Question 1

An 11-month-old girl is brought to the physician with a rash on her abdomen and cheeks that is exacerbated by constant scratching.  Her abdomen and cheeks are frequently itchy, red, and scaly.  Crusted lesions are present sometimes.  The rash has worsened this summer, especially after bathing.  There is a family history of chronic, pruritic rashes in paternal cousins and allergy symptoms in the father.  Her height and weight are both tracking along the 50th percentiles.  Examination shows a blanching, erythematous, scaly rash on her abdomen, back, and face.  Physical examination is otherwise normal.  Her parents are very concerned about the rash.  Which of the following is the most appropriate response?

Accepted Answer

Explanation: 11ec2b69_be6f_a16a_8f63_19a674b11776_MD0005_00 This clinical scenario is consistent with atopic dermatitis (eczema) and is very common in children. Infants with eczema typically have pruritus, erythema, and scaly/crusted lesions on the trunk, extensor surfaces of the extremities, cheeks, and scalp; diaper areas are usually spared. The pathogenesis involves genetic defects in protein and lipids that normally act to keep the epidermis hydrated and protected. However, disruption of this barrier results in an inflammatory reaction to triggers such as excessive bathing, irritating detergents, and extreme temperatures. Management requires compulsive elimination of triggers and frequent emollients to provide a barrier and restore hydration. If emollients are inadequate, topical steroid creams/ointments may be applied on the body. Low-potency steroids are preferred on the face and skin folds due to risk of skin atrophy. (Choice A) Staphylococcus aureus colonization is associated with atopic dermatitis and may contribute to exacerbation by locally-acting staphylococcal superantigens. Eczema is a risk factor for impetigo (honey-crusted lesions) and cellulitis (focal erythema, warmth, swelling), which require antibiotic treatment. These diagnoses are unlikely based on this patient's examination. (Choice C) Eczema is a clinical diagnosis based on history and physical examination. Although serum IgE levels may be elevated, laboratory testing is not recommended or necessary to confirm the diagnosis. (Choice D) Wiskott-Aldrich syndrome is an X-linked disorder associated with severe eczema, but these patients are immunocompromised and have severe bleeding from thrombocytopenia. Eczema may have a genetic basis based on twin studies, but there is no evidence that the condition alone is inherited in an X-linked pattern. (Choice E) Atopic dermatitis typically clears in nearly 40% of patients by adulthood, but unlike infections, protective antibodies do not play a role in this disease process. Educational objective: Atopic dermatitis in infants typically presents with pruritic, scaly, erythematous lesions on the trunk, cheeks, scalp, and extensor surfaces of the extremities. Diagnosis is made clinically. Avoidance of triggers and compulsive use of emollients are the first-line treatments. Corticosteroids are often indicated to treat exacerbations. References: What's new in the topical treatment of allergic skin diseases (http://www.ncbi.nlm.nih.gov/pubmed/25061854) Evaluation of the child with atopic dermatitis (http://www.ncbi.nlm.nih.gov/pubmed/22093041)

Question 2

A 25-year-old African-American medical student comes to see you in the office.  His girlfriend noticed an area of circular hair loss over the back of his head.  He is concerned that he is losing his hair and will be bald soon.  He is otherwise in good health and denies any history of smoking, alcohol, or illicit drug use.  He has had a monogamous relationship with his girlfriend for the past three years.  On examination, there is a 1 cm area of complete, smooth and circular hair loss with distinct margins.  There is no scaling or inflammation present in or around the area of hair loss.
Which of the following statements is true regarding the above condition?

Accepted Answer

Explanation: The exact etiology of alopecia areata is unknown. An autoimmune process is thought to play at least a partial role in its pathogenesis. This is supported by the finding of T-cell infiltration around the hair follicles and the association of other autoimmune conditions (i.e., pernicious anemia, vitiligo, and thyroid diseases) with alopecia areata. The disease can recur in up to one-third of these patients. Some factors associated with the higher chance of relapse include a longer duration of the disease, a more extensive disease, involvement of peripheral areas, and onset prior to puberty. (Choice A)Alopecia areata is not a contagious disease. It does not get transmitted by direct person-to-person contact. (Choice B)The incidence of lymphoma is not higher in these patients. (Choice C)Drug treatment can promote hair growth, but does not cure the disease. Patients can still have recurrence of the disease after successful treatment. Educational Objective: Alopecia areata can commonly recur in patients even after successful treatment and normal hair growth.

Question 3

A 65-year-old woman is brought to the emergency department by paramedics after falling on a snow-covered sidewalk.  The patient fell backward onto her hands while trying to maintain her balance and immediately felt a sharp, excruciating pain in her right arm.  She also notes mild tenderness and bruising on the right flank and right buttock.  The patient has a history of osteoporosis and hypertension and takes valsartan, alendronate, and a vitamin D supplement.  She does not use tobacco, alcohol, or illicit drugs.  In the emergency department, radiograph reveals a displaced fracture of the right distal radius.  The patient is admitted to the hospital and undergoes open reduction and internal fixation of the radius fracture.  On postoperative day 2, she reports severe, constant, burning pain over her right flank.  The postsurgical pain in the right arm is mild and well controlled with low-dose morphine as needed.  Temperature is 37.8 C (100 F), blood pressure is 145/84 mm Hg, pulse is 97/min, and respirations are 16/min.  Mucous membranes are moist and the oropharynx is without lesions.  Cardiopulmonary auscultation reveals clear lungs and normal heart sounds.  The abdomen is soft, nontender, and nondistended.  The right flank is tender to light touch with a rash over the area, as shown in the exhibit.  The surgical wound is healing normally without signs of infection. 
What is the most appropriate treatment for this patient?

Accepted Answer

Explanation: This patient had a traumatic accident and then developed burning pain of the right flank and a unilateral, vesicular rash, suggesting herpes zoster (shingles). Herpes zoster is due to the reactivation of varicella-zoster virus (VZV) from the dorsal root ganglia of a sensory nerve following initial infection with varicella (chickenpox) during childhood or early adulthood. Risk of VZV reactivation is greatest in those with advanced age due to waning cell-mediated immunity. Recent physical trauma (eg, right flank bruising) may also increase risk due to traumatic sensory nerve stimulation inducing viral replication. The most characteristic manifestation is a unilateral dermatomal rash that begins as erythematous papules, evolves into grouped vesicles, and crusts over within 7-10 days. One dermatome is typically affected, but the immediately adjacent dermatomes are sometimes involved. Dermatomal pain (burning, throbbing, stabbing, pruritic) often precedes the rash by days or weeks and may be severe. Diagnosis is usually made clinically, and most patients who present <72 hours after rash onset receive 7 days of oral valacyclovir to reduce transmission risk, new lesion formation, and (possibly) risk of postherpetic neuralgia. Analgesics are also often required. (Choice A) Patients with localized herpes zoster (1 dermatome or 1 dermatome and immediately adjacent dermatomes) do not typically need intravenous acyclovir unless they are immunocompromised (eg, HIV). In addition, patients require at least 7 days of treatment. (Choice B) This patient has significant pain that requires treatment. Morphine should not be discontinued. In addition, corticosteroid creams are not typically administered for herpes zoster due to increased risk of secondary bacterial infections. (Choice C) Oral acyclovir requires dosing 5 times a day; valacyclovir is typically preferred as it is taken 3 times a day. Steroids are generally contraindicated in uncomplicated zoster due to increased risk of secondary bacterial infections and little proven benefit. (Choice E) Patients who present >72 hours after rash onset are often given analgesia and topical rash care (eg, zinc oxide cream), but those who have had a rash <72 hours should be given antiviral medication. Educational objective: Patients with localized herpes zoster should be given oral antiviral therapy if they present <72 hours after skin rash onset to reduce transmission risk, new lesion formation, and risk of postherpetic neuralgia. There is no proven benefit of corticosteroids for localized herpes zoster. References: Herpes zoster and postherpetic neuralgia: prevention and management. (http://www.ncbi.nlm.nih.gov/pubmed/21671543)

Question 4

A 25-year-old African-American medical student comes to see you in the office.  His girlfriend noticed an area of circular hair loss over the back of his head.  He is concerned that he is losing his hair and will be bald soon.  He is otherwise in good health and denies any history of smoking, alcohol, or illicit drug use.  He has had a monogamous relationship with his girlfriend for the past three years.  On examination, there is a 1 cm area of complete, smooth and circular hair loss with distinct margins.  There is no scaling or inflammation present in or around the area of hair loss.
Which of the following is the most likely cause of the above findings?

Accepted Answer

Explanation: Hair loss is a common problem that can have severe psychological effects in younger patients. The patient in the above vignette appears to be suffering from alopecia areata. It is a relatively common disease and is characterized by discrete, smooth and circular areas of hair loss over the scalp. There is typically no associated scaling or inflammation present in the area of hair loss. The hair loss usually develops over a few weeks and has a recurring pattern. Most of the patients will have regrowth of the hair in the involved areas over time. (Choice A)Patients with tinea capitis have an associated scaling and inflammation of the scalp in the areas of hair loss. (Choice B)Localized discoid lupus erythematosus of the scalp causes hair loss, scaling, inflammation, scarring, and hypopigmentation of the skin. There may be associated lesions present over the face or extremities. (Choice D)Areas of hair loss in secondary syphilis are not smooth and discrete. The lesions usually have a "moth-eaten" appearance and are associated with significant scarring. (Choice E)Hair loss in men with androgenetic alopecia starts in the frontal or temporal areas and progresses gradually (male pattern baldness). Educational Objective: Alopecia areata is characterized by smooth and discrete areas of complete hair loss. There is no associated scaling, scarring, or inflammation.

Question 5

A 70-year-old man comes to the office due to a skin rash.  He has widespread redness and blistering across his neck and trunk, which are associated with severe itching.  The rash was preceded by 4 weeks of widespread pruritus and occasional urticaria.  The patient has a history of hypertension controlled with amlodipine for 2 years and lisinopril for the last 6 months.  Vital signs are within normal limits.  On examination, he has scattered vesicles and bullae with underlying erythema and urticaria, as shown in the image below:  Which of the following is the most appropriate next step in management of this patient's condition?

Accepted Answer

Explanation: 11ec2b69_be71_00fd_8f63_9db1ddb8a1fc_MD0005_00 This older patient with pruritus and bullae has the typical features of bullous pemphigoid, an autoimmune blistering disease that most commonly affects individuals age >60. A prodromal phase of pruritic, eczematous or urticarial rash may proceed the development of bullae by weeks to months, as in this patient. Bullae are typically tense, have erythematous bases, and may rupture to form erosions. Lesion distribution can be localized or diffuse, involving the trunk and extremities; mucosal involvement is rare. Associated pruritus can be disabling. autoimmune blistering disease Bullae The diagnosis must be confirmed with skin biopsy before starting therapy, which is often chronic and can involve agents with significant toxicity (eg, systemic corticosteroids). A biopsy sample is obtained from the edge of an intact blister for routine histology and from perilesional skin for direct immunofluorescence. Subepidermal cleavage and linear deposition of IgG and/or C3 along the basement membrane are found on biopsy. Serology for antibodies against bullous pemphigoid antigens (ie, hemidesmosomes) can further support the diagnosis. Subepidermal cleavage (Choice A) Bullous pemphigoid is usually idiopathic, although certain drugs (eg, lisinopril) can cause drug-induced bullous pemphigoid. A suspected drug can be temporarily stopped pending definitive diagnosis, but stopping the medication without performing a biopsy for confirmation is insufficient for management of suspected bullous pemphigoid. (Choice B) Prednisone is a treatment option for bullous pemphigoid. Although therapy may be initiated pending biopsy results when symptoms are disabling (eg, severe pruritus), empiric treatment alone (ie, without biopsy) is not appropriate because the diagnosis must be confirmed. (Choice C) Valacyclovir is used to treat herpes zoster (shingles), which presents with acute, burning (neuropathic) pain and grouped vesicles on erythematous bases in a unilateral, dermatomal distribution. Bilateral distribution and a chronic course are not characteristic. grouped vesicles (Choice E) High-potency (eg, clobetasol), not medium-potency (eg, triamcinolone), corticosteroids are used to treat bullous pemphigoid even when widespread lesions are present because it has fewer adverse effects compared to systemic corticosteroids. Educational objective: Bullous pemphigoid is a pruritic, autoimmune blistering disorder that typically occurs in patients age >60. Diagnosis must include skin biopsy (ie, routine histology, direct immunofluorescence), which shows subepidermal cleavage and deposition of IgG and/or C3 along the basement membrane. References: Bullous pemphigoid. (http://www.ncbi.nlm.nih.gov/pubmed/31090818)

Question 6

A 65-year-old woman is brought to the emergency department by paramedics after falling on a snow-covered sidewalk.  The patient fell backward onto her hands while trying to maintain her balance and immediately felt a sharp, excruciating pain in her right arm.  She also notes mild tenderness and bruising on the right flank and right buttock.  The patient has a history of osteoporosis and hypertension and takes valsartan, alendronate, and a vitamin D supplement.  She does not use tobacco, alcohol, or illicit drugs.  In the emergency department, radiograph reveals a displaced fracture of the right distal radius.  The patient is admitted to the hospital and undergoes open reduction and internal fixation of the radius fracture.  On postoperative day 2, she reports severe, constant, burning pain over her right flank.  The postsurgical pain in the right arm is mild and well controlled with low-dose morphine as needed.  Temperature is 37.8 C (100 F), blood pressure is 145/84 mm Hg, pulse is 97/min, and respirations are 16/min.  Mucous membranes are moist and the oropharynx is without lesions.  Cardiopulmonary auscultation reveals clear lungs and normal heart sounds.  The abdomen is soft, nontender, and nondistended.  The right flank is tender to light touch with a rash over the area, as shown in the exhibit.  The surgical wound is healing normally without signs of infection. The patient has an otherwise uncomplicated postoperative course and is ready for discharge.  Her skin lesions are partially crusted, and she will continue oral valacyclovir as an outpatient.  The patient plans to host a small family dinner tonight and is concerned about the risk of disease transmission.  There will be no infants, pregnant women, or immunocompromised individuals at this gathering.  Which of the following is the most appropriate recommendation for this patient?

Accepted Answer

Explanation: This patient is being treated with oral antiviral medication for a localized herpes zoster infection. Although her rash has improved, lesions that are not completely crusted over may still transmit varicella-zoster virus (VZV) to other individuals via direct contact (primarily) or aerosolization (rare). As such, patients treated in the outpatient setting for active herpes zoster lesions should be advised to cover the rash to prevent direct contact and to avoid patients who are highly susceptible to illness, such as pregnant women who have never had varicella or the varicella vaccine, low-birth-weight infants, and immunocompromised individuals. Patients may otherwise go about their normal activities without restriction. (Choice A) A mask and gloves are required for visitors of patients hospitalized with disseminated zoster due to increased risk of transmission from widespread lesions. Localized zoster is typically treated on an outpatient basis; lesions should be covered but no mask or gloves are required. (Choices C, D, and E) Patients with herpes zoster may transmit VZV to other individuals from the onset of the rash until lesions are completely crusted over. While antivirals may expedite this process, patients remain infectious while on treatment until the rash is dry. This patient can attend her family activity but is still infectious (due to partially crusted lesions); she must cover the lesions to prevent direct contact with other individuals. Educational objective: Patients with herpes zoster may transmit varicella-zoster virus to other individuals from the onset of the lesion until it is completely crusted over. Most transmissions occur via direct contact, but aerosolized virus from active lesions has occasionally caused infections. Patients treated on an outpatient basis for herpes zoster should be advised to keep a lesion covered until it is completely crusted over. References: Herpes zoster: diagnostic, therapeutic, and preventive approaches. (http://www.ncbi.nlm.nih.gov/pubmed/24113666)

Question 7

A 2-week-old boy is brought to the office for evaluation of a skin lesion.  His parents first noticed the lesion on the right side of his forehead a week ago.  His mother says, "It doesn't seem to hurt him, but it is bright red and I am afraid it could bleed."  The parents say there is no history of trauma or other skin lesions.  The patient was born at term via spontaneous vaginal delivery with no complications, and he has no known medical conditions.  His maternal aunt has a history of melanoma, and his paternal grandmother has had several basal cell carcinomas.  Temperature is 36.7 C (98 F), blood pressure is 75/45 mm Hg, pulse is 135/min, and respirations are 40/min; pulse oximetry is 99% on room air.  Physical examination shows a fair-skinned, well-nourished infant with a nontender lesion on the forehead that is 1.5 cm in diameter.  There is no ulceration or bleeding, and the remainder of the skin examination is normal.  Cardiac examination reveals a normal rate and rhythm with no murmurs.  The lungs are clear to auscultation.  Which of the following is the most accurate statement regarding this patient's condition?

Accepted Answer

Explanation: 11ec2b69_be75_46c4_8f63_27a3f6d42fe2_MD0005_00 This patient has an infantile hemangioma, the most common pediatric vascular lesion. Hemangiomas may appear as a patch of telangiectasias at birth. They quickly progress into a bright red, nontender, nonblanching nodule and continue to proliferate during the first year of life. After age 1, most hemangiomas undergo gradual, spontaneous involution through age 9 and require no intervention (Choice C). Treatment may be warranted in cases of cosmetic concerns, complicated hemangiomas, or those in high-risk locations. Complications include ulceration, bleeding, and scarring. Lesions near the anterior neck may obstruct the airway during the proliferative stage, and those on the eyelid may obscure vision. Such lesions may require beta blocker therapy (eg, propranolol) or, rarely, surgical intervention. (Choice A) Erythema toxicum neonatorum is a benign, asymptomatic rash that presents with erythematous papules and pustules in the first 2 weeks of life. Lesions may appear and disappear but typically resolve within a week. Erythema toxicum neonatorum (Choices D and E) Nevus flammeus and nevus simplex are also vascular lesions that present at birth. Nevus flammeus, or port-wine stains, are uncommon, blanchable, red capillary malformations that are usually unilateral and do not cross midline. When associated with a syndrome (eg, Sturge-Weber), leptomeningeal vascular malformations may also be present and brain MRI is indicated for evaluation. Nevus simplex are blanchable pink patches that usually fade with time and are classically located on the eyelids, glabella, and nape of the neck. vascular lesions Educational objective: Most superficial infantile hemangiomas proliferate during infancy and regress throughout early childhood. Management is observation unless there are cosmetic concerns, bleeding or ulceration, and/or functional impairment (eg, airway compromise). References: Infantile hemangiomas: an update on pathogenesis and therapy. (http://www.ncbi.nlm.nih.gov/pubmed/23266916)

Question 8

A 65-year-old woman is brought to the emergency department by paramedics after falling on a snow-covered sidewalk.  The patient fell backward onto her hands while trying to maintain her balance and immediately felt a sharp, excruciating pain in her right arm.  She also notes mild tenderness and bruising on the right flank and right buttock.  The patient has a history of osteoporosis and hypertension and takes valsartan, alendronate, and a vitamin D supplement.  She does not use tobacco, alcohol, or illicit drugs.  In the emergency department, radiograph reveals a displaced fracture of the right distal radius.  The patient is admitted to the hospital and undergoes open reduction and internal fixation of the radius fracture.  On postoperative day 2, she reports severe, constant, burning pain over her right flank.  The postsurgical pain in the right arm is mild and well controlled with low-dose morphine as needed.  Temperature is 37.8 C (100 F), blood pressure is 145/84 mm Hg, pulse is 97/min, and respirations are 16/min.  Mucous membranes are moist and the oropharynx is without lesions.  Cardiopulmonary auscultation reveals clear lungs and normal heart sounds.  The abdomen is soft, nontender, and nondistended.  The right flank is tender to light touch with a rash over the area, as shown in the exhibit.  The surgical wound is healing normally without signs of infection. A diagnosis of herpes zoster is made and the patient is started on oral valacyclovir.  The patient's nurse comes to the office due to concern that she may have been exposed.  The nurse is pregnant and in her first trimester.  She reports a history of varicella as a child and has never received a varicella or zoster immunization.  What is the most appropriate treatment for this nurse?

Accepted Answer

Explanation: All health care personnel (HCP) should receive pre-employment screening to ensure immunity to varicella-zoster virus (VZV). HCP are considered immune if they have a documented previous history of varicella (as in this nurse) or have received the 2-dose varicella vaccine. Immune HCP do not require postexposure prophylaxis after working with patients with herpes zoster. HCP who do not have immunity to VZV typically receive postexposure prophylaxis with the varicella vaccine within 5 days of exposure (Choice C). This reduces risk of transmission by approximately 80%. For HCP who do not have immunity to VZV and are also immunocompromised or pregnant, varicella-zoster immune globulin or antiviral therapy (if immunoglobulin is unavailable) is typically required (Choices B and D). (Choice E) The zoster vaccine is recommended for people age >60 to reduce risk of herpes zoster. This vaccine is not used for postexposure prophylaxis. Educational objective: All health care personnel (HCP) should receive pre-employment screening to ensure immunity to varicella-zoster virus. HCP are considered immune if they have a documented history of varicella or have received the 2-dose varicella vaccine. Postexposure prophylaxis is not required in HCP who are considered immune. References: A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. (http://www.ncbi.nlm.nih.gov/pubmed/15930418) Cost-effectiveness of vaccination against herpes zoster and postherpetic neuralgia: a critical review. (http://www.ncbi.nlm.nih.gov/pubmed/24534737)

Question 9

A 16-year-old boy comes to the office due to an itchy rash on his back and shoulders.  The rash has been present for the last 3 months, but he has had similar symptoms intermittently in other body areas over the last 10 years.  The patient has no fever and has had no recent illnesses.  Current medications include daily cetirizine for seasonal allergies and topical benzoyl peroxide for acne.  Vital signs are normal.  On skin examination, there are excoriated lichenified plaques on the back and right shoulder, as shown in the exhibit. The patient returns to the office in 4 weeks with only modest improvement.  The rash continues to itch and is disrupting his sleep.  Examination findings are largely unchanged.  Which of the following is the most appropriate next step in management of this patient's symptoms?

Accepted Answer

Explanation: The foundation of management for atopic dermatitis (AD) includes oral antihistamines, emollients to maintain skin hydration, and avoidance of excessively hot or dry environments. However, many patients continue to have significant pruritus despite these measures. Most patients with AD will benefit from topical glucocorticoids. Low-potency agents (eg, hydrocortisone) may be adequate for mild symptoms. More significant symptoms may warrant moderate- to high-potency glucocorticoids (eg, triamcinolone, betamethasone). Topical glucocorticoids are relatively contraindicated for AD on the face, eyelids, or flexural areas; calcineurin inhibitors (eg, tacrolimus) may be considered for use in these areas (Choice D). Severe AD may require ultraviolet phototherapy or systemic immunosuppressants. (Choice A) Doxycycline is frequently used in a variety of dermatologic conditions, including acne, rosacea, and hidradenitis suppurativa. It is not beneficial for AD. (Choice B) Clotrimazole is indicated for superficial fungal dermatoses such as tinea corporis. Concurrent tinea infections may contribute to AD symptoms, but clotrimazole is otherwise not useful for AD. tinea corporis (Choice C) Oral antihistamines are useful to control itching in AD. However, topical antihistamines are less effective and may contribute to hypersensitivity. Educational objective: Topical glucocorticoids are effective treatment for most cases of atopic dermatitis. Topical calcineurin inhibitors (eg, tacrolimus) are an alternate therapy for areas in which glucocorticoids are relatively contraindicated (eg, face, eyelids). Severe atopic dermatitis may require phototherapy or systemic immunosuppressants. References: Atopic dermatitis: an overview. (http://www.ncbi.nlm.nih.gov/pubmed/22962911)

Question 10

A 7-month-old girl is brought to the office due to a rash.  The mother states, "The rash began 3 days ago on her buttocks and has spread to her genitalia.  I have been changing her diapers constantly and tried different brands of baby wipes, but the rash is getting worse."  She reports that the child has been tugging at her diaper and has been "a little fussier than normal" but otherwise playful.  The patient has been drinking her usual 4 bottles of formula daily, and her sleep pattern has not changed.  A week ago, the child had a mild diarrheal illness that has since resolved.  She has had no fever, runny nose, or cough.  The patient was born full term without complications and has no chronic medical conditions.  Family history is significant for allergic rhinitis in her mother and asthma in her 4-year-old sister.  All vaccinations are up to date.  Temperature is 36.7 C (98.1 F), and all other vital signs are normal.  Physical examination reveals an active child in no distress.  The rash is shown in the image below.  A similar rash is present over the labia but not over the inguinal folds or thigh creases.  Which of the following is the best treatment for this patient?

Accepted Answer

Explanation: 11ec2b69_be73_9912_8f63_e3eae3817e93_MD0005_00 Irritant, or contact, diaper dermatitis is due to several factors, including overhydration, friction, maceration, and prolonged contact with excretions. Physical examination demonstrates erythema in the diaper region, sparing the skinfolds that are typically not exposed to the contributing factors. The appearance of the rash after an episode of diarrhea is very characteristic. erythema in the diaper region Diaper dermatitis is diagnosed clinically. Management focuses on keeping the diaper area as dry as possible. Measures include frequent diaper changes, avoidance of excessively tight-fitting diapers, exposure of the skin to air, and application of barrier creams (eg, zinc oxide, petrolatum). Gentle cleansing with soap and water or alcohol- and fragrance-free wipes are also recommended. A low-potency corticosteroid ointment can be considered if the rash persists. High-potency corticosteroids (Choice B) should never be used in the diaper area due to the risk of systemic absorption and adrenal suppression. (Choice A) Bacterial superinfection can occur in diaper dermatitis but presents with pustular drainage or honey-crusted lesions. Topical antibiotics (eg, bacitracin, mupirocin) are first-line treatment. (Choices C and D) Nystatin is a topical antifungal agent used in the treatment of candidal diaper dermatitis, which presents with "beefy"-red plaques, satellite lesions, and involvement of skinfolds. Miconazole is also used in the treatment of candidal diaper dermatitis, but the powder formulation of any diaper dermatitis therapy should be avoided due to aspiration risk. This patient's rash spares the skinfolds. Educational objective: Irritant diaper dermatitis presents with erythema that spares the skinfolds. Management includes frequent diaper changes, avoidance of excessively tight-fitting diapers, exposure of the skin to air, and application of barrier creams (eg, zinc oxide, petrolatum). References: Diaper dermatitis: a review and update. (http://www.ncbi.nlm.nih.gov/pubmed/22790100) Prevention, treatment and parent education for diaper dermatitis. (http://www.ncbi.nlm.nih.gov/pubmed/26264797)

Question 11

A 25-year-old African-American medical student comes to see you in the office.  His girlfriend noticed an area of circular hair loss over the back of his head.  He is concerned that he is losing his hair and will be bald soon.  He is otherwise in good health and denies any history of smoking, alcohol, or illicit drug use.  He has had a monogamous relationship with his girlfriend for the past three years.  On examination, there is a 1 cm area of complete, smooth and circular hair loss with distinct margins.  There is no scaling or inflammation present in or around the area of hair loss.
Which of the following is the most appropriate treatment for this condition?

Accepted Answer

Explanation: Topical or intralesional corticosteroids are the treatment of choice for patients with alopecia areata. Patient education and information is also the key part of treatment. Patients should be made aware that: (1) the disease is usually benign, (2) they can have multiple relapses in spite of treatment, and (3) most patients have normal hair growth within the next one to two years even without treatment. They should also be informed that treatment with steroids, either intralesional or topical, can restore normal hair growth but does not cure the disease. After a steroid injection, new hair growth is usually seen in the next four to six weeks. (Choice A)There is no indication for the use of topical antifungal agents in this patient. (Choice B) A single intramuscular injection of penicillin G is useful in the treatment of patients with secondary syphilis. Antibiotics have no role in the treatment of alopecia areata. (Choice D)Alopecia areata is a chronic and relapsing disease. The risk of use of long-term oral corticosteroids outweighs the potential benefits in the patients. (Choice E) Topical tacrolimus is a calcineurin inhibitor. It is a useful alternative to topical corticosteroids in the treatment of inflammatory skin disorders such as atopic dermatitis. It has no role in the treatment of alopecia areata. Educational Objective: Topical or intralesional corticosteroids are the preferred first-line treatment in patients with alopecia areata.

Question 12

A 72-year-old man comes to the office because of a skin lesion on his hand that first appeared 6 months ago.  The lesion does not itch or cause pain.  The patient has had similar lesions on his face; some spontaneously resolved, and some were successfully treated with topical liquid nitrogen therapy.  Skin examination reveals a 1.3-cm lesion, as shown in the exhibit;it is nontender.  Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_be6e_41d9_8f63_630dc3c3cf0e_MD0005_00 This patient has an erythematous, hyperkeratotic plaque on the dorsal hand. Although it is most likely actinic keratosis (AK), squamous cell carcinoma (SCC) cannot be excluded. AK most commonly presents as erythematous, scaly papules with a sandpaper texture in fair-skinned individuals. Because they are related to chronic sun exposure, lesions often appear on skin with other signs of actinic damage (eg, dyspigmentation, atrophy, telangiectasia). Some lesions can spontaneously resolve, others can persist as AKs, and the remainder (1%-20%) can transform to SCC. The diagnosis of AK is typically apparent based on appearance; however, due to similarities in appearance between a large, hyperkeratotic AK and SCC, biopsy for definitive diagnosis is indicated for lesions ?1 cm. Other signs of malignant transformation that warrant biopsy include tenderness or induration and rapid growth of the lesion. Typical lesions that do not respond to treatment (eg, liquid nitrogen cryotherapy, topical fluorouracil or imiquimod) also should be biopsied. (Choices B, C, and D) Because of the risk for transformation to SCC, the treatment of AK should not be delayed. However, lesions ?1 cm, as in this patient, have a higher likelihood of being SCC, so biopsy should be performed as soon as possible to guide treatment. (Choice E) Topical retinoids are typically used to treat comedonal acne. Although a few studies have shown that they can reduce the number of AKs, more data are needed to establish their role in routine management. comedonal acne Educational objective: Actinic keratosis typically presents as scaly, erythematous papules on sun-exposed skin. Lesions that are ?1 cm, are tender/indurated, exhibit rapid growth, or fail to respond treatment should be biopsied to rule out squamous cell carcinoma. References: Current perspective on actinic keratosis: a review. (http://www.ncbi.nlm.nih.gov/pubmed/27500794)

Question 13

A 43-year old man comes to the physician with a 2-day history of blistering and severe itching on his hand.  He developed a superficial burn on his index finger from hot candle wax 1 week ago and has been treating the burn with a topical ointment containing neomycin, polymyxin B, and bacitracin.  His past medical history is significant for irritable bowel syndrome with chronic diarrhea.  The patient is not taking any prescription medications and has no known drug allergies.  On examination, he has faint erythema of the skin between the index and middle fingers, several vesicles and small bullae are present as shown in the image below:  Which of the following is the most appropriate next step in management of this patient's skin disorder?

Accepted Answer

Explanation: This patient has vesiculation and faint erythema associated with topical antibiotic use; these are typical features of acute allergic contact dermatitis (ACD). ACD is most commonly due to urushiol (ie, poison oak/poison ivy dermatitis). Other common causative allergens include topical antibiotics, fragrances, and a variety of chemicals used in rubber, plastic, and leather processing. Management includes avoidance of the offending agent. Low-potency topical glucocorticoids may also be considered if the itching and discomfort are intolerable. Topical antibiotics are useful for full-thickness burns and partial-thickness burns with loss of epithelium. However, superficial burns with an intact epithelium and most minor cuts and scrapes do not require topical antibiotics as these would only increase ACD risk and contribute to antibiotic resistance. (Choice B) Cephalexin is indicated for moderate skin and skin-structure infections such as cellulitis. However, this patient's skin findings and recent topical antibiotic use are more consistent with ACD. cellulitis (Choice C) Valacyclovir is indicated for the treatment of shingles (herpes zoster). Shingles is characterized by a papular or vesicular outbreak in a dermatomal distribution. Itching is possible, but burning or pain is more typical. shingles (Choice D) Dermatitis herpetiformis (DH) is an autoimmune disorder characterized by pruritic vesicles and papules in a widespread distribution, primarily on the elbows, knees, lower back, and buttocks. It is associated with celiac disease. Skin biopsy is usually performed to differentiate DH from other autoimmune vesicular/bullous diseases. Dermatitis herpetiformis vesicular/bullous diseases (Choice E) Tinea manuum is a superficial fungal infection of the hands that is often seen in patients with pre-existing tinea pedis. Characteristic findings include erythema, cracking, scaling, and pruritus. Tinea manuum Educational objective: Allergic contact dermatitis is a common adverse effect of topical antibiotic use. Topical antibiotics also increase the risk for antibiotic-resistant organisms. References: Postoperative topical antimicrobial use. (http://www.ncbi.nlm.nih.gov/pubmed/18674453) Contact allergy to neomycin sulfate: results of a multifactorial analysis. (http://www.ncbi.nlm.nih.gov/pubmed/15880442)

Question 14

A 4-month-old boy is brought to the office by his father due to a severe diaper rash that has been present for 4 days and is progressively worsening.  His mother has been applying over-the-counter barrier cream to the rash with each diaper change but has seen no improvement.  The child attends day care, and the day care attendant advised that the rash be evaluated to "make sure it is not contagious to other children."  The patient was recently admitted to the hospital for pneumonia, requiring parenteral antibiotics and intravenous fluids.  He was discharged a week ago and still has a mild cough but is otherwise playful with normal appetite.  The patient was born at 38 weeks gestation without complications.  Weight and height are at the 65th percentile.  Temperature is 36.7 C (98 F).  Physical examination shows a well-appearing, interactive infant.  Skin examination shows multiple erythematous, confluent, papular lesions in the diaper area, including the genitalia, buttocks, perineum, and genitocrural folds.  There are also several isolated, bright-red papules with scaling beyond the diaper area on the inner thighs.  There are no lesions on the chest, abdomen, or extremities.  The lungs are clear to auscultation.  Which of the following is the most appropriate pharmacotherapy for this patient?

Accepted Answer

Explanation: 11ec2b69_be74_3553_8f63_43f12d90035d_MD0005_00 This child is presenting with candidal diaper dermatitis, which occurs most commonly in young infants. Moisture and/or skin breakdown coupled with skin colonization by yeast (eg, Candida albicans) from the gastrointestinal tract predisposes children to infection. Children who have recently received antibiotics are at higher risk for candidal infection, as the antibiotic-mediated decrease in normal bacterial flora favors yeast production. Clinical features include "beefy" red papules and plaques in the diaper area, accompanied by satellite lesions (erythematous papules separate from the main rash). Diaper rashes from candidal infections involve the skin folds, distinguishing it from the skin-fold sparing seen in irritant/contact diaper dermatitis. Diagnosis is clinical. Treatment of candidal rashes involves a topical antifungal such as nystatin or clotrimazole. "beefy" red papules and plaques (Choice B) Powder (eg, cornstarch, talcum) should be avoided in the prevention or treatment of diaper dermatitis due to the risk of aspiration. (Choice C) Although topical corticosteroids can temporarily decrease inflammation, they are typically not used in the treatment of candidal infections. Use of high-potency corticosteroids should be particularly avoided in the diaper area due to the risk of systemic absorption and adrenal suppression. (Choice D) Mupirocin can be used for a suspected bacterial superinfection, which typically presents with pustules or honey-crusted drainage. Mupirocin is not effective in the treatment of candidal infections. (Choice E) Zinc oxide creams and petrolatum ointment are beneficial for irritant diaper dermatitis and can be used as adjuvant therapies in yeast infections. However, antifungal therapy is first-line treatment for a candidal infection. Educational objective: Candidal diaper dermatitis presents with "beefy" red plaques, satellite papules, and involvement of the genitocrural folds. First-line therapy is a topical antimycotic agent (eg, nystatin, clotrimazole). References: Prevention, treatment and parent education for diaper dermatitis. (http://www.ncbi.nlm.nih.gov/pubmed/26264797)

Question 15

A 36-year-old woman comes to the physician for a rash on her lower abdomen.  The rash first appeared 3 months ago and has been slowly expanding in the same area.  It is mildly pruritic but otherwise asymptomatic.  Treatment with topical emollients has not been beneficial.  The patient has a history of depression for which she takes citalopram but is otherwise healthy.  Skin examination findings are shown in the image below.  Which of the following is the most likely explanation for this patient's symptoms?

Accepted Answer

Explanation: This patient has excoriated, lichenified plaques at the beltline; these are typical features of chronic allergic contact dermatitis (ACD). Common ACD triggers include a variety of household and occupational allergens including nickel and other metals, cleaning products, fragrances, and various chemicals involved in rubber, plastic, and leather processing. Identifying a specific allergen is often difficult and may require patch testing. However, the distribution of lesions and a careful history may identify the causative allergen. For example, nickel allergy often presents near sites of frequently-worn jewelry or clothing fasteners, latex allergy often appears near clothing waistbands, and leather allergy typically appears on the feet. Management of chronic ACD requires careful avoidance of allergens. Topical high-potency glucocorticoids (eg, betamethasone, fluocinonide) are useful for treatment of flares in intermittent short courses (<4 weeks). Topical tacrolimus is an alternative for areas where glucocorticoids are contraindicated (eg, the face). (Choice B) Psoriasis is a common inflammatory skin disorder characterized by erythematous, well-defined plaques covered by thick silvery scales. These lesions are typically seen over the scalp, knees, elbows, back, and nail plates. Patients are usually asymptomatic, but some may have mild itching. Psoriasis (Choice C) Tinea corporis is characterized by pink annular plaques with a scaly border and central clearing. This patient has pale lichenified plaques that are more consistent with ACD. Tinea corporis (Choice D) Dyshidrotic dermatitis presents as a vesicular rash on the palms and/or soles that is associated with pruritus, redness, and scaling. The sides of the digits may also be involved, but lesions on the trunk are not typical. Dyshidrotic dermatitis (Choice E) Lichen simplex chronicus ("neurodermatitis") is characterized by thickened excoriated plaques caused by persistent scratching and rubbing. It is associated with anxiety disorders and typically occurs in areas that are easy to reach (eg, arms, legs, neck). Lichen simplex chronicus Educational objective: Chronic allergic contact dermatitis is characterized by pruritic lichenified plaques. The locations correlate with the causative allergen. Common triggers include metals (eg, nickel), cleaning products, and a variety of chemicals used in rubber, plastic, and leather processing. References: Metal allergy--a review on exposures, penetration, genetics, prevalence, and clinical implications. (http://www.ncbi.nlm.nih.gov/pubmed/19831422)

Question 16

A 62-year-old Caucasian woman presents to her primary care physician complaining about her facial appearance.  She says she dislikes "looking so much worse than all my friends."  Specifically, she mentions that the deep wrinkles and brown spots on her face are what she finds most disturbing.  Her past medical history is significant for breast cancer, hypothyroidism, and diverticulosis.  Her only medications are levothyroxine, tamoxifen, and a multivitamin.  She is a divorced mother of two and has recently retired from working as the supervising gardener of a large estate.  She has a forty-year history of smoking one pack of tobacco per day and consumes one or two glasses of wine each night.  She admits to occasional marijuana usage when she was a younger adult.  Examination of her facial skin is remarkable for a general leathery appearance with many deep furrows and wrinkles.  The wrinkles are especially prominent on the forehead and at the lateral corners of the eyes.  The skin is sallow and has variable pigmentation.  The surface texture is rough in areas.  There are scattered flesh-colored scaly patches with slightly irregular margins and occasional clusters of what appear to be dilated superficial capillaries and venules.
Which of the following is the most likely diagnosis?

Accepted Answer

Explanation: Photoaging (Choice B) is a phenomenon that arises from intrinsic aging and damage caused by ultraviolet light. While intrinsic aging tends to result in fine wrinkles on an otherwise smooth skin surface, photodamage tends to result in coarse, deep wrinkles on a rough skin surface. Photoaged skin is often marked with actinic keratoses, telangiectasias and brown ("liver") spots. Erythrasma (Choice A)is an infection of the skin that occurs most often in intertriginous spaces and is caused by Corynebacterium minutissimum. The appearance of erythrasma includes a confluence of pruritic, reddish brown, finely wrinkled papules. The use of a Wood lamp reveals a coral-red fluorescence caused by the Corynebacterium porphyrins. Corynebacterium minutissimum Corynebacterium Pityriasis rosea (Choice C) is a self-limited condition of unknown etiology that first manifests as a single primary plaque ("herald patch") with a fine collarette scale. A generalized eruption develops 1 to 2 weeks later, with fine, scaling papules and plaques in the "Christmas tree" distribution. Rosacea (Choice D) is a chronic inflammatory disease that causes erythema of the central face. It first manifests as easy flushing and later results in persistent erythema and telangiectasia. Patients are sensitive to chemical or physical insults and should limit exposure to sunlight. Seborrheic dermatitis (Choice E)is a chronic, superficial, inflammatory process that arises in areas rich in sebaceous glands. The condition worsens during infancy and puberty, when the sebaceous glands are more active. In adults with seborrheic dermatitis, erythema with fine scale is evident on the scalp ("dandruff"), eyebrows, eyelids, nasolabial creases, ears, sternal area, axillae, umbilicus, groin, and gluteal crease. Educational Objective: Photoaging arises from the combination of intrinsic aging and damage caused by ultraviolet light. It results in coarse, deep wrinkles on a rough skin surface and may be accompanied by actinic keratoses, telangiectasias and brown (liver) spots.

Question 17

A 62-year-old Caucasian woman presents to her primary care physician complaining about her facial appearance.  She says she dislikes "looking so much worse than all my friends."  Specifically, she mentions that the deep wrinkles and brown spots on her face are what she finds most disturbing.  Her past medical history is significant for breast cancer, hypothyroidism, and diverticulosis.  Her only medications are levothyroxine, tamoxifen, and a multivitamin.  She is a divorced mother of two and has recently retired from working as the supervising gardener of a large estate.  She has a forty-year history of smoking one pack of tobacco per day and consumes one or two glasses of wine each night.  She admits to occasional marijuana usage when she was a younger adult.  Examination of her facial skin is remarkable for a general leathery appearance with many deep furrows and wrinkles.  The wrinkles are especially prominent on the forehead and at the lateral corners of the eyes.  The skin is sallow and has variable pigmentation.  The surface texture is rough in areas.  There are scattered flesh-colored scaly patches with slightly irregular margins and occasional clusters of what appear to be dilated superficial capillaries and venules.
The diagnosis is made.  Which of the following factors is most likely to be responsible for worsening this woman's condition?

Accepted Answer

Explanation: Smoking tobacco is known to have a significant impact on the appearance of skin. Smokers have more wrinkles than nonsmokers, and are especially prone to developing coarse wrinkles prominent at the lateral corners of the eyes. It has been hypothesized that cigarette smoking may cause harmful changes in blood flow or that circulating toxins from cigarette smoke may alter production of collagen or elastin. (Choice A) Although alcohol usage has been shown to worsen rosacea, it is not associated with an amplification of photoaging. (Choice B)Photoaging occurs in both genders, though men are usually considered more likely than women to engage in prolonged outdoor activities over a period of many years. (Choice C) Hypothyroidism can cause dry, thickened, and inelastic skin independent of exposure to ultraviolet light. It is not a known risk factor for worsened photoaging. (Choice D) Heavy marijuana usage could hypothetically cause increased susceptibility to photoaging, though this has not been clearly demonstrated. Since this woman's marijuana usage is remote, it is unlikely that it played as significant a role in her appearance as does her tobacco usage. Educational Objective: Cigarette smokers have been shown to have more and deeper wrinkles than do nonsmokers.

Question 18

A 16-year-old boy comes to the office due to an itchy rash on his back and shoulders.  The rash has been present for the last 3 months, but he has had similar symptoms intermittently in other body areas over the last 10 years.  The patient has no fever and has had no recent illnesses.  Current medications include daily cetirizine for seasonal allergies and topical benzoyl peroxide for acne.  Vital signs are normal.  On skin examination, there are excoriated lichenified plaques on the back and right shoulder, as shown in the exhibit. 
Which of the following is the most appropriate advice to reduce this patient's symptoms?

Accepted Answer

Explanation: 11ec2b69_be70_3dab_8f63_e3fc852122e7_MD0005_00 This patient, with a chronic pruritic rash with excoriations and lichenification, has features typical of atopic dermatitis (AD). AD most often first appears in childhood and is frequently associated with other atopic conditions such as asthma and seasonal or perennial allergies. The foundation of management for AD includes avoidance of factors that contribute to itching, such as excessively hot or dry environments and harsh soaps and detergents. Oral antihistamines are also useful. Regular use of emollients to maintain skin hydration can also relieve pruritus. (Choice A) A gluten-free diet is recommended for patients with dermatitis herpetiformis. This condition is usually associated with celiac disease and is characterized by intensely pruritic papules and vesicles on the extensor surfaces of the elbows and knees as well as on the buttocks and back. dermatitis herpetiformis (Choice B) Cotton clothing is generally recommended for patients with AD, as wool and synthetic fibers may increase the itching. However, care must still be taken as some fabric dyes or bacterial/fungal colonization in the material may cause a hypersensitivity reaction. (Choices D and E) Patients with AD frequently have evidence of hypersensitivity on antigen patch testing, but environmental and food antigen mitigation efforts have shown only minimal utility in the management of AD. Educational objective: Initial management of atopic dermatitis (AD) includes topical emollients and avoidance of excessively hot/dry environments and harsh soaps and detergents. Although patients with AD often have evidence of hypersensitivity on antigen patch testing, mitigation of environmental and food allergens does not have a significant benefit for most patients. References: Skin barrier breakdown: a renaissance in emollient therapy. (http://www.ncbi.nlm.nih.gov/pubmed/19633599) Steroid-free emollient formulations reduce symptoms of eczema and improve quality of life. (http://www.ncbi.nlm.nih.gov/pubmed/24809884)

Question 19

A 62-year-old Caucasian woman presents to her primary care physician complaining about her facial appearance.  She says she dislikes "looking so much worse than all my friends."  Specifically, she mentions that the deep wrinkles and brown spots on her face are what she finds most disturbing.  Her past medical history is significant for breast cancer, hypothyroidism, and diverticulosis.  Her only medications are levothyroxine, tamoxifen, and a multivitamin.  She is a divorced mother of two and has recently retired from working as the supervising gardener of a large estate.  She has a forty-year history of smoking one pack of tobacco per day and consumes one or two glasses of wine each night.  She admits to occasional marijuana usage when she was a younger adult.  Examination of her facial skin is remarkable for a general leathery appearance with many deep furrows and wrinkles.  The wrinkles are especially prominent on the forehead and at the lateral corners of the eyes.  The skin is sallow and has variable pigmentation.  The surface texture is rough in areas.  There are scattered flesh-colored scaly patches with slightly irregular margins and occasional clusters of what appear to be dilated superficial capillaries and venules.
Which of the following would be the most appropriate treatment for this woman's condition?

Accepted Answer

Explanation: Tretinoin (Choice A) is the generic name for all-trans-retinoic acid. It is an emollient cream approved by the FDA for reduction of fine wrinkles, mottled hyperpigmentation, and roughness of the facial skin. Tretinoin is also successful in reducing actinic keratoses and in improving the appearance of brown spots, regardless of etiology. It would therefore be an excellent choice in this woman. trans Metronidazole (Choice B) is an antibiotic prescribed for treatment of rosacea. It is not indicated for the treatment of photoaging. Tar-based creams and shampoos (Choice C) are used in the treatment of seborrheic dermatitis. They are not indicated in the treatment of photoaging. Interferon alfa (Choice D) can be used to treat cutaneous T cell lymphomas (and mycosis fungoides in particular). Fluorouracil (Choice E) is sometimes used in the treatment of actinic keratoses, but it requires particular attentiveness on the part of both the patient and physician. Skin irritation is also a common occurrence with fluorouracil usage. Since tretinoin has been shown to improve the appearance of photoaged skin overall in addition to decreasing the number and size of actinic keratoses, it is a superior treatment choice for this woman. Educational Objective: Tretinoin is an emollient cream approved by the FDA for reduction of fine wrinkles, mottled hyperpigmentation, and roughness of the facial skin. Tretinoin is also successful in reducing actinic keratoses and in improving the appearance of brown spots, regardless of etiology.

Question 20

A 48-year-old man comes to the physician with a red skin lesion on his abdomen.  He first noticed it 6 months ago and says that it has been enlarging recently.  The lesion bleeds occasionally when disturbed but is otherwise asymptomatic.  The patient has a history of hypertension and actinic keratosis.  He has a 25-pack-year smoking history and drinks a 6-pack of beer daily.  Physical examination findings are shown in the image below.  Which of the following is the most appropriate next step in management of this patient's skin lesion?

Accepted Answer

Explanation: This patient's skin lesion is consistent with a cherry angioma (CA), which is a common benign vascular tumor seen in adults. CA is characterized by sharply circumscribed areas of congested capillaries and post-capillary venules in the papillary dermis. Patients usually develop multiple small, vascular, bright-red, and dome-shaped papules. CAs are most commonly found on the trunk, and occur only in skin and not in deep tissues or mucosa. The lesions usually blanch with pressure, but some lesions can become fibrotic over time and will not blanch. CAs usually do not regress spontaneously and are sometimes called senile hemangiomas as they increase in number as the patient ages. They may occasionally bleed if disturbed but are otherwise asymptomatic and do not need treatment other than for cosmetic reasons. Electrocauterization under local anesthesia can treat small lesions, while shave excision with electrocauterization is required for larger lesions (Choice A). (Choice B) Kaposi sarcoma (KS) is most often seen in patients who have coinfection with HIV and human herpesvirus type 8 (HHV-8); it is considered an AIDS-defining condition. KS usually appears as deep red, purple, or brown macules on the trunk, extremities, and face. The lesions can also present as plaques or nodules that are ovoid and linear in shape along skin tension lines. Kaposi sarcoma (KS) nodules (Choice C) Spider angiomas usually present as bright red central papules surrounded by several outwardly radiating vessels. They occur due to dilated central arterioles and associated superficial capillary networks. Spider angiomas are estrogen dependent and are commonly found in patients with cirrhosis. Spider angiomas (Choice D) Propranolol is a treatment option for infantile (strawberry) hemangiomas. These grow rapidly but spontaneously regress by age 5-8. Most infantile hemangiomas may be managed conservatively, though beta-blockers may occasionally be needed for ulcerating lesions. infantile (strawberry) hemangiomas Educational objective: Cherry angiomas (CAs) usually present as multiple small, vascular, bright-red, and dome-shaped papular lesions in adults. CAs are benign lesions that increase in number with age and do not regress spontaneously. Most lesions do not require treatment.

Exam 1: Advanced Clinical Medicine