1) This document discusses several dermatopathology cases with images and histology findings. 2) Case 1 is diagnosed as syringoma, characterized by cords and strands of epithelial cells with scattered lumens often lined with clear cells. 3) Case 2 is diagnosed as extramammary Paget's disease, characterized by large epidermotropic cells with bluish cytoplasm forming nests beneath a compressed basal layer.

1. Dermatopathology
1) Both mesenchymal and epithelial elements may be found in this tumor:
A. Bednar tumor
B. Cylindroma
C. Chondroid syringomaCorrect Choice
D. Microcystic adnexal carcinoma
E. Folliculosebaceous cystic hamartoma
Cutaneous mixed tumor, also known as Chondroid syringoma, represents an acquired hamartoma
with folliculosebaceous-apocrine differentiation that has been generally interpreted as a form of
adnexal adenoma (neoplasm). It has both a mesenchymal and epithelial component
2) What is the diagnosis?
A. Papillary eccrine adenoma
B. SyringomaCorrect Choice
C. Adenoid cystic carcinoma
D. Trichoadenoma
E. Dermal duct tumor
This is a syringoma, in which there are small cords and strands of epithelial cells, some in a
“tadpole” configuration. There are scattered lumens, often lined with clear cells, with a bluish
substance within them. No horn cysts are present
3) The diagnosis is:
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A. clear cell Bowen's disease
B. extramammary Paget'sCorrect Choice
C. epidermotropic sebaceous carcinoma
D. epidermotropic Merkel cell carcinoma
E. epidermotropic balloon-cell melanoma
In extramammary Paget’s disease, there are epidermotropic, large cells with a bluish cytoplasm. At
times these cells can form “nests”, but in general, there is usually a compressed basal layer beneath
the “nests”.
4) This is a desmoplakin:
A. Plakophilin
B. Plakoglobin
C. BPAg1 Correct Choice
D. Beta-catenin
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2. E. Desmocollin
Desmoplakins include desmoplakin 1, BPAg1, envoplakin, and periplakin
5) Histologically, adenoma sebaceum represent which of the following lesions?
A. Angiokeratomas
B. Angiofibromas Correct Choice
C. Collagenomas
D. Neurofibromas
E. Smooth muscle hamartomas
Adenoma sebaceum, fibrous papules and pearly penile papules all have similar features
histologically, presenting as angiofibromas. Features include atrophic epidermis with patchy
melanocytic hyperplasia and hyperkeratosis, vertically oriented collagen, increased fibroblasts and
blood vessels
6) Lipomembranous change is seen in:
A. Sclerosing panniculitis Correct Choice
B. Sebaceous carcinoma
C. Cystic sebaceous adenoma
D. Hibernoma
E. Mucocele
Lipomembranous change is a non-specific histologic pattern that is most commonly seen in
lipodermatosclerosis, which is also known as sclerosing panniculitis; this condition may be
secondary to venous stasis
7) The diagnosis is:
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A. sarcoidosis
B. foreign body
C. lupus miliaris et disseminata
D. lichen nitidusCorrect Choice
E. lymphocytoma cutis
8) What is the diagnosis?
A. Pilomatrixoma
B. Metastatic carcinoma
C. Tattoo
D. Wood splinter
E. Calcinosis cutisCorrect Choice
This is calcinosis cutis, in which there is calcification (blue chunky material) in the dermis
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3. 9) The diagnosis is:
A. Neurilemmoma
B. Granular cell tumor
C. Xanthoma Correct Choice
D. Reticulohistiocytoma
E. Neuroma
NEEDS EXPLANATIONS
10) The diagnosis is:
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A. spiradenoma
B. mastocytosis
C. hidradenoma
D. glomangiomaCorrect Choice
E. Kimura's
In glomangiomas, one sees multiple lumina lined by cells with pink cytoplasm and indisctinct
borders with very round nuclei. Generally, the lumina are lined by one or two layers of glomus cells.
11) 62-year old female with history of acute myeloid leukemia presents with multiple edematous,
erythematous papules after starting G-CSF.
A. Bowel bypass dermatosis
B. Leukocytoclastic vasculitis
C. Erythema multiforme
D. Polymorphous light eruption
E. Sweet's syndromeCorrect Choice
Sweet's syndrome, or acute febrile neutrophilic dermatoses, is often associated with AML and G-
CSF. Histologically, there is marked dermal edema with a prominent infiltrate composed of
neutrophils with leukocytoclasia. There is an absence of extensive vascular damage
12) Multiple such lesions are seen in this syndrome:
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A. Nicolau and Balus'
B. Alagille's
C. Rubinstein-Taybi's
D. Schopf's
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4. E. Brooke-SpieglerCorrect Choice
In Brooke-Spiegler syndrome, there are multiple trichoepitheliomas, cylindromas, and
spiradenomas. Nicolau and Balus’ syndrome has multiple eruptive syringomas, milia, and
atrophoderma vermiculata. Alagille’s syndrome is the association of arteriohepatic dsyplasia with
nevus comdonicus. Schopf’s syndrome associates multiple hidrocystomas with hypodontia,
palmoplantar hyperkeratosis, and onychodystrophy. In Rubinstein-Taybi’s syndrome, patients are
short of stature with broad thumbs and multiple pilomatricomas
13) This patient has multiple lesions showing the following histology. She has a family history of
such lesions. You check her for:
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A. fumarate hydrataseCorrect Choice
B. transglutaminase
C. epoxide hydrolase
D. sulfatase
E. urease
14) The diagnosis is::
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A. incontinentia pigmentiCorrect Choice
B. pemphigus vulgaris
C. epidermal nevus
D. bullous pemphigoid
E. dermatitis herpetiformis
15) The diagnosis is:
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A. adenoid cystic carcinomaCorrect Choice
B. trichoepithelioma
C. dermal duct tumor
D. syringoma
E. tubular apocrine adenoma
In adenoid cystic carcinoma, there are cords and tubules of basaloid cells, arranged in a cribiform
pattern. The cystic spaces contain a bluish material. Perineural invasion is common. The cells stain
positively for epithelial membrane antigen (EMA).
15) The diagnosis is:
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A. adenoid cystic carcinomaCorrect Choice
B. trichoepithelioma
C. dermal duct tumor
D. syringoma
E. tubular apocrine adenoma
In adenoid cystic carcinoma, there are cords and tubules of basaloid cells, arranged in a cribiform
pattern. The cystic spaces contain a bluish material. Perineural invasion is common. The cells stain
positively for epithelial membrane antigen (EMA
16) For this patient, you request that the lab perform indirect immunofluorescence using what
substrate?
A. Monkey esophagus
B. Mouse epithelium
C. Rat bladder
D. Guinea pig esophagusCorrect Choice
E. Hep-2 cells
This patient has pemphigus folicaceus, and indirect immunofluorescence works best on guinea pig
esophagus
17) This patient may need blood tests to check her:
A. Renal function
B. White blood cell count
C. Liver function
D. ThyroidCorrect Choice
E. Glucose
Herpes gestationis is associated with an increased incidence of Graves’ disease.
18) The diagnosis is:
A. Wegener’s granulomatosis
B. Syphilis
C. Fixed drug reaction
D. Granuloma faciale Correct Choice
E. Angiolymphoid hyperplasia with eosinophilia
NEEDS EXPLANATIONS
19) Multiple clear cell acanthomas are associated with:
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6. A. Immunosuppression
B. Ichthyosis Correct Choice
C. Gastrointestinal polyps
D. Breast cancer
E. Cowden’s
Clear cell acanthoma is associated with ichthyosis
20) The diagnosis is:
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A. metastatic carcinoma
B. Merkel cell carcinoma
C. pyogenic granuloma
D. bacillary angiomatous
E. glomus tumorCorrect Choice
In a glomus tumor, generally vascular spaces are not particularly prominent, and there are cords as
well as solid areas of uniform cells with very monomorphous rounded nuclei
21) The diagnosis is:
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A. Large cell acanthoma
B. Clear cell acanthomaCorrect Choice
C. Hidroacanthoma simplex
D. Poroma
E. White sponge nevus
In a clear cell acanthoma, there is regular acanthosis, often with some parakeratotic scale with
neutrophils overlying it. The keratinocytes making up the thickened epidermis are often clear, or
pale, due to an increased glycogen content secondary to a deficiency of phosphorylase. There is
often a very abrupt demarcation at the margins of the acanthotic pale/clear cells and the normal
epidermis
22) The gene defect:
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A. DSG3
B. ATP2A2
C. ATP2C1Correct Choice
D. SERCA2
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7. E. CHRNA9
In Hailey-Hailey disease, there is full-thickness acantholysis of the epidermis. The gene defect is in
ATP2C1
23) This tumor is vimentin+ and cytokeratin+:
A. Neurothekeoma
B. Dermatofibroma
C. Angiosarcoma
D. Epithelioid sarcoma Correct Choice
E. Nodular fasciitis
Characteristic immunohistochemistry of epithelioid sarcoma is vimentin- and cytokeratin- positivity
24) The diagnosis is:
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A. argyriaCorrect Choice
B. minocycline-induced pigmentation
C. hemochromatosis
D. ochronosis
E. gold effect
In argyria, the silver deposits (black particles) are often seen around eccrine glands.
25) The diagnosis is:
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A. traumatic neuroma
B. acral angiofibroma
C. accessory digit
D. Koenen's tumor
E. acquired digital fibrokeratomaCorrect Choice
This is an acquired digital fibrokeratoma, with a thickened stratum corneum indicating an acral
location and an absence of nerves in the dermis. Collagen is increased in the dermis
26) With immunofluorescence, the most likely pattern would be:
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A. granular IgG
B. granular IgACorrect Choice
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8. C. linear IgG, IgM, C3, and IgA
D. tubular IgG
E. linear IgM
In dermatitis herpetiformis, there are characteristic clusters of neutrophils at the tips of dermal
papillae. Immunofluorescence will show granular IgA in the dermal papillae. Neutrophils at the
dermo-epidermal junction of a bulla can also be seen in bullous systemic lupus erythematosus,
linear IgA disease, neutrophilic bullous pemphigoid, and inflammatory epidermolysis bullosa
acquisita
27) The diagnosis is:
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A. epidermal nevus
B. poromaCorrect Choice
C. bowenoid papulosis
D. large cell acanthoma
E. verruca
In a poroma, there is a down-growing epidermal proliferation composed of uniform cells, often with
indistinct cytoplasmic borders that have rounded, monomorphous nuclei. Within this proliferation,
there are often ducts lined by an eosinophilic cuticle
28) Which immunohistochemical stain would be positive in eosinophilic granuloma?
A. Congo red
B. Mucin
C. Cytokeratin 20
D. CD1aCorrect Choice
E. HMB-45
Eosinophilic granuloma is a form of Langerhans Cell Histocytosis (LCH), previously called
Histiocytosis X. Eosinophilic granuloma is a localized, benign form which is more common in males
and generally affects the bones. All forms of LCH are characterized by the infiltration of Langerhans
cells on pathology, which staing for S-100, CD1a and contain cytoplasmic birbeck granules
29) What is the diagnosis?
A. Lichen nitidusCorrect Choice
B. Lupus
C. Lichen planus
D. Lichen planus-like keratosis
E. Lichen striatus
The histologic features shown are indicative of lichen nitidus. Lichen nitidus has a very characteristic
"claw clutching ball" appearance where the rete ridges extend downward around a lichenoid
infiltrate
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9. 30) An increased number of miniaturized hairs are seen in:
A. Lichen planopilaris and alopecia areata
B. Alopecia areata Correct Choice
C. Trichotillomania
D. Lichen planopilaris
E. Telogen effluvium
In alopecia areata, especially early stages, increased miniaturized catagen hairs can be seen in
addition to the finding of peribulbar lymphocytes resembling a “swarm of bees.” Lichen planopilaris
is a scarring alopecia in which vertical tracts of fibrosis are seen in place of follicles. Trichotillomania
displays follicular plugging, trichomalacia, pigmented casts, hemorrhage, and increased catagen
hairs on biopsy. Telogen effluvium is characterized by an increased number of telogen hairs
31) The diagnosis is:
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A. Monsel's reaction
B. chrysiasis
C. amalgam tattoo
D. minocycline-induced pigmentation
E. ochronosisCorrect Choice
In ochronosis, there is slightly thickened banana-shaped collagen in the superficial dermis that
appears yellow-brown in color
32) The diagnosis of this biopsy is:
A. Erythema nodosum
B. Polyarteritis nodosaCorrect Choice
C. Granuloma annulare
D. Leukocytoclstic vasculitis
E. Reumatoid nodule
Polyarteritis nodosa is a necrotizing vasculitis of medium-sized arteries in the derma-subcutaneous
junction. It is a septal panniculitis as a result of vasculitis. There is more fibrinous changes than in
thrombophlebitis and less necrosis than erythema induratum
33) What is the pathologic diagnosis of this lesion?
A. Acanthosis nigricans
B. Verruca planaCorrect Choice
C. Seborrheic keratosis
D. Normal skin
E. Epidermal nevus
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10. The histologic characteristics of verruca plana are presence of hyperkeratosis and acanthosis.
Koilocytes appear in the upper one-third of the epidermis
34) Similar follicles can be seen on skin from the:
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A. fiinger
B. glans penis
C. nose
D. labia majora
E. eyelidCorrect Choice
Vellus hair follicles are seen commonly in accessory tragic and eyelid skin
35) The diagnosis is:
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A. Bowen's disease
B. melanoma
C. sebaceous carcinoma
D. pagetoid reticulosis
E. Paget's diseaseCorrect Choice
In Paget’s disease, there are epidermotropic cells in a variably acanthotic epidermis. The
epidermotropic cells have abundant cytoplasm that is often blue-gray in color. The cells are single
or in nests throughout the epidermis. There should be a compressed rim of basal cells beneath
nests that are located near the dermoepidermal junction
36) The diagnosis is::
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A. mixed tumor
B. follicular mucinosisCorrect Choice
C. alopecia areata
D. lichen planopilaris
E. pityrosporum folliculitis
37) Eosinophils are typically found in each of the following except:
A. Incontinentia pigmenti
B. PlasmacytomaCorrect Choice
C. Urticaria
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11. D. Lichenoid drug reactions
E. Pemphigus vulgaris
Plasmacytomas are characterized by the presence of monoclonal plasma cells. Plasmacytomas may
occur from primary cutaneous focus or secondarily from myeloma
38) The diagnosis is:
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A. Merkel cell carcinomaCorrect Choice
B. neuroblastoma
C. plasmacytoma
D. Lymphoma
E. melanoma
This is a Merkel cell carcinoma, in which there is a dense collection of small blue cells with scant
cytoplasm in the dermis. The cells are sometimes arranged in trabeculae and other times in
nodules. The cells appear very blue on low power, and on higher power have somewhat pale nuclei
that have paler/darker foci within them in a salt-and-pepper pattern
39) Which of the following lesions demonstrates a pseudo-Darier’s sign?
A. Mastocytoma
B. Spitz nevus
C. Smooth muscle hamartomaCorrect Choice
D. Pilomatricoma
E. Bullous pemphigoid
Smooth muscle hamartomas are benign tumors which arise from smooth muscle of the dermis.
Pseudo-Darier's sign may be elicited due to transient piloerection after rubbing. Histologically, red-
orange bundles and fascicles are present with blunt-ended nuclei
40) The diagnosis is:
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A. apocrine adenoma
B. amyloidosis
C. Masson's tumorCorrect Choice
D. intravascular pyogenic granuloma
E. papillary digital adenocarcinoma
41) The most likely diagnosis for this painful neoplasm is:
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12. A. Glomus tumor
B. Neurilemmoma
C. Cutaneous endometriosisCorrect Choice
D. Blue rubber bleb nevus
E. Angiolipoma
Cutaneous endometriosis usually occurs after gynecologic surgery. The rich, cellular stroma with
regularly shaped channels and glandular structures are typical. Hemorrhage may also be present in
deeper sections
42) What infectious agent is most likely responsible for this reaction of fibrin and antibodies which
help to prevent phagocytosis?
A. ActinomycosisCorrect Choice
B. Anthrax
C. Candida albicans
D. Ricketsii species
E. Nocardia
Hoeppli-Splendore reaction is characterized histologically by intensely eosinophilic material
consisting of fibrin and antibodies. Causes of the phenomenon include Actinomycosis israelii, Staph
aureus, Proteus, Pseudomonas and E. coli
43) Goblet cells are seen in:
A. Bronchogenic cyst Correct Choice
B. Steatocystoma
C. Cutaneous ciliated cyst
D. Dermoid cyst
E. Endometriosis
Bronchogenic cysts have a pseudostratified cuboidal or columnar lining that is ciliated; goblet cells
are found in the lining as well
44) The diagnosis is:
A. Metastatic carcinoma
B. Mixed tumor Correct Choice
C. Papillary eccrine adenoma
D. Nodular hidradenoma
E. Mucinous carcinoma
NEEDS EXPLANATIONS
45) The most common cause of this in the U.S. is:
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13. A. Microsporum distortum
B. Epidermophyton floccosum
C. Trichophyton rubrumCorrect Choice
D. Microsporum canis
E. Trichophyton mentagrophytes
Trichophyton rubrum is the most common cause of Majocchi’s granuloma, a type of folliculitis where
the dermatophyte likely tracks down the follicle and creates a foreign-body-type inflammatory
reaction in the dermis
46) This patient recently developed this rash. You decide to patch test her, but in the meanwhile
you tell her to avoid:
A. Primin
B. Abietic acid
C. Benzocaine
D. CinnamonCorrect Choice
E. Chamomile
This patient likely has a fragrance allergy. Patients allergic to fragrances also need to avoid certain
spices like cinnamon
47) Multiple such lesions may be seen associated with:
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A. Cowden's
B. Wermer'sCorrect Choice
C. Cowper's
D. Werner's
E. Brooke's
MEN type I (Wermer's Syndrome) is sometmes associated with multiple angiofibromas. Tuberous
sclerosis is also associated with adenoma sebaceum (angiofibromas
48) Turk cells are found in what infection?
A. Rubeola
B. Mumps
C. Roseola
D. Syphilis
E. RubellaCorrect Choice
Turk cells are atypical lymphocytes found in rubella
49) The diagnosis is:
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A. Masson's
B. bacillary angiomatosis
C. hemangioendothelioma
D. fibrosing pyogenic granulomaCorrect Choice
E. apocrine adenoma
50) Which disease process best describes Texier's disease?
A. Deposition disorder
B. PanniculitisCorrect Choice
C. Granulomatous disease
D. Neutrophilic dermatosis
E. Infectious process
Texier's disease is a panniculitis secondary to vitamin K injections causing sclerotic lesions with lilac
borders on the buttocks and thighs resembling a cowboy belt and holster
51) A patient with dystrophic nails and multiple lesions with this histologic finding may have what
gene defect?
A. Phosphorylase
B. Keratin 6b/17Correct Choice
C. Beta-catenin
D. Keratin 6a/16
E. Keratin 1/10
Pachonychia congenita type II (also known as Jackson-Lawler) is a autosomal dominant disorder
characterized by natal teeth, steatocystoma multiplex, and pincer nails. Steatocystomas have cyst
walls that are intricately folded or crenulated. Sebaceous glands are present within the cyst wall
52) What is the diagnosis?
A. Warty dyskeratoma
B. Molluscum contagiosumCorrect Choice
C. Trichilemmoma
D. Ecthyma contagiosum
E. Orf
This is a lesion of Molluscum contagiosum, in which there is a lobulated down-growth (cup-shaped)
of keratinocytes; centrally towards the surface, the keratinocytes are enlarged with cytoplasmic
pink inclusions (Henderson-Patterson bodies
53) Multiple such lesions can be associated with:
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A. Gaucher's
B. Sipple's
C. fucosidosisCorrect Choice
D. Louis-Barr
E. Bourneville's
multiple angiokeratomas in a bathing trunk distribution may be associated with Fabry's disease
(angiokeratoma corporis diffusum) or fucosidosis as well as some other storage diseases as well as
possibly being a normal finding. There has been a recent report of angiokeratomas in a bathing
trunk distribution in a woman with no other signs of a storage disorder
54) What is the diagnosis?
A. Lipoid protinosis
B. Erythrpoietic protoporphyria
C. Lichen sclerosus et atrophicusCorrect Choice
D. Lichen amyolidosus
E. Morphea
This is lichen sclerosus et atrophicus in which there is hyperkeratosis overlying an atrophic
epidermis. Underlying the epidermis is a layer of homogenized light pink collagen. Beneath that,
there is a somewhat band-like inflammatory infiltrate of predominantly lymphocytes, but also
histiocytes and plasma cells
55) What is the diagnosis?
A. Seborrheic keratosis
B. Hidroacanthoma simplex
C. Epidermal nevus
D. Fibroepithelioma of PinkusCorrect Choice
E. Nevus sebaceus
Fibroepithelioma of Pinkus is a form of basal cell carcinoma. Histology shows long, thin,
anastomosing strans of basal cell embedded in fibrous stroma with many connections to the
epidermis
56) A newborn infant presents with bullous lesions. Based upon the pathology, what is the most
likely gene defect causing her skin condition?
A. Keratin 1 and 10
B. PAX3
C. NEMOCorrect Choice
D. Keratin 5 and 14
E. SPINK5
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16. Incontinentia pigmenti is an X_linked dominant genodermatosis which presents in the newborn
period with vesicles in a Blaschkoid distribution. A biopsy would show eosinophilic spongiosis with
dyskeratotic keratinocytes and pigment incontinence. A gene defect in NEMO has been identified as
the cause for the constellation of fingings
57) The most common location for this lesion would be:
A. Upper lip
B. Sole of footCorrect Choice
C. Buttock
D. Finger
E. Groin
Eccrine poroma is a benign, solitary tumor arsing in the lower portion of the epidermis. It is
characterized by small, uniformly cuboidal cells with deeply basophilic nuclei. The tumor mass is
assembled in broad anastomosing bands and may have narrow ductal lumina lined by eosinophilic
cuticle
58) The diagnosis is:
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A. microcystic adenexal carcinoma
B. breast carcinomaCorrect Choice
C. neuroendocrine carcinoma
D. tubular apocrine adenoma
E. infiltrative basal cell carcinoma
The diagnosis is metastatic breast carcinoma. In this example, there is a dense collection of cells
throughout the ermis. On closer examination, tehre are strands/cords of cells as well as some cells
arranged around lumina infiltrating through the dermis
59) Steatocystoma multiplex is associated with:
A. Jackson-Lawler Correct Choice
B. Jadassohn-Lewandowsky
C. Zinsser-Engman-Cole
D. Schaufer-Brunauer
E. Touraine-Solente-Gole
Jackson-Lawler (Jackson-Sertoli) is known as pachyonychia congenital type 2. Multiple steatocysts
can be seen in this condition
60) Weibel-Palade bodies are seen in:
A. Spitz Nevi
B. Endothelial cells Correct Choice
C. Cells infected with MCV
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17. D. Plasmacytoid Cells
E. Malakoplakia
Weibel-Palade bodies are seen in endothelial cells and are therefore found in vascular lesions.
Kamino bodies are found in Spitz nevi. Henderson Patterson bodies are seen in molluscum. Dutcher
bodies are intranuclear inclusions seen in plasmacytoid cells. Michaelis Gutmann bodies are partially
digested bacteria seen in malakoplakia
61) Eosinophilia-Myalgia syndrome is caused by:
A. Norwegian salt-petter
B. Unadultered Spanish grapeseed oil
C. Excessive anaerobic exercise
D. L-Tryptophan Correct Choice
E. Pb intoxication
The eosinophilia myalgia syndrome is characterized by marked peripheral eosinophilia with a clinical
spectrum of signs and symptoms, including generalized myalgias, pneumonitis, myocarditis,
neuropathy, encephalopathy and fibrosis. Many patients progress to a clinical picture clinically
indistinguishable from eosinophilic fasciitis. The disease is caused by the ingestion of certain lots of
L-tryptophan
62) Blue-gray pigmentation on the legs secondary to minocycline on biopsy stains with:
A. Fontana Masson and Perls Correct Choice
B. All of these answers are correct
C. Sudan black
D. Fontana Masson
E. Perls
There are three types of pigmentary change that are caused by minocycline. The blue-gray
pigmentation on the legs and the blue pigment in scars is thought to be secondary to a drug-protein
complex deposited in the dermis. The blue-gray pigment on the legs stains with Perls and Fontana-
Masson. The blue in scars (often on the face) stains with Perls. The muddy-brown discoloration on
sun-exposed areas shows increased basilar pigment and melanin incontinence on biopsy. It is likely
secondary to phototoxicity.
63) The diagnosis is:
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A. Artecoll reaction
B. goutCorrect Choice
C. mucinous carcinoma
D. Urbach-Wiethe's
E. Hunter's
In gout, there are characteristic amorphous light pink masses of material within which it is
sometimes possible to see outlines of needle-like spaces. The urate crystals can only be seen if
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18. alcohol fixation is used. The amorphous material is generally surrounded by histiocytes and foreign-
body giant cells
64) The histologic finding of "shoulder parakaratosis", parakeratosis with prediliection for the
follicular ostia, is characteristic of pityriasis rubra pilaris as well as:
A. Stasis dermatitis
B. Atopic dermatitis
C. Seborrheic dermatitisCorrect Choice
D. Nummular dermatitis
E. Allergic contact dermatitis
Parakeratosis refers to pyknotic keratinocyte nuclei in the stratum corneum, where nuclei are not
usually present. It is common in diseases with changes in the epidermis. Histologically seborrheic
dermatitis can shows "shoulder parakeratosis" with epidermal spongiosis. Histologically atopic,
nummular and contact dermatitis present with spongiosis with or without vesicles. Stasis dermatitis
presents with more dilated papillary dermal small blood vessels and hemosiderin
65) The diagnosis is:
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A. scleroderma, early
B. erythema induratum
C. sarcoidosis
D. erythema nodosumCorrect Choice
E. subcutaneous granuloma annulare
In erythema nodoosum, one sees a predominantly septal panniculitis with some septal thickening
and fibrosis and an inflammatory infiltrate within the septae composed of lymphocytes, histiocytes,
eosinophils, and giant cells
66) The diagnosis is:
A. Psoriasis
B. Bowen's disease
C. Clear cell acanthoma Correct Choice
D. Trichilemmoma
E. Poroma
NEEDS EXPLANATIONS
67) Which type of artifact is shown here?
A. Electrodessication
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19. B. Dessication
C. Gel foamCorrect Choice
D. Microtome knife chatter
E. Freeze
The presence of deeply basophilic, wavy, angulated foreign material characteristic of gel foam
artifact
68) This is associated with MEN IIa:
A. Malignant peripheral nerve sheath tumor
B. Macular amyloidosis Correct Choice
C. Mucocele
D. Neurothekeoma
E. Chondroid syringoma
Macular amyloidosis is associated with MEN IIa
69) The diagnosis is:
A. Lymphoma
B. Small cell melanoma
C. Glomus tumor
D. Merkel cell carcinoma Correct Choice
E. Rhabdomyosarcoma
NEEDS EXPLANATIONS
70) The diagnosis is:
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A. acrospiroma
B. reticulated seborrheic keratosis
C. fibroepithelioma of PinkusCorrect Choice
D. syringofibroadenoma
E. tumor of the follicular infundibulum
In fibroepithelioma of Pinkus, there is a reticulated network of basaloid cells coming off of the
epidermis in a plate-like fashion. There is some peripheral palisading of cells. The cells are
embedded in a fibrotic stroma
71) Paraproteinemia is associated with all except:
A. Plane xanthoma
B. Necrobiotic xanthogranuloma
19

20. C. Scleromyxedema
D. Sclerosing panniculitis Correct Choice
E. Scleredema
Sclerosing panniculitis (lipodermatosclerosis) displays characteristic changes in the fat
(lipomembranous change); it is not associated with paraproteinemia. Generalized plane xanthomas,
scleromyxedema, necrobiotic xanthogranuloma, scleredema, erythema elevatum diutinum,
xanthoma disseminatum, and pyoderma gangrenosum have all been associated with a
paraproteinemia
72) The diagnosis is:
A. Cylindroma
B. Trichoblastoma
C. Hidradenoma
D. Acrospiroma
E. Spiradenoma Correct Choice
NEEDS EXPLANATIONS
73) All of the following are true of reticulohistiocytoma except:
A. Trauma is precipitating factor
B. Rare occurrence in children
C. Association with arthritisCorrect Choice
D. Immunostaining is positive for OKM1
E. Giant cells with “ground-glass” cytoplasm
Reticulohistiocytomas, also called giant cell reticulohistiocytomas, occur almost exclusively in adults.
They are generally solitary, and unlike the multicentric type, are not associated with mutilating
arthritis or predisposition for malignancy
74) What is the diagnosis?
A. Spiradenoma
B. CylindromaCorrect Choice
C. Dermal duct tumor
D. Syringocystadenoma papilliferum
E. Trichoblastoma
This is a cylindroma, in which there is a jigsaw puzzle type arrangement of islands of basaloid cells
with intervening fibrous, pink stroma. The basaloid cells are sometimes rimmed by a thick, pink
basement membrane
75) Mulberry cells contain increased:
A. Mitochondria Correct Choice
B. Phagolysosomes and mitochondria
20

21. C. Phagolysosomes
D. Golgi
E. Ribosomes
Hibernomas commonly arise in the neck, axillae, and posterior shoulder. The cells are
multivacuolated and resemble mulberries; the cells are filled with mitochondria, as are the cells in
normal brown fat
76) The endemic form of this disease may be transmited by:
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A. Glossina
B. SimuliumCorrect Choice
C. Lutzomyia
D. Phlebotomus
E. Triatoma
Triatoma (reduviid bug) species transmit American trypanosomiasis. Glossina is the genus of tsetse
flies that transmit African trypanosomiasis. Simulium is the genus of the black fly that can tranmit
Onchocerciasis and possibly the endemic form of pemphigus foliceus (fogo selvagem). Phlebotomus
and Lutzomyia are types of sandflies that can transmit Leishmaniasis, Carrion’s disease, and viral
sandfly fever
77) Which of the following hitologic features would be most helpful in differentiating lichenoid drug
eruption from lichen planus?
A. Squamatization of the basal layer
B. Band-like infiltrate with “Saw-tooth” rete ridges
C. Parakeratosis and eosinophilsCorrect Choice
D. Presence of pruritus
E. Civatte bodies
Lichenoid drug eruptions share clinical and histopathologic features with lichen planus. Sometimes
differentiation is not possible; however, eosinophil, parakeratosis, and a deeper perivascular
infiltrate is more suggestive of lichenoid drug. Implicated medications include captopril,
penicillamine, and chloroquine
78) In this patient, this test will be helpful in making the diagnosis:
A. Direct immunofluorescenceCorrect Choice
B. Tissue culture
C. Fluorescent antibody test for herpes
D. Patch test
E. KOH exam
This patient has penicillamine-induced pemphigus foliaceus. Direct immunofluorescence testing will
be very helpful as it should reveal intercellular antibodies within the epidermis
21

22. 79) This patient says the rash is spreading and not controlled with topical therapy. You give him a
course of oral treatment that lasts:
A. 1 week
B. 3 weeksCorrect Choice
C. 5 weeks
D. 4 weeks
E. 2 weeks
Generally, for poison ivy dermatitis, if patients are given a course of oral steroids, the course should
be at least 3 weeks long, as if the duration is shorter, patients may develop a rapid rebound
80) Langerhans cells express or are characterized by all of the following except:
A. HLA-DR
B. ChromagraninCorrect Choice
C. Birbeck granules
D. CD1a
E. S-100
Chromagranin stain neuroendocrine cells, Merkel cellcarcinomas and eccrine glands. They do not
stain Langerhans cells
81) What is the diagnosis?
A. Dermatomyofibroma
B. Leiomyosarcoma
C. Palisaded encapsulated neuromaCorrect Choice
D. Leiomyoma
E. Traumatic neuroma
This is a palisaded encapsulated neuroma, in which there are small bundles of cells that have wavy,
thin (elongated) nuclei and pink cytoplasm. The cells are separated by artifactual clefting. The
bundles are often located very superficially. Encapsulation is often incomplete/not obvious
82) This woman should have a workup for:
A. Nephrolithiasis
B. HemochromatosisCorrect Choice
C. Lymphoma
D. Thalassemia
E. Pancreatic cancer
Porphyria cutanea tarda has been shown to be associated with hemochromatosis. Patients with
porphyria cutanea tarda have mutations in the HFE gene, and early detection of mutations can
improve life expectancy for these patients
22

23. 83) The diagnosis is:
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A. myxedema
B. digital mucous cystCorrect Choice
C. reticulated erythematous mucinosis
D. mucinous granuloma annulare
E. papular mucinosis
In a digital mucous cyst, one sees a collection of mucin in the dermis beneath acral skin. This entity
is not a true cyst as there is no epithelial lining to the cyst. The mucin is largely composed of
hyaluronic acid
84) The diagnosis is:
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A. neurothkeoma
B. palisaded encapsualted neuromaCorrect Choice
C. amelanotic blue nevus
D. dermatofibroma
E. leiomyoma
In palisaded encapsulated neuroma, there are broad fascicles of spindle cells set in a clear matrix.
The fascicles of spindle cells are sometimes clearly separated from the surrounding normal dermis
by a capsule, but other times blend into the dermis. The spindle cells have elongated, thin/tapered
nuclei. Palisading of nuclei is often not obvious
85) The diagnosis is:
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A. granuloma faciale
B. pigmented purpura
C. leukocytoclastic vasculitisCorrect Choice
D. mastocytosis
E. acrodermatitis of Mali
In leukocytoclastic vasculitis, on low power there is an inflammatory infiltrate generally clustered
around the vessels (although sometimes more dense and interstitial). There is extravasation of
erythrocytes around vessels with predominantly neutrophils around vessels and often within the
walls of the vessels. There is fragmentation of neutrophilic nuclei (“nuclear dust”) with fibrin (pink
amorphous material) within the walls of vessels and sometimes frank destruction of vessels
86) Which type of artifact is illustrated here?
23

24. A. ElectrodessicationCorrect Choice
B. Gel foam
C. Knife chatter
D. Dessication
E. Freeze
The elogation of cells and spindling of nuclei with typical "string bean" appearance are characteristic
of electrodessication artifact
87) This patient’s biopsy will likely show:
A. Mononuclear cells with abundant cytoplasm around superficial vessels
B. Eosinophils at the dermoepidermal junction
C. Leukocytoclasia around superficial vessels
D. Lymphocytes at the dermoepidermal junctionCorrect Choice
E. Neutrophils at the dermoepidermal junction
This patient has erythema multiforme, and biopsy should show a lichenoid infiltrate of lymphocytes
at the dermoepidermal junction
88) The promontory sign is seen in:
A. Tufted angioma
B. Acroangiodermatitis of Mali
C. Kaposi’s sarcoma Correct Choice
D. Glomeruloid hemangioma
E. Spindle cell hemangioendothelioma
The promontory sign refers to the formation of new vessels around existing vessels and adnexal
structures. This is seen in Kaposi’s
89) What is the diagnosis?
A. Lupus erythematosus
B. Mycosis fungoides
C. Poroma
D. Porokeratosis
E. PsoriasisCorrect Choice
This is psoriasis, in which there is parakeratosis with entrapped neutrophils overlying a regularly
acanthotic epidermis. There is hypogranulosis of the epidermis with increased mitoses in the basal
layer. There are thinned suprapapillary plates with dilated vessels in the superficial dermal papillae.
There is a lympho-histiocytic infiltrate around superficial vessels. Occasionally, clusters of
neutrophils can be seen in the stratum spinosum (spongiform pustules of Kogoj
90) What is the diagnosis?
A. Melanoma
24

25. B. Extramammary Paget’sCorrect Choice
C. Sebaceous carcinoma
D. Bowen’s
E. Condyloma
This is an example of extramammary Paget’s, in which there are atypical cells singly and in groups
within the epidermis. The cells have abundant bluish cytoplasm
91) This is secondary to:
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A. paraproteinemia
B. a dull blade
C. silicone injections
D. gel foamCorrect Choice
E. metastatic carcinoma
Gel foam in tissue sections is a characteristic wavy material that stains bluish-gray
92) The predominant location of the cleft in transient neonatal pustular melanosis is:
A. Suprabasal
B. Basement membrane zone
C. Subcorneal/granularCorrect Choice
D. Dermal
E. Basal keratinocytes
Transient neonatal pustular melanosis is an idiopathic pustular eruption of newborns, mostly on the
chest, that heals with hyperpigmentation. It is most common on pigmented individuals.
Histologically it presents as subcorneal pustules with eosinophils and neutrophils
93) What is the diagnosis?
A. ChondrodermatitisCorrect Choice
B. Granular cell tumor
C. Bromoderma
D. Lichen simplex chronicus
E. Actinic keratosis
This is chondrodermatitis nodularis helices, in which there is hyperkeratosis and parakeratosis
overlying an altered/thickened epidermis. Beneath that area, in the dermis, there is often fibrosis.
Flanking the fibrosis on either side, there is a proliferation of vessels and inflammation (resembling
granulation tissue
94) A lichenoid infiltrate that surrounds eccrine glands is seen in:
A. Lichen planus
25

26. B. Lichenoid purpura
C. Lichen striatusCorrect Choice
D. Lichenoid drug rection
E. Lichen planopilaris
Lichen striatus is an uncommon inflammatory dermatitis seen most commonly in children aged 5 to
15. It presents unilaterally along Blaschko's lines as raised, slightly scaly, erythematous papules,
which are often pruritic. These lesions typically regress spontaneously within a year. The
histopathologic features of lichen striatus include a superficial perivascular inflammatory
lymphohistiocytic infiltrate with rare plasma cells and eosinophils. There is a focal lichenoid infiltrate
in the papillary dermis with basilar vacuolar alteration and necrotic keratinocytes. Spongiosis with
exocytosis of lymphocytes can be seen in the epidermis. A specific and distinctive feature of lichen
striatus is the presence of an inflammatory infiltrate that surrounds hair follicles and eccrine glands
95) Similar follicles can be seen on skin from the:
A. EyelidCorrect Choice
B. Nose
C. Finger
D. Glans penis
E. Labia majora
Vellus hair follicles are seen commonly in accessory tragic and eyelid skin
96) What is the diagnosis?
A. Incontinentia pigmenti
B. Lichen striatus
C. Lichen simplex chronicus
D. Lichen planusCorrect Choice
E. Pityriasis lichenoides et varioliformis acuta
This is lichen planus, in which there is hyperkeratosis (and no parakeratosis), irregular acanthosis of
the epidermis, hypergranulosis (often in wedge shapes), saw-toothing of the basal layer, and a
band-like inflammatory infiltrate of predominantly lymphocytes (usually no eosinophils) at the
dermoepidermal junction. Occasionally, artifactual clefting can be seen at the dermoepidermal
junction (Max-Joseph space). Colloid bodies/Civatte bodies (amorphous pink material in globs) may
also be seen near the dermoepidermal junction
97) This reaction is most likely secondary to:
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A. nicotinamide
B. tetracycline
C. mycophenolic acid
D. captoprilCorrect Choice
E. cyclosporine
26

27. Bullous pemphigoid can be drug-induced and a common inciting drug is captopril. Other causes
include lasix, nalidixic acid, penicillamine, antibiotics (penicillin, amoxicillin, ampicillin), and PUVA
98) All have been associated with increased risk of breast cancer except:
A. Birt-Hogg-Dube Correct Choice
B. ataxia telangiectasia
C. Multicentric reticulohistiocytosis
D. Peutz-Jeghers
E. Cowden’s
Birt-Hogg-Dube is associated with renal cancer and thyroid cancer. Female carriers of a mutated
ATM (homozygous mutations ATM cause ataxia telangiectasia) have an increased risk of breast
cancer
99) The diagnosis is:
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A. microcystic adnexal carcinoma
B. mixed tumorCorrect Choice
C. syringofibroadenoma
D. mucinous carcinoma
E. papillary eccrine adenoma
Some authors separate mixed tumors into eccrine and apocrine types. In the eccrine mixed tumor
(pictured here), there are cords, clusters, and strands of basaloid cells forming lumina, some lined
by eosinophilic cuticles. These clusters of cells are embedded in a bluish myxoid/cartilaginous
stroma
100) The predominant location of the cleft in acropustulosis of infancy is:
A. Dermal
B. Basment mebrane zone
C. Subcorneal/granularCorrect Choice
D. Suprabasal
E. Basal keratinocytes
Acropustulosis of infancy presents as idiopathic pustules on acral skin. Diagnosis is made only after
other causes of pustules have been ruled out, and it usually resolves in a few years. The cleft in
acropustulosis of infancy is subcorneal/granular with neutrophils
101) Cicatricial pemphigoid antibodies directed against this are associated with high frequency of
malignancy:
A. Laminin 5 Correct Choice
B. Beta4-integrin
C. BPAg2
27

28. D. Laminin 6
E. All of these answers are correct
Anti-laminin 5 cicatricial pemphigoid (CP) is also known as anti-epiligrin CP. Anti-epiligrin CP is
associated with an increased frequency of internal adenocarcinomas. Laminin 5 is composed of
three chains (heterotrimer), alpha3, beta3, gamma2. Antibodies are frequently directed against the
alpha3 chain, and so cross-reactivity can be observed with laminin 6, as laminin 6
(alpha3beta1gamma1) has the alpha3 chain as well. Beta4-integrin antibodies have been associated
with ocular CP. BPAg2 antibodies are seen in CP patients that have mucosal as well as skin disease
102) This patient may have antibodies to:
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A. metalloproteinase
B. transglutaminase
C. myeloperoxidaseCorrect Choice
D. proteinase-3
E. aminotransferase
The figures are consitent with polyarteritis nodosa. Patients with polyarteritis nodosa may have
antibodies to p-ANCA or myeloperoxidase
103) The diagnosis is:
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A. malignant fibrous histiocytoma
B. nodular fascitisCorrect Choice
C. epithelioid sarcoma
D. neurofibroma
E. dermatofibrosarcoma protuberans
In nodular fasciitis, there is a ill-defined deep (often extending into fat) proliferation of plump
spindle cells that on higher power resemble “tissue-culture fibroblasts” with elongated cytoplasm
often set in a background of many small vessels and extravasated erythrocytes. The spindle cells
are arranged haphazardly, and the stroma is often myxoid. Mitoses are common
104) What is the diagnosis?
A. Psoriasis
B. Granular parakeratosisCorrect Choice
C. Lichen nitidus
D. Dermatophyte
E. Lichen planus
28

29. Granular parakeratosis results from abnormal keratinization which generally occurs in the flexural
areas. Histologically, the thick parakeratotic layer with retention of keratohyaline granules. In
addition, the granular layer is preserved with relatively normal epidermis
105) What is the diagnosis?
A. Mastocytosis
B. Leprosy
C. Sarcoid
D. Lichenoid actinic keratosis
E. Lichen nitidusCorrect Choice
This is lichen nitidus, in which there is a “ball” of lymphocytes and histiocytes in the superficial
dermis abutting the epidermis surrounded on both sides by “claws” of the epidermis (rete
106) Which of the following drugs has been known to cause pyogenic granuloma?
A. CapecitabineCorrect Choice
B. Paclitaxel
C. Isosfamide
D. Daunorubicin
E. Mithramycin
Systemic retinoids, indinavir and capecitabine have all been describe to cause pyogenic granulomas
107) Which of the following histologic features is seen in aging skin?
A. Increased sebum production
B. Increased number of terminal hairs
C. Thickened dermal-epidermal junction
D. Fewer Langerhans cellsCorrect Choice
E. Increased mast cells
Histologic features of aging epidermis include flattened dermo-epidermal junction, occasional
nuclear atypia, decrease in the number of melanocytes and Langerhans cells. Changes that are
present in the dermis include atrophy, decrease in fibroblasts, mast cells and blood vessels
108) In this patient, this test will be helpful in making the diagnosis:
A. Patch test
B. Fluorescent antibody test for herpesCorrect Choice
C. Tissue culture
D. KOH exam
E. Indirect immunofluorescence
This patient has herpes zoster. A direct fluorescent antibody test for the varicella zoster virus can be
performed to confirm the diagnosis.
29

30. 109) This patient also has anemia. He needs screening for::
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A. malignancyCorrect Choice
B. liver cirrhosis
C. diabetes
D. pulmonary firbrosis
E. immunosuppression
The histology shows numerous neutrophils in the dermis with a lack of vasculitis, consistent with
Sweet’s syndrome. In a patient with Sweet’s syndrome, the presence of anemia is associated with
an internal malignancy.
110) Multiple such lesions are associated with::
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A. Cowden'sCorrect Choice
B. Gorlin's
C. Werner's
D. Bloom's
E. Sipple's
Multiple sclerotic fibromas are seen in Cowden’s syndrome.
111) The diagnosis is:
A. Dermatofibrosarcoma
B. Angiolipoma Correct Choice
C. Epithelioid sarcoma
D. Nodular fasciitis
E. Liposarcoma
NEEDS EXPLANATIONS
112) Cellular neurothekeoma stains with:
A. Low molecular weight keratin
B. Stromelysin-3
C. Desmin
D. PGP-9.5 Correct Choice
E. S-100
PGP-9.5 and S100-a6 stains cellular neurothekeoma. Stromelysin-3 is positive in dermatofibromas
and negative in dermatofibrosarcoma protuberans. Desmin stains rhabdomyosarcoma. S-100 stains
neural tumors and melanocytic tumors among other things, but cellular neurothekeomas are
generally S100-negative
30

31. 113) What stain may be used to differentiate this entity from metastatic oat cell carcinoma of the
lung?
A. HMB 45
B. CEA
C. PAS
D. Cytokeratin 20Correct Choice
E. S-100
Merkel cell carcinoma is a neuroendocrine cancer, usually of the head and neck. The tumor stain
with cytokeratin 20 which is expressed in a paranuclear dot-like pattern. This stain helps to
differentiate Merkel cell carcinoma from metastatic oat cell carinoma of the lung.
114) The diagnosis is:
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A. Epithelioid sarcoma
B. Angiosarcoma
C. Epithelioid hemangioendothelioma
D. Kaposi's sarcomaCorrect Choice
E. Aneurismal dermatofibroma
In nodular Kaposi’s sarcoma, one sees a proliferation of spindle cells, often arranged in nodules
separated by fibrous bands. On higher power examination of the spindle cells, numerous
extravasated erythrocytes can be seen between the cells. Often, hemosiderin-filled macrophages
and plasma cells can be seen as well. The spindle cells are packed closely together and often will
have intracytoplasmic pink inclusions (erythrophagolysosomes
115) The diagnosis is:
A. Psoriasis
B. Pityriasis rubra pilarisCorrect Choice
C. Inflammatory linear verrucous epidermal nevus
D. Prurigo nodularis
E. Ichthyosis
NEEDS EXPLANATION
116) What is the diagnosis?
A. Dilated poreCorrect Choice
B. Fibrofolliculoma
C. Pilar sheath acanthoma
D. Keratosis pilaris
31

32. E. Trichoadenoma
This is a dilated pore, in which there is an invagination lined by epidermis that is slightly acanthotic
117) These cells should stain with:
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A. S100
B. factor XIIIa
C. cytokeratin
D. CD34
E. actinCorrect Choice
This is a dermatomyofibroma. Dermatomyofibromas are often found over the scapula of women.
The spindle cells are oriented parallel to the epidermis, and stain with vimentin and non-specific
muscle actin. The spinde cells do not stain with desmin, S100, CD34, or Factor XIIIa
118) What is the diagnosis?
A. Impetigo
B. Bullous pemphigoidCorrect Choice
C. Subcutaneous lupus erythematosus
D. Dermatitis herpetiformis
E. Polymorphous light eruption
This is bullous pemphigoid, in which a subepidermal bullae/vesicle displays numerous eosinophils
lining up at the dermo-epidermal junction
119) This developed in a patient with a history of breast cancer s/p surgical excision/radiation. Her
diagnosis is:
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A. Horner's
B. Stewart-TrevesCorrect Choice
C. Parkes-Weber
D. Kettle's
E. Klippel-Trenaunay
Angiosarcoma can develop in a lymphedematous extremity. When it develops in the upper
extremity after surgical treatment of breast cancer, it is referred to as Stewart-Treves syndrome.
When it develops in the lower extremity after lymph node dissection for a melanoma, it is referred
to as Kettle's syndrome
120) What is the diagnosis?
A. Trichofolliculoma
32

33. B. Spiradenoma
C. Trichilemmoma
D. Mixed tumor
E. TrichoepithliomaCorrect Choice
This is a trichoepithelioma, in which there are islands of basaloid cells in a somewhat fibrous stroma
with no retraction between the islands and the stroma. Often horn cysts are seen (not shown).
121) The inclusions in infantile digital fibromatosis stain for trichrome and:
A. Thioflavin T
B. Pentahydroxy flavanol
C. Osmium tetroxide
D. Phosphotungstic acid hematoxylin Correct Choice
E. Bodian
Osmium tetroxide stains fat. Thioflavin T stains amyloid. The Bodian stain is for nerves.
Pentahydroxy flavanol is a fluorescent stain for calcium
122) The diagnosis is:
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A. myofibromatosis
B. schwannoma
C. Kaposi's sarcoma
D. neurofibromaCorrect Choice
E. leiomyoma
This is a plexiform neurofibroma. There are discrete nodules of spindle cells within the dermis. On
higher power, the cells have wavy nuclei with pink cytoplasm
123) What is the diagnosis?
A. Carbon tattooCorrect Choice
B. Monsel’s reaction
C. Blue nevus
D. Postinflammatory hyperpigmentation
E. Minocycline-induced hyperpigmentation
This is a carbon tattoo, in which there are extracellular and intracellular particles of black material in
the superficial dermis
124) What is the diagnosis?
A. Deep penetrating nevus
33

34. B. Recurrent nevus
C. Congenital nevusCorrect Choice
D. Epithelioid blue nevus
E. Nevoid melanoma
This is a congenital nevus, in which there are nests of nevomelanocytic cells at the dermoepidermal
junction and extending deep into the dermis. In the deeper dermis, the cells infiltrate through
collagen bundles and extend around adnexal structures. There is hyperkeratosis, acanthosis, and
papillomatosis of the surface epidermis
125) The green color in chloroma is secondary to:
A. Stromelysin
B. Myeloperoxidase Correct Choice
C. Fumarase
D. Chloracetate
E. Alkaline phosphatase
Chloromas are greenish tumor grossly secondary to involvement of the skin in acute granulocytic
leukemia. The green color is secondary to myeloperoxidase
126) Supporting evidence for the diagnosis of mycosis fungoides is CD4+ lymphocytes with loss of
CD7 as well as loss of
A. CD20
B. CD2
C. CD30
D. CD5 Correct Choice
E. CD3
CD5 as well as CD7 are sometimes lost on the surface of epidermotropic T cells in mycosis
fungoides. CD2, CD3, and CD5 are T cell markers. CD20 is a B cell marker. CD30 is positive in
anaplastic large cell lymphoma cells, Hodgkin’s lymphoma, and lymphomatoid papulosis. Reactive
infiltrates can also have some CD30-positive cells
127) Clinically, a nondescript hyperkeratotic papule on the ulnar side of the base of the fifth finger
is most likely:
A. Cutaneous horn
B. Accessory digit Correct Choice
C. Digital fibromatosis
D. Acquired digital fibrokeratoma
E. Glomus tumor
Accessory digits (supernumerary digits) are usually found at the base of the fifth finger, often
bilaterally
128) Multiple trichoepitheliomas are seen in all except:
34

35. A. Brooke-Fordyce syndrome
B. Rombo syndrome
C. Gorlin's syndrome Correct Choice
D. Brooke-Spiegler syndrome
E. Bazex's syndrome
Gorlin's syndrome is nevoid basal cell carcinoma syndrome; multiple trichoepitheliomas are not
seen. Several syndromes have been associated with multiple trichoepitheliomas: Basex, Brooke-
Fordyce, Brooke-Spiegler, Rombo, and possibly Rasmussen. (Rasmussen described one family in
1975 with autosomal dominant inheritance of multiple trichoepitheliomas, milia, and cylindromas.)
Basex syndrome (follicular atrophoderma, hypotrichosis, occasional trichoepitheliomas, basal cell
carcinomas, and localized or generalized hypohidrosis) is inherited in an X-linked dominant manner.
Brooke and Fordyce both described multiple trichoepitheliomas concurrently in 1892, and therefore
multiple familial trichoepitheliomas are sometimes called “Brooke-Fordyce” sydrome. Spiegler
described patients with multiple cylindromas in 1899 and also noted that many of these patients
had mutiple trichoepitheliomas; more recently it has been noted that multiple spiradenomas may be
seen in patients with multiple trichoepitheliomas and cylinidromas; this co-occurrence of tumors has
been referred to as “Brooke-Spiegler” syndrome. (Brooke-Fordyce and Brooke-Spiegler are likely
the same syndrome.) Rombo syndrome is characterized by vermiculate atrophoderma, multiple
BCCs, multiple trichoepitheliomas, cyanosis and peripheral vasodilation
129) The diagnosis is::
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A. hypertrophic scarCorrect Choice
B. leiomyoma
C. dermatomyofibroma
D. neurofibroma
E. dermatofibroma
130) What is the diagnosis?
A. Adenoid cystic carcinoma
B. Trichoblastoma
C. Microcystic adnexal carcinoma
D. Trichodiscoma
E. Morpheaform basal cell carcinomaCorrect Choice
This is a morpheaform basal cell carcinoma, in which there are very infiltrative islands of basaloid
cells, extending deep into the dermis. Around some of the basaloid islands, there is new, pink
collagen. The basaloid proliferation off of the surface of the epidermis is more typical of a superficial
multicentric basal cell carcinoma and aids in the diagnosis
131) This patient should be examined for::
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35

36. A. photosensitivity
B. keratoacanthomasCorrect Choice
C. pigmentary anomalies
D. odontogenic cysts
E. arsenical keratoses
The figures show a sebaceous adenoma. Sebaceous adenomas are associated with Muir-Torre
syndrome, in which patients can have an internal malignancy and multiple keratoacanthomas
132) The most likely diagnosis for this lesion would be:
A. Verruca
B. Acrochordon
C. Acquired digital fibrokeratomaCorrect Choice
D. Amputation neuroma
E. Supernumery digit
The diagnosis of this acral lesion is an acquired digital fibrokeratoma which shows a small, exophytic
circumscribed lesions. Collagen bundles are oriented perpendicularly to the skin surface. The lesion
lacks nerve twigs and bone, which may be present in supernumery digit or amputation neuroma
133) Clear cell syringomas are associated with:
A. Sarcoidosis
B. Malignancy
C. Diabetes Correct Choice
D. Lichen myxedematosis
E. Argyria
Clear cell syringomas are associated with diabetes. Syringomas are associated with Down’s
syndrome
134) The diagnosis is:
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A. tubular apocrine adenoma
B. dermal duct tumor
C. syringoma
D. trichoepithelioma
E. adenoid cystic carcinomaCorrect Choice
In adenoid cystic carcinoma, there are cords and tubules of basaloid cells, arranged in a cribiform
pattern. The cystic spaces contain a bluish material. Perineural invasion is common. The cells stain
positively for epithelial membrane antigen (EMA).
135) What is the cause of this pigmentary condition?
36

37. A. Hemochromatosis
B. Post-inflammatory hyperpigmetation
C. Minocycline ingestion
D. ArgyriaCorrect Choice
E. Chrysiasis
The characteristic feature of argyria is the presence of black granules in the eccrine glands. It
differentiates this condition from other pigmentary disorders
136) The diagnosis is:
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A. Erythropoietic protoporphyria
B. Lipoid proteinosis
C. Radiation dermatitis
D. Colloid milium
E. Lichen sclerosus et atrophicusCorrect Choice
In lichen sclerosus et atrophicus, there is often an atrophic epidermis with overlying orthokeratosis
that is thicker than the stratum spinosum, with some follicular plugging. There is sometimes a
subepidermal separation. The upper dermis is homogenized and pink/pale. Sometimes underlying
the homogenized zone, there is a band-like infiltrate (not seen here
137) A patient with a blue-red discoloration of the nail plate reports that the same finger becomes
very tender when exposed to the cold. You suspect a:
A. Pyogenic granuloma
B. Glomus tumorCorrect Choice
C. Periungual verruca
D. Mucous cyst
E. Pterygium
Glomus tumors are tumors of the arterio-venous anastamosis of the digital dermis. They occur most
frequently in the nail bed. The commonly have a bluish-red discoloration and may be tender or
painful with exposure to heat or cold
138) Verruciform xanthoma is seen most commonly on:
A. Distal extremities
B. Mucosal surfaces and trunk/proximal extremities
C. Oral mucosae and genital areas Correct Choice
D. Nail bed and periungual areas
E. Head and neck
NEEDS EXPLANATION
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38. 139) This patient developed an acute vesicular rash after eating a mango. She has returned for a
routine follow-up. She needs to be careful of exposure to:
A. All of these answers are correct
B. Ginkgo fruitCorrect Choice
C. Croton
D. Ragweed
E. Tea tree oil
Patients allergic to the peel of a mango can also be allergic to other plants/products of the
Anacardiaceae family. Cross-reactions can occur with exposure to any plants of the genus
Toxicodendron, to the oil from the cashew nut shell, to the Brazilian pepper tree, to lacquer from
the Japanese lacquer tree, to ink from the Indian marking nut, and to the fruit pulp of the ginkgo
tree, and others
140) The diagnosis is:
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A. Blastomycosis
B. Cryptococcosis
C. Histoplasmosis
D. Toxoplasmosis
E. LeishmaniaisisCorrect Choice
The diagnosis is Leishmaniasis. In this condition, the epidermis is often ulcerated (not seen in this
case) with a dense infiltrate is seen within the dermis. There are numerous macrophages
(Leishman-Donovan bodies) within the infiltrate that have intracellular amastigotes within them. On
close examination of the parasites, a kinetoplast is evident. In contrast to histoplasmosis, a discrete
halo is not seen around the amastigotes
141) Caterpillar bodies are seen in:
A. Dyskeratosis congenital
B. Porphyria cutanea tarda Correct Choice
C. Amyloidosis
D. Lipoid proteinosis
E. Mucocele
Caterpillar bodies are thought to be type IV collagen
142) A healthy 6 month old girl has a subcutaneous nodule above her right eyebrow. A skin biopsy
demonstrates a cystic lesion with adnexal structures in the wall. Your diagnosis is:
A. Nevus sebaceous
B. Epidermal inclusion cyst
C. Steatocystoma
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39. D. Pilar cyst
E. Dermoid cystCorrect Choice
Dermoid cysts present along lines of embryonic closure. The are most commonly found on the head
(around the eyes) and the neck. They are lined by an epidermis that contains various epidermal
appendages that are usually fully matured
143) The diagnosis is:
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A. basaloid squamous cell carcinoma
B. malignant acrospiroma
C. poroid squamous cell carcinoma
D. porocarcinoma
E. basosquamous carcinomaCorrect Choice
In basosquamous carcinomas, there are areas that appear typical of basal cell carcinoma (with
basaloid cells coming off the epidermis in buds with peripheral palisading) as well as areas typical of
squamous cell carcinoma (with atypical keratinocytes that are more pink and angular than basaloid
cells). Often, ulcerated basal cell carcinomas have squamous differentiation at the base of the ulcer
and this is not to be confused with a basosquamous carcinoma, in which there are areas of both
basal cell carcinoma and squamous cell carcinoma
144) The diagnosis is:
A. Dermatofibroma Correct Choice
B. Dermatomyofibroma
C. Neurofibroma
D. Plexiform fibrohistiocytic tumor
E. Infantile digital fibromatosis
NEEDS EXPLANATIONS
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