C. Ketoconazole
shampoo
D. Benzoyl peroxide and
clindamycin gel
E. Hydroquinone cream
Progressive Macular Hypomelanosis
• Young adults, females > males, dark skin types
• Symmetric, asymptomatic hypopigmented
macules/patches on trunk and proximal
extremities
• Progressive
• Ddx: PIH, pityriasis alba, tinea versicolor, MF,
leprosy
• Genetic predisposition & P.acnes
 follicular red fluorescence if density high enough
• Histology – decreased melanin in keratinocytes
• Topical benzoyl peroxide, clindamycin,
tetracyclines, phototherapy
Distractors
A. Careful sun protection and avoidance- helpful
for postinflammatory pigmentary alteration
B. Triamcinolone 0.1% cream- inflammatory
dermatoses
C. Ketoconazole shampoo- treatment for tinea
versicolor
E. Hydroquinone cream –treatment for
hyperpigmentation
A 43 year old African American female presents with a 4 month history of
blue-gray patches over the trunk and proximal extremities. At first onset, the
lesions were noted to have an erythematous border and were mildly pruritic.
The pathology shows vacuolar interface dermatitis and marked pigment
incontinence with melanophages. The best treatment is:
A. Prednisone
B. Plaquenil
C. Clofazamine
D. Isoniazid
E. Griseofulvin
A 43 year old African American female presents with a 4 month history of
blue-gray patches over the trunk and proximal extremities. At first onset, the
lesions were noted to have an erythematous border and were mildly pruritic.
The pathology shows vacuolar interface dermatitis and marked pigment
incontinence with melanophages. The best treatment is:
A. Prednisone
B. Plaquenil
C. Clofazamine
D. Isoniazid
E. Griseofulvin
A 43 year old African American female presents with a 4 month
history of blue-gray patches over the trunk and proximal
extremities. At first onset, the lesions were noted to have an
erythematous border and were mildly pruritic. The pathology
shows vacuolar interface dermatitis and marked pigment
incontinence with melanophages. The best treatment is:
A. Prednisone
B. Plaquenil
C. Clofazamine
D. Isoniazid
E. Griseofulvin
•
•
•
•
Erythema dyschromicum perstans
(ashy dermatosis)
Females, all age groups, darker skin types
Late stage lichen planus vs separate etiology
Etiology unclear
Ddx: drug eruption, pigmented contact
dermatitis, PIH, fixed drug eruption, lichen planus
pigmentosus
• Histology: vacuolar interface dermatitis, pigment
incontinence and dermal melanophages
• Clofazamine (largest case series), isotretinoin,
dapsone, NB-UVB phototherapy
Distractors
All of the following have been reported as not
being helpful in case reports:
•
•
•
•
Prednisone
Plaquenil
Isoniazid
Griseofulvin
A 55 year old woman presents with a 3 month history
of localized nail dystrophy shown below. The most
likely cause of this finding is which of the following?
A.
B.
C.
D.
E.
Glomus tumor
Onychopapilloma
Bowen’s disease
Darier’s disease
Amelanotic melanoma
A 55 year old woman presents with a 3 month history
of localized nail dystrophy shown below. The most
likely cause of this finding is which of the following?
A.
B.
C.
D.
E.
Glomus tumor
Onychopapilloma
Bowen’s disease
Darier’s disease
Amelanotic melanoma
A 55 year old woman presents with a 3 month history
of localized nail dystrophy shown below. The most
likely cause of this finding is which of the following?
A.
B.
C.
D.
E.
Glomus tumor
Onychopapilloma
Bowen’s disease
Darier’s disease
Amelanotic melanoma
Longitudinal Erythronychia
• Longitudinal band of erythema with lucency of lunula,
distal nail splitting, splinter hemorrhage, and
subungual hyperkeratosis
• Localized or multifocal
• Onychopapilloma is most common cause of localized
disease
 Benign tumor of nail bed and matrix
 Histology- matrix/nail bed acanthosis with matrix
metaplasia and subungual hyperkeratosis
 May also present as leukonychia
• Ddx (localized): SCCIS, glomus tumor, wart, melanoma
• Ddx (multifocal): Darier’s disease, LP, EB, primary
amyloidosis, GVHD
• Longitudinal excisional biopsy – diagnostic & curative
Distractors
None of these is most common cause
• Glomus tumor –cause of localized disease
• Bowen’s disease (SCCIS) –cause of localized
disease
• Darier’s disease – cause of polydactylous
disease
• Amelanotic melanoma –cause of localized
disease
A 12 year old girl presents with a 5 month history of an
erythematous and tender right distal 3rd toe lesion with thining
of the nail plate. What is the next best step in
evaluation/treatment?
A. Radiographic imaging
B. Nail clipping for
culture
C. Nail avulsion and
biopsy with
cauterization
D. Intralesional Kenalog
E. Bactrim
A 12 year old girl presents with a 5 month history of an
erythematous and tender right distal 3rd toe lesion with thining
of the nail plate. What is the next best step in
evaluation/treatment?
A. Radiographic imaging
B. Nail clipping for
culture
C. Nail avulsion and
biopsy with
cauterization
D. Intralesional Kenalog
E. Bactrim
A 12 year old girl presents with a 5 month history of an
erythematous and tender right distal 3rd toe lesion with thining
of the nail plate. What is the next best step in
evaluation/treatment?
A. Radiographic imaging
B. Nail clipping for
culture
C. Nail avulsion and
biopsy with
cauterization
D. Intralesional Kenalog
E. Bactrim
Subungual Exostosis
• Distal subungual erythematous nodule forms and
enlarges with nail deformity, pain, ulceration and
hyperkeratosis
• Females > males, 2nd -3rd decade
• Possibly due to trauma or chronic irritation
• Solitary except in rare, multiple exostosis
syndrome (AD)
• Radiograph required for diagnosis
• Osteochondroma (can undergo malignant
transformation) vs. exostosis
• Requires excisional surgery with histologic
evaluation
Distractors
• Nail clipping for culture- onychomycosis
• Nail avulsion and biopsy with cautery –
hemangioma/pyogenic granuloma
• Intralesional kenalog- inflammatory
dermatosis
• Bactrim – infection
A 45 year old male presented with fever, headache, fatigue, myalgias,
arthralgias, and a large erythematous patch with central clearing 7
days following a tick bite from the species shown below. What is the
most likely diagnosis?
A.
B.
C.
D.
E.
Tularemia
Lyme Disease
Erlichiosis
Heartland Virus
Southern TickAssociated Rash Illness
A 45 year old male presented with fever, headache, fatigue, myalgias,
arthralgias, and a large erythematous patch with central clearing 7
days following a tick bite from the species shown below. What is the
most likely diagnosis?
A.
B.
C.
D.
E.
Tularemia
Lyme Disease
Erlichiosis
Heartland Virus
Southern TickAssociated Rash Illness
A 45 year old male presented with fever, headache, fatigue, myalgias,
arthralgias, and a large erythematous patch with central clearing 7
days following a tick bite from the species shown below. What is the
most likely diagnosis?
A.
B.
C.
D.
E.
Tularemia
Lyme Disease
Erlichiosis
Heartland Virus
Southern TickAssociated Rash Illness
Southern Tick-Associated Rash Illness
(STARI)
• Erythema migrans-like rash following lone star tick
(Amblyomma americanum)
• Described in rural Missouri 20 years ago
• Etiology unknown, but is not B. burgdorferi
• Symptoms develop sooner after bite is noted, usually is
solitary, and is smaller in size than erythema migrans
• Patients are usually treated with doxycycline and not
clear if beneficial
• CDC recommends keeping ticks for identification and
report systemic symptoms that occur within 30 days of
bite
Distractors
• Tularemia – transmitted by dog tick (Dermacentor
variabilis), the wood tick (Dermacentor andersoni), and
the lone star tick, and deer flies. Francisella tularensis,
causes ulceroglandular lesion on skin at site of bite
• Lyme disease- Ixodes scapularis tick, Borrelia
burgdorferi, erythema migrans eruption
• Erlichiosis – lone star tick Ehrlichia chaffeensis,
Ehrlichia ewingii, and Ehrlichia species provisionally
called Ehrlichia muris-like (EML). Flu-like symptoms
• Heartland Virus – lone star tick, phlebovirus, described
in 2012 in St. Joseph, Missouri by Dr. Scott Folk (other
cases in TN & OK), fatal in 2/10 reported cases. Flu-like
symptoms, elevated transaminases, thrombocytopenia