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Dermatology Board Review
Dr Usama Al Haddabi
2015
Dermatology board review
Dermatology board review
Dermatomyositits
.Juvenille DM vs adult DM – list 5 clinical differences
Juvenile Adult
Calcinosis cutis No calcinosis
No malignancy Malignancy (ovarian)
No sex predominance F:M = 2-7:1
10% overlap with other CTD 20% overlap with other CTD
More vasculitis Less vasculitis
what is in adults but not children ?
malignancy (12% vs 0%)
serology in adults not in children ?
anti-synthetase ab (Jo-1)
List myositits specific antibodies and their significant ?
Dermatology board review
What are the cutaneouse & systemic findings in DM ?
Dermatology board review
Two medications can induce DM
Statin – type lipid lowering agents.
Hydroxyurea
Two important clinical features differ lesion of DM from LE
Violaceouse hue
Pruritus
List 4 Indications for systemic treatment of hemangiomas
obscure visual axis
compromise airway
ulceration & pain
cosmetically sensitive area like tip of nose or lip
ulceration and infection
Your approach for starting propranolol for IH
Dermatology board review
3 clinical differences between Linear IgA disease and drug-induced
LAD.
Duration : drug induced is limited,
idiopathic is prolonged
Refractory nature: drug induced
no, idiopathic yes
Age group: drug induced –
adults>kids , idiopathic –
kids>adults
Mechanism of action of ACE-induced angioedema
ACE inhibitors lead to an increased level of
bradykinin. Bradykinin causes vasodilation
increased vascular
permeability and hypotension
emedicine: ACEI block action of enzyme kinase II
which converts ang I to ang II. Ang ii is a potent
vasoconstrictor and inactivates bradykinin.
Acei block conv of ang 1 to II, which increases
bradykinin levels
Protein C deficiency
Protein S deficiency
Obesity
Female sex (4x that of men)
incorrect or too rapid anticoagulation dosing
institution of warfarin without concurrent heparin
institution of warfarin with loading doses
Warfarin necrosis – 3 risk factors for this
List the different phases of cell cycle – describe what happens at each
stage
Gap1- major period of growth of the cell, protein
production
S- Synthesis: DNA duplication in preparation for
mitosis
Gap2 – preparation for mitosis, shortest part of cell
cycle, checkpoint before mitosis to ensure no errors in
replication of DNA during S phase
M - Mitosis
G0 – resting phase, can be entered from either G1 or
G2. no replication of DNA
SCORTEN for TEN – list criteria
MABIGUT
Malignancy
Age
Bicarbonate
Initial surface detachment
Glucose
Urea
Tachycardia
BCC histologic subtypes: which one looks like a
scar clinically, which one likely has positive
margins on local excision.
Superficial
Nodular
Micronodular
Infiltrative- + margin
Morpheaform – looks like a scar, +
margin
Basosquamous – behaves more like an
scc
Less common subtypes
- fibroepithelioma of pinkus
MTX- 4 drugs with interactions of MTX
:-Displace MTX from plasma proteins
Tetracyclines
salicylates (also decrease renal excretion)
NSAIDs (also decreases renal excretion)
Sulfonamide (also decreases renal excretion)
Phenytoin
Chloramphenicol
Phenothiazines
-Increased intracellular accumulation:
dipyridamole
probenecid (also decreases renal function)
-Concurrent inhibition of Folic Acid metabolic
:pathway
Dapsone (inhibits DHS)
Trimethoprim (inhibits DHFR)
Sulfonamides (inhibits DHS)
-Synergistic Hepatic toxicity:
retinoids, alcohol
Dermatology board review
MTX …….Absolute and relative contraindications
2 FDA approved dermatology indications of MTX
4 indications of MTX in psoriasis
Dermatology board review
IP- list four stages
what is defect
what gene is mutated
what other organs involved (2 others)
Vesicular, Verrucous, Pigemented,
Hypopigmented
Defect is in the gamma subunit of the
Inhibitor Kappa Kinase
Gene = NEMO
X-linked dominant
Ophthalmologic – starbismus, cataracts
blindness
Dental – anodontia, conical teeth
Neurologic – MR, seizures, spastic paralysis
Imiquimod
FDA approved use/ dose
DoseFDA use
3 times/week maximum 16 weeksExternal genital and perianal warts
5 times/week for 6 weeksSuperficial small (<2 cm) non-facial BCC
2 times/week for 16 weeksActinic keratoses
TLR ? 7
New reported side effect of aldara
Eruptive epidermoid cysts
What are Histopathological differences between Ps and PRP
PRPPsfeature
alternating vert and
horiz PK
confluent pkparakeratosis
-+intracorneal pustules –
Munroes
-+intraspinous pustule –
Kojog
-+suprapapillary thinning
-+psoriasiform hyperplasia
-+incr vascularity
Clinical subtypes of Ps
Clinical Subtypes
-plaque type psoriasis vulgaris
-guttate psoriasis
-inverse psoriasis
-erythrodermic psoriasis
-nail psoriasis
-pustular psoriasis
impetigo herpetiformis
annular
generalized (von zumbusch)
-palmoplantar pustulosis and acrodermatitis
continua
-drug-induced psoriasis
what kind of allergic/adverse reactions can happen with tattoos
-granulomatous reaction
-lichenoid
-eczematous
-photoallergic – inflamed nodules in red or
yellow tattoo (cadmium)
-migration to local node simulating metastatic
melanoma on SNBx
-keloid
-Koebner phenomenon: psoriasis, lichen
planus
-Inoculation of disease: HIV, HCV, mTB, esp
prison tattoos
2 nutrients that cause skin discoloration in healthy people
1 nutrient that causes skin discoloration in someone w
genetic predisposition
carotenemia (yellow skin discoloration: elevated serum carotenoids, plant
pigments-
carotene, dietary precursor of Vit A: deeper green or yellow colored vegetables
and fruits, red palm cooking oil)
lycopenemia (orange-yellow skin discoloration: lycopene-an inert isomer of -
carotene, found chiefly in tomatoes, beets, and rose hips)
bronze diabetes, hemachromatosis, iron overload
3 nutrients that can cause periorificial dermatitis if deficient
2 nutrients that can cause purpura if deficient
biotin deficiency
essential fatty acid deficiency
zinc deficiency
Vit C
Vit K
What are 3 diseases/syndromes associated with HTLV-1
1.Adult T-cell lymphoma/leukemia (etiological role firmly
established), conclusive evidence for a primary etiologic role lacking
in MF
2.Chronic progressive myelopathy: tropical spastic paraparesis
3.Infective dermatitis: chronic relapsing eczema + infection
[pruritus most common cutaneous symptom, xerosis, acquired
icthyosis]
4 clinical types of pustular psoriasis
Explain Auspitz sign
1) generalized pustular psoriasis (von Zumbusch) exanthematous febrile eruption of
pustules
2) annular pattern GPP
3) exanthematic type GPP
4) localized patter PP
pustulosis palms and soles
acrodermatitis continua of Hallopeau-pustules
Pinpoint bleeding when psoriatic scale is forcibly removed; occurs because of the
severe thinning of the epidermis over the tips of the dermal papillae
3 systemic disease associated with psoriasis
5 drugs that exacerbate psoriasis
Cardiovascular disease (MI, PE, CVA)
Crohn’s disease (+ psoriasis + AnkSpond = HLA-B27)
Diabetes
Liver-fatty infiltration, periportal inflammation & focal necrosis
5 clinical features of Reiter’s
Arthritis/seronegative spondyloarthropathy
Conjunctivitis
urethritis/cervicitis
buccal ulcers/stomatitis
circinate balanitis
keratoderma blenhorragica (acral pustules)
Also: fever, weakness, keratitis, optic neuritis
Name 5 systemic associations with erythema elevatum diutinum
1.strep
2.CTD (RA/SLE/relapsing polychondritis)
3.IBD, celiac dz
4.IgA gammaglob, myeloma, myelodysplastic synd
5.HIV
Name 3 possible infectious causes of Kawasaki’s disease
1) bacteria (rickettsiae, staphylococci,
streptococci)Staph [TSS-toxin-producing
staphylococcus, superantigens produced by
pathogenic S. aureus] Strep [pyrogenic
exotoxin B & C] (toxin secreting bacteria)
2) viruses (EBV, parvovirus, retrovirus)
3) fungi (Candida albicans).
Name an infection thought to predispose an infant to acute
hemorrhagic edema
URTIs (adeno, staph, strep)
Name 5 clinical presentations of gold dermatitis
List 5 clinical features that would suggest an allergy to bacitracin
1.Localized to wound area
2.Nonhealing wound
3.Morphology of ACD
4.Anaphylaxis
5.Contact urticaria
List 2 medical diseases where allergy to bacitracin is most
common.
1.Venous ulcer
2.Eczema/Atopic dermatitis
What are 3 causes of (lingua villosa nigra)
What anatomic structure on the tongue is
responsible
excessive smoking, poor oral hygiene, use of
oxidizing mouthwashes, hot beverages
use of oral antibiotics, presence of Candida on
surface of tongue
Benign hyperplasia of the filiform papillae of the
anterior 2/3 of the tongue resulting in long conical
filaments of orthokeratotic and parakeratotic cells
Which tetracycline is safest in renal failure?
Doxycycline (renal failure prolongs the half life
of most tetracyclines except doxycycline;
doxycycline excreted primarily by the GI tract)
What is the most common anatomic site for white sponge nevus?
What is the inheritance pattern?
What are 2 ways to distinguish white sponge nevus from the
leukokeratosis of pachyonychia congenita?
WSN Pachyonychia Congenita
1. No extramucosal lesions
2. Mostly on buccal mucosa
 Progression stops at puberty
Sites: mouth, vagina, rectum
Histo: acanthosis, vacuolated prickle
layer
EM: clumped tonofilaments
1. Multiple assoc findings
2. Leukokeratosis of tongue, +/- oral
mucosa, +/- laryngeal involv’t
with hoarseness
Diseases associated with cobblestone appearance
Dariers disease
Cowden syndrome
Lipoid protenosis
Crohns disease
Name a skin finding associated with hyperparathyroidism
Calciphylaxis-
metastatic calcinosis
MEN Type 1 – tumours parathyroid, pancreas, pituitary;
hypercalcemia. (skin findings: multiple angiofibromas,
collagenomas, CALMs, lipomas)
pseudogout – calcium pyrophosphate (CPP) crystals
Describe 5 patterns of parakeratosis and list a disease
for each pattern.
1) confluent parakeratosis permeated by neutrophils (Munro’s
microabscesses) – psoriasis.
2) alternating para with ortho both vertical & horizontal
‘checkerboard’– pityriasis rubra pilaris
3) (tiers) slanted columns of parakeratosis/stacked
porokeratosis – cornoid lamella of porokeratosis/wart
4) shoulder parakeratosis (predilection for the follicular ostia-
‘follicular lipping’) – seborrheic dermatitis
5) mound-like (lenticular) parakeratosis ‘staccato parakeratosis’
& ‘skipping scale’ – pityriasis rosea
Dermatology board review
Dermatology board review
Dermatology board review
Dermatology board review
What is the maximum safe duration of time to
have a tourniquet in place?
Max 15 minutes. After that, increased risk of nerve damage.
What is the maximum safe dose of lidocaine
with epinephrine?
4.5 mg/kg without EPI, 7 mg/kg WITH EPI
List 3 advantages of using lidocaine with
epinephrine.
1.Decreased absorption of lidocaine
2.Prolonged anesthesia
3.Reduced risk of systemic toxicity
4.Reduced bleeding at operative site
Which layer of the skin does HPV infect?
Epidermis
List 2 genes responsible for carcinogenicity .
1. E6 – degrades p53 which normally puts brakes on cell
cycling in st. malphigii
2. E7 – binds retinoblastoma (tsg) to liberate E2F from Rb
inhibition. This allows synthesis of genes required for DNA
replication
List 2 HPV types that cause Heck’s disease
HPV 13, 32
List 7 infectious causes of oral ulcers in the immunocompetent host
1. HSV 1&2
2. Rare EBV??
3. Erosive candida
4. primary VZV
5. HPV induced SCC
6. Hand-foot-mouth – Coxsackie A16 (uvula, tonsillar pillars)
7. Herpangina – coxsackie A & B, echoviruses (soft palate)
8. HCV-induced erosive lichen planus
9. Syphilitic chancre
10. Chancroid (H.ducryei)
11. TB (TB cutis orificialis)
12.Rarely histoplasmosis or cryptococcus (but usually in
immunocompromised)
What is a medical way to reverse eyelid ptosis from Botox?
Lid ptosis results from migration of the BTX to the levator palpebrae
superioris muscle.
•It usually lasts 2-6 weeks.
Medical mgmt is with apraclonidine (Iopidine, Alcon), an alpha-
adrenergic agent that stimulates the Meüller muscle and immediately
elevates the upper eyelid (use 1-2 drops TID until ptosis resolves). This tx
usually can raise the eyelid 1-3 mm.
ALTERNATIVE: phenylephrine hydrochloride 2.5% (Neosynephrine) drops
Name 3 broad groupings of agents used in
sclerotherapy and give an example of each
Hypertonic- NaCl, NaCl + dextrose
(Sclerodex)
Detergent- sodium tetradecyl sulfate,
polidocanol
Chemical irritant- polyiodide iodide
Dermatology board review
Eight cutaneous forms of LP.
1. Annular
2. Linear
3. Generalized
4. Actinic
5-pemphigoides
6. Atrophic
7. Bullous
7. Ulcerative (on feet)
8. Hypertrophic
9. Follicular
10. Mucosal
11. Lichen planopilaris
12. Nail LP
13- Drug induced LP
14-LP-LE OVERLAP
Dermatology board review
Four ways to histologically tell apart drug-induced LP
from regular LP
1. Focal parakeratosis (vs. compact
hyperkeratosis in LP)
2. Colloid bodies higher up, in spinous and
granular layers (vs. lower epidermis in LP)
3. Prescence of eosinophils or plasma cells in
infiltrate (vs. lymphocytic in LP)
4. Superficial and deep perivascular infiltrate
(vs. lichenoid and superficial in LP)
List 5 features of lichen planus seen on pathology.
1.Saw tooth acanthosis
2.Wedge-shaped hypergranulosis
3.Max-Joseph space
4.Hyperkeratosis
5.lichenoid lymphocytic infiltrate with pigment
incontinence
6.colloid bodies (dermal)/Civatte bodies
(epidermal)
List 4 diseases mediated by staphylococcal exfoliative toxin
List 7 skin infections caused by localized streptococcal
infection.
Ecthyma
cellulitis
Erysipelas
necrotizing fasciitis
blistering distal dactylitis
perianal dermatitis
impetigo
List 3 skin diseases that are reactions to streptococcal
infection
EN
Sweet’s
guttate ps
scleredema
strep toxic shock like syndrome
List 7 important causes of leukoplakia
in an HIV positive individual.
1.Candida – thrush
2.EBV – oral hairy leukoplakia
3.HPV induced SCC
4.Oral florid papillomatosis – HPV 6,11??
5.Syphilitic mucous patches
6.HCV induced oral LP (+/- SCC induced from this)
7-Malignant and premalignant leukoplakia in tobacco users,
ETOH, and from chronic irritation
8.Pseudo-hairy leukoplakia (identical clinically and histologically
to EBV but no virus identified and etiology is unknown – seen in
OTR)
What are the 2 most common HPV types in epidermodysplasia
verruciformis?
5,8
Explain the Rumple-Leeds test
Petechial after application of a BP
cuff in those with RMSF
factors that result in chronic, non-healing wounds
1.Poor surgical technique (excessive tension,
devitalized tissue)
2.Vascular disorders (atherosclerosis, venous
insufficiency)
3.Tissue ischemia
4.Infectious process
5.Topically applied medications (C/S, iodine)
6.Hemostatic agents (aluminum chloride, ferric
subsulfate)
7.Foreign body
8.Adverse wound environment (dry instead of
moist occlusive)
9.Pressure
10.Neuropathy
11.Chronic radiation injury
local
•Malnutrition, protein deprivation, vit A & C
deficiency
•Systemic meds : c/s, penicillamine, nictoine,
NSAID’s, antineoplastic agents
•Chronic debilitation dz (hepatic, renal, heme,
CVS, AI, oncologic)
•Endocrine disorders (DM, Cushing)
•Systemic vascular disorders (vasculitis,
atherosclerosis)
•CTD (Ehlers Danlos)
•Advanced age (possibly thru impaired
expression of MMP’s)
systemic
Define SPF
UVB only; UV for 1 MED @ 2mg/cm2 divided by UV for 1 MED no sunscreen.
Ratio of the duration of UV radiation exposure necessary to produce MED in
sunscreen-protected skin compared to the time for unprotected skin.
List the wavelengths of the following
UVA-I
UVA-II
UV-B
UV-C
340-400
320-340
290-320
200-290
what are the different histological types of BCC
1. Nodular
2. Superficial
3. Micronodular
4. Sclerosing/morpheaform
5. Infiltrative
6. Metatypical (large pale tumor
cells, no pallisading, significant cytological
atypia)
7. Basosquamous carcinoma (rare
with true squamous differentiation)
8. Fibroepithelioma of Pinkus
What histological types are more aggressive?
1.Morpheaform
2.Micronodular
3.Infiltrative
4.basosquamous
5.metatypical
How is Mohs performed?
Steps involved Mohs
1. Patient prep and local anesthesia
2. debulk and delineate extent of tumor with curette
3. excise tumor with a 2-3 mm margin of normal tissue – scalpel held at 45
degree angle (undercutting is done parallel for saucerized excision)
4. tissue is cut into quadrants and hatch marks are placed for orientation
5. map is drawn of the excised pieces relative to the patient and pieces are
numbered on the map
6. tissue sections are inked – sky blue (up/right); red (down/left)
7. tissues are oriented according to map on a petri dish with moist gauze
(a mark is made to note specific orientation of the pieces)
8. technician embeds tissues upside down (epidermis down)
9. frozen sections are cut and stained with H&E or toluidine blue
10. Slides are reviewed microscopically and tumor is marked on map
11. further resection and histologic examination is performed
12. reconstruction is performed once margins are clear (some cases require
permanent sections)
Dermatology board review
Ten indications for Mohs
“Where tumor recurrence would have an unacceptably low cure rate (or be devastating)
and/or where tissue preservation is imperative”
Tumor factors
1. Recurrent tumor or positive margin with
prior excision
2. Large tumor (> 2 cm)
3. Poorly defined clinical borders
4. High-risk anatomic location (periorbital,
perinasal, perioral, periauricular)
5. Other cosmetic/functionally important sites
(periungual, genital)
Histological factors
6. Aggressive histology
-Sclerosing, micronodular, metatypical BCC
-Poorly differentiated or deeply invasive SCC
-Other tumor types with high recurrence with
conventional surgery (eg, DFSP, MAC)
7. Perineural invasion
Patient factors
8. Previously irradiated skin
9. Immunosuppressed patient
10. Tumor in chronic scar (Marjolin’s ulcer)
11. Nevoid basal cell carcinoma syndrome
12. Xeroderma pigmentosum
13. Basex’s syndrome
1) Papular (or small nodular form/micronodular) – numerous 2-5 mm red-
brown papules that turn yellow usually on the upper part of the body.
2) Nodular – less frequent 1-2 cm lesions often with surface
telangiectasias; although rare to have mucous lesions, they are seen more
commonly in the nodular form.-the “Cyrano form” causes disfiguring
nasal lesions.
3) Giant JXG - >2 cm.
4) Mixed form – both small and large nodules present.
5) JXG en plaque – lesions tend to coalesce.
6) Lichenoid JXG
7) Subcutaneous JXG – usually congenital and on the head.
8) Erdheim-Chester disease – cutaneous and systemic xanthogranulomas
involving bone (usually seen with nodular form).
9) keratotic JXG
10) Pedunculated JXG
Juvenile xanthogranuloma – clinical types,
monitoring, complications
Epidemiology:
•75% occur before age 1;
•20-30% at birth
•10% in adults. In adults the peak incidence is
20-30yo
Clinical:
•pink-red-brown domed nodule yellows with
age due to progressive lipidization
•usually H&N and upper trunk
•Extracutaneous sites: 1) ocular* *(most
common) 2)pulmonary 3) visceral, bone, CNS
lesions rare
Monitoring:
•Full skin exam for CALM (in 20%) and
stigmata of NF1
•Ophthalmology assessment if less than 2y.o.
(Ocular JXG’s affect the iris and can cause
hyphema or glaucoma leading to blindness).
Ocular involvement usually occurs before the
age of 2 years. (Note 0.5% of those with
cutaneous JXG develop ocular involvement,
while 40% of patients with ocular JXG’s have
cutaneous lesions)
•Monitor for signs and symptoms of juvenile
CML (risk increases 20 fold if pt has both JXG’s
and NF1)
Dermatology board review
Sweet’s syndrome – causes, criteria for
diagnosis, treatment options.
Causes- Idiopathic, CA (AML, GU, Breast, GI),
infection (strep, yrsenia, HIV, Hep C, CMV),
pregnancy, meds (GMCSF, OCP, ATRA, lasix,
minocin, septra), CT disease, IBD
Treatment- ILK, pred, KI, dapsone, colchicine,
cyclosporine, tetracyclines, clofazamine,
NSAIDs, IFN-a, cyclophosphamide.
Photoeruption – approach to photodermatitis
1-Idiopathic (PMLE, juv spring erup, actinic prurigo, chronic actinic derm.
Solar urticaria
2-DNA repair defects (XP, Cockayne, Bloom, Rothmund-Thomson, Hartnup,
Trichothiodystrophy…)
3-Photoaggrevation of dermatosis (Rosacea, LE, DM, REM…)
4-Photokoebenerization (vitiligo, ps, acne , LP actinicus…)
3/4 (overlap)- includes viruses like HSV, EM, GA, pemphigus erythematosus
5- Sun damage lesions (BCC, SCC, AKs, lentigines)
6- Medication (topical and systemic phototoxic and photoallergic reactions)
7- Porphyrias (PCT, EPP, pseudoporphyria....)
HSV – how do you do a Tzanck smear?
-Tzanck- Scrape base, (fix in alcohol), stain with
Giemsa or Wright, look for multinucleated
giant keratinocytes.
what has IgG & C3 along the DEJ (name 4)
1)Bullous pemphigoid
2)Herpes gestationis (usually only C3 detected)
3)EBA
4)Cicatricial pemphigoid
5)Bullous SLE
6)Paraneoplastic pemphigus
List all diseases with IgA staining:
Dermatitis herpetiformis
Linear IgA disease
Chronic bullous dermatosis of childhood
Drug-induced forms of linear IgA disease
IgA pemphigus – subcorneal pustular dermatosis subtype
IgA pemphigus – intraepidermal neutrophilic IgA dermatosis subtype
IgA can also be a component along with IgG of the immunofluorescence in other
autoimmune diseases such as bullous pemphigoid, EBA, CP
5 skin SE of isotretenoin
1) xerosis
2) palmoplantar peeling
3) photosensitivity
4) retinoid dermatitis
5) pyogenic-like granulomas
6) paronychia
7) cheilitis
3 things to avoid while on accutane
8) Pregnancy
9) Alcohol
10) Vitamin A limited to less than 5000
IU per day.
11) Avoid an excessively fatty diet
when post can you have CO2 laser
Name five teratogenic effects of Accutane
1) Cardiovascular
-ASD/VSD; abnormal origin of subclavian arteries;
hypoplastic/interrupted aortic arch; overriding aorta.
2) Craniofacial
-cleft palate; depressed midface; jaw malformation; triangular
microcephalic skull.
3) Ocular
-microphthalmia; optic nerve atrophy.
4) Auditory
-sensorineural hearing loss; absent auditory canals; vestibular
dysfunction.
5) Bone
-absent thumb; absent clavicle and scapula; aplasia of long bones;
short
sternum.
6) CNS
-agenesis of cerebellar vermis; hydrocephalus; microcephaly,
meningomyelocele; leptomeningeal neuroglial heterotopias.
7) Thymus aplasia or hypoplasia.
8) Anal and vaginal atresia.
Dermatology board review
Lupus erythematosus
a. Name 11 criteria:
Malar rash
Discoid Rash
Photosensitivity
Oral or nasal ulcers (painless)
Arthritis (non-erosive in 2 or more peripheral joints)
Serositis (pleuritis or pericarditis)
Renal disorder (proteinuria >0.5 g/d or 3+ or cellular casts)
Neurological (seizures or psychosis)
Hematologic (hemolytic anemia, leukopenia (<4), lymphopenia (<1.5),
or thrombocytopenia (<100))
Immunologic (LE cell prep +, anti-DNA, anti-
Sm, VDRL, anti-cardiolipin Ab)
ANA +
Dermatology board review
Dermatology board review
b. Patterns of LE
(Gilliam Classification system):
LE-specific skin disease:
1)ACLE
i) localized (malar rash)
ii) generalized ACLE
2)SCLE
i) Annular
ii) Psoriasiform
3)CCLE
i) Discoid
ii) Hypertrophic/verrucous DLE
iii) Lupus profundus/lupus panniculitis
iv) Mucosal DLE –oral or conjunctival
v) Lupus tumidus
vi) Chilblain LE
vii) Lichenoid DLE (LE/LP overlap)
LE-nonspecific skin disease:
i) Vasculitis – LCV, urticarial vasculitis
ii) Vasculopathy – degos-like lesions, atrophie blanche,
periungual telangiectasia, livedo reticularis,
thrombophlebitis, Raynaud’s phenomenon, erythromelalgia.
iii) Non-scarring alopecia – lupus hair, telogen effluvium,
alopecia areata.
iv) Sclerodactyly.
v) Rheumatoid nodules.
vi) Calcinosis cutis
vii) Urticaria
viii) Papulonodular mucinosis
ix) Cutis laxa/anetoderma
x) Acanthosis nigricans
xi) Erythema multiforme
xii) Leg ulcers
xiii) Lichen planus
Dermatology board review
Dermatology board review
c. 2 patterns of SCLE
1)Annular (lupus marginatus)
2)Psoriasiform (papulosquamous SCLE)
3)-drug-induced – HCTZ, ACE inhibitors, diltiazem, terbinafine,
naproxen, piroxicam, sulfonylureas, sprionolactone, ranitidine,
griseofulvin.
d.name pathology features (5 criteria of DLE)
-thickened basement membrane zone.
-superficial and deep perivascular and periadnexal lymphocytic
infiltrate.
-vacuolar alteration of DEJ with lichenoid infiltrate.
-eosinophilic colloid bodies.
-follicular plugging.
-mucin deposition in reticular dermis.
-melanophages with pigmentary incontinence.
E . treatment of DLE
Sun protection
Potent topical corticosteroids and intralesional
corticosteroids.
Hydroxychloroquine sulphate (<6.5
mg/kg/day) – smoking cessation.
-quinacrine may be added
Chloroquine (3.5-4 mg/kg/day maximum).
Oral retinoids
Thalidomide
Gold
Clofazamine
Systemic corticosteroids
Give two disease with +ve Auspitz sign not including Ps
Auspitz sign can be positive is Darier's disease
and actinic keratosis.
What is Darier's sign and what is pseudo darier sign?
Give 3 diseases with +ve darier sign
Rubbing a lesion of mastocytoma causes urtication, flare, swelling and
sometimes blister formation due to release of histamine. In contrast, pseudo-
Darer's sign is seen in smooth muscle hamartoma where there is increase in
induration and piloerection after firm stroking
Other conditions where one could find
positive Darier's sign are:
- leukemia cutis
- juvenile xanthogranuloma
- Langerhans cell histiocytosis
Pyoderma gangrenosum:
a. 4 Major clinical forms:
1) Ulcerative
2) Bullous – AML
3) Pustular – IBD, bowel-associated
dermatitis-arthritis syndrome, Behcet’s.
4) Superficial granulomatous
b. Associations:
1)Inflammatory bowel disease – Crohns, ulcerative colitis
2)Lymphoproliferative disorders
-hairy cell leukemia, monoclonal gammopathy (IgA), multiple
myeloma.
3)Arthritis-rheumatoid arthritis, bowel-associated dermatitis-
arthritis syndrome.
4)Myelodysplastic disorders-AML, myelofibrosis,
myelodysplasias
5)Vasculitis-Behcet’s, Wegener’s granulomatosis
Dermatology board review
Dermatology board review
c. two topical treatments, two systemic
treatments:
-potent topical steroids (clobetasol propionate)
-topical tacrolimus
-prednisone, dapsone,
minocycline, clofazamine, cyclosporine.
Dermatology board review
Malignant acanthosis nigricans
What is most common maliganacy ?
What is the clinical features of malignant AN ?
The stomach is the most common site for the
tumor
Malignant AN has a different clinical
appearance
1- Lesions develop rapidly and tend to be more
severe and extensive
2- Hyperpigmentation is prominent and is not
limited to the hyperkeratotic areas.
3- Mucous membrane involvement and
thickening of the palms and soles occur more
frequently
4- Itching is common
phototoxic vs photoallergic reactions
Name all of the cutaneous forms of sarcoid:
i) Specific (contain granulomas):
1) Maculopapular – most common (acute sarcoid)
2) Nodular
3) Annular plaque – chronic sarcoid
4) Darier-Roussy nodules
5) Infiltrative/scar sarcoid
6) Lupus pernio – hallmark of chronic fibrotic disease.
7) Ichthyotic
8) Ulcerative
9) Perforating
10) Angiolupoid
11) Many others – Hypopigmented, verrucous, psoriasiform,
folliculitis, lichenoid, eruptive, erythrodermic, penile,
granulomatous cheilitis, morpheaform, umbilicated.
ii) Non-specific/reactive
1) Erythema nodosum
2) Prurigo
Alopecia areata:
a) Morphological patterns:
1.Alopecia areata circumscripta (patchy).
2.Reticular pattern
3.Ophiasis pattern
4.Sisapho (ophiasis inverse) – fronto-parieto scalp.
5.Diffuse alopecia areata.
6.Alopecia totalis.
7.Alopecia universalis.
List 4 bad prognostic signs:
1.Atopy (up to 40%).
2.Family history.
3.Comorbid autoimmune disorders (thyroid, vitiligo, IBD)
.
4.Young age of onset (children under age 5
5.Nail dystrophy (pitting, trachyonychia, onychorrhexis,
onychomadesis, red-spotted lunulae, koilonychia).
6.Extensive hair loss (totalis/universalis).
7.Duration of hair loss in a given area.
8.Ophiasis pattern.
List 2 local treatments:
1.Topical steroids.
2.Topical immunomodulators.
3.Topical contact sensitizers
(diphenylcyclopropenone, anthralin, squaric
acid dibutyl esters).
4.Topical Minoxidil.
5.Intralesional corticosteroids.
•What’s a flame figure? Three diseases it’s found in
Flame figure:
- poorly circumscribed focus of eosinophilic collagen
- from eosinophilic granules (major basic protein) adhering to
dermalcollagen bundles
-sometimes see basophilic fibrillar material at periphery
Found in:
1. Eosinophilic cellulitis (Well’s syndrome)
2. Arthropod reactions
3. Parasitic infections (Splendore-Hoeppli deposits around parasites in tissues)
Also in: -BP
-Herpes gestationis
-diffuse erythemas
dermatophyte infections
Two new topical treatment for Rosacea
•List 5 cutaneous manifestations of Crohn’s disease
1. Oral Crohn’s disease
2. Cutaneous Crohn’s disease (metastatic Crohn’s)
3. Contiguous perianal Crohn’s disease (1/3 of all patients)
4. Reactive skin findings
-Cutaneous PAN
-LCV
-Pyoderma gangrenosum
-EN
-EM
-Clubbing
-Palmar erythema
-EBA
5. Nutritional deficiency
-Zinc-deficiency mimicking acrodermatitis enteropathica
Dermatology board review
Dermatology board review
Four causes of hirsutism
1. Idiopathic hirsuitism
2. PCOS
3. Androgen-secreting tumor (ovarian or adrenal)
4. Late-onset congenital adrenal hyperplasia (21-
hydroxylase deficiency)
5. Prolactinoma/Hyperprolactinemia
6. Severe insulin resistance syndromes
7. Drug (androgenic progestins, anabolic steroids)
Four drugs to treat hirsutism and the MOA
1. Oral contraceptive Suppress ovarian androgen production,
increase SHBG
2. Spironolactone ↓ Ovarian testosterone production, androgen
receptor blockade
3. Flutamide Androgen receptor blockade
4. Cyproterone acetate Androgen receptor blockade
Dermatology board review
Ten cutaneous associations with renal failure
1. Skin colour changes
-Pallor
-Sallow yellowish cast
-Hyperpigmentation
2. Solar elastosis
3. Ecchymoses (due to platelet dysfunction)
4. Xerosis
5. Acquired ichthyosis
6. Decreased skin turgor
7. Uremic frost
8. Half-and-half nails
9. Pruritus (most common)
10. Acquired perforating dermatoses
11.Metastatic calcification
-Calcinosis cutis
-Calciphylaxis
12. Bullous dermatoses
-PCT
-Pseudoporphyria
Five vascular changes with alcoholic liver disease
1. Spider angioma
2. Palmar eythema
3. Corkscrew scleral vessels
4. Caput medusae
5. Plethoric facies
6. Transient flushing
6. Unilateral nevoid telangectasia
Photodynamic therapy:
Describe the pathophysiology of cellular damage
-In PDT, a photosensitizing chemical is given either topically (ALA or
mALA; hydrophilic)
or systemically (porfimer sodium, temoporfin; hydrophobic). This is
taken up by the cells
and is converted to protoporphyrin IX (PpIX) in the mitochondria. It leaks
from the mitochondria to other cellular structures and then to the blood
vessels. The target tissue is then irradiated with photo-activating light
(blue light – 417 nm for epidermal lesions; red light – 630 nm for deeper
lesions). Porphyrins are able to convert from a ground state to a singlet
and finally to a triplet state possessing a longer lifetime. If tissue oxygen
is present, an interaction occurs and singlet oxygen is created. This singlet oxygen
oxidizes amino acids, DNA and lipids causing molecular cross-linking.
Preferential inactivation of bcl-2 occurs; cytochrome c leaks from the
Mitochondrial membrane and activates caspase-3 and get apoptosis.
Dermatology board review
Name 5 diseases that respond to PDT
Actinic keratosis (FDA indication)
Actinic cheilitis
Bowen’s disease
Psoriasis
CTCL
Superficial BCC
Acne
Condylomata
Draw IgA Molecule
Vasculitis classification by vessel size and examples
of each.
List advantages to using nb-UVB (311-313 nm)
1. nbUVB is less erythemogenic than broad-band UVB
(BB)
2. More effective for treatment of psoriasis than BB
-higher clearance rates and duration of remission; though
lower than PUVA
3. As effective as PUVA for vitiligo
4. More convenient than PUVA (no oral medication or
bath required)
5. Possibly less long-term risk of photocarcinogenesis than
PUVA (but long-term data lacking)
EBM
Sensitivity: Proportion of people who actually have disease that test positive
Negative result of a sensitive test rules out disease “SnOut”
Test with high sensitivity: won’t miss anyone who has disease (but will also
have false positives)
eg, negative ANA helps rule out SLE
Specificity: Proportion of patients without the disease that test negative
Specific test will rarely misdiagnose people who don’t have disease as
diseased
Positive result on specific test rules in disease “SpPin”
eg, positive anti-Sm makes you pretty confident that someone has SLE
PPV: Proportion of people with positive test who actually have the disease
PPV increases with disease prevalence
NPV: Proportion of people with negative test who truly do not have disease
NPV decreases with increasing disease prevalence
Odds ratio: Ratio of odds of exposure among those with and without outcome of
interest
Measure of risk in a case-control study
“the equivalent of relative risk in a case-control study” – R. Hayes
p-value: the likelihood that an observed association has
arisen by chance alone
-(whereas, in fact, no such
association exists)
low p-value (eg, < 0.05) is statistically
significant (but may not be clinically significant)
-difference observed in study would
be expected to occur by random chance alone in less than
5% of repetitions of study
CI: range of plausible values
a measure of precision; width
corresponds to most likely range of values to contain the
true value
clinical difference between SCLE and DLE (list 5):
SCLE vs DLE
1. SCLE no scarring vs DLE scarring
2. SCLE despite the name, at least 50% of patients meet the criteria for a
diagnosis of SLE (75% have arthralgia or arthritis, 20% have leucopenia, 80%
have +ANA) vs DLE no associated systemic involvement and rare to progress
to SLE ~5% patients
3. drug-induced SCLE vs no drug induced DLE
4. SCLE +ANA ~80% vs <5% +ANA (if positive, may progress to SLE)
5. SCLE: scaly papules, which evolve into either psoriasiform, more
commonly, or polycyclic annular lesions (scale is thin, easily detached,
telangiectasis and dyspigmentation are nearly always present – follicles are
not involved and there is no scarring) vs DLE: dull red macules with
adherent scales extending into patulous follicles (remove scale,
undersurface has carpet tack scale – horny plugs that fill the follicles),
patches heal centrally first, with atrophy, scaring, dyspigmentation and
telangiectasia.
DLESCLEDifference
+-Scaring
-+Drug induce
5%50%Symptoms of SLE
5%80%ANA +VE
dull red macules with
adherent scales
extending into
patulous follicles
(remove scale,
undersurface has
carpet tack scale –
horny plugs that fill the
follicles), patches heal
centrally first, with
atrophy, scaring,
dyspigmentation and
telangiectasia.
scaly papules, which
evolve into either
psoriasiform, more
commonly, or polycyclic
annular lesions (scale is
thin, easily detached,
telangiectasis and
dyspigmentation are
nearly always present –
follicles are not involved
and there is no scarring
Lesions
List 6 clinical features that may suggest a subungual
melanoma in a patient with melanonychia
1. melanonychia which begins in a single digit of a person during 4th-6th decade of
life or later (however, subungual melanoma has been seen in children)
2. melanonychia develops abruptly in a previousl normal nail plate
3. it becomes suddenly darker or wider
4. occurs in either thumb, index finger or great toe
5. occurs singly in the digit of a dark-skinned patient, particularly if the thumb or
great toe is affected
6. demonstrates blurred, rather than sharp, lateral borders
7. occurs in a person who gives a history of malignant melanoma
8. occurs in a person in who the risk of melanoma is increased (dysplastic nevus
syndrome)
9. is accompanied by nail dystrophy, such as partial nail destruction or
disappearance
10. occurs in a person who gives a history of digital trauma (several authors have
implicated trauma in the pathogenesis of subungual melanoma)
11. Hutchinson’s sign: periungual spread of pigmentation to the proximal and
lateral nail folds as well as to the tip of a single digit (corresponds to the radial
growth phase of subungual melanoma)
Dermatology board review
 Hutchinson’s sign
 single nail vs multiple nails
 blurred margin
 proximal portion of band is
wider than distal
 history of change (size, color)
 accompanying nail dystrophy
Red Flag
List 3 nail signs seen in liver disease
- Terry’s nails
- Muehrcke lines (from hypoalbuminemia)
- clubbing.
Skin diseases/syndromes with cardiac involvmet
Cardiac involvmentDisease
tetralogy, Ao aneurysm, ASD, pulm artery
stenosis, spont large vessel rupture, mitral
regurg, valvular prolapse
EDS( 1,2,4,5)
dissecting Ao aneurysms, mitral and Ao
regurgitation, MVP
Marfans
Ao aneurysm, cor pulmonale, peripheral
pulmonic stenosis, MVP
Cutis laxa
rhabdomyosarcoma (TS rhabdomyoma),
renovasc HTN, pulm stenosis
NF-1
AV fistula esp pulm, pulmonary HTNOsler-weber-rendu
accelerated atherosclerosis, HTNProgeria
atrial myxomasCarney complex
pulmonary stenosisWatson synd
atherosclerosisHomocysteinuria
arrythmias with heart block, cardiac
failure
Refsum disease
The 2013 Contact Allergen of the Year ??
methylisothiazolinone
Methylisothiazolinones are biocidal
preservatives added to bubble solutions,
bubble baths, soaps and cosmetic
products
diaper wipes
AllergenYear
Formaldehyde biocidal preservative used in a wide range of products, such
as tissue specimen and cadaveric preservation solutions, nail polish, Brazilian
blowout treatments and wrinkle-free fabrics
2015
Benzophenones sunscreens, perfumes, soaps, nail polish, hair sprays and
dyes, body washes, body moisturizers, shampoos, paints, pesticides, textiles, inks,
adhesives and plastic lens filters used in color photography
2014
Methylisothiazolinone biocidal preservatives added to bubble solutions,
bubble baths, soaps and cosmetic products
2013
Acrylic acid artificial nails, dental cements and composite dental resins.2012
Dimethyl fumarate (DMF) shoe dermatitis , sofa dermatitis2011
Neomycin medicated ophthalmic and antibiotic drops, deodorants, soaps and
root canal fillings
2010
Mixed Dialkylthiourea synthetic rubbers used in car parts, diving and
sports gear and orthopedic medical devices
2009
Nickel2008
Relationship of h.pylori to skin diseases
Chronic urticaria
Rosacea
Psoriasis
Sjogren syndrome
Others : sweet, henoch schonlein purpura,lichen planus
What is R.E.M Disease
Reticular erythematous mucinosis
Midline mucinosis
It most often affects middle-aged women
What are systemic photoprotective agents
b. Caroten
Antimalaria
Ascorbic acid
Retinol
Green tea
Antihistamines
Aspirin
Indomethacin
corticosteroids
What is angry back ?
excited skin syndrome
•Strong patch test reactions may induce a state of hyperirritability
(“angry back”) in which negative tests appear as weakly positive
Give one MOA of why neutrophils are seen in psoriasis
plaques
•In psoriasis TNF-is a major cytokine which induces the expression of IL-8,
which enhances accumulation of neutrophils and T-lymphocytes.
•IL-8 is chemotactic for neutrophils and T-lymphocytes. It also activates neutrophils.
Give 8 skin types of TB :
a) exogenous exposure/direct inoculation:
1. primary TB chancre
2. TB verrucosa cutis (warty tuberculosis,
prosector’s wart)
b) endogenous infection :
3. scrofuloderma
4. acute miliary TB
5. lupus vulgaris
6. tuberculous gumma (metastatic
tuberculous ulcer)
7. orificial tuberculosis (autoinoculation)
c) Tuberculids:
8. papulonecrotic eruption,
9. lichen scrofulosorum
10. erythema induratum of Bazin
Dermatology board review
Dermatology board review
primary TB chancreTB verrucosa cutis
lupus vulgaris scrofuloderma
orificial tuberculosis
papulonecrotic eruption erythema induratum of Bazin
Dermatology board review
Pregnant and chickenpox
Common complication of chickenpox in pregnant women ?
Pneumonia ------10 – 20%
What are the Risk factors for varicella pneumonia during pregnancy?
- Smoking
- Number of lesions more than 100
What is risk of developing congenital varicella syndrome?
congenital varicella syndrome is uncommon
The risk is greatest when infection occurs during the first 20 weeks of
pregnancy
The absolute risk of embryopathy after maternal varicella infection in the first
20 weeks of pregnancy is approximately 2%.
Features of congenital varicella syndrome
Clinical features of congenital varicella syndrome — Congenital varicella syndrome,
first described in 1947, is characterized by the following findings :
- Cutaneous scars in a dermatomal pattern
- Neurological abnormalities (eg, mental retardation, microcephaly,
hydrocephalus, seizures, Horner’s syndrome)
- Ocular abnormalities (eg, optic nerve atrophy, cataracts, chorioretinitis,
microphthalmos, nystagmus)
- Limb abnormalities (hypoplasia, atrophy, paresis)
- Gastrointestinal abnormalities (gastroesophageal reflux, atretic or stenotic
bowel)
- Low birth weight
Congenital varicella syndrome is associated with a mortality rate of 30 percent
in the first few months of life and a 15 percent risk of developing herpes zoster
in the first four years of life
Dermatology board review
maternal antibody can develop
and transfer via the placenta
Maternal infection that develops more than 2
days after delivery is associated with onset of
disease in a newborn approximately 2 weeks
later, at which point the immune system is
better able to respond to the infection.
Where are the hyphae in the most
common form of onychomycosis
Distal/lateral subungual- close to the
nail bed at the lowest portion of the nail plate
AGEP (Acute generalized exanthematous pustulosis)
1. List the 2 most common antibiotic causes
B-lactams, macrolides (Bolognia)
2. Describe the histology
Spongiform pustules within and just under the stratum corneum. Some
papillary dermal edema, and perivascular infiltrate with eosinophils
3. List 2 clinical dDx
Pustular psoriasis,
Sneddon-Wilkinson
4. Most common lab finding
1- Hi WBC (with increased neuts). Can also get
some eosinophilia
2- transient renal dysfunction
3- hypocalcemia.
5. Treatment
Drug withdrawal
topical corticosteroids
supportive measures (including antipyretics)
6. Any way to confirm the diagnosis
with a diagnostic test?
Patch testing
Dermatology board review
How can you differentiate etween AGEP and Pustular Ps ?
- The pustules seen in both diseases are clinically indistinguishable
- Additional skin lesions, including petechiae, purpura, atypical target-like
lesions and vesicles, are more frequently observed in AGEP.
- the acuteness of the disease and the drug history in AGEP (( 1-2 Days))
- The histologic findings can be helpful. Massive edema in the superficial
dermis, vasculitis, exocytosis of eosinophils, and necrosis of
keratinocytes are all suggestive of AGEP, whereas acanthosis is more
characteristic of pustular psoriasis
AGEP seems to be seen more frequently in patients with a history of
psoriasis, thus making the differential diagnosis even more difficult in
some patients.
Histo: differentiate by 2 H +E methods the following:
Steatocystoma from epidermoid cyst
Sebaceous gland in wall, thin keratinized cuticle lining
cyst without granular layer.
Dermatology board review
Pagets from bowens
No intercellular bridges, mucin is +ve
Dariers from hailey-hailey
More dyskeratosis, less diffuse acantholysis (ie no dilapidated brick wall)
Dermatology board review
GA from NLD
Central mucin (as opposed to central necrobiosis), much fewer plasma
cells
Dermatology board review
Name the immunostain the distinguishes the two (positive for the 1st, negative for the 2nd)
1. merkel vs bowens
paranuclear dot CK20 or “pankeratin”
2. extramamm pagets vs bowens
LMWK (CAM 5.2 = cytokeratins 8, 18)
3. melanoma vs langerhans histiocytosis
HMB-45, Melan-A/MART-1
4. angiosarcoma vs atypical fibroxanthoma
CD31
5. DFSP vs DF
CD34
DFSPangiosar
coma
extramamm
pagets
melanomamerkel
CD34DF
LMWK (CAM 5.2 =
cytokeratins 8, 18)
paranuclear dot
CK20
bowens
HMB-45,
Melan-
A/MART-1
langerhans
histiocytosis
CD31atypical
fibroxantho
ma
+VE
-VE
Describe the 2 mechanisms for drug-induced
pemphigus and describe what happens to the
eruption once the drug is discontinued
1) direct interference with or non-immune destruction of adhesion molecules
(DG1, DG3) resulting in acantholysis. This tends to be linked to thiol (-SH)
containing drugs (penicillamine, ACEi, gold).
2) Induction of antibody reaction against DGs, possibly through modification
of the DGs to make them more antigenic. This mechanism tends to be linked
to drugs without thiol groups (antibiotics, nifedipine, propanolol, piroxicam,
phenobarb). The active component in this group may be an amide.
Generally, patients remit when drug is d/ced. Some may progress to
PV. Non-thiol drugs have a worse prognosis than thiol drugs because
of the non-thiols’ association with antibody generation.
(E-Medicine)
name 2 tumours which can be acantholytic and
have an impact on the prognosis of the tumour
1- Acantholytic SCC – poorer px (3-10x increased risk of mets)
2- Acantholytic AK – less responsive to cryotx
•AKs: what are 3 clinical variants?
hypertrophic, pigmented, actinic cheilitis, atrophic
What are 5 histological variants?
Hypertrophic (lichenoid is variant of this), atrophic, pigmented, bowenoid,
acantholytic
•What are 8 ways to treat AKs?
1. LN2
2. 5FU topically (2.5%, 5%, 0.5% Carac)
3. topical diclofenac (Solaraze gel)
4. Imiqimod cream
5. Chemical peel – Jessner’s/TCA
6. ALA-PDT
7. Shave excision or curettage
8. Systemic retinoid (acitretin)
9. CO2 for actinic chelitis
•What are 5 clinical variants of MF (besides patch, plaque or
tumour)
1- clinical variants such as bullous and hyper- or hypopigmented
MF have a clinical behaviour similar to that of classical MF and are therefore
NOT CONSIDERED separately – Bolognia
2- Follicular MF (MF-associated follicular mucinosis)
3- Pagetoid reticulosis (Woringer-Kolopp disease-localized type)
4- Granulomatous slack skin
How do you differentiate clinically b/w Vitiligo and Leprosy?
Leprosy is more hypopigmented than depigmented, it can
have raised lesions (plaques, nodules), it can have overlying
sensory change, it can have associated nerve enlargment
Different types of Miliaria and their microscopic
locations?
1- Crystallina (stratum corneum aspect of acrosyringium),
2- rubra (stratum spinosum)
3- pustulosa (is a type of miliara rubra)
4- profunda (upper dermis/DEJ).
Tinea Pedis
4 types
1- moccasin - T. ruburm/E. floccosum - Difficult to clear
b/c low immunogenicity limits host response
2- Interdigital - T. mentag/rubrum, E. floccosum -
Usually last 2 webs. Assoc with dermatophytosis complex
3- Inflam/vesicular - T. mentag - Assoc with
dermatophytid on hands
4- Ulcerative - T. rubrum, menta, E. floccosum - Erosive
changes in webs seen with immunosupp, diabetes
4 complications
1- dermatophytosis complex – bacterial
superinfection
2- dermatophytid rxn
3- cellulitis (those with venous HTN)
4- osteomyelitis (diabetics)
List 5 side effects of PUVA
Short-term:
1. Nausea and vomiting (oral PUVA)
2. Redness/swelling/blistering
3. Hyperpigmentation
4. Persistent pruritis
Long-term:
5. Cataract formation (oral PUVA; although no clinical evidence of risk)
6. Dermatoheliosis
7. PUVA lentigines
8. Increased risk of SCC (> 200 treatments means 30x ↑ risk of SCC)
What are painfull skin tumors
"LEND AN EGG".
- Leiomyoma
- Eccrine spiradenoma
- Neuroma
- Dermatofibroma
- Angiolipoma
- Neurilemmoma
- Endometrioma
- Glomus tumor
- Granular cell tumor
Dermatosis on the shin of tibia
Itchy :
1.Lichen simlex chronicus
2.Hyperk. LP
3.Lichen amyloidosus
4.Prurigo nodularis
1.Erythema nodosum
2.NBLD
3.Ecthyma
4.Pretibial myxedema
Non itchy :
Dermatoses with island of normal skin
PRP
MF
BB
Dermatoses on the posterior aspect of the leg
Nodular vasculitis (erythema induratum of Basin)
List causes of genital ulcers
Sexually transmitted diseases
1- Herpes simplex
2- Syphilis
3- LGV
4- Chancroid
5- Granuloma injuinale
6- Scabies
7- HIV
Non sexually transmitted diseases
1- fixed drug eruption
2- malignant ulcer
3-bollouse diseases
4- traumatic ulcer
5-herpes zoster
6-erosive balanitis
7- tuberculosis ulcer
Dermatology board review
Thank you
2014 Year in Review
Infectious Disease
FDA Approves Two Topical Treatments for Onychomycosis
Currently, oral terbinafine provides the best reported
cure rates
dermatologists are in need of safer and more efficacious
treatment options
1- Topical efinaconazole 10% solution
the first topical triazole to receive FDA approval for the
treatment of toenail onychomycosis.
2- tavaborole 5% solution
While efinaconazole and tavaborole do not appear more efficacious
than systemic antifungals, they provide safe treatment alterantives
Dermatology board review
Dermatology board review
New Antibiotics Approved for Treatment of Skin Infections
Several new agents have efficacy and safety
profiles similar to vancomycin or linezolid in
the treatment of acute cellulitis, wound
infections and abscesses, including infections
caused by methicillin-resistant Staphylococcus
aureus (MRSA).
Dalbavancin
was FDA approved on May 23, 2014 for the
treatment of acute bacterial skin and skin
structure infections (ABSSSI) caused by S
aureus and Streptococcus pyogenes.4 Two
doses of intravenous (IV) dalbavancin (1 g IV
on day 1 and 500 mg IV on day 8) were as
effective as a 3-day dose of IV vancomycin (1 g
every 12 hours) with or without extension of
therapy 10 to 14 days with oral linezolid (600
mg every 12 hours). Clinical success was
observed in 91% of patients treated with
dalbavancin and 94% of patients treated with
vancomycin with or without linezolid. Adverse
events of nausea, diarrhea and pruritus were
reported less in the dalbavancin group than
the vancomycin group with or without
linezolid.
Dermatology board review
Tedizolid phosphate
was also approved by the FDA on June 20, 2014, for the
treatment of ABSSSI.
This second-generation oxazolidinone was
evaluated in 2 Phase III trials (ESTABLISH-1 and
ESTABLISH-2), which demonstrated non-
inferiority in the group receiving tedizolid
phosphate 200 mg once daily for 6 days
compared to linezolid 600 mg twice daily for
10 days.5 The most common adverse events,
such as nausea and diarrhea, were reported
less in the tedizolid phosphate groups in both
studies
Dermatology board review
Oritavancin
received FDA approval in August 2014
Two Phase III studies (SOLO I and SOLO II)
demonstrated that a single 1,200 mg IV dose
of oritavancin yielded similar efficacy to a 7- to
10-day IV dose of vancomycin.7,8 The incidence
of adverse events was also slightly less in the
oritavancin group. The more desirable safety
profiles, as well as the likelihood for greater
patient adherence with shorter and more
convenient dosing, make these new
antibacterial agents a promising option,
particularly in the treatment of MRSA
infections.
Innovative Treatment for Recurrent Herpes Labialis
Once daily, high dose, oral antiviral drugs have long been the mainstay
of herpes labialis treatment. Acyclovir Lauriad (Sitavig, Innocutis), is a
novel mucoadhesive buccal tablet (MBT) that delivers a high
concentration of acyclovir directly to the affected site through the
mucous membrane.9 It is recommended to apply the 50 mg MBT at
the onset of prodromal symptoms to the upper gum. Phase III trials
using a single application of the 50 mg acyclovir Lauriad MBT yielded
greater improvement in symptoms, reduced outbreak duration and
reduced recurrence compared with placebo.10 This is exciting news for
dermatologists and patients alike, as this innovative treatment serves
to combat the often debilitating and stigmatizing symptoms of herpes
labialis
Dermatology board review
Topical Ivermectin for Papulopustular Rosacea
Papulopustular rosacea (PPR) is a chronic inflammatory disorder that has limited treatment
options; however, a new topical therapy may be on the horizon. The results of 2 randomized,
double-blind, vehicle-controlled studies published in March 2014 found once-daily ivermectin
1% cream (Galderma Laboratories) to be more effective than vehicle in treatment of
moderate-to-severe PPR. About 40% of subjects using ivermectin 1% cream achieved
Investigator’s Global Assessment (IGA) of clear or almost clear at 12 weeks, compared to
about 12% to 18% with vehicle (P<.001 in both studies).14 A Phase III, investigator-blinded,
randomized, parallel group study published in September 2014 found once-daily ivermectin
1% cream to be superior to twice-daily metronidazole 0.75% cream (84.9% vs 75.4%,
respectively, of subjects achieving IGA of clear or almost clear; P<.001).15 Adverse events were
comparable between groups, and local tolerability was superior with ivermectin
Dermatology board review
Dermatology board review
Psoriasis and Related Biologics
Apremilast Approved for Plaque Psoriasis
On March 21, 2014, apremilast (Otezla,
Celgene Corporation) was approved by the
FDA for the treatment of adults with active
psoriatic arthritis.17 On September 23, 2014,
the treatment received an expanded indication
for patients with moderate-to-severe plaque
psoriasis who are candidates for phototherapy
or systemic therapy.
Apremilast is an oral inhibitor of
phosphodiesterase 4, which results in
increased intracellular cyclic adenosine
monophosphate, which indirectly modulates
the production of inflammatory mediators
Most common side effects reported include
diarrhea, nausea, upper respiratory tract
infection and headache
Cutaneous Malignancy
Programmed Death Inhibitor for Refractory Melanoma
On September 4, 2014, pembrolizumab(Keytruda, Merck & Co.,
Inc.) received accelerated FDA approval and is the first programmed death-1
(PD-1) inhibitor in the United States for the treatment of advanced
melanoma
The most commonly reported averse events were
fatigue, arthralgia, pruritus and rash;
immune-mediated adverse events with pembrolizumab
included hyperthyroidism and hypothyroidism (9.4%),
pneumonitis (2.9%), colitis (1%), nephritis (0.7%), hepatitis
(0.5%) and hypophysitis (0.5%).
Smoothened Inhibitors for Treatment of
Advanced Basal Cell Carcinoma
FDA Mandates Black Box Warning for Sunlamp
Products
On May 29, 2014, the FDA
reclassified sunlamp products
(including tanning beds and
booths) and ultraviolet (UV) lamps
from low-risk (Class I) to moderate-
risk (Class II) devices
Systemic Propranolol for Infantile Hemangiomas
The FDA approved propranolol hydrochloride (Hemangiol,
Pierre Fabre Dermatologie) in March 2014
Based on the trial, the most effective dose
was 3 mg/kg/day using twice-daily
dosing.49 Previous consensus reports
recommended treatment with propranolol 1 to
3 mg/kg/day divided into 3 times a day dosing
with a minimum of 6 hours between doses.
Dermatology board review
Anti-Depressant Effects of OnabotulinumtoxinA
A study published in the Journal of Clinical
Psychiatry in August 2014 suggested that there
may be more benefit to botulinum toxin
treatment than meets the eye.58 A
randomized, double-blind, placebo-controlled
trial demonstrated that patients receiving
onabotulinumtoxinA (Botox, Allergan) in the
glabellar region had statistically significant
improvement in depressive symptoms
compared to placebo, based on the 21-item
Hamilton Depression Rating Scale (HDRS-21).
HDRS-21 scores decreased by 46% and 35% in
the first and second treatment groups,
respectively, versus a 2% drop in the placebo
group (P< .0001). The improvement in major
depressive disorder symptoms was sustained
over 24 weeks, even after the cosmetics
effects had worn off around 12 to 16 weeks
Topical Botulinum Toxin Type A in Phase III Trials
A topical gel formulation of botulinum toxin
(RT001, Revance Therapeutics) is undergoing
Phase III trials in the United States for the
treatment of lateral canthal lines (commonly
referred to as crow’s feet). RT001 has the
potential to be the first approved non-
injectable botulinum toxin product. This topical
formulation will be used to treat wrinkles
caused by superficial muscle groups.59 Deeper
muscles, like those in the glabellar area, will
likely continue to require injectable botulinum
toxin for best outcomes. The topical botulinum
toxin will also be aimed at treatment of
hyperhidrosis. A second product formulated by
the same company, RTOO2, is a novel
injectable formulation of botulinum toxin type
A targeted toward longer lasting effects when
compared with currently available toxins
Omalizumab for Treatment of Urticaria
an anti-IgE receptor antibody, was approved earlier this year
for treatment of chronic idiopathic urticaria
Omalizumab 300 mg administered subcutaneously every 4 weeks
Dermatology board review
JAK Inhibitors for Treatment of Alopecia Areata
In a letter to the editor in the Journal of Investigative Dermatology in June 2014,
a team of researchers reported a case of reversal of hair loss in a patient with
alopecia universalis taking toficitinib citrate (Xeljanz, Pfizer, Inc.), a Janus kinase
(JAK) inhibitor, for treatment of plaque psoriasis.63 Researchers at Columbia
University Medical Center later published data related to the identification of
key immune mediators related to the JAK pathway that are thought to be
involved in the destruction of hair follicles by T cells in patients with alopecia
areata.64 They additionally reported a small study of 3 patients with alopecia
areata treated with the JAK inhibitor ruxolitinib (Jakafi, Incyte Corporation) who
had significant regrowth of hair over 5 months. This is an exciting discovery in
the field of hair loss, and further studies are underway to delineate the clinical
and pathophysiologic role JAK inhibitors play in alopecia areata.
Sirolimus, also known as rapamycin (SRL, Rapamune®)
potent immunosuppressant, anti-angiogenic and anti-proliferative
properties
Skin Cancer in Solid Organ Transplantation
Kaposi’s Sarcoma
Cutaneous T-Cell Lymphomas
Tuberous Sclerosis
Pachyonychia Congenita Psoriasis
Graft Versus Host Disease (GVHD)
Anti-Aging
Dermatology board review
Dermatology board review
Dermatology board review
Dermatology board review
Dermatology board review
Thank you
Good luck

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Dermatology board review

  • 1. Dermatology Board Review Dr Usama Al Haddabi 2015
  • 5. .Juvenille DM vs adult DM – list 5 clinical differences Juvenile Adult Calcinosis cutis No calcinosis No malignancy Malignancy (ovarian) No sex predominance F:M = 2-7:1 10% overlap with other CTD 20% overlap with other CTD More vasculitis Less vasculitis what is in adults but not children ? malignancy (12% vs 0%) serology in adults not in children ? anti-synthetase ab (Jo-1)
  • 6. List myositits specific antibodies and their significant ?
  • 8. What are the cutaneouse & systemic findings in DM ?
  • 10. Two medications can induce DM Statin – type lipid lowering agents. Hydroxyurea Two important clinical features differ lesion of DM from LE Violaceouse hue Pruritus
  • 11. List 4 Indications for systemic treatment of hemangiomas obscure visual axis compromise airway ulceration & pain cosmetically sensitive area like tip of nose or lip ulceration and infection
  • 12. Your approach for starting propranolol for IH
  • 14. 3 clinical differences between Linear IgA disease and drug-induced LAD. Duration : drug induced is limited, idiopathic is prolonged Refractory nature: drug induced no, idiopathic yes Age group: drug induced – adults>kids , idiopathic – kids>adults
  • 15. Mechanism of action of ACE-induced angioedema ACE inhibitors lead to an increased level of bradykinin. Bradykinin causes vasodilation increased vascular permeability and hypotension emedicine: ACEI block action of enzyme kinase II which converts ang I to ang II. Ang ii is a potent vasoconstrictor and inactivates bradykinin. Acei block conv of ang 1 to II, which increases bradykinin levels
  • 16. Protein C deficiency Protein S deficiency Obesity Female sex (4x that of men) incorrect or too rapid anticoagulation dosing institution of warfarin without concurrent heparin institution of warfarin with loading doses Warfarin necrosis – 3 risk factors for this
  • 17. List the different phases of cell cycle – describe what happens at each stage Gap1- major period of growth of the cell, protein production S- Synthesis: DNA duplication in preparation for mitosis Gap2 – preparation for mitosis, shortest part of cell cycle, checkpoint before mitosis to ensure no errors in replication of DNA during S phase M - Mitosis G0 – resting phase, can be entered from either G1 or G2. no replication of DNA
  • 18. SCORTEN for TEN – list criteria MABIGUT Malignancy Age Bicarbonate Initial surface detachment Glucose Urea Tachycardia
  • 19. BCC histologic subtypes: which one looks like a scar clinically, which one likely has positive margins on local excision. Superficial Nodular Micronodular Infiltrative- + margin Morpheaform – looks like a scar, + margin Basosquamous – behaves more like an scc Less common subtypes - fibroepithelioma of pinkus
  • 20. MTX- 4 drugs with interactions of MTX :-Displace MTX from plasma proteins Tetracyclines salicylates (also decrease renal excretion) NSAIDs (also decreases renal excretion) Sulfonamide (also decreases renal excretion) Phenytoin Chloramphenicol Phenothiazines -Increased intracellular accumulation: dipyridamole probenecid (also decreases renal function) -Concurrent inhibition of Folic Acid metabolic :pathway Dapsone (inhibits DHS) Trimethoprim (inhibits DHFR) Sulfonamides (inhibits DHS) -Synergistic Hepatic toxicity: retinoids, alcohol
  • 22. MTX …….Absolute and relative contraindications 2 FDA approved dermatology indications of MTX
  • 23. 4 indications of MTX in psoriasis
  • 25. IP- list four stages what is defect what gene is mutated what other organs involved (2 others) Vesicular, Verrucous, Pigemented, Hypopigmented Defect is in the gamma subunit of the Inhibitor Kappa Kinase Gene = NEMO X-linked dominant Ophthalmologic – starbismus, cataracts blindness Dental – anodontia, conical teeth Neurologic – MR, seizures, spastic paralysis
  • 26. Imiquimod FDA approved use/ dose DoseFDA use 3 times/week maximum 16 weeksExternal genital and perianal warts 5 times/week for 6 weeksSuperficial small (<2 cm) non-facial BCC 2 times/week for 16 weeksActinic keratoses TLR ? 7 New reported side effect of aldara Eruptive epidermoid cysts
  • 27. What are Histopathological differences between Ps and PRP PRPPsfeature alternating vert and horiz PK confluent pkparakeratosis -+intracorneal pustules – Munroes -+intraspinous pustule – Kojog -+suprapapillary thinning -+psoriasiform hyperplasia -+incr vascularity
  • 28. Clinical subtypes of Ps Clinical Subtypes -plaque type psoriasis vulgaris -guttate psoriasis -inverse psoriasis -erythrodermic psoriasis -nail psoriasis -pustular psoriasis impetigo herpetiformis annular generalized (von zumbusch) -palmoplantar pustulosis and acrodermatitis continua -drug-induced psoriasis
  • 29. what kind of allergic/adverse reactions can happen with tattoos -granulomatous reaction -lichenoid -eczematous -photoallergic – inflamed nodules in red or yellow tattoo (cadmium) -migration to local node simulating metastatic melanoma on SNBx -keloid -Koebner phenomenon: psoriasis, lichen planus -Inoculation of disease: HIV, HCV, mTB, esp prison tattoos
  • 30. 2 nutrients that cause skin discoloration in healthy people 1 nutrient that causes skin discoloration in someone w genetic predisposition carotenemia (yellow skin discoloration: elevated serum carotenoids, plant pigments- carotene, dietary precursor of Vit A: deeper green or yellow colored vegetables and fruits, red palm cooking oil) lycopenemia (orange-yellow skin discoloration: lycopene-an inert isomer of - carotene, found chiefly in tomatoes, beets, and rose hips) bronze diabetes, hemachromatosis, iron overload
  • 31. 3 nutrients that can cause periorificial dermatitis if deficient 2 nutrients that can cause purpura if deficient biotin deficiency essential fatty acid deficiency zinc deficiency Vit C Vit K
  • 32. What are 3 diseases/syndromes associated with HTLV-1 1.Adult T-cell lymphoma/leukemia (etiological role firmly established), conclusive evidence for a primary etiologic role lacking in MF 2.Chronic progressive myelopathy: tropical spastic paraparesis 3.Infective dermatitis: chronic relapsing eczema + infection [pruritus most common cutaneous symptom, xerosis, acquired icthyosis]
  • 33. 4 clinical types of pustular psoriasis Explain Auspitz sign 1) generalized pustular psoriasis (von Zumbusch) exanthematous febrile eruption of pustules 2) annular pattern GPP 3) exanthematic type GPP 4) localized patter PP pustulosis palms and soles acrodermatitis continua of Hallopeau-pustules Pinpoint bleeding when psoriatic scale is forcibly removed; occurs because of the severe thinning of the epidermis over the tips of the dermal papillae
  • 34. 3 systemic disease associated with psoriasis 5 drugs that exacerbate psoriasis Cardiovascular disease (MI, PE, CVA) Crohn’s disease (+ psoriasis + AnkSpond = HLA-B27) Diabetes Liver-fatty infiltration, periportal inflammation & focal necrosis
  • 35. 5 clinical features of Reiter’s Arthritis/seronegative spondyloarthropathy Conjunctivitis urethritis/cervicitis buccal ulcers/stomatitis circinate balanitis keratoderma blenhorragica (acral pustules) Also: fever, weakness, keratitis, optic neuritis
  • 36. Name 5 systemic associations with erythema elevatum diutinum 1.strep 2.CTD (RA/SLE/relapsing polychondritis) 3.IBD, celiac dz 4.IgA gammaglob, myeloma, myelodysplastic synd 5.HIV
  • 37. Name 3 possible infectious causes of Kawasaki’s disease 1) bacteria (rickettsiae, staphylococci, streptococci)Staph [TSS-toxin-producing staphylococcus, superantigens produced by pathogenic S. aureus] Strep [pyrogenic exotoxin B & C] (toxin secreting bacteria) 2) viruses (EBV, parvovirus, retrovirus) 3) fungi (Candida albicans).
  • 38. Name an infection thought to predispose an infant to acute hemorrhagic edema URTIs (adeno, staph, strep)
  • 39. Name 5 clinical presentations of gold dermatitis
  • 40. List 5 clinical features that would suggest an allergy to bacitracin 1.Localized to wound area 2.Nonhealing wound 3.Morphology of ACD 4.Anaphylaxis 5.Contact urticaria
  • 41. List 2 medical diseases where allergy to bacitracin is most common. 1.Venous ulcer 2.Eczema/Atopic dermatitis
  • 42. What are 3 causes of (lingua villosa nigra) What anatomic structure on the tongue is responsible excessive smoking, poor oral hygiene, use of oxidizing mouthwashes, hot beverages use of oral antibiotics, presence of Candida on surface of tongue Benign hyperplasia of the filiform papillae of the anterior 2/3 of the tongue resulting in long conical filaments of orthokeratotic and parakeratotic cells
  • 43. Which tetracycline is safest in renal failure? Doxycycline (renal failure prolongs the half life of most tetracyclines except doxycycline; doxycycline excreted primarily by the GI tract)
  • 44. What is the most common anatomic site for white sponge nevus? What is the inheritance pattern? What are 2 ways to distinguish white sponge nevus from the leukokeratosis of pachyonychia congenita? WSN Pachyonychia Congenita 1. No extramucosal lesions 2. Mostly on buccal mucosa  Progression stops at puberty Sites: mouth, vagina, rectum Histo: acanthosis, vacuolated prickle layer EM: clumped tonofilaments 1. Multiple assoc findings 2. Leukokeratosis of tongue, +/- oral mucosa, +/- laryngeal involv’t with hoarseness
  • 45. Diseases associated with cobblestone appearance Dariers disease Cowden syndrome Lipoid protenosis Crohns disease
  • 46. Name a skin finding associated with hyperparathyroidism Calciphylaxis- metastatic calcinosis MEN Type 1 – tumours parathyroid, pancreas, pituitary; hypercalcemia. (skin findings: multiple angiofibromas, collagenomas, CALMs, lipomas) pseudogout – calcium pyrophosphate (CPP) crystals
  • 47. Describe 5 patterns of parakeratosis and list a disease for each pattern. 1) confluent parakeratosis permeated by neutrophils (Munro’s microabscesses) – psoriasis. 2) alternating para with ortho both vertical & horizontal ‘checkerboard’– pityriasis rubra pilaris 3) (tiers) slanted columns of parakeratosis/stacked porokeratosis – cornoid lamella of porokeratosis/wart 4) shoulder parakeratosis (predilection for the follicular ostia- ‘follicular lipping’) – seborrheic dermatitis 5) mound-like (lenticular) parakeratosis ‘staccato parakeratosis’ & ‘skipping scale’ – pityriasis rosea
  • 52. What is the maximum safe duration of time to have a tourniquet in place? Max 15 minutes. After that, increased risk of nerve damage. What is the maximum safe dose of lidocaine with epinephrine? 4.5 mg/kg without EPI, 7 mg/kg WITH EPI List 3 advantages of using lidocaine with epinephrine. 1.Decreased absorption of lidocaine 2.Prolonged anesthesia 3.Reduced risk of systemic toxicity 4.Reduced bleeding at operative site
  • 53. Which layer of the skin does HPV infect? Epidermis List 2 genes responsible for carcinogenicity . 1. E6 – degrades p53 which normally puts brakes on cell cycling in st. malphigii 2. E7 – binds retinoblastoma (tsg) to liberate E2F from Rb inhibition. This allows synthesis of genes required for DNA replication List 2 HPV types that cause Heck’s disease HPV 13, 32
  • 54. List 7 infectious causes of oral ulcers in the immunocompetent host 1. HSV 1&2 2. Rare EBV?? 3. Erosive candida 4. primary VZV 5. HPV induced SCC 6. Hand-foot-mouth – Coxsackie A16 (uvula, tonsillar pillars) 7. Herpangina – coxsackie A & B, echoviruses (soft palate) 8. HCV-induced erosive lichen planus 9. Syphilitic chancre 10. Chancroid (H.ducryei) 11. TB (TB cutis orificialis) 12.Rarely histoplasmosis or cryptococcus (but usually in immunocompromised)
  • 55. What is a medical way to reverse eyelid ptosis from Botox? Lid ptosis results from migration of the BTX to the levator palpebrae superioris muscle. •It usually lasts 2-6 weeks. Medical mgmt is with apraclonidine (Iopidine, Alcon), an alpha- adrenergic agent that stimulates the Meüller muscle and immediately elevates the upper eyelid (use 1-2 drops TID until ptosis resolves). This tx usually can raise the eyelid 1-3 mm. ALTERNATIVE: phenylephrine hydrochloride 2.5% (Neosynephrine) drops
  • 56. Name 3 broad groupings of agents used in sclerotherapy and give an example of each Hypertonic- NaCl, NaCl + dextrose (Sclerodex) Detergent- sodium tetradecyl sulfate, polidocanol Chemical irritant- polyiodide iodide
  • 58. Eight cutaneous forms of LP. 1. Annular 2. Linear 3. Generalized 4. Actinic 5-pemphigoides 6. Atrophic 7. Bullous 7. Ulcerative (on feet) 8. Hypertrophic 9. Follicular 10. Mucosal 11. Lichen planopilaris 12. Nail LP 13- Drug induced LP 14-LP-LE OVERLAP
  • 60. Four ways to histologically tell apart drug-induced LP from regular LP 1. Focal parakeratosis (vs. compact hyperkeratosis in LP) 2. Colloid bodies higher up, in spinous and granular layers (vs. lower epidermis in LP) 3. Prescence of eosinophils or plasma cells in infiltrate (vs. lymphocytic in LP) 4. Superficial and deep perivascular infiltrate (vs. lichenoid and superficial in LP)
  • 61. List 5 features of lichen planus seen on pathology. 1.Saw tooth acanthosis 2.Wedge-shaped hypergranulosis 3.Max-Joseph space 4.Hyperkeratosis 5.lichenoid lymphocytic infiltrate with pigment incontinence 6.colloid bodies (dermal)/Civatte bodies (epidermal)
  • 62. List 4 diseases mediated by staphylococcal exfoliative toxin
  • 63. List 7 skin infections caused by localized streptococcal infection. Ecthyma cellulitis Erysipelas necrotizing fasciitis blistering distal dactylitis perianal dermatitis impetigo
  • 64. List 3 skin diseases that are reactions to streptococcal infection EN Sweet’s guttate ps scleredema strep toxic shock like syndrome
  • 65. List 7 important causes of leukoplakia in an HIV positive individual. 1.Candida – thrush 2.EBV – oral hairy leukoplakia 3.HPV induced SCC 4.Oral florid papillomatosis – HPV 6,11?? 5.Syphilitic mucous patches 6.HCV induced oral LP (+/- SCC induced from this) 7-Malignant and premalignant leukoplakia in tobacco users, ETOH, and from chronic irritation 8.Pseudo-hairy leukoplakia (identical clinically and histologically to EBV but no virus identified and etiology is unknown – seen in OTR)
  • 66. What are the 2 most common HPV types in epidermodysplasia verruciformis? 5,8
  • 67. Explain the Rumple-Leeds test Petechial after application of a BP cuff in those with RMSF
  • 68. factors that result in chronic, non-healing wounds 1.Poor surgical technique (excessive tension, devitalized tissue) 2.Vascular disorders (atherosclerosis, venous insufficiency) 3.Tissue ischemia 4.Infectious process 5.Topically applied medications (C/S, iodine) 6.Hemostatic agents (aluminum chloride, ferric subsulfate) 7.Foreign body 8.Adverse wound environment (dry instead of moist occlusive) 9.Pressure 10.Neuropathy 11.Chronic radiation injury local •Malnutrition, protein deprivation, vit A & C deficiency •Systemic meds : c/s, penicillamine, nictoine, NSAID’s, antineoplastic agents •Chronic debilitation dz (hepatic, renal, heme, CVS, AI, oncologic) •Endocrine disorders (DM, Cushing) •Systemic vascular disorders (vasculitis, atherosclerosis) •CTD (Ehlers Danlos) •Advanced age (possibly thru impaired expression of MMP’s) systemic
  • 69. Define SPF UVB only; UV for 1 MED @ 2mg/cm2 divided by UV for 1 MED no sunscreen. Ratio of the duration of UV radiation exposure necessary to produce MED in sunscreen-protected skin compared to the time for unprotected skin. List the wavelengths of the following UVA-I UVA-II UV-B UV-C 340-400 320-340 290-320 200-290
  • 70. what are the different histological types of BCC 1. Nodular 2. Superficial 3. Micronodular 4. Sclerosing/morpheaform 5. Infiltrative 6. Metatypical (large pale tumor cells, no pallisading, significant cytological atypia) 7. Basosquamous carcinoma (rare with true squamous differentiation) 8. Fibroepithelioma of Pinkus What histological types are more aggressive? 1.Morpheaform 2.Micronodular 3.Infiltrative 4.basosquamous 5.metatypical
  • 71. How is Mohs performed? Steps involved Mohs 1. Patient prep and local anesthesia 2. debulk and delineate extent of tumor with curette 3. excise tumor with a 2-3 mm margin of normal tissue – scalpel held at 45 degree angle (undercutting is done parallel for saucerized excision) 4. tissue is cut into quadrants and hatch marks are placed for orientation 5. map is drawn of the excised pieces relative to the patient and pieces are numbered on the map 6. tissue sections are inked – sky blue (up/right); red (down/left) 7. tissues are oriented according to map on a petri dish with moist gauze (a mark is made to note specific orientation of the pieces) 8. technician embeds tissues upside down (epidermis down) 9. frozen sections are cut and stained with H&E or toluidine blue 10. Slides are reviewed microscopically and tumor is marked on map 11. further resection and histologic examination is performed 12. reconstruction is performed once margins are clear (some cases require permanent sections)
  • 73. Ten indications for Mohs “Where tumor recurrence would have an unacceptably low cure rate (or be devastating) and/or where tissue preservation is imperative” Tumor factors 1. Recurrent tumor or positive margin with prior excision 2. Large tumor (> 2 cm) 3. Poorly defined clinical borders 4. High-risk anatomic location (periorbital, perinasal, perioral, periauricular) 5. Other cosmetic/functionally important sites (periungual, genital) Histological factors 6. Aggressive histology -Sclerosing, micronodular, metatypical BCC -Poorly differentiated or deeply invasive SCC -Other tumor types with high recurrence with conventional surgery (eg, DFSP, MAC) 7. Perineural invasion Patient factors 8. Previously irradiated skin 9. Immunosuppressed patient 10. Tumor in chronic scar (Marjolin’s ulcer) 11. Nevoid basal cell carcinoma syndrome 12. Xeroderma pigmentosum 13. Basex’s syndrome
  • 74. 1) Papular (or small nodular form/micronodular) – numerous 2-5 mm red- brown papules that turn yellow usually on the upper part of the body. 2) Nodular – less frequent 1-2 cm lesions often with surface telangiectasias; although rare to have mucous lesions, they are seen more commonly in the nodular form.-the “Cyrano form” causes disfiguring nasal lesions. 3) Giant JXG - >2 cm. 4) Mixed form – both small and large nodules present. 5) JXG en plaque – lesions tend to coalesce. 6) Lichenoid JXG 7) Subcutaneous JXG – usually congenital and on the head. 8) Erdheim-Chester disease – cutaneous and systemic xanthogranulomas involving bone (usually seen with nodular form). 9) keratotic JXG 10) Pedunculated JXG
  • 75. Juvenile xanthogranuloma – clinical types, monitoring, complications Epidemiology: •75% occur before age 1; •20-30% at birth •10% in adults. In adults the peak incidence is 20-30yo Clinical: •pink-red-brown domed nodule yellows with age due to progressive lipidization •usually H&N and upper trunk •Extracutaneous sites: 1) ocular* *(most common) 2)pulmonary 3) visceral, bone, CNS lesions rare
  • 76. Monitoring: •Full skin exam for CALM (in 20%) and stigmata of NF1 •Ophthalmology assessment if less than 2y.o. (Ocular JXG’s affect the iris and can cause hyphema or glaucoma leading to blindness). Ocular involvement usually occurs before the age of 2 years. (Note 0.5% of those with cutaneous JXG develop ocular involvement, while 40% of patients with ocular JXG’s have cutaneous lesions) •Monitor for signs and symptoms of juvenile CML (risk increases 20 fold if pt has both JXG’s and NF1)
  • 78. Sweet’s syndrome – causes, criteria for diagnosis, treatment options. Causes- Idiopathic, CA (AML, GU, Breast, GI), infection (strep, yrsenia, HIV, Hep C, CMV), pregnancy, meds (GMCSF, OCP, ATRA, lasix, minocin, septra), CT disease, IBD Treatment- ILK, pred, KI, dapsone, colchicine, cyclosporine, tetracyclines, clofazamine, NSAIDs, IFN-a, cyclophosphamide.
  • 79. Photoeruption – approach to photodermatitis 1-Idiopathic (PMLE, juv spring erup, actinic prurigo, chronic actinic derm. Solar urticaria 2-DNA repair defects (XP, Cockayne, Bloom, Rothmund-Thomson, Hartnup, Trichothiodystrophy…) 3-Photoaggrevation of dermatosis (Rosacea, LE, DM, REM…) 4-Photokoebenerization (vitiligo, ps, acne , LP actinicus…) 3/4 (overlap)- includes viruses like HSV, EM, GA, pemphigus erythematosus 5- Sun damage lesions (BCC, SCC, AKs, lentigines) 6- Medication (topical and systemic phototoxic and photoallergic reactions) 7- Porphyrias (PCT, EPP, pseudoporphyria....)
  • 80. HSV – how do you do a Tzanck smear? -Tzanck- Scrape base, (fix in alcohol), stain with Giemsa or Wright, look for multinucleated giant keratinocytes.
  • 81. what has IgG & C3 along the DEJ (name 4) 1)Bullous pemphigoid 2)Herpes gestationis (usually only C3 detected) 3)EBA 4)Cicatricial pemphigoid 5)Bullous SLE 6)Paraneoplastic pemphigus List all diseases with IgA staining: Dermatitis herpetiformis Linear IgA disease Chronic bullous dermatosis of childhood Drug-induced forms of linear IgA disease IgA pemphigus – subcorneal pustular dermatosis subtype IgA pemphigus – intraepidermal neutrophilic IgA dermatosis subtype IgA can also be a component along with IgG of the immunofluorescence in other autoimmune diseases such as bullous pemphigoid, EBA, CP
  • 82. 5 skin SE of isotretenoin 1) xerosis 2) palmoplantar peeling 3) photosensitivity 4) retinoid dermatitis 5) pyogenic-like granulomas 6) paronychia 7) cheilitis 3 things to avoid while on accutane 8) Pregnancy 9) Alcohol 10) Vitamin A limited to less than 5000 IU per day. 11) Avoid an excessively fatty diet when post can you have CO2 laser
  • 83. Name five teratogenic effects of Accutane 1) Cardiovascular -ASD/VSD; abnormal origin of subclavian arteries; hypoplastic/interrupted aortic arch; overriding aorta. 2) Craniofacial -cleft palate; depressed midface; jaw malformation; triangular microcephalic skull. 3) Ocular -microphthalmia; optic nerve atrophy. 4) Auditory -sensorineural hearing loss; absent auditory canals; vestibular dysfunction. 5) Bone -absent thumb; absent clavicle and scapula; aplasia of long bones; short sternum. 6) CNS -agenesis of cerebellar vermis; hydrocephalus; microcephaly, meningomyelocele; leptomeningeal neuroglial heterotopias. 7) Thymus aplasia or hypoplasia. 8) Anal and vaginal atresia.
  • 85. Lupus erythematosus a. Name 11 criteria: Malar rash Discoid Rash Photosensitivity Oral or nasal ulcers (painless) Arthritis (non-erosive in 2 or more peripheral joints) Serositis (pleuritis or pericarditis) Renal disorder (proteinuria >0.5 g/d or 3+ or cellular casts) Neurological (seizures or psychosis) Hematologic (hemolytic anemia, leukopenia (<4), lymphopenia (<1.5), or thrombocytopenia (<100)) Immunologic (LE cell prep +, anti-DNA, anti- Sm, VDRL, anti-cardiolipin Ab) ANA +
  • 88. b. Patterns of LE (Gilliam Classification system): LE-specific skin disease: 1)ACLE i) localized (malar rash) ii) generalized ACLE 2)SCLE i) Annular ii) Psoriasiform 3)CCLE i) Discoid ii) Hypertrophic/verrucous DLE iii) Lupus profundus/lupus panniculitis iv) Mucosal DLE –oral or conjunctival v) Lupus tumidus vi) Chilblain LE vii) Lichenoid DLE (LE/LP overlap)
  • 89. LE-nonspecific skin disease: i) Vasculitis – LCV, urticarial vasculitis ii) Vasculopathy – degos-like lesions, atrophie blanche, periungual telangiectasia, livedo reticularis, thrombophlebitis, Raynaud’s phenomenon, erythromelalgia. iii) Non-scarring alopecia – lupus hair, telogen effluvium, alopecia areata. iv) Sclerodactyly. v) Rheumatoid nodules. vi) Calcinosis cutis vii) Urticaria viii) Papulonodular mucinosis ix) Cutis laxa/anetoderma x) Acanthosis nigricans xi) Erythema multiforme xii) Leg ulcers xiii) Lichen planus
  • 92. c. 2 patterns of SCLE 1)Annular (lupus marginatus) 2)Psoriasiform (papulosquamous SCLE) 3)-drug-induced – HCTZ, ACE inhibitors, diltiazem, terbinafine, naproxen, piroxicam, sulfonylureas, sprionolactone, ranitidine, griseofulvin.
  • 93. d.name pathology features (5 criteria of DLE) -thickened basement membrane zone. -superficial and deep perivascular and periadnexal lymphocytic infiltrate. -vacuolar alteration of DEJ with lichenoid infiltrate. -eosinophilic colloid bodies. -follicular plugging. -mucin deposition in reticular dermis. -melanophages with pigmentary incontinence.
  • 94. E . treatment of DLE Sun protection Potent topical corticosteroids and intralesional corticosteroids. Hydroxychloroquine sulphate (<6.5 mg/kg/day) – smoking cessation. -quinacrine may be added Chloroquine (3.5-4 mg/kg/day maximum). Oral retinoids Thalidomide Gold Clofazamine Systemic corticosteroids
  • 95. Give two disease with +ve Auspitz sign not including Ps Auspitz sign can be positive is Darier's disease and actinic keratosis. What is Darier's sign and what is pseudo darier sign? Give 3 diseases with +ve darier sign Rubbing a lesion of mastocytoma causes urtication, flare, swelling and sometimes blister formation due to release of histamine. In contrast, pseudo- Darer's sign is seen in smooth muscle hamartoma where there is increase in induration and piloerection after firm stroking Other conditions where one could find positive Darier's sign are: - leukemia cutis - juvenile xanthogranuloma - Langerhans cell histiocytosis
  • 96. Pyoderma gangrenosum: a. 4 Major clinical forms: 1) Ulcerative 2) Bullous – AML 3) Pustular – IBD, bowel-associated dermatitis-arthritis syndrome, Behcet’s. 4) Superficial granulomatous
  • 97. b. Associations: 1)Inflammatory bowel disease – Crohns, ulcerative colitis 2)Lymphoproliferative disorders -hairy cell leukemia, monoclonal gammopathy (IgA), multiple myeloma. 3)Arthritis-rheumatoid arthritis, bowel-associated dermatitis- arthritis syndrome. 4)Myelodysplastic disorders-AML, myelofibrosis, myelodysplasias 5)Vasculitis-Behcet’s, Wegener’s granulomatosis
  • 100. c. two topical treatments, two systemic treatments: -potent topical steroids (clobetasol propionate) -topical tacrolimus -prednisone, dapsone, minocycline, clofazamine, cyclosporine.
  • 102. Malignant acanthosis nigricans What is most common maliganacy ? What is the clinical features of malignant AN ? The stomach is the most common site for the tumor Malignant AN has a different clinical appearance 1- Lesions develop rapidly and tend to be more severe and extensive 2- Hyperpigmentation is prominent and is not limited to the hyperkeratotic areas. 3- Mucous membrane involvement and thickening of the palms and soles occur more frequently 4- Itching is common
  • 104. Name all of the cutaneous forms of sarcoid: i) Specific (contain granulomas): 1) Maculopapular – most common (acute sarcoid) 2) Nodular 3) Annular plaque – chronic sarcoid 4) Darier-Roussy nodules 5) Infiltrative/scar sarcoid 6) Lupus pernio – hallmark of chronic fibrotic disease. 7) Ichthyotic 8) Ulcerative 9) Perforating 10) Angiolupoid 11) Many others – Hypopigmented, verrucous, psoriasiform, folliculitis, lichenoid, eruptive, erythrodermic, penile, granulomatous cheilitis, morpheaform, umbilicated. ii) Non-specific/reactive 1) Erythema nodosum 2) Prurigo
  • 105. Alopecia areata: a) Morphological patterns: 1.Alopecia areata circumscripta (patchy). 2.Reticular pattern 3.Ophiasis pattern 4.Sisapho (ophiasis inverse) – fronto-parieto scalp. 5.Diffuse alopecia areata. 6.Alopecia totalis. 7.Alopecia universalis.
  • 106. List 4 bad prognostic signs: 1.Atopy (up to 40%). 2.Family history. 3.Comorbid autoimmune disorders (thyroid, vitiligo, IBD) . 4.Young age of onset (children under age 5 5.Nail dystrophy (pitting, trachyonychia, onychorrhexis, onychomadesis, red-spotted lunulae, koilonychia). 6.Extensive hair loss (totalis/universalis). 7.Duration of hair loss in a given area. 8.Ophiasis pattern.
  • 107. List 2 local treatments: 1.Topical steroids. 2.Topical immunomodulators. 3.Topical contact sensitizers (diphenylcyclopropenone, anthralin, squaric acid dibutyl esters). 4.Topical Minoxidil. 5.Intralesional corticosteroids.
  • 108. •What’s a flame figure? Three diseases it’s found in Flame figure: - poorly circumscribed focus of eosinophilic collagen - from eosinophilic granules (major basic protein) adhering to dermalcollagen bundles -sometimes see basophilic fibrillar material at periphery Found in: 1. Eosinophilic cellulitis (Well’s syndrome) 2. Arthropod reactions 3. Parasitic infections (Splendore-Hoeppli deposits around parasites in tissues) Also in: -BP -Herpes gestationis -diffuse erythemas dermatophyte infections
  • 109. Two new topical treatment for Rosacea
  • 110. •List 5 cutaneous manifestations of Crohn’s disease 1. Oral Crohn’s disease 2. Cutaneous Crohn’s disease (metastatic Crohn’s) 3. Contiguous perianal Crohn’s disease (1/3 of all patients) 4. Reactive skin findings -Cutaneous PAN -LCV -Pyoderma gangrenosum -EN -EM -Clubbing -Palmar erythema -EBA 5. Nutritional deficiency -Zinc-deficiency mimicking acrodermatitis enteropathica
  • 113. Four causes of hirsutism 1. Idiopathic hirsuitism 2. PCOS 3. Androgen-secreting tumor (ovarian or adrenal) 4. Late-onset congenital adrenal hyperplasia (21- hydroxylase deficiency) 5. Prolactinoma/Hyperprolactinemia 6. Severe insulin resistance syndromes 7. Drug (androgenic progestins, anabolic steroids)
  • 114. Four drugs to treat hirsutism and the MOA 1. Oral contraceptive Suppress ovarian androgen production, increase SHBG 2. Spironolactone ↓ Ovarian testosterone production, androgen receptor blockade 3. Flutamide Androgen receptor blockade 4. Cyproterone acetate Androgen receptor blockade
  • 116. Ten cutaneous associations with renal failure 1. Skin colour changes -Pallor -Sallow yellowish cast -Hyperpigmentation 2. Solar elastosis 3. Ecchymoses (due to platelet dysfunction) 4. Xerosis 5. Acquired ichthyosis 6. Decreased skin turgor 7. Uremic frost 8. Half-and-half nails 9. Pruritus (most common) 10. Acquired perforating dermatoses 11.Metastatic calcification -Calcinosis cutis -Calciphylaxis 12. Bullous dermatoses -PCT -Pseudoporphyria
  • 117. Five vascular changes with alcoholic liver disease 1. Spider angioma 2. Palmar eythema 3. Corkscrew scleral vessels 4. Caput medusae 5. Plethoric facies 6. Transient flushing 6. Unilateral nevoid telangectasia
  • 118. Photodynamic therapy: Describe the pathophysiology of cellular damage -In PDT, a photosensitizing chemical is given either topically (ALA or mALA; hydrophilic) or systemically (porfimer sodium, temoporfin; hydrophobic). This is taken up by the cells and is converted to protoporphyrin IX (PpIX) in the mitochondria. It leaks from the mitochondria to other cellular structures and then to the blood vessels. The target tissue is then irradiated with photo-activating light (blue light – 417 nm for epidermal lesions; red light – 630 nm for deeper lesions). Porphyrins are able to convert from a ground state to a singlet and finally to a triplet state possessing a longer lifetime. If tissue oxygen is present, an interaction occurs and singlet oxygen is created. This singlet oxygen oxidizes amino acids, DNA and lipids causing molecular cross-linking. Preferential inactivation of bcl-2 occurs; cytochrome c leaks from the Mitochondrial membrane and activates caspase-3 and get apoptosis.
  • 120. Name 5 diseases that respond to PDT Actinic keratosis (FDA indication) Actinic cheilitis Bowen’s disease Psoriasis CTCL Superficial BCC Acne Condylomata
  • 122. Vasculitis classification by vessel size and examples of each.
  • 123. List advantages to using nb-UVB (311-313 nm) 1. nbUVB is less erythemogenic than broad-band UVB (BB) 2. More effective for treatment of psoriasis than BB -higher clearance rates and duration of remission; though lower than PUVA 3. As effective as PUVA for vitiligo 4. More convenient than PUVA (no oral medication or bath required) 5. Possibly less long-term risk of photocarcinogenesis than PUVA (but long-term data lacking)
  • 124. EBM
  • 125. Sensitivity: Proportion of people who actually have disease that test positive Negative result of a sensitive test rules out disease “SnOut” Test with high sensitivity: won’t miss anyone who has disease (but will also have false positives) eg, negative ANA helps rule out SLE Specificity: Proportion of patients without the disease that test negative Specific test will rarely misdiagnose people who don’t have disease as diseased Positive result on specific test rules in disease “SpPin” eg, positive anti-Sm makes you pretty confident that someone has SLE PPV: Proportion of people with positive test who actually have the disease PPV increases with disease prevalence NPV: Proportion of people with negative test who truly do not have disease NPV decreases with increasing disease prevalence Odds ratio: Ratio of odds of exposure among those with and without outcome of interest Measure of risk in a case-control study “the equivalent of relative risk in a case-control study” – R. Hayes
  • 126. p-value: the likelihood that an observed association has arisen by chance alone -(whereas, in fact, no such association exists) low p-value (eg, < 0.05) is statistically significant (but may not be clinically significant) -difference observed in study would be expected to occur by random chance alone in less than 5% of repetitions of study CI: range of plausible values a measure of precision; width corresponds to most likely range of values to contain the true value
  • 127. clinical difference between SCLE and DLE (list 5): SCLE vs DLE 1. SCLE no scarring vs DLE scarring 2. SCLE despite the name, at least 50% of patients meet the criteria for a diagnosis of SLE (75% have arthralgia or arthritis, 20% have leucopenia, 80% have +ANA) vs DLE no associated systemic involvement and rare to progress to SLE ~5% patients 3. drug-induced SCLE vs no drug induced DLE 4. SCLE +ANA ~80% vs <5% +ANA (if positive, may progress to SLE) 5. SCLE: scaly papules, which evolve into either psoriasiform, more commonly, or polycyclic annular lesions (scale is thin, easily detached, telangiectasis and dyspigmentation are nearly always present – follicles are not involved and there is no scarring) vs DLE: dull red macules with adherent scales extending into patulous follicles (remove scale, undersurface has carpet tack scale – horny plugs that fill the follicles), patches heal centrally first, with atrophy, scaring, dyspigmentation and telangiectasia.
  • 128. DLESCLEDifference +-Scaring -+Drug induce 5%50%Symptoms of SLE 5%80%ANA +VE dull red macules with adherent scales extending into patulous follicles (remove scale, undersurface has carpet tack scale – horny plugs that fill the follicles), patches heal centrally first, with atrophy, scaring, dyspigmentation and telangiectasia. scaly papules, which evolve into either psoriasiform, more commonly, or polycyclic annular lesions (scale is thin, easily detached, telangiectasis and dyspigmentation are nearly always present – follicles are not involved and there is no scarring Lesions
  • 129. List 6 clinical features that may suggest a subungual melanoma in a patient with melanonychia 1. melanonychia which begins in a single digit of a person during 4th-6th decade of life or later (however, subungual melanoma has been seen in children) 2. melanonychia develops abruptly in a previousl normal nail plate 3. it becomes suddenly darker or wider 4. occurs in either thumb, index finger or great toe 5. occurs singly in the digit of a dark-skinned patient, particularly if the thumb or great toe is affected 6. demonstrates blurred, rather than sharp, lateral borders 7. occurs in a person who gives a history of malignant melanoma 8. occurs in a person in who the risk of melanoma is increased (dysplastic nevus syndrome) 9. is accompanied by nail dystrophy, such as partial nail destruction or disappearance 10. occurs in a person who gives a history of digital trauma (several authors have implicated trauma in the pathogenesis of subungual melanoma) 11. Hutchinson’s sign: periungual spread of pigmentation to the proximal and lateral nail folds as well as to the tip of a single digit (corresponds to the radial growth phase of subungual melanoma)
  • 131.  Hutchinson’s sign  single nail vs multiple nails  blurred margin  proximal portion of band is wider than distal  history of change (size, color)  accompanying nail dystrophy Red Flag
  • 132. List 3 nail signs seen in liver disease - Terry’s nails - Muehrcke lines (from hypoalbuminemia) - clubbing.
  • 133. Skin diseases/syndromes with cardiac involvmet Cardiac involvmentDisease tetralogy, Ao aneurysm, ASD, pulm artery stenosis, spont large vessel rupture, mitral regurg, valvular prolapse EDS( 1,2,4,5) dissecting Ao aneurysms, mitral and Ao regurgitation, MVP Marfans Ao aneurysm, cor pulmonale, peripheral pulmonic stenosis, MVP Cutis laxa rhabdomyosarcoma (TS rhabdomyoma), renovasc HTN, pulm stenosis NF-1 AV fistula esp pulm, pulmonary HTNOsler-weber-rendu accelerated atherosclerosis, HTNProgeria atrial myxomasCarney complex pulmonary stenosisWatson synd atherosclerosisHomocysteinuria arrythmias with heart block, cardiac failure Refsum disease
  • 134. The 2013 Contact Allergen of the Year ?? methylisothiazolinone Methylisothiazolinones are biocidal preservatives added to bubble solutions, bubble baths, soaps and cosmetic products diaper wipes
  • 135. AllergenYear Formaldehyde biocidal preservative used in a wide range of products, such as tissue specimen and cadaveric preservation solutions, nail polish, Brazilian blowout treatments and wrinkle-free fabrics 2015 Benzophenones sunscreens, perfumes, soaps, nail polish, hair sprays and dyes, body washes, body moisturizers, shampoos, paints, pesticides, textiles, inks, adhesives and plastic lens filters used in color photography 2014 Methylisothiazolinone biocidal preservatives added to bubble solutions, bubble baths, soaps and cosmetic products 2013 Acrylic acid artificial nails, dental cements and composite dental resins.2012 Dimethyl fumarate (DMF) shoe dermatitis , sofa dermatitis2011 Neomycin medicated ophthalmic and antibiotic drops, deodorants, soaps and root canal fillings 2010 Mixed Dialkylthiourea synthetic rubbers used in car parts, diving and sports gear and orthopedic medical devices 2009 Nickel2008
  • 136. Relationship of h.pylori to skin diseases Chronic urticaria Rosacea Psoriasis Sjogren syndrome Others : sweet, henoch schonlein purpura,lichen planus
  • 137. What is R.E.M Disease Reticular erythematous mucinosis Midline mucinosis It most often affects middle-aged women
  • 138. What are systemic photoprotective agents b. Caroten Antimalaria Ascorbic acid Retinol Green tea Antihistamines Aspirin Indomethacin corticosteroids
  • 139. What is angry back ? excited skin syndrome •Strong patch test reactions may induce a state of hyperirritability (“angry back”) in which negative tests appear as weakly positive
  • 140. Give one MOA of why neutrophils are seen in psoriasis plaques •In psoriasis TNF-is a major cytokine which induces the expression of IL-8, which enhances accumulation of neutrophils and T-lymphocytes. •IL-8 is chemotactic for neutrophils and T-lymphocytes. It also activates neutrophils.
  • 141. Give 8 skin types of TB : a) exogenous exposure/direct inoculation: 1. primary TB chancre 2. TB verrucosa cutis (warty tuberculosis, prosector’s wart) b) endogenous infection : 3. scrofuloderma 4. acute miliary TB 5. lupus vulgaris 6. tuberculous gumma (metastatic tuberculous ulcer) 7. orificial tuberculosis (autoinoculation) c) Tuberculids: 8. papulonecrotic eruption, 9. lichen scrofulosorum 10. erythema induratum of Bazin
  • 144. primary TB chancreTB verrucosa cutis
  • 147. papulonecrotic eruption erythema induratum of Bazin
  • 149. Pregnant and chickenpox Common complication of chickenpox in pregnant women ? Pneumonia ------10 – 20% What are the Risk factors for varicella pneumonia during pregnancy? - Smoking - Number of lesions more than 100
  • 150. What is risk of developing congenital varicella syndrome? congenital varicella syndrome is uncommon The risk is greatest when infection occurs during the first 20 weeks of pregnancy The absolute risk of embryopathy after maternal varicella infection in the first 20 weeks of pregnancy is approximately 2%. Features of congenital varicella syndrome
  • 151. Clinical features of congenital varicella syndrome — Congenital varicella syndrome, first described in 1947, is characterized by the following findings : - Cutaneous scars in a dermatomal pattern - Neurological abnormalities (eg, mental retardation, microcephaly, hydrocephalus, seizures, Horner’s syndrome) - Ocular abnormalities (eg, optic nerve atrophy, cataracts, chorioretinitis, microphthalmos, nystagmus) - Limb abnormalities (hypoplasia, atrophy, paresis) - Gastrointestinal abnormalities (gastroesophageal reflux, atretic or stenotic bowel) - Low birth weight Congenital varicella syndrome is associated with a mortality rate of 30 percent in the first few months of life and a 15 percent risk of developing herpes zoster in the first four years of life
  • 153. maternal antibody can develop and transfer via the placenta Maternal infection that develops more than 2 days after delivery is associated with onset of disease in a newborn approximately 2 weeks later, at which point the immune system is better able to respond to the infection.
  • 154. Where are the hyphae in the most common form of onychomycosis Distal/lateral subungual- close to the nail bed at the lowest portion of the nail plate
  • 155. AGEP (Acute generalized exanthematous pustulosis) 1. List the 2 most common antibiotic causes B-lactams, macrolides (Bolognia) 2. Describe the histology Spongiform pustules within and just under the stratum corneum. Some papillary dermal edema, and perivascular infiltrate with eosinophils 3. List 2 clinical dDx Pustular psoriasis, Sneddon-Wilkinson
  • 156. 4. Most common lab finding 1- Hi WBC (with increased neuts). Can also get some eosinophilia 2- transient renal dysfunction 3- hypocalcemia. 5. Treatment Drug withdrawal topical corticosteroids supportive measures (including antipyretics) 6. Any way to confirm the diagnosis with a diagnostic test? Patch testing
  • 158. How can you differentiate etween AGEP and Pustular Ps ? - The pustules seen in both diseases are clinically indistinguishable - Additional skin lesions, including petechiae, purpura, atypical target-like lesions and vesicles, are more frequently observed in AGEP. - the acuteness of the disease and the drug history in AGEP (( 1-2 Days)) - The histologic findings can be helpful. Massive edema in the superficial dermis, vasculitis, exocytosis of eosinophils, and necrosis of keratinocytes are all suggestive of AGEP, whereas acanthosis is more characteristic of pustular psoriasis AGEP seems to be seen more frequently in patients with a history of psoriasis, thus making the differential diagnosis even more difficult in some patients.
  • 159. Histo: differentiate by 2 H +E methods the following: Steatocystoma from epidermoid cyst Sebaceous gland in wall, thin keratinized cuticle lining cyst without granular layer.
  • 161. Pagets from bowens No intercellular bridges, mucin is +ve
  • 162. Dariers from hailey-hailey More dyskeratosis, less diffuse acantholysis (ie no dilapidated brick wall)
  • 164. GA from NLD Central mucin (as opposed to central necrobiosis), much fewer plasma cells
  • 166. Name the immunostain the distinguishes the two (positive for the 1st, negative for the 2nd) 1. merkel vs bowens paranuclear dot CK20 or “pankeratin” 2. extramamm pagets vs bowens LMWK (CAM 5.2 = cytokeratins 8, 18) 3. melanoma vs langerhans histiocytosis HMB-45, Melan-A/MART-1 4. angiosarcoma vs atypical fibroxanthoma CD31 5. DFSP vs DF CD34
  • 167. DFSPangiosar coma extramamm pagets melanomamerkel CD34DF LMWK (CAM 5.2 = cytokeratins 8, 18) paranuclear dot CK20 bowens HMB-45, Melan- A/MART-1 langerhans histiocytosis CD31atypical fibroxantho ma +VE -VE
  • 168. Describe the 2 mechanisms for drug-induced pemphigus and describe what happens to the eruption once the drug is discontinued 1) direct interference with or non-immune destruction of adhesion molecules (DG1, DG3) resulting in acantholysis. This tends to be linked to thiol (-SH) containing drugs (penicillamine, ACEi, gold). 2) Induction of antibody reaction against DGs, possibly through modification of the DGs to make them more antigenic. This mechanism tends to be linked to drugs without thiol groups (antibiotics, nifedipine, propanolol, piroxicam, phenobarb). The active component in this group may be an amide. Generally, patients remit when drug is d/ced. Some may progress to PV. Non-thiol drugs have a worse prognosis than thiol drugs because of the non-thiols’ association with antibody generation. (E-Medicine)
  • 169. name 2 tumours which can be acantholytic and have an impact on the prognosis of the tumour 1- Acantholytic SCC – poorer px (3-10x increased risk of mets) 2- Acantholytic AK – less responsive to cryotx
  • 170. •AKs: what are 3 clinical variants? hypertrophic, pigmented, actinic cheilitis, atrophic What are 5 histological variants? Hypertrophic (lichenoid is variant of this), atrophic, pigmented, bowenoid, acantholytic •What are 8 ways to treat AKs? 1. LN2 2. 5FU topically (2.5%, 5%, 0.5% Carac) 3. topical diclofenac (Solaraze gel) 4. Imiqimod cream 5. Chemical peel – Jessner’s/TCA 6. ALA-PDT 7. Shave excision or curettage 8. Systemic retinoid (acitretin) 9. CO2 for actinic chelitis
  • 171. •What are 5 clinical variants of MF (besides patch, plaque or tumour) 1- clinical variants such as bullous and hyper- or hypopigmented MF have a clinical behaviour similar to that of classical MF and are therefore NOT CONSIDERED separately – Bolognia 2- Follicular MF (MF-associated follicular mucinosis) 3- Pagetoid reticulosis (Woringer-Kolopp disease-localized type) 4- Granulomatous slack skin
  • 172. How do you differentiate clinically b/w Vitiligo and Leprosy? Leprosy is more hypopigmented than depigmented, it can have raised lesions (plaques, nodules), it can have overlying sensory change, it can have associated nerve enlargment
  • 173. Different types of Miliaria and their microscopic locations? 1- Crystallina (stratum corneum aspect of acrosyringium), 2- rubra (stratum spinosum) 3- pustulosa (is a type of miliara rubra) 4- profunda (upper dermis/DEJ).
  • 174. Tinea Pedis 4 types 1- moccasin - T. ruburm/E. floccosum - Difficult to clear b/c low immunogenicity limits host response 2- Interdigital - T. mentag/rubrum, E. floccosum - Usually last 2 webs. Assoc with dermatophytosis complex 3- Inflam/vesicular - T. mentag - Assoc with dermatophytid on hands 4- Ulcerative - T. rubrum, menta, E. floccosum - Erosive changes in webs seen with immunosupp, diabetes
  • 175. 4 complications 1- dermatophytosis complex – bacterial superinfection 2- dermatophytid rxn 3- cellulitis (those with venous HTN) 4- osteomyelitis (diabetics)
  • 176. List 5 side effects of PUVA Short-term: 1. Nausea and vomiting (oral PUVA) 2. Redness/swelling/blistering 3. Hyperpigmentation 4. Persistent pruritis Long-term: 5. Cataract formation (oral PUVA; although no clinical evidence of risk) 6. Dermatoheliosis 7. PUVA lentigines 8. Increased risk of SCC (> 200 treatments means 30x ↑ risk of SCC)
  • 177. What are painfull skin tumors "LEND AN EGG". - Leiomyoma - Eccrine spiradenoma - Neuroma - Dermatofibroma - Angiolipoma - Neurilemmoma - Endometrioma - Glomus tumor - Granular cell tumor
  • 178. Dermatosis on the shin of tibia Itchy : 1.Lichen simlex chronicus 2.Hyperk. LP 3.Lichen amyloidosus 4.Prurigo nodularis 1.Erythema nodosum 2.NBLD 3.Ecthyma 4.Pretibial myxedema Non itchy :
  • 179. Dermatoses with island of normal skin PRP MF BB
  • 180. Dermatoses on the posterior aspect of the leg Nodular vasculitis (erythema induratum of Basin)
  • 181. List causes of genital ulcers Sexually transmitted diseases 1- Herpes simplex 2- Syphilis 3- LGV 4- Chancroid 5- Granuloma injuinale 6- Scabies 7- HIV Non sexually transmitted diseases 1- fixed drug eruption 2- malignant ulcer 3-bollouse diseases 4- traumatic ulcer 5-herpes zoster 6-erosive balanitis 7- tuberculosis ulcer
  • 184. 2014 Year in Review
  • 185. Infectious Disease FDA Approves Two Topical Treatments for Onychomycosis Currently, oral terbinafine provides the best reported cure rates dermatologists are in need of safer and more efficacious treatment options 1- Topical efinaconazole 10% solution the first topical triazole to receive FDA approval for the treatment of toenail onychomycosis. 2- tavaborole 5% solution While efinaconazole and tavaborole do not appear more efficacious than systemic antifungals, they provide safe treatment alterantives
  • 188. New Antibiotics Approved for Treatment of Skin Infections Several new agents have efficacy and safety profiles similar to vancomycin or linezolid in the treatment of acute cellulitis, wound infections and abscesses, including infections caused by methicillin-resistant Staphylococcus aureus (MRSA). Dalbavancin was FDA approved on May 23, 2014 for the treatment of acute bacterial skin and skin structure infections (ABSSSI) caused by S aureus and Streptococcus pyogenes.4 Two doses of intravenous (IV) dalbavancin (1 g IV on day 1 and 500 mg IV on day 8) were as effective as a 3-day dose of IV vancomycin (1 g every 12 hours) with or without extension of therapy 10 to 14 days with oral linezolid (600 mg every 12 hours). Clinical success was observed in 91% of patients treated with dalbavancin and 94% of patients treated with vancomycin with or without linezolid. Adverse events of nausea, diarrhea and pruritus were reported less in the dalbavancin group than the vancomycin group with or without linezolid.
  • 190. Tedizolid phosphate was also approved by the FDA on June 20, 2014, for the treatment of ABSSSI. This second-generation oxazolidinone was evaluated in 2 Phase III trials (ESTABLISH-1 and ESTABLISH-2), which demonstrated non- inferiority in the group receiving tedizolid phosphate 200 mg once daily for 6 days compared to linezolid 600 mg twice daily for 10 days.5 The most common adverse events, such as nausea and diarrhea, were reported less in the tedizolid phosphate groups in both studies
  • 192. Oritavancin received FDA approval in August 2014 Two Phase III studies (SOLO I and SOLO II) demonstrated that a single 1,200 mg IV dose of oritavancin yielded similar efficacy to a 7- to 10-day IV dose of vancomycin.7,8 The incidence of adverse events was also slightly less in the oritavancin group. The more desirable safety profiles, as well as the likelihood for greater patient adherence with shorter and more convenient dosing, make these new antibacterial agents a promising option, particularly in the treatment of MRSA infections.
  • 193. Innovative Treatment for Recurrent Herpes Labialis Once daily, high dose, oral antiviral drugs have long been the mainstay of herpes labialis treatment. Acyclovir Lauriad (Sitavig, Innocutis), is a novel mucoadhesive buccal tablet (MBT) that delivers a high concentration of acyclovir directly to the affected site through the mucous membrane.9 It is recommended to apply the 50 mg MBT at the onset of prodromal symptoms to the upper gum. Phase III trials using a single application of the 50 mg acyclovir Lauriad MBT yielded greater improvement in symptoms, reduced outbreak duration and reduced recurrence compared with placebo.10 This is exciting news for dermatologists and patients alike, as this innovative treatment serves to combat the often debilitating and stigmatizing symptoms of herpes labialis
  • 195. Topical Ivermectin for Papulopustular Rosacea Papulopustular rosacea (PPR) is a chronic inflammatory disorder that has limited treatment options; however, a new topical therapy may be on the horizon. The results of 2 randomized, double-blind, vehicle-controlled studies published in March 2014 found once-daily ivermectin 1% cream (Galderma Laboratories) to be more effective than vehicle in treatment of moderate-to-severe PPR. About 40% of subjects using ivermectin 1% cream achieved Investigator’s Global Assessment (IGA) of clear or almost clear at 12 weeks, compared to about 12% to 18% with vehicle (P<.001 in both studies).14 A Phase III, investigator-blinded, randomized, parallel group study published in September 2014 found once-daily ivermectin 1% cream to be superior to twice-daily metronidazole 0.75% cream (84.9% vs 75.4%, respectively, of subjects achieving IGA of clear or almost clear; P<.001).15 Adverse events were comparable between groups, and local tolerability was superior with ivermectin
  • 198. Psoriasis and Related Biologics Apremilast Approved for Plaque Psoriasis On March 21, 2014, apremilast (Otezla, Celgene Corporation) was approved by the FDA for the treatment of adults with active psoriatic arthritis.17 On September 23, 2014, the treatment received an expanded indication for patients with moderate-to-severe plaque psoriasis who are candidates for phototherapy or systemic therapy. Apremilast is an oral inhibitor of phosphodiesterase 4, which results in increased intracellular cyclic adenosine monophosphate, which indirectly modulates the production of inflammatory mediators Most common side effects reported include diarrhea, nausea, upper respiratory tract infection and headache
  • 199. Cutaneous Malignancy Programmed Death Inhibitor for Refractory Melanoma On September 4, 2014, pembrolizumab(Keytruda, Merck & Co., Inc.) received accelerated FDA approval and is the first programmed death-1 (PD-1) inhibitor in the United States for the treatment of advanced melanoma The most commonly reported averse events were fatigue, arthralgia, pruritus and rash; immune-mediated adverse events with pembrolizumab included hyperthyroidism and hypothyroidism (9.4%), pneumonitis (2.9%), colitis (1%), nephritis (0.7%), hepatitis (0.5%) and hypophysitis (0.5%).
  • 200. Smoothened Inhibitors for Treatment of Advanced Basal Cell Carcinoma
  • 201. FDA Mandates Black Box Warning for Sunlamp Products On May 29, 2014, the FDA reclassified sunlamp products (including tanning beds and booths) and ultraviolet (UV) lamps from low-risk (Class I) to moderate- risk (Class II) devices
  • 202. Systemic Propranolol for Infantile Hemangiomas The FDA approved propranolol hydrochloride (Hemangiol, Pierre Fabre Dermatologie) in March 2014 Based on the trial, the most effective dose was 3 mg/kg/day using twice-daily dosing.49 Previous consensus reports recommended treatment with propranolol 1 to 3 mg/kg/day divided into 3 times a day dosing with a minimum of 6 hours between doses.
  • 204. Anti-Depressant Effects of OnabotulinumtoxinA A study published in the Journal of Clinical Psychiatry in August 2014 suggested that there may be more benefit to botulinum toxin treatment than meets the eye.58 A randomized, double-blind, placebo-controlled trial demonstrated that patients receiving onabotulinumtoxinA (Botox, Allergan) in the glabellar region had statistically significant improvement in depressive symptoms compared to placebo, based on the 21-item Hamilton Depression Rating Scale (HDRS-21). HDRS-21 scores decreased by 46% and 35% in the first and second treatment groups, respectively, versus a 2% drop in the placebo group (P< .0001). The improvement in major depressive disorder symptoms was sustained over 24 weeks, even after the cosmetics effects had worn off around 12 to 16 weeks
  • 205. Topical Botulinum Toxin Type A in Phase III Trials A topical gel formulation of botulinum toxin (RT001, Revance Therapeutics) is undergoing Phase III trials in the United States for the treatment of lateral canthal lines (commonly referred to as crow’s feet). RT001 has the potential to be the first approved non- injectable botulinum toxin product. This topical formulation will be used to treat wrinkles caused by superficial muscle groups.59 Deeper muscles, like those in the glabellar area, will likely continue to require injectable botulinum toxin for best outcomes. The topical botulinum toxin will also be aimed at treatment of hyperhidrosis. A second product formulated by the same company, RTOO2, is a novel injectable formulation of botulinum toxin type A targeted toward longer lasting effects when compared with currently available toxins
  • 206. Omalizumab for Treatment of Urticaria an anti-IgE receptor antibody, was approved earlier this year for treatment of chronic idiopathic urticaria Omalizumab 300 mg administered subcutaneously every 4 weeks
  • 208. JAK Inhibitors for Treatment of Alopecia Areata In a letter to the editor in the Journal of Investigative Dermatology in June 2014, a team of researchers reported a case of reversal of hair loss in a patient with alopecia universalis taking toficitinib citrate (Xeljanz, Pfizer, Inc.), a Janus kinase (JAK) inhibitor, for treatment of plaque psoriasis.63 Researchers at Columbia University Medical Center later published data related to the identification of key immune mediators related to the JAK pathway that are thought to be involved in the destruction of hair follicles by T cells in patients with alopecia areata.64 They additionally reported a small study of 3 patients with alopecia areata treated with the JAK inhibitor ruxolitinib (Jakafi, Incyte Corporation) who had significant regrowth of hair over 5 months. This is an exciting discovery in the field of hair loss, and further studies are underway to delineate the clinical and pathophysiologic role JAK inhibitors play in alopecia areata.
  • 209. Sirolimus, also known as rapamycin (SRL, Rapamune®) potent immunosuppressant, anti-angiogenic and anti-proliferative properties Skin Cancer in Solid Organ Transplantation Kaposi’s Sarcoma Cutaneous T-Cell Lymphomas Tuberous Sclerosis Pachyonychia Congenita Psoriasis Graft Versus Host Disease (GVHD) Anti-Aging