RAVING RASHES
SQUATTERS!
CSI: Your Skin
Potent Problems of Pigmentation
The Freckle's Ugly Cousin
100
A 32-year-old man is evaluated for an intermittent pruritic rash of 8 years' duration. Medical history is significant for mild persistent asthma. His only medications are an albuterol inhaler and an inhaled glucocorticoid.
On physical examination, vital signs are normal. There is mild xerosis with erythematous plaques on the bilateral antecubital fossae, volar wrists, and anterior lower legs. Lichenification is present on the dorsal hands. Linear excoriations are found within many of the erythematous plaques on the arms.
Which of the following is the most appropriate treatment?
A. Oral cephalexin
B. Oral prednisone
C. Topical glucocorticoids
D. Topical ketoconazole
E. Topical mupirocin
C. Topical glucocorticoids
100
A 20-year-old male college student presents to your office for evaluation of a rash. He recently returned from a trip to the eastern coast of Mexico, which he took during spring break. His rash appeared 1 day after he returned from Mexico, and it has persisted for 7 days. Abdominal examination is significant for several erythematous serpiginous lines in the skin, with secondary excoriation.
For this patient, which of the following treatments is indicated at this time?
A. Symptomatic treatment with antihistamines, topical antipruritic agents, and topical corticosteroids
B. Occlusion with an agent such as liquid paraffin or lubricating jelly
C. Oral albendazole
D. A pentavalent antimony compound
C. Oral albendazole
100
A 25-year-old man is evaluated for recurrent skin eruption with oval lesions on the chest and upper back, which are occasionally itchy. The lesions began in late spring and worsened over the summer. Medical history is unremarkable, and he takes no medications.
On physical examination, vital signs are normal. Skin findings on the chest are shown.
Extremities and feet are unaffected.
Which of the following is the most likely diagnosis?
A. Candida albicans infection
B. Erythrasma
C. Pityriasis versicolor
D. Tinea corporis
C. Pityriasis versicolor
100
A 24-year-old woman is evaluated for a rash on her face for several months' duration. It is asymptomatic but has gotten worse over the summer. She washes her face with soap and water twice daily and has recently changed soaps. Previously her skin was normal. She is otherwise healthy. Her only medication is an oral contraceptive pill, which she started 3 months ago.
On physical examination, vital signs are normal. Skin findings are shown.
Which of the following is the most likely diagnosis?
A. Irritant contact dermatitis
B. Melasma
C. Morbilliform drug eruption
D. Postinflammatory hyperpigmentation
B. Melasma
100
An 82-year-old woman is evaluated for a spot on her left cheek. Six months ago, she was diagnosed with an actinic keratosis. This lesion was treated with cryotherapy two times; however, the lesion is still persistent. On palpation, it is indurated. The lesion is shown.
Which of the following is the most appropriate next step in management?
A. Cryotherapy
B. Biopsy
C. Topical imiquimod
D. Wide local excision
B. Biopsy
200
A 60-year-old woman is evaluated for follow-up treatment of long-standing psoriasis. Medical history is significant for hypertension and hypercholesterolemia. Family history includes multiple family members with psoriasis. She has no joint symptoms, and her medications are atenolol and simvastatin.
On physical examination, vital signs are normal. There is no joint swelling.
She has a total of 30% body surface area involvement with psoriasis without nail involvement.
Which of the following is the most appropriate treatment?
A. Methotrexate
B. Oral prednisone
C. Tacrolimus ointment
D. Topical calcitriol
A. Methotrexate
200
A 34-year-old man acquired leishmaniasis in an area known to be endemic for mucocutaneous disease.
A. Sodium stibogluconate
B. Topical poromomycin
C. Cryosurgery
D. Microwave energy heat therapy
E. Intralesional injection of antimonials
A. Sodium stibogluconate
200
A 35-year-old woman is evaluated for severe pain on the left side of the chest for 1 week followed by increased redness and the development of small blisters. Medical history is significant for rheumatoid arthritis. Medications are naproxen as needed, methotrexate folic acid, and an oral contraceptive.
On physical examination, skin findings are shown.
The remainder of the examination is unremarkable.
Which of the following is the most likely diagnosis?
A. Chicken pox (varicella)
B. Eczema herpeticum
C. Herpes simplex virus
D. Herpes zoster
D. Herpes zoster
200
A 20-year-old woman is evaluated for white spots on her eyelids, hands, elbows, and knees for several months' duration. There was no previous rash. She is otherwise healthy and takes no medications.
On physical examination, vital signs are normal. Representative skin findings on the eyelids are shown.
The remainder of the examination is normal.
Which of the following is the most likely diagnosis?
A. Pityriasis alba
B. Tinea versicolor
C. Tuberous sclerosis
D. Vitiligo
D. Vitiligo
200
A 63-year-old woman is evaluated for a lesion on her nose that is slowly enlarging and nonhealing. She is otherwise in good health and takes no medications.
On physical examination, vital signs are normal. The skin examination demonstrates a 0.8 × 0.6-cm pearly ulcerated papule with arborizing telangiectasias. The remainder of the examination is normal.
Biopsy of the lesion demonstrates basal cell carcinoma with high-risk micronodular and infiltrative histologic features.
Which of the following is the most appropriate treatment of this lesion?
A. Cryotherapy
B. Electrodesiccation and curettage
C. Mohs micrographic surgery
D. Topical 5-fluorouracil
E. Vismodegib
C. Mohs micrographic surgery
300
A 65-year-old man is evaluated in the ICU for a rash limited to his back that was first noticed this morning. He was admitted to the ICU for hospital-acquired pneumonia following hip replacement surgery 3 days ago. Because of deteriorating respiratory function, he was intubated and placed on mechanical ventilation. His current medications are fentanyl and piperacillin-tazobactam.
On physical examination, temperature is 38.3 °C (100.9 °F), blood pressure is 110/60 mm Hg, pulse rate is 115/min, and respiration rate is 18/min (ventilator set rate is 14/min). Pulmonary examination reveals diffuse crackles. Skin findings are shown.
Which of the following is the most likely diagnosis?
A. Acute generalized exanthematous pustulosis
B. Candida albicans infection
C. Miliaria
D. Povidone iodine contact dermatitis
C. Miliaria
300
Dr. Martinez's husband, who recently served in Afghanistan, presents to your clinic 3 months after returning to the United States from his latest tour of duty. He complains of a verrucuous, ulcerated lesion on his nose that began as a red-brown papule 2 weeks before he left Afghanistan. He has had no other systemic symptoms and has never had anything like this before. You are concerned for squamous cell carcinoma and perform a skin biopsy. Histopathologic evaluation reveals leishmaniasis.
Before he kills you for now knowing his top secret location, which species of Leishmania is the most likely cause of his lesion?
A. Leishmania braziliensis
B. Leishmania mexicana
C. Leishmania major
D. Leishmania donovani
C. Leishmania major
300
A 25-year-old woman is evaluated for pruritic lesions on the legs and in the groin area that first appeared several months ago. The patient is otherwise in good health and takes no medications.
On physical examination, vital signs are normal. Skin findings are shown.
Which of the following is the most likely diagnosis?
A. Condylomata acuminata
B. Herpes simplex virus infection
C. Molluscum contagiosum infection
D. Seborrheic keratoses
C. Molluscum contagiosum infection
300
A 56-year-old man presents with complaints of a rash on his arms, which he first noticed 2 months ago. The rash has gotten progressively worse since that time. It is not associated with any systemic or local symptoms, including fever or pruritus. Skin examination reveals three patches of depigmented skin without surrounding erythema or induration. The borders are distinct and irregular. The patient reports that a family member has similar skin lesions. You suspect vitiligo.
What disease is thought to be seen in association with vitiligo?
A. Hypothyroidism
B. Diabetes
C. Chronic kidney disease
D. Lung cancer
A. Hypothyroidism
300
A 40-year-old man is evaluated for a firm, flesh-colored lesion that has been growing on the back for several months. Foul-smelling material can be expressed from the lesion. The patient is bothered by the periodic drainage. He is otherwise healthy and takes no medications.
On physical examination, vital signs are normal. There is a 3-cm subepidermal nodule with a central punctum on the upper back. There is no erythema or warmth of surrounding skin.
Which of the following is the most appropriate treatment for this patient?
A. Excision
B. Incision
C. Incision and drainage
D. Oral antibiotics
A. Excision
400
A 68-year-old woman is evaluated for a 12-month history of swelling of both of her lower legs. Over the past 4 months, there was worsening edema, erythema, scaling, and itching of the lower legs. She has not used any prescription or over-the-counter topical medications or emollients. Medical history is significant for hypertension and type 2 diabetes mellitus. Medications are lisinopril, amlodipine, hydrochlorothiazide, and metformin.
On physical examination, vital signs are normal. BMI is 32. Skin findings are shown.
There is no tenderness. Pedal pulses are strong bilaterally.
Laboratory studies, including leukocyte count, are within normal range.
Which of the following is the most likely diagnosis?
A. Allergic contact dermatitis
B. Cellulitis
C. Leukocytoclastic vasculitis
D. Psoriasis
E. Stasis dermatitis
E. Stasis dermatitis
400
To distinguish zoonotic mite infestation from scabies, the physician should do which of the following?
A. Examine the patient for the presence of burrows
B. Treat all animals in the patient’s house with oral ivermectin
C. Obtain blood for a polymerase chain reaction (PCR) assay
D. Perform a biopsy for direct immunofluorescence
E. Obtain serum for indirect immunofluorescence
A. Examine the patient for the presence of burrows
400
A 71-year-old man is evaluated for erythema and tenderness of the left lower leg for 1 week's duration. This is the second similar episode of the left lower leg. The last episode was 2 months ago. He was previously treated successfully with antibiotics.
On physical examination, temperature is 38.1 °C (100.6 °F), blood pressure is 125/75 mm Hg, respiration rate is 16/min, and pulse rate is 85/min. There is a well-demarcated, warm and tender erythematous patch on the anterior lower left leg extending from dorsal foot to mid shin. There is tissue maceration and fissuring between second and third toe spaces bilaterally. The remainder of the physical examination is normal.
In addition to initiating antibiotic therapy, which of the following is the most appropriate management?
A. Following acute therapy, start prophylactic antibiotics
B. Obtain blood cultures
C. Obtain skin punch biopsy
D. Staphylococcal decolonization with intranasal mupirocin
E. Treat the interdigital intertrigo
E. Treat the interdigital intertrigo
400
A 22-year-old white man with albinism comes to your clinic to establish primary care. His immunizations are up-to-date, and the patient is otherwise healthy. Physical examination reveals a lack of pigmentation in the patient's skin and hair; otherwise, the examination is normal.
About which of the following preventive measures should this patient be counseled?
A. Yearly prostate examinations
B. Pneumonia vaccination
C. Sunscreen use
D. Avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs)
C. Sunscreen use
400
A 69-year-old man is evaluated for a new lesion behind his ear. It is asymptomatic. His wife noted that it first appeared last year and is growing. The patient is a farmer and has had many sunburns over his lifetime. He has no other medical problems and takes no medications.
On physical examination, vital signs are normal. Skin findings are shown.
Which of the following is the most likely diagnosis?
A. Junctional melanocytic nevus
B. Melanoma in situ, lentigo maligna
C. Nodular melanoma
D. Solar lentigo
B. Melanoma in situ, lentigo maligna
500
A 60-year-old man is evaluated for dry skin and a pruritic rash of 6 months' duration. He is a farmer and has extensive exposure to the sun. The rash is transient, occurring most frequently during the winter and spring when his skin is dry, and is worsened by heat and sweating during the summer. The patient is otherwise well, has no other medical problems, and takes no medications.
On physical examination, vital signs are normal. Skin findings on the upper torso are shown.
The arms, legs, face, and mucous membranes are unaffected. The remainder of the examination is unremarkable.
Which of the following is the most likely diagnosis?
A. Allergic contact dermatitis
B. Atopic dermatitis
C. Lichen planus
D. Transient acantholytic dermatosis
D. Transient acantholytic dermatosis
500
You serve as the physician for a local nursing home. Recently, the nursing home has been struggling with a large outbreak of scabies in its resident population. You have been called by the nurse manager to evaluate the affected patients and recommend a therapeutic regimen.
Which of the following statements regarding the treatment of scabies outbreaks in institutional settings is correct?
A. Besides the affected residents, only their roommates need to be treated
B. Permethrin cream should be applied to all of the residents of the nursing home
C. Ivermectin should be administered to all affected residents
D. With appropriate treatment of the residents, the risk of reinfestation is low
C. Ivermectin should be administered to all affected residents
500
A 28-year-old man is evaluated for a 4-day history of a tender nodule on the left dorsal hand. The patient thought the lesion started as a “spider bite,” and it continued to increase in size and tenderness. He has no fever or chills. No other lesions are present.
Medical history is unremarkable, and he takes no medications.
On physical examination, vital signs are normal. Skin findings are shown.
The remainder of the examination is normal.
Laboratory values, including leukocyte count , are within normal range.
Which of the following is the most appropriate treatment?
A. Antibiotic therapy based on culture result
B. Incision and drainage
C. Incision and drainage plus oral cephalexin
D. Oral trimethoprim-sulfamethoxazole
B. Incision and drainage
500
A 21-year-old man with unremitting epistaxis presents to your hospital’s emergency department during your shift. You manage the bleeding appropriately but, in taking a careful history, cannot establish the cause of the epistaxis. On physical examination, you note that the patient has very light skin and almost white hair; there are also several bruises on his limbs. You review the literature and find a list of congenital syndromes that include secondary albinism as a component, and you find one that ties together this patient’s symptoms and examination findings.
Which of the following disorders best explains this patient’s presentation?
A. Chédiak-Higashi syndrome
B. Hermansky-Pudlak syndrome
C. Cross-McKusick-Breen syndrome
D. Prader-Willi syndrome
E. Angelman syndrome
B. Hermansky-Pudlak syndrome
500
An 83-year-old man is seen in the office for routine follow-up. He has a history of hypertension and atrial fibrillation. Medications are hydrochlorothiazide and warfarin.
On physical examination, vital signs are normal. During lung auscultation, a 0.4 × 0.4-cm pink pearly papule with telangiectasias on his back is found.
Biopsy of the lesion reveals a basal cell carcinoma with low-risk histology.
Which of the follow is the most appropriate treatment?
A. Electrodesiccation and curettage
B. Mohs micrographic surgery
C. Radiation
D. Vismodegib
A. Electrodesiccation and curettage