Transcript A 4-mm punch biopsy is taken, which proves to be

A 24-year-old woman presents with an asymptomatic nodule extant on her lip for more than a year. When the lesion
first manifested, it ruptured with slight trauma, drained a clear liquid, then disappeared, only to form again weeks
later. But for the past six months, the nodule has gotten larger. The patient cannot remember any trauma to the area.
She was not pregnant at the time of the initial appearance.
The most likely
diagnosis is:
A) Traumatic fibroma
B) Pyogenic granuloma
C) Fordyce's granules
D) Mucocele
A 55-year-old man presents with darkening of his facial skin, which he reports has been worsening during the past
two years. He did not notice the discoloration until friends pointed it out, and he is otherwise asymptomatic.
History reveals that the patient has been taking minocycline for several years for treatment of rosacea. Otherwise,
he is in good health; findings from a recent physical examination and related blood tests were all normal.
Nonetheless, he requested and received a referral to dermatology.
Examination of the skin shows definite bilateral, patchy, slate-colored macular areas of hyperpigmentation,
particularly on the sides of the face. There is no epidermal disturbance (ie, scale, broken skin, papularity) in these
areas. Examination of his ears, teeth, gums, and sclerae reveal no abnormality.
A) Ochronosis
B) Hemochromatosis
C) Drug reaction to minocycline
D) Addison's disease
A 27-year-old woman is referred to dermatology for evaluation of a recurrent "staph infection of the eye," always
manifesting in the same location (just below the right eye), always tingling and itching, with slight pain, and always
resolving in 10 to 14 days. She has experienced premonitory symptoms with each episode, at which point she has
sought medical evaluation and been given oral antibiotics. While the treatment seems effective, the problem persists.
She is an otherwise healthy individual and is not prone to skin infections in general, although she has had cold sores.
Examination reveals a collection of papulovesicular lesions on an erythematous base below the right eye. There is
no adenopathy in the area, and the eye itself is not involved, nor has it been during past episodes
A) Recurrent staph infection
B) Recurrent shingles (varicella-zoster virus)
C) Contact dermatitis
D) Herpes simplex virus
70-year-old man is referred to dermatology for evaluation of "ringworm" on his legs and trunk, which has been
unresponsive to topical and oral antifungal medications. The lesions initially manifested in the early fall and
increased in number with the onset of winter. The patient owns no pets or livestock and has no contact with
children or with the soil. He is immunocompetent and otherwise healthy. He uses his hot tub several times a week
and likes to take long, hot showers. Family medical history is negative for skin diseases of any kind.
Examination shows approximately 20 round, uniformly and superficially scaly pinkish-brown papulosquamous
lesions ranging from 1.0 to 2.8 cm on the patient's legs (shown), buttocks, and trunk. KOH examination of these
lesions is negative. Elsewhere on his body, his skin is extremely dry, but his elbows, knees, nails, and scalp are
otherwise normal in appearance
A) Nummular eczema
B) Tinea corporis
C) Psoriasis
D) Bowen's disease
A 24-year-old woman is referred to dermatology for evaluation of lesions that have been present on her face for three days. She
reports several prior outbreaks of a similar nature, each of which lasted 10 to 12 days. The patient reports symptoms of tingling and
itching, with a small amount of pain in the lesions -- symptoms that are identical to previous attacks. Although the patient has a
history of chickenpox as a child -- and even though she feels fine -- her primary care provider initially made a diagnosis of
chickenpox, then changed the diagnosis to shingles. Previous attacks were treated with a five-day course of valacyclovir, and the
lesions gradually resolved, only to reappear later. The patient's medical history is unremarkable except for having atopic dermatitis.
Examination shows the lesions to be discrete 3- to 5-mm vesicles, many with umbilicated centers, distributed evenly over the inferior
one third of the face and upper neck.
A) Staph infection
B) Eczema herpeticum, or Kaposi's
varicelliform eruption
C) Varicella
D) Molluscum contagiosum
For three weeks, a 22-year-old woman has had a rash, which has persisted over a good part of her
body despite application of topical antifungal and steroid creams. She says that the rash started
with one large, round, scaly lesion on her lower abdomen, followed within a day or two by the
appearance of hundreds of smaller but similar lesions that are still manifesting after three weeks.
The patient reports no other symptoms, but she is greatly concerned nonetheless. She denies fever
and malaise and is otherwise healthy, and she has a monogamous relationship with her husband.
On examination, the pinkish tan lesions are found to be papulosquamous, predominantly annular,
with a curious fine scale in the center. They appear primarily on truncal skin, sparing the face,
palms, soles, and lower legs. KOH examination of the scale is negative.
A) Pityriasis rosea
B) Tinea versicolor
C) Tinea corporis
D) Secondary syphilis
A 40-year-old woman presents with a highly debilitating hand rash that started six weeks prior to this visit. She was
referred by her primary care provider after he treated her with oral antibiotics (cephalexin 500 mg four times a day for
10 days) to no good effect. The patient is otherwise in good health, with no history of skin diseases or other serious
illness. She has, however, been under more stress than she is accustomed to.
The examination shows a bilateral palmar eruption characterized by discrete and coalescent pustules and erosions,
producing raw skin in the central palm of both hands. There are no palpable nodes in either epitrochlear or axillary
locations, and there is little if any redness around the rash. Examination elsewhere reveals a few 1- to 2-cm
papulosquamous lesions on the legs; the patient reports that these appeared at about the same time as the palmar
eruption. Moreover, there are pits in three of 10 fingernail plates, and a curious pink rash without scale in the upper
intergluteal area. The feet are clear.
A) Chronic staph infection
B) Contact dermatitis
C) Psoriasis
D) Chronic fungal infection
A 45-year-old woman is referred to dermatology by her primary care provider for removal of cosmetically
unacceptable lesions that have been present on her face, lips, neck, and arms for most of her life. She has been seen
for them on a number of occasions, but the emphasis had always been on how to eliminate them rather than on
determining their origin. The patient is otherwise healthy but has a family history of the lesions; a sibling has the
same kind of lesions on her face, and her father, who also had an extensive history of gastrointestinal bleeds leading
to a partial colectomy, had them as well. All three experienced excessive nosebleeds as children. The patient has no
history of Raynaud's phenomenon or of esophageal complaints.
Examination reveals a collection of blood-red papules and telangiectases on the tongue, cheeks, chin, neck, sclerae,
and (to a lesser extent) the fingertips. These are obviously vascular in origin, being blanchable and nontender. The
skin examination is otherwise normal
A) Dermatoheliosis (sun damage)
B) Spider angiomas
C) Hereditary hemorrhagic telangiectasia
D) CRST syndrome
A 14-year-old boy is brought in by his mother for evaluation of lesions present since age 6 months. The child is
otherwise healthy and there is no history of skin disease in the family. The boy's pediatrician had suspected
neurofibromatosis (NF), but since there was no family history of that malady and since the boy had not
demonstrated any other signs of the disease, the decision had been made to wait and see what developed. But by
now his mother is more concerned and has obtained a referral to dermatology.
Examination reveals eight lesions ranging in size from 3 to 10 cm. They are roughly oval and are located on the
trunk and in the axillary areas. They are macular and uniformly light tan. No other stigmata of NF are seen, but the
patient is referred to an ophthalmologist, who confirms the diagnosis of neurofibromatosis type 1 (NF1) based on
the presence of a particular lesion in the patient's iris.
The name of that lesion is:
A) Janeway's lesion
B) Darier's sign
C) Gottron's papule
D) Lisch nodule
E. Café Au Lait spot
Crowe’s sign
A 70-year-old woman presents for evaluation of a slightly sensitive erythematous patch of skin on her nose that has
been present for more than a year. She reports that it has been slowly growing and that it is exacerbated by direct sun
exposure. Because the lesion has persisted despite previous treatment for possible infection with oral and topical
antibiotics and topical hydrocortisone 1% cream, her primary care provider referred her to dermatology. At this point,
however, no medication has been applied to the lesion for months.
The patient is otherwise healthy and has no joint pain, fever, or malaise. She is not diabetic, and there is no history of
trauma to the area. No other skin lesions or conditions are noted on examination.
The nose lesion is erythematous and nontender. It blanches with light pressure, and there is a faint amount of scale on
its surface. There are no palpable nodes in the area
A 3-mm punch biopsy is performed, and it
proves to be diagnostic. What is the most likely
diagnosis?
A) Impetigo or other cutaneous bacterial infection
B) Discoid lupus erythematosus
C) Actinic keratosis
D) Contact dermatitis
A 4-mm punch biopsy is taken, which proves to be diagnostic. What
is the most likely diagnosis?
Pityriasis rosea
Psoriasis
Dermatophytosis (tinea corporis)
Nummular eczema
A 37-year-old businessman is referred to dermatology for the evaluation of round, scaly lesions that appeared suddenly three months
previously, at around the same time his first child was born. The lesions, which are mostly asymptomatic, have been unresponsive to
the application of over-the-counter antifungal creams (tolnaftate and clotrimazole). There are no pets in the house, and no one else in
the household is similarly affected. Although he denies any history of skin problems, he believes his father had psoriasis. The patient
does not smoke cigarettes, drink alcohol, or use prescription medications. He denies joint pain or swelling.
Examination reveals a total of five round, uniformly scaly lesions on truncal and extensor extremity skin (a right anterior tibial lesion
is pictured). They average about 2.5 cm in diameter. There is a salmon pink erythema in the background, and the scale is notably white
and tenaciously attached to the underlying skin. Microscopic examination of scrapings from the periphery of two of the lesions (using
a KOH preparation) is negative for fungal elements.
Elsewhere on the patient's body, definite pits in four of 10 fingernail plates, scaly white plaques in the scalp, and scaling in both
external auditory meatus are found. The patient's skin is not especially dry.
A 6-year-old boy is referred by his pediatrician to the dermatology department for evaluation and possible removal
of a lesion. The lesion has been present since birth and has grown slowly with the child's growth. Initially thought to
be a wart, it has persisted despite treatment with liquid nitrogen. The mother's main concern at this point is that her
son's classmates are teasing him about the lesion. The child is otherwise healthy, and he is motivated to have the
lesion removed.
Examination reveals a linear 6 1-cm epidermal collection of brown, relatively dry, warty papules. Examination of the
rest of the patient's skin reveals no other remarkable findings.
Epidermal nevus, congenital
Seborrheic keratosis
Wart
Congenital compound nevus
A 56-year-old woman presents with a lesion on the lateral aspect of her right foot. She reports that she first noticed it five years ago
and that it has been slowly growing in size. Then, a few months ago, the lesion began to focally ulcerate. The patient consulted her
primary care provider, who diagnosed the lesion as cellulitis and prescribed cephalexin. The lesion failed to respond, however, so the
patient was referred to the dermatology department.
The oddly pigmented, asymmetrical, 3-cm lesion is mostly macular, with focal areas of ulceration. It is not tender, red, or hot. The
patient has red hair, fair skin, and blue eyes. She reports advanced sun damage from years of working as a lifeguard in Oklahoma.
An incisional biopsy is performed, incorporating the darkest, most irregular portion of the lesion. The results are diagnostic.
Malignant melanoma, acral-lentiginous type
Birthmark (congenital nevus)
Wart
Persistent cellulitis
0.75 mm (comparable to Clark Level II)
> 0.75 - 1.5 mm (comparable to Clark Level III)
> 1.5 - 4.0 mm (comparable to Clark Level IV)
> 4.0 mm (comparable to Clark Level V)
the overall five-year survival rate was 52 percent for patients with
a primary melanoma of the foot or ankle compared to 84 percent
for patients with melanoma on the thigh or calf.
A 40-year-old woman is seen in the dermatology clinic for evaluation of a "fungal infection" in her thumbnail. It has
been present for six months -- despite an initial 10-day course of cephalexin and a two-month course of oral
terbinafine, neither of which produced any change in the condition.
The patient is nondiabetic, not immunosuppressed, and otherwise healthy. Her toenails are not involved, nor are any
other fingernails. She reports that she is prone to vaginal yeast infections which occur for no apparent reason several
times a year. Personal and family history of psoriasis is negative.
Examination of the affected thumbnail reveals partial separation of the nail plate from the cuticle, a mildly dystrophic
nail plate, modest edema, and scaling of the paronychial skin. Palpation of the latter is painful and produces a drop of
pus, which is cultured. There are no rashes on her elbows or knees
A) Psoriatic nail disease
B) Bacterial infection
C) Squamous cell carcinoma
D) Chronic candidal paronychia
E) Onychomycosis (fungal infection)
68-year-old woman presents with an "infection" in her right arm that has been unresponsive to oral and parenteral antibiotics
(cephalexin, ciprofloxacin, and vancomycin). The problem started four weeks earlier, with a small rash that she treated with topical
antibiotic cream. The outbreak rapidly worsened and the patient consulted her primary care provider, who placed her on the oral
antibiotics and, when that failed, admitted her to the hospital.
The hospital's consulting infectious disease specialist obtains skin and blood cultures (neither showing any growth) and starts
parenteral antibiotics, which yield no improvement. Since the patient's blood work results are unremarkable and she has no pain or
fever, she is discharged and referred on an urgent basis to a dermatologist.
More history taking reveals that the patient and her family have been applying a number of topical agents to the arm throughout the
course of the episode, including a hydroxyquinoline sulfate salve and triple antibiotic cream. Examination reveals an afebrile patient
in no distress. The dorsum of her right arm is bright red, with an extensive papulovesicular rash covering the entire extensor surface
in a sharply demarcated pattern. Neither epitrochlear nor axillary nodes are palpable. The arm itself is not tender, but there is
significant edema present. The volar surface of the arm is unaffected.
Bacterial infection
Herpes zoster
Bowen's disease (intraepidermal squamous cell
carcinoma)
Contact dermatitis
A 35-year-old man presents complaining of bumps on his upper back that have slowly grown slightly larger.
The patient reports that although they are not painful, one in particular frequently gets irritated from contact
with clothing. He believes that they have been present for years; there are no lesions elsewhere on his body.
The patient's medical history is remarkable for hypertension, which is well controlled with ramipril. His
family medical history is unremarkable.
A 33-year-old man presents with an eruption of painful, itchy "blisters" on his hands and forearms evident for the
past two days. There are no lesions elsewhere on his skin or mucous membranes. Contact history is negative, and
the patient is taking no medications. He denies any previous eruptions.
A 29-year-old man presents for evaluation of changes in and around a mole on his face. He states that the mole has
been present for as long as he can remember but in recent months has begun to "lose some color". The patient is
particularly concerned because the skin surrounding the mole has also lightened in color. He has several other
moles that have not changed. The patient's medical history and family medical history are unremarkable, and he is
taking no medications.
A 14-year-old boy presents with a history of localized hair loss. His
mother is not sure exactly how long this has been occurring: They may
have noticed the patient's condition only because he is in the process of
growing his hair to a longer style. She believes the area of hair loss may
be slowly expanding.
The patient admits to mild pruritus but is more concerned about teasing
from his football teammates. His medical history is unremarkable, and
he is taking no medications.
A 27-year-old man presents for treatment of "jock itch," which he states
has been present for about six weeks. He has been using an over-thecounter powder marketed for this problem, without any result. He notes
a prior history of athlete's foot, now resolved, and states that one of his
teammates said the two conditions could be related. Past medical history
is otherwise unremarkable. Physical examination reveals the lesions
shown above but is otherwise unremarkable. There are no skin changes
on the feet. KOH prep of the lesions above is positive; KOH prep of the
interdigital spaces of the foot is negative
A 22-year-old man presents with an eruption on both forearms. He says that
the eruption has been present for a week and has not responded to over-thecounter hydrocortisone cream (0.5%). The eruption is intensely pruritic, and
the patient scratches the affected area almost continuously during your
interview. Past medical history reveals problems with chronic diarrhea (for
which he is currently being worked up) and bipolar disorder. He is currently
taking loperamide and lithium (his lithium level is within therapeutic range).
The patient is employed by a lawn maintenance service
A 65-year-old man presents for a routine physical examination. There are
several sharply demarcated, hyperpigmented macules on his shoulders, neck,
and forearms. The patient reports increasing numbers of these macules in
recent years but no symptoms associated with them. The lesions are nonscaling
and have distinct margins and relatively uniform color, although some show
intralesional pigment variation. The patient is currently taking atorvastatin
calcium for hyperlipidemia; his medical history is otherwise unremarkable.
A 33-year-old woman presents for a pruritic eruption
on her lower left shin that has been present and
worsening for two to three months. She is employed
as a systems analyst. The patient is taking no
medications. She has a negative contact history and an
unremarkable medical history and review of systems.
Examination reveals an eruption, confined to a single
location, involving epidermal thickening and
excoriation.
A 48-year-old woman presents for evaluation of "moles" on her eyelids. She
states they have been present for several months and are slowly enlarging. She
denies any associated symptoms such as pruritus, pain, or bleeding and has
noted no other similar lesions. Past medical history is remarkable for
hysterosalpingo-oophorectomy at age 45 years for fibroids, and she is currently
receiving hormone replacement therapy. Family medical history is remarkable
for coronary artery disease in her father and one brother.
A 23-year-old man presents for a persistent,
slowly worsening rash to the face. He states
that it first occurred in January; it is now
March. He denies any pruritus. He has
experienced some relief with over-thecounter 0.5% topical hydrocortisone. The
patient has tried changing soaps and
shampoos without effect. He notes a fair
amount of cosmetically unacceptable scale,
including the scalp area, which he has been
attempting to wash off. Past medical history
and review of systems are unremarkable,
and the patient is using no medications.
A 67-year-old man presents with a complaint of worsening "eczema." He states
that he has a long history of eczema, with eruptions that worsen somewhat in the
winter months. However, this current eruption on the trunk and extremities is
more severe and pruitic than he has ever experienced. It has been present for
about 10 days and has not responded to increased oral hydration, topical
moisturizers, or topical corticosteroids. Past medical history is remarkable for
episodic gout, for which he began allopurinol therapy last m
A 40-year-old man presents for treatment of "athlete's foot." He has a history
of recurrences, which in the past have responded well to prescribed or overthe-counter topical antifungal agents. His current pruritic eruption has been
gradually worsening for several weeks despite the use of topical clotrimazole.
He has no other significant positive medical history. Examination reveals the
eruption shown. The plantar surfaces and interdigital spaces are unremarkable,
and KOH prep is negative.