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CMN 572 Unit 4 Practice Exam With
Complete Solution
Primary lesions - ANSWER Primary lesions are physical changes in the skin considered to be caused directly by the disease process. Types of primary lesions are rarely specific to a single disease entity.
Macule - ANSWER A macule is a change in the color of the skin. It is flat, if you were to close your eyes and run your fingers over the surface of a purely macular lesion, you could not detect it. A macule greater than 1 cm. may be referred to as a patch.
Papule - ANSWER A papule is a solid raised lesion that has distinct borders and is less than 1 cm in diameter. Papules may have a variety of shapes in profile (domed, flat-topped, umbilicated) and may be associated with secondary features such as crusts or scales.
Nodule - ANSWER A nodule is a raised solid lesion more than 1 cm. and may be in the epidermis, dermis, or subcutaneous tissue.
Tumor - ANSWER A tumor is a solid mass of the skin or subcutaneous tissue; it is larger than a nodule. (Please bear in mind this definition does not at all mean that the lesion is a neoplasm.)
Plaque - ANSWER A plaque is a solid, raised, flat-topped lesion greater than 1 cm. in diameter. It is analogous to the geological formation, the plateau.
Vesicle - ANSWER Vesicles are raised lesions less than 1 cm. in diameter that are filled with clear fluid.
Bullae - ANSWER Bullae are circumscribed fluid-filled lesions that are greater
than 1 cm. in diameter.
Pustule - ANSWER Pustules are circumscribed elevated lesions that contain pus. They are most commonly infected (as in folliculitis) but may be sterile (as in pustular psoriasis).
Wheal - ANSWER A wheal is an area of edema in the upper epidermis.
Burrow - ANSWER Burrows are linear lesions produced by infestation of the skin and formation of tunnels (e.g., with infestation by the scabitic mite or by cutaneous larva migrans).
Telangiectasia - ANSWER Telangiectasia are the permanent dilatation of superficial blood vessels in the skin and may occur as isolated phenomena or as part of a generalized disorder, such as ataxia telangiectasia.
Scale - ANSWER Scale consists of flakes or plates that represent compacted desquamated layers of stratum corneum. Desquamation occurs when there are peeling sheets of scale following acute injury to the skin.
Secondary Leisons - ANSWER Secondary lesions may evolve from primary lesions, or may be caused by external forces such as scratching, trauma, infection, or the healing process. The distinction between a primary and secondary lesion is not always clear.
Crust - ANSWER Crusting is the result of the drying of plasma or exudate on the skin. Please remember that crusting is different from scaling. The two terms refer to different phenomena and are not interchangeable. One can usually be distinguished from the other by appearance alone.
Atrophy - ANSWER Atrophy is thinning or absence of the epidermis or subcutaneous fat.
Lichenification - ANSWER "Lichenification" refers to a thickening of the
ring shape. Tinea corporis, erythema migrans (the lesion associated with lyme disease), and granuloma annulare are three common examples.
Patterns and distribution: Discrete - ANSWER Discrete lesions tend to remain separate. This is a helpful descriptive term but has little specific diagnostic significance.
Patterns and distribution: Clustered - ANSWER Clustered lesions are those that are grouped together. They are commonly seen in herpes simplex or with insect bites, for example.
Patterns and distribution: Confluent - ANSWER Confluent lesions tend to run together.
Patterns and distribution: Dermatomal/zosteriform - ANSWER Dermatomal, zosteriform lesions follow a dermatome. The lesions of varicella zoster (also known as shingles) are the classic example, but there are other lesions that may assume the same pattern.
Patterns and distribution: Eczematoid - ANSWER Eczematoid lesions are inflamed with a tendency toward clustering, oozing, or crusting.
Patterns and distribution: Follicular - ANSWER It is sometimes helpful to determine if lesions specifically involve the hair follicle.
Patterns and distribution: Guttate - ANSWER Guttate lesions look as though someone took a dropper and dropped this lesion on the skin. Guttate lesions are characteristic of one form of psoriasis, though that is not the only example.
Patterns and distribution: Iris or Target - ANSWER Iris or target lesions
Patterns and distribution: Koebner phenomenon - ANSWER The Koebner phenomenon, also called the isomorphic response, refers to the appearance
of lesions along a site of injury. This phenomenon is seen in a variety of conditions; for example, lichen planus, warts, molluscum contagiosum, psoriasis, lichen nitidus, and the systemic form of juvenile rheumatoid arthritis.
Patterns and distribution: Linear - ANSWER Linear lesions occur in a line or band-like configuration. This descriptive term may apply to a wide variety of disorders. (One should be certain that the lesions are not following a dermatome.)
Patterns and distribution: Multiform - ANSWER Patients with multiform lesions have lesions of a variety of shapes.
Patterns and distribution: Reticular - ANSWER Reticular or net-like lesions can be seen in a variety of circumstances; e.g., very commonly in newborns (or even grown children and adults) as cutis marmorata, or with livedo reticularis. The former fades as the skin is warmed the latter becomes more florid.
Patterns and distribution: Serpiginous - ANSWER Serpiginous lesions wander as though following the track of a snake.
Patterns and distribution: Universalis - ANSWER Universalis refers to a widespread disorder that affects the entire skin. (Alopecia)
Patterns and distribution: Scarlatiniform - ANSWER Scarlatiniform rashes have the pattern of scarlet fever. The patient with a scarlatiniform rash has innumerable small red papules that are widely and diffusely distributed. Note that the term scarlatiniform does not mean that the patient has scarlet fever, although by definition all patients with scarlet fever have a scarlatiniform rash. Patients with a variety of other conditions such as Kawasaki disease, viral infections, or drug reactions may have rashes with the same pattern.
Blue nevi are more common in people of Asian heritage. If the lesion is 'old' and unchanged for several years, it can be considered benign. A new lesion or one that has changed- should be evaluated immediately.
Additional Pigmented Lesions - ANSWER Freckles (ephelides)- hereditary, increase with sun exposure and fade without sun exposure
Lentigines (sun spots)- sun exposed areas (face, dorsal hands, upper back/chest). Can be treated with topical agents, laser/light therapy or cryotherapy.
Seborrheic keratosis- benign papules and plaques, beige to brown in color- some may be black. 3-20 mm - may appear velvety or thick/scaly-wart like in appearance. Have a 'stuck on' appearance. Very common. Can be removed by cutting or cryotherapy but only if irritated or inflamed-
Malignant Melanoma - ANSWER Malignant melanoma- flat or raise- suspected in any pigmented skin lesions that have had a recent change in appearance. May be red, white, blue, or black (requires good lighting)
***Tumor thickness is the single most important prognostic factor.
Life expectancy is based upon thickness of tumor- 10 years survival: <1 mm 95%, 1-2 mm 80%, 2-4mm 55%, and greater than 4 mm 30%.
Lymph node involvement: 62% at 5 years but if there is distant metastasis: 16%
Moh's Surgical Excision
Keep these patients in close follow up with dermatology
Bleeding and ulceration are ominous signs
The larger the number of moles, the higher your risk of melanoma.
Excision is the treatment of choice- margins depend upon thickness of the tumor.
ABCDE - ANSWER A = Asymmetry: One half is unlike the other half
B= Border: An irregular, scalloped, or poorly defined border
C= Color: Varied from one area to another; has shades of tan, brown, or black, or is sometimes white, red, or blue
D= Diameter: Melanomas are usually 6 mm or larger when diagnosed but can be smaller
E = Evolving: Looks different from the rest; changes shape, size, or color
Atopic Dermatitis - ANSWER Face, neck, upper trunk, wrists, hands, and antecubital and popliteal folds
Recurrent- onset in childhood typically- rare over age of 30 years
Family hx of asthma, allergic rhinitis, or atopic dermatitis (Triangle of A)
Dx criteria: Must have pruritus, typical morphology and distribution (flexural lichenifciation, hand eczema, nipple eczema, eyelid eczema in adults), onset in childhood with chronicity
Itching is a key clinical feature- may be severe/prolonged
Scaly red plaques (no thickening as with psoriasis) - can be long term with weeping- consider staph infections.
***Infra-auricular fissure is a cardinal sign of secondary infection
Prevention: avoid triggers/anything that irritates the skin- use soap on the 'have to' areas- limit baths when possible (once a day max), pat skin dry (no rubbing with towel), use emollient creams/lotions- cotton fabrics or
phenomenon)
Beta blockers, anti-malarial, statins, and lithium may create a flare/exacerbate existing plaques.
Systemic corticosteroids can lead to severe rebound-
Limited disease: <10% of BSA- high to ultra-potent topical corticosteroids are first line treatment
Numerous small plaques would respond best to photo therapy-
Limit topical cortisone therapy to 2-3 weeks maximum
Can use Calcipotriene ointment 0.005% or calcitriol ointment 0.003% - Vitamin D analogs- twice daily for plaque psoriasis. Start with both corticosteroid and vitamin D twice daily until plaques improve- then continue the vitamin D once a day for at least two more weeks
Scalp: Tar Shampoo- use it daily if tolerated. 6% salicylic acid gel (Keralyt) and other preparations can be utilized at night, followed by shower cap- then washed out in the AM
Pityriasis Rosea - ANSWER Oval, fawn colored, scaly eruption that follows the cleavage lines of the trunk "Christmas Tree Pattern"
Herald Patch occurs 1-2 weeks prior to lesions
Occasional pruritus
50% more common in females over males- mild, acute inflammatory process
Spring or fall more so than summer/winter
Oval plaques up to 2 cm in diameter- crinkled or cigarette paper appearance- tiny scale on the edges but clear in the center
Usually clears in 6-8 weeks
If plantar, palmar, or mucous membranes lesions are present- screen for secondary syphilis
Treat the symptoms only- consider UV therapy if necessary
Mycotic Infections of the Skin - ANSWER Superficial
Tinea corporis/tinea cruris,
Dermatophytosis of the feet,
Dermatophytid of the hands,
Tinea unguium (onyhcomycosis)
Tinea versicolor.
Confirm by KOH preparation, culture, or biopsy
Corn starch can exacerbate s/s (feeds it)
Tinea Corporis (Ringworm) - ANSWER Ring shaped lesions with scaly border/central clearing or scaly patches with a distinct border
Exposed skin surfaces - can be pretty much anywhere on the body
Itching may be present- complications include pyoderma and involvement of the hair follicles
Most topical antifungals will work nicely- available OTC now- continue for 7-14 days after clearing (OTC instructions state 14 days therapy total)
No Cortisone- including Lotrisone
Systemic treatment includes griseofulvin 350-500 mg bid (4-6 weeks of therapy)
colonizer of all humans-
Few patients complain of itching-
Differs from vitiligo as vitiligo (a) does not scale, (b) has total depigmentation of the skin, and (c) larger areas involved- often periorifical (around an orifice, particularly the mouth) and acral (distal areas such as fingers, toes, soles, palms, ears, nose)
KOH prep for dx
Topical tx includes selenium sulfide lotion- apply from neck to waist daily- leave on for 5-15 minutes then wash off. Do this once a day for 7 days then once a week x 4 weeks then once a month for maintenance.
Ketoconazole(Nizoral) shampoo (1 or 2%)- lather on body- leave for 5 minutes before rinsing- can be used for weekly tx and to prevent recurrence. **Caution patient that repigmentation may take weeks or months
Ketoconazole 200 mg daily for 1 week or 400mg as single oral dose with exercise to the point of sweating after taking the pill- can cure up to 90% of patients- however, do not shower for 8-12 hours after sweating so that the medicine can work-
Fluconazole- 300mg - one dose then repeat in 14 days- has similar efficacy-
Lupus - ANSWER Chronic cutaneous lupus erythematosus (CCLE): chronic scarring (discoid) lesions (DLE) and erythematous non scarring red plaques (subacute cutaneous LE: SCLE)- both different from systemic lupus erythematosus (SLE) although patients with SLE may have DLE or SCLE.
Localized violaceous red plaques- usually on face and scalp for DLE while SCLE is found on the trunk
Scaling follicular plugging, atrophy dyspigmentation and telangiectasia of involved areas
Distinctive histology, photosensitivity are noted.
DLE: scales are dry and "thumbtack like"-
May be triggered by common medications such as HCTZ, calcium channel blockers, H2- blockers, PPIs, ACE inhibitors, and terbinafine.
Protect skin from sunlight- utilize a high SPF (>50 spf) with both UVB and UVA coverage- do not use radiation therapy-
Can treat limited lesions with high potency corticosteroid cream-applied once every pm followed by occlusive dressing such as Saran wrap-
Actinic Keratosis - ANSWER Small (0.2-0.6) macules or papules- flesh colored, pink, or slightly hyper-pigmented- that feel rough like sandpaper, are tender when the finger moves over them. Sun exposed areas on fair skinned people- considered to be 'pre-malignant'- may progress to SCC
Cryotherapy is effective treatment- may require more than one tx
Paget's Disease and Bowen Disease - ANSWER Paget's Disease
Scaling, red plaque on the breast (may be bilateral) that resembles an eczema- associated with intraductal mammary carcinoma
Bowen Disease
0.5-3 cm, sl raised, pink to red plaque, may be scaly- may resemble a psoriatic plaque or large actinic keratosis- treatment through excision
Herpes Simplex - ANSWER HSV 1- [Oral] > 85% of adults will test positive - can be provoked by sun exposure, surgery, stress, fever, viral infections, etc.
them- you may do so. If the patient is negative for antibodies, then they would need varicella vaccines -- one dose four weeks apart- total of 2 doses.
Pompholyx Vesiculobullous Hand Eczema (Dyshidrosis) - ANSWER Pruritic 'tapioca' vesicles 1-2mm each on the palms, soles, and sides of fingers. May form blisters (multiple vesicles grouping together)
Scaling and fissures may develop after vesicles dry
About half of the patients have a hx of atopic dermatitis
May be increased with stress
Always check the feet to make sure it is not tinea pedis with palmar involvement
May be allergen driven (such as nickel allergy)
Topical corticosteroids provide some relief- since this is a recurrent issue, oral corticosteroids may not be appropriate-
Avoid irritants - use cotton gloves inside of latex/vinyl gloves, use long handled brushes, and emollient therapy after washing hands/bathing, etc
Impetigo - ANSWER Macules, vesicles, bullae, pustules, and honey colored crusts
Contagious - staphylococci or streptococci
Face and other 'exposed' body parts
Soaks and scrubbing can be helpful- clears the pus
Topical agents such as bacitracin and mupirocin (Bactroban) are indicated first line
Widespread infection- systemic antibiotics are indicated including cephalexin, doxycycline, and consider coverage with trimethoprim-sulfamethoxazole for possible MRSA related impetigo. Culture and sensitivity may be prudent.
Contact Dermatitis - ANSWER Results from contact with an allergen or chemical. Soaps, detergents, solvents, metals, antimicrobials such as bacitracin or polysporin, artificial nails, adhesive tape, etc. Consider latex as well.
Poison Ivy or Poison Oak- linear patterns-
Tiny vesicles with weepy to crusted lesions-
Erythematous macules, papules, and vesicles- look for patches, such as where something may have rubbed or brushed against the skin-
Treatment: prompt and thorough washing of affected area with liquid dishwashing soap to remove the oils must be done within 30 minutes to decrease the effects of the irritant. McPhee suggests Dial Ultra. Barrier creams - applied prior to exposure- include Stokogard, Hollister Moisture Barrier, and Hydropel.
Symptomatic treatment with monitoring for subsequent cellulitis- treat the itching with caladryl, calamine, Benadryl cream OR Benadryl tablets, Vistaril, etc. New treatment option- Zanfel- may prove beneficial- according to the package instructions- it may be used anytime after exposure. Reports 10 year half life (15 treatments per box)
Severe Acne - ANSWER Isotretinoin- Accutane-
only for those who have not responded to conventional therapy.
Absolutely contraindicated in pregnancy- two serum pregnancy tests must be performed prior to initiating therapy in women of child bearing age.
It is suggested that this continue each month before prescribing additional meds.
Only one month supply may be prescribed.
2 forms of effective of birth control (abstinence can be 1 form) must be utilized.
Informed consent must be given and patient enrolled in a monitoring program
Rosacea - ANSWER Common chronic disorder - affects the face-
Erythema and telangiectasia with a tendency to flush easily
May have associated flares with acne- papules and pustules
Hyperplasia of the soft tissue of the nose- rhinophyma
May be triggered by heat, hot/spicy food/drink, sunlight, exercise, alcohol, emotions, or hormones (menopause).
Burning and stinging may accompany the flushing-
Treatment begins with education- avoid triggers- use broad spectrum sunscreen (although this might take some experimenting to find one that is well tolerated). Metronidazole gel, 0.75% can be applied bid or 1% applied qd. Another alternative is clindamycin gel. Oral medications can be used when topical are not effective.
Avoid harsh chemicals (such as peels, scrubs, etc.) Find a good moisturizer and gentle cleansing agent, typically for sensitive skin.
Laser therapy to treat veins in the face as well as gentle resurfacing may be helpful.
Acne associated with these two rosacea flares- across nose, on cheeks and the chin. The patient on the far lower right has an early rhinophyma.
Folliculitis - ANSWER Itching/burning pustules in hair follicles
Multiple causes, typically staph infections- may be more frequent in a diabetic patient
Hot tub folliculitis- appears 1-4 days after bathing in an affected hot tub, whirlpool, or swimming pool- this is usually due to Pseudomonas. Tender, pruritic pustular lesions. Some systemic s/s may be noted such as fatigue, malaise, and low grade fever. Usually self limiting but Silvadene can be used up to bid. If s/s do not clear
Pseudofolliciulits- occurs within the beard area of the face/neck- best treated by growing a beard, using chemical removal agents, or using a foil guard razor. Laser hair removal is a great option for these patients as well.
Mucocutaneous Candidiasis - ANSWER Thrush
Itching - beefy red areas with or without satellite vesicopustules
Whitish curd like concretions on the mucosa
Keep dry and open to air as much as possible
