INT.

MEDICINE
Batch 2014- College of Medicine
EVALS # 1
TOPICS:
ANATOMY AND PHYSIOLOGY OF THE SKIN DR. DAYRIT
DERMATOLOGIC INFECTIONS AND INFESTATIONS DR. ESCUADRO
ECZEMA, PSORIASIS AND EXFOLIATIVE DERMATITIS DR. TOLEDO
CUTANEOUS MANIFESTATIONS OF SYSTEMIC DISEASE DR. CRISOSTOMO
HEALTHCARE-ASSOCIATED INFECTIONS DR. ABU

BY: RJ Paras and Kristine Espinoza

1.

Squamous cell carcinoma of the skin is a malignant proliferation of

a. Melanocytes
b. Langerhans cells
c. Keratinocytes
d. Lymphocytes

Three basic cell types of the epidermis:

Keratinocytes
1. squamous cell
2. ectodermal origin
3. production of keratin
a. surface coat of the epidermis
b. structural protein of hair & nails
4. Key Implications: Atopic dermatitis, Squamous cell carcinoma (C. Answer)
ii. Melanocytes (A.)
1. neural crest origin
2. nucleus smaller & more deeply basophilic than basal keratinocyte , dendritic cytoplasm
3. 1 melanocyte:4 basal keratinocytes (cheeks) to 1:10 (limbs) forming with them an epidermal melanin unit
4. production of melanin
5. Key Implications: Vitiligo, Melanoma, Hyperpigmentation
iii. Langerhans cells (B.)
1. clear, dendritic cells just above the middle of the spinous zone of the epidermis
2. striking cytoplasmic vacuolation
3. electron microscopy: lobulated nucleus and Birbeck granules (rod/racquet inclusions
4. potent stimulators of T-cell mediated immunoreactions
5. Key Implications: Inflammatory skin diseases
iv. Lymphocytes (D.)
i.

2.

The ratio of the epidermal-melanin unit (melanocyte:basal cells) on the limbs is:
a. 1:2
b. 1:4
c. 1:10
d. 1:20

From the Answer to Question 1, digest.

1 melanocyte : 4 basal keratinocytes (in the cheeks), whereas 1:10 (in the limbs) which forme with them an epidermal
melanin unit. (C.)
3.

Clonal proliferation of Langerhans cells which is rare and usually presents in infancy as a widespread eruption of
erythematous macules and papules, fever and organomegaly
a. Mastocytosis
b. Juvenile xanthogranuloma
c. Histiocytosis x
d. Eruptive xanthoma

External source:
Clonal proliferation of Langerhans cells, abnormal cells deriving from bone marrow and capable of migrating from skin
to lymph nodes. Clinically, its manifestations range from isolated bone lesions to multisystem disease. Langerhans cells
Histiocytosis is part of a group of clinical syndromes called histiocytoses, which are characterized by an abnormal
proliferation of histiocytes (an archaic term for activated dendritic cells and macrophages). These diseases are related to
other forms of abnormal proliferation of white blood cells, such as leukemias and lymphomas.
Commonly seen are a rash which varies from scaly erythematous lesions to red papules pronounced in intertriginous areas.
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Up to 80% of LCH patients have extensive eruptions on the scalp.

4.

A.

B.

C.

D.

A connective tissue disease which demonstrates sclerosis and hyalinization of collagen, and appears clinically as
tense, hardened skin:
a. Lupus profundus
b. Scleroderma
c. Dermatomyositis
d. Juvenile Rheumatoid arthritis

Lupus erythematosus (Profundus )

1. Acute cutaneous lupus erythematosus

Classic butterfly rash or malar rash of SLE

Localized ACLE confluent symmetric erythema and edema are centered over the malar eminences
and bridges over the nose; nasolabial folds are characteristically spared

Generalized ACLE widespread morbilliform or exanthematous eruption often focused over the
extensor aspects of the arms and hands and characteristically sparing the knuckles

Precipitated or exacerbated by exposure to UV light

Scleroderma (Systemic Sclerosis)

Typical presenting features are esophageal reflux and dysmotility and swelling or skin textural changes in
the extremities

First presentation is typically arthralgia, stiffness and swelling of the extremities. Later, the features of skin
sclerosis develop
Dermatomyositis

In 60% of patients, cutaneous lesions and muscle weakness present simultaneously.

Onset of cutaneous disease is typically accompanied by pruritus and/or a burning skin sensation

Gottron sign and Gottron papules are pathognomonic

Periorbital, confluent, macular, violaceous (heliotrope) erythema/edema and grossly visible periungual
telangiectasia are highly characteristic
Rheumatoid arthritis
1. Rheumatoid nodule

subcutaneous nodule that occurs in approximately of patients with RA

more than 90% of patients have seropositive RA

usual location is over pressure points such as the olecranon, the extensor surface of the forearms
and achilles tendon
2. Bywaters lesions

Digital pulp papules associated with nail fold telangiectasias and minute digital ulcerations or
petechiae
Manifestations of mild vasculitis
5.

Clonal proliferation of medium sized to large lymphocytes with convoluted nuclei and have tendency for
epidermotropism. Clinically appears as erythematous patches and plaques with hypo- and hyper- (mottled
pigmentation) and atrophy on sun-protected areas:
a. Langerhans cell histiocytosis
b. Plasmacytoma
c. Mastocytosis
d. Cutaneous T-cell lymphoma / Mycosis fungoides
External source:

Most common form of cutaneous T-cell lymphoma.

It generally affects the skin, but may progress internally over time.

Symptoms include rash, tumors, skin lesions, and itchy skin.

While the cause remains unclear, most cases are not genetic or hereditary.

Most cases are in people over 20 years of age, and it is more common in men than women. Treatment options include
sunlight exposure, ultraviolet light, topical steroids, chemotherapy, and radiation.
6. Major cell involved in granulomatous diseases such as Cutaneous Tuberculosis and Leprosy in which one of its major
functions is phagocytosis
a. Neutrophils
b. Eosinophils
c. Histiocytes
d. Mast cells
Fact. Digest.
7.

a.
b.
c.

A form of alopecia where there is total loss of scalp and body hair
a. Alopecia universalis
b. Alopecia totalis
c. Alopecia mucinosa
d. Ophiasis

Alopecia universalis - total loss of body hair (includes scalp)

Alopecia totalis - complete scalp baldness
Alopecia mucinosa - erythematous plaques or flat patches without hair primarily on the scalp and face

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d.

Ophiasis - form of alopecia characterized by the loss of hair in the shape of a wave at the circumference of the head
8.

An infectious disease which presents with varied skin lesions and abnormal sensation and is characterized histiogically
by perineural infiltration by histiocytes and lymphocytes
a. Leishmaniasis
b. Tuberculosis verrucosa cutis
c. Leprosy
d. Impetigo

External source:
Leprosy is characterized by noncaseating granulomas, destruction of dermal nerves, loss of sweat glands and hair follicles,
and absent bacilli. Leprosy demonstrates a normal epidermis, subepidermal granulomas particularly around blood vessels,
nerves, and skin appendages, foamy histiocytes, and many intracellular acid-fast bacilli. The histologic slide of LL leprosy
shows large numbers of acid-fast bacilli (in clusters) in histiocytes and within nerves.
9.

Pitting of the nail is usually secondary to abnormal keratinisation of the nail matrix and is normally observed in
a. Iron deficiency anemia
b. Psoriasis
c. Emphysema
d. Cutaneous T-cell lymphoma

Iron deficiency presents with angular stomatitis, smooth painful tongue, and fragile/brittle nails, which have
longitudinal ridging and lamellation. Marked iron deficiency koilonychia develops. Hair changes include diffuse scalp
alopecia with brittle, split hairs
10. Usual duration of chronic urticaria
a. >2 weeks
b. >4weeks
c. <6weeks
d. >6weeks

Acute urticaria: less than 6 weeks

Chronic urticaria: beyond 6 weeks
11. The following are cutaneous manifestations in patients with gastrointestinal malignancy, EXCEPT
a. Acanthosis nigricans
b. Hypertrichosis lanuginose
c. Terrys nails
d. Adult-onset dermatomyositis
Gastrointestinal Malignancy

Adult-onset dermatomyositis is associated with underlying malignant disease. (C.)

Pancreatic, gastric and colorectal cancers are the third most common after bronchogenic and ovarian cancers

In two-thirds of patients with acanthosis nigricans and cancer, the tumor is gastric, usually adenocarcinoma of the
stomach or bowel. (A.)

Hypertrichosis lanuginosa is a rare complication of gastrointestinal cancer. (B.)

Skin manifestations of hepatobilary disease

Jaundice increased cellular or connective tissue binding of bilirubin and its metabolits in the skin

Cholestatic pruritus although retained cutaneous bile acids have been implicated, there is a poor correlation
between the plasma bilirubin and the severity of pruritus

Nail changes intensely white nails (Terrys nails), splinter haemorrhages, flat or spoon nails (C.)

Palmar erythema (liver palms)

12. Which of the following is seen in patients with chronic liver disease
a. Ichthyosis-like scaling of the skin
b. Loss of forearm, axillary and pubic hair
c. Pale skin color
d. Photosensitivity
Chronic Liver Disease

Hormone-induced changes of the skin include loss of forearm, axillary and pubic hair in both sexes.

Telangiectatic changes, mainly on light-exposed skin (dollar paper markings). They fade on pressure with a glass
slide and rarely pulsate. (B.)

In addition to jaundice, a diffuse muddy gray color in patients is due to basal cell melanin.
13. The following are cutaneous manifestations in patients with chronic liver disease EXCEPT
a. Striae distensae
b. Dollar paper markings
c. Spider nevus
d. Eruptive xanthomas
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Chronic Liver Disease

Hormone-induced changes of the skin include loss of forearm, axillary and pubic hair in both sexes.

Men experience decreased rate of growth of facial hair, pectoral alopecia, and female pubic hair distribution, as well
as loss of libido, testicular atrophy and oligospermia.

Stria distensae in both men and women.

Telangiectatic changes, mainly on light-exposed skin (dollar paper markings). They fade on pressure with a glass
slide and rarely pulsate. (B.)

In addition to jaundice, a diffuse muddy gray color in patients is due to basal cell melanin.

Spider nevus or spider angioma is the most representative and classic vascular lesion. Most common on the face, neck,
and upper part of the chest (i.e., over the region drained by the superior vena cava) (C.)
Corkscrew sclera vessels (tortuous small arteries that traverse the margins of the ocular sclera)
*Eruptive xanthomas are related to diabetic skin disease, later discussed in this rationale.
14. Which of the following is TRUE of primary biliary cirrhosis
a. Melanosis involves intertriginous areas
b. Pathogenesis of melanosis is due to the presence of excess melanin with no stainable iron
c. Lightening of freckles and areola
d. Diffuse linear pigmentation on the palms
Primary biliary cirrhosis

Melanosis is common and may be an early presenting sign. It initially involves exposed areas, but it gradually becomes
generalized. (A.)

Pathogenesis: presence of excess melanin with no stainable iron (B.)

Accentuation of normal freckling and areolar pigmentation (C.)

Localized linear pigmentation may appear in the creases of the fingers and palms. (D.)

Blotchy, circumscribed areas of dirty brown pigmentation

Pigmentation resembling chloasma

Guttate hypomelanosis appear on the buttocks, back, thighs and forearms

Dermal, subcutaneous and tendon xanthomas are common and can be extensive
15. The following are cutaneous manifestations in patients with chronic renal failure EXCEPT
a. Uremic frost
b. Renal pruritus
c. Subepidermal bullae
d. Metastatic calcification of the skin
Chronic renal failure

Skin of patients are typically dry, often with ichthyosis-like scaling due in part from altered vitamin A metabolism
along with the fluid volume shifts of dialysis

Skin color is pale from anemia and often exhibits a distinctive gray-yellow hue due to accumulation of carotenoid and
nitrogenous pigments (urochromes) in the dermis.

Renal pruritus incidence is as high as 90% of patients undergoing hemodialysis. (B.)

Is thought to be caused by a combination of increased serum histamine, vitamin A and parathyroid hormone;
mast cell hyperplasia; peripheral polyneuropathy; and xerosis

Porphyria cutanea tarda has been described in patients with CRF undergoing hemodialysis - may be due to
inadequate clearance of plasma-bound porphyria precursors by urine excretion or hemodialysis; presents as
photosensitivity and subepidermal bullae (C.)

Metastatic calcification of the skin results from secondary or tertiary hyperparathyroidism. Abnormally elevated
levels of PTH may trigger deposition of crystalline calcium pyrophosphate in the dermis, subcutatneous fat or arterial
walls. (D.)

More Information
Occasionally, calcified vessels may thrombose acutely, resulting in calciphylaxis
Acquired perforating dermatosis can occur in association with CRF and diabetes mellitus occurs in up to 10% of
patients undergoing hemodialysis
Nephrogenic fibrosing dermopathy resembles scleromyxedema, presenting with progressively developing
erythematous, sclerotic dermal plaques on the arms and legs, with sparing of the head and neck; pruritus is common.
16. Acanthosis nigricans associated with diabetes mellitus
a. Presents as brown to gray-black cutaneous thickening in the extensor areas
b. Has a symmetric distribution
c. Inguinal area is most severely affected
d. No improvement with weight loss

Acanthosis nigricans

Presents as brown to gray-black papillomatous cutaneous thickening in the flexural areas, including the posterolateral
neck, axillae, groin and abdominal folds (A.)

Distribution is symmetric (B.)

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Affected skin has a dirty, velvety texture

The back of the neck is the most consistently and severely affected area (C.)
When the palms are involved, the rugated appearance of the palmar surface has been called tripe palms
Treatment is generally ineffective and may include calcipotriol, salicylic acid, urea, systemic and topical retinoids.
Improvement or resolution does occur with weight loss in some obese patients. (D.)
17. Scleroderma diabeticorum
a. Painful indurations and thickening of the skin on the upper back and neck
b. Has a symmetric distribution
c. Treatment is usually successful
d. Found in patients with early diabetes

Scleroderma Diabeticorum

Painless, symmetric induration and thickening of the skin on the upper back and neck, spreading to the face,
shoulders and anterior torso (A.)

Skin retains a nonpitting, woody, peau dorange quality

Affects 2.5-14% of patients with diabetes and is a disease of long-standing diabetes associated with obesity (D.)

Treatment is usually successful, including radiotherapy, low-dose methotrexate, bath psoralen and ultraviolet A light
(PUVA), extracorporeal photophoresis, factor XIII, and prostaglandin E1. (C.)
(B.) was referring to Question 16.
18. True of eruptive xanthomas in patients with diabetes mellitus EXCEPT
a. Often with underlying severe hypertriglyceridemia
b. Generally asymptomatic
c. Lesions occur in crops and may coalesce into plaques
d. Treatment is ineffective
Eruptive xanthomas

Often with underlying severe hypertriglyceridemia (>1000mg/dl) (A.)

1-4mm reddish-yellow papules on the buttocks and extensor surfaces of the extremities; generally asymptomatic (B.)

Lesions occur in crops and may coalesce into plaques over time (C.)
Responds rapidly to treatment of hypertriglyceridemia and control of underlying diabetes and usually resolve
completely in 6-8 weeks. (D.)
19. Which cutaneous manifestation improves rapidly with control of underlying diabetes mellitus
a. Acanthosis nigricans
b. Scleroderma diabeticorum
c. Eruptive xanthomas
d. Necrobiosis lipoidica
A.
B.
C.
D.

Acanthosis nigricans - Treatment is generally ineffective and may include calcipotriol, salicylic acid, urea, systemic and
topical retinoids. Improvement or resolution does occur with weight loss in some obese patients. (A.)
Scleroderma diabeticorum - Treatment is usually successful, including radiotherapy, low-dose methotrexate, bath
psoralen and ultraviolet A light (PUVA), extracorporeal photophoresis, factor XIII, and prostaglandin E1. (C.)
Eruptive xanthomas - Responds rapidly to treatment of hypertriglyceridemia and control of underlying diabetes and
usually resolve completely in 6-8 weeks.
Necrobiosis lipoidica - Treatment include topical, intralesional or systemic steroids, topical retinoids and topical PUVA

Other Skin Diseases Associated with Diabetes Mellitus

Diabetic ulcers

Callus formation precedes necrosis and breakdown of tissue overy bony prominences of feet, usually on great toe and
sole, over first and/or second metacarpophalangeal joints

Ulcers are surrounded by a ring of callus and may extend to underlying joint and bone

Standard therapy for neuropathic diabetic ulcers includes debridement, off-loading (often non-weight bearing), moist
wound care, and protective dressings.
Necrobiosis lipoidica

Presents with one to several sharply demarcated yellow-brown plaques on the anterior pretibial region.

The lesions have a violaceous, irregular border that may be raised and indurated

Initially, NL often presents as red-brown papules and nodules. Over time, the lesions flatten, and a central yellow or
orange area becomes atrophic and commonly telangiectasias are visible, taking on the characteristic glazedporcelain sheen.

Aside from the shins, other sites include ankles, calves, thighs, and feet.

Although pain and pruritus have been reported, most lesions are asymptomatic.

Anesthesia of the plaques does occur.

Treatment include topical, intralesional or systemic steroids, topical retinoids and topical PUVA. (D.)
Diabetic dermopathy

Small (<1cm) atrophic, pink to brown scar-like macules on the pretibial areas.

Lesions are asymptomatic and clear within 1-2 years with slight residual atrophy or hypopigmentation
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No treatment necessary.
20. Found in patients with hypothyroidism
a. Dollar paper markings
b. Tripe palms
c. Myxedema
d. Bywaters lesions
a.
b.
c.
d.

Dollar paper markings indication of Chronic Liver Disease

Tripe palms indication of Acanthosis Nigricans
Myxedema
Bywaters lesions - indication of Rheumatoid Arthritis

Hypothyroidism

Decreased core temperature and increased peripheral vasoconstriction cause the skin to be cool and pale; xerotic

Myxedema is the most classic finding. It occurs as a result of dermal accumulation of mucopolysaccharides, namely
hyaluronic acid and chondroitin sulphate, and tends to resolve with treatment of the hypothyroidism.

Characteristic facial changes include a broadened nose, thickened lips, puffy eyelids, and macroglossia with a smooth
and clumsy tongue

Skin can be doughy, swollen and waxy but without pitting

Hair is coarse, dry and brittle with slowed growth.

There can be a loss of eyebrow hair involving the outer third.

Nails grow slowly and can be thickened and brittle with longitudinal and transverse striations.
21. A 26 year old male presents to your clinic complaining of a rashes on his back of 4 weeks duration. He describes small,
whitish lesions that are not painful and do not itch on his macules that coalesce on his upper back. When the lesions
are scratched, fine scales are produced. How should you proceed in the management of this patient?
a. A fungal culture from the lesion should be obtained
b. A skin biopsy should be performed
c. The lesions should be scraped and a KOH stain should be performed
d. The patient should be started on oral Terbinafine
Suspect: Pityriasis/Tinea Versicolor

Etiology: Malassezia furfur or Pityrosporum orbiculare

Short thick fungal hyphae &spores (spaghetti & meatballs)

Clinical Manifestation

Yellowish or brownish macules in pale skin or hypopigmented macules in dark skin

Coalesce to form patches

Delicate scaling (grattinage)

Mild itching & minimal inflammation

Sites of Predilection: Sternal region & sides of chest, abdomen, back, pubis, neck, intertriginous areas

Diagnosis

Woods Lamp: yellowish or brownish fluorescence

Skin Scraping with 10% KOH: spaghetti & meatballs

22. A 56 year old female with poorly controlled diabetes mellitus developed dry, erythematous scaling patches over her
axillary area. Similar lesions are seen in her inguinal area. You bring the patient to a darkened room and use Woods
lamp. If the lesions fluoresce, what color is diagnostic of erythrasma?
a. Coral yellow
b. Coral green
c. Coral red
d. Coral orange
From: Rooks Textbook of Dermatology
Wood's lamp is additionally useful in diagnosing erythrasma. The ultraviolet light of a Wood's lamp causes the organism to
fluoresce a coral red color, differentiating it from fungal infections and other skin conditions.
23. A 6 year old boy comes with his mother to your clinic with scalp lesion. He developed this lesion a few weeks ago. On
physical examination, the patient has an area of alopecia on his scalp; associated with the alopecia is a painful
inflammatory mass with pus and sinus tracts. A skin specimen treated with potassium hydroxide (KOH) shows the
presence of dermatophytes. A Gram stain shows no bacterial organisms. What is the likely diagnosis for this patient,
what is the causal organism, and how should his condition be treated?
a. Kerion; Microsporum or Trycophyton; oral griseofulvin
b. Bacterial abscess; staphylococcus aureus; oral dicloxacillin
c. Fungal and bacterial coinfection; Trycophyton and Staphylococcus aureus; oral itraconazole and dicloxacillin
d. Sebaceous tumor; surgical removal
Tinea capitis (Ringworm of scalp & Kerion)

Clinical Manifestations

1. Non Inflammatory Types - Black-dot, Gray patch

2. Inflammatory Type Kerion, Favus , Tinea Capitis

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Non-inflammatory Type

A. Black dot- endothrix; infected hairs broken off at or below the surface of the scalp

B. Gray patch- ectothrix; scaly patches with areas of stubs of broken hair

Endothrix: arthrospores are formed inside the hair shaft; no fluorescence (T. tonsurans, T. schoenleinii, T. violaceum)

Ectothrix: hair is surrounded w/ sheath of tiny spores; greenish fluorescence

Microsporum species (T. verrucosum, T. mentagrophytes, T. megnini)

Inflammatory Type

Begins as erythematous, scaly, papular eruptions w/ loose & broken off hairs

A. Kerion- localized spot w/ pronounced swelling, creating a boggy & indurated area exuding pus

B. Favus- concave, sulfur-yellow crust forming around loose wiry hairs

Hyphae & air spaces within the hairshaft

Bluish-white fluorescence
Treatment

Griseofulvin x 2-4 mos or at least 2 weeks after negative microscopic and culture examinations

Terbinafine 250mg/ Tab x 2 weeks (Trichophyton) and 4 weeks (Microsporum)

Itraconazole 100mg/caps, 2 caps/day x 4-6 weeks

Ketoconazole 200mg/tab x 4-6 weeks

Others: short courses of systemic steroids for inflammatory type; Selenium sulfide Shampoo or Ketoconazole
Shampoo left for 5 mins 3x a week
24. A 33 year old male presented with a tender erythematous well demarcated edematous plaques over his left medial
leg. He reposts episodes of fever and chills. What is your primary impression?
a. Necrotizing fasciitis
b. Cellulitis
c. Erythrasma
d. Erysipelas
Erysipelas A.K.A. St. Anthonys Fire

Etiology:

Group A Beta hemolytic Strep-supfl dermal lymphatics

Strep C or G-occasional

Group B Strep- newborns, abdominal or perineal erysipelas in post partum women

Erysipelas

Predisposing Factors

Break in the skin barrier

Operative wounds

Fissures in the nares, auditory meatus, under the earlobes, on the anus, penis, between or under the toes
(little toe)

Accidental scalp wounds

Chronic leg ulcers

Clinical Presentation

Sites: face & legs

Prodrome: malaise, chills, high grade fever, headache, vomiting & joint pains

Lesions: intensely erythematous (scarlet), warm, swollen, brawny, well-demarcated plaque w/ characteristic
raised indurated border

+/- vesicles/bullae w/ seropurulent fluid

Spread; peripheral extension

Lesions

On face: ear may become swollen & distorted; +/- delirium

Leukocytosis (PMNLs >/= 20,000/mm3)

Complications:

Septicemia

Deep Cellulitis - In newborns or surgical operations in the elderly

Treatment

Systemic: at least 10 days, rapid improvement in 24-48 hours

Penicillin V , IV Penicillin, Erythromycin

Supportive Measures: cold compresses

25. A 37 year old woman presents with intense perineal itching. On examination, she has both red papules and blue
macules on the inner thighs. In addition, there are excoriated, crusted lesions in the same region. Tiny tan swellings
are seen at the bases of some of the pubic hair shafts. What is your diagnosis?
a. Dermatitis herpetiformis
b. Genital herpes virus
c. Pediculosis
d. Scabies
Dermatitis herpetiformis

Characteristics:
o intensely itchy
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o
o

chronic papulovesicular eruptions

distributed symmetrically on extensor surfaces (buttocks, back of neck, scalp, elbows, knees, back, hairline,
groin, or face)
o
The blisters vary in size from very small up to 1 cm across.
o Extremely itchy

Intense itching or burning sensations are sometimes felt before blisters appear in a particular area.
External source:

First signs and symptoms of dermatitis herpetiformis are intense itching and burning, the first visible signs are the
small papules or vesicles that usually look like red bumps or blisters. Sometimes they appear on the face and along
the hairline, and, on occasion, on the shoulders, the lower end of the spinal column, and within the mouth

The rash rarely occurs on other mucous membranes, excepting the mouth or lips. The symptoms range in severity
from mild to serious, but they are likely to disappear if gluten ingestion is avoided and appropriate treatment is
administered.

Dermatitis herpetiformis symptoms are chronic, and they tend to come and go, mostly in short periods of time.
Sometimes, these symptoms may be accompanied by symptoms of coeliac disease, commonly including abdominal
pain, bloating or loose stool, and fatigue.
26. A 17 year old boy living at home with his parents presents with an intensely pruritic papulovesicular eruption
involving the hands and wrists. Skin scrapings identify eggs and waste products of Sarcoptes scabiei. Which of the
following management options is most appropriate?
a. Treat the patient and symptomatic household members with Permethrin 5% cream and tell them to wash
all clothing and linens with which they have come into contact over the past 2 days.
b. Treat the patient and all household members with Permethrin 5% cream, and tell them to wash all
clothing and linens with which they have come into contact over the past 2 days.
c. Treat the patient and symptomatic household members with Permethrin 5% cream and tell them to wash
all clothing and linens with which they have come into contact over the past 10 days.
d. Treat the patient and all household members with Permethrin 5% cream and tell them to wash all clothing
and linens with which they come into contact over the past 10 days.
External Source (CDC):

It is important to remember that the first time a person gets scabies they usually have no symptoms during the
first 2 to 6 weeks they are infested; however they can still spread scabies during this time.
st

Permethirin 5% cream is the 1 line of treatment in treating Scabies.

Treatment is also recommended for household members and sexual contacts, particularly those who have had
prolonged direct skin-to-skin contact with the infected person. Both sexual and close personal contacts who have
had direct prolonged skin-to-skin contact with an infected person within the preceding month should be
examined and treated. All persons should be treated at the same time to prevent reinfestation.

Bedding, clothing, and towels used by infested persons or their household, sexual, and close contacts during
the two to three days before treatment should be decontaminated by washing in hot water and drying in a hot
dryer, by dry-cleaning, or by sealing in a plastic bag for at least 72 hours. Scabies mites generally do not survive
more than 2 to 3 days away from human skin.
27. A 33 year old man comes to your clinic complaining of weight loss. He has also been experiencing occasional diarrhea.
He started to have these symptoms 4 months ago. He says he has been trying to eat more, but he is still losing weight.
Physical examination shows bitemporal wasting diffuse cervical lymphadenopathy, and proximal white subungual
lesions. These lesion show dermatophytes on potassium hydroxide (KOH) staining. What is the most likely diagnosis
for this patient?
a. Graves disease
b. HIV infection
c. Lymphoma
d. Inflammatory bowel disease
Proximal Subungal Onychomycosis:

Type of Dermatophytoses

Involves the proximal nail fold (PNF)

White spot appears from beneath the PNF which gradually fills the lunula & moving distally

Maybe an indicator of HIV infection

28. A 22 year old male complained of skin-colored verrucous plaque over his left knee. He claimed that the lesion started
as a small, skin-colored papule 4 weeks ago. He reported a history of accidentally falling on a cemented floor 6weeks
ago. What is your primary diagnosis?
a. Tuberculosis Verrucous Cutis
b. Verruca Vulgaris
c. Hansens disease
d. Ecthyma
Tuberculosis Verrucous Cutis:

Paucibacillary caused by exogenous re infection (inoculation) in previously sensitized individuals w/ high

immunity

Clinical Manifestations:

Small asymptomatic papule or papulopustule w/ puple inflammatory halo

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Hyperkeratotic
Slow growth & peripheral expansion verrucous plaque w/ irregular border; solitary
Spontaneous involutionatrophic scar

29. A 32 year old female complained of solitary, slightly erythematous plaque over her left arm. The plaque has a
characteristic elevated border and atrophic center. No pruritus is reported. On further examination, the lesion
presented with hyposthesia. What is your impression?
a. Leprosy, tuberculoid
b. Tinea Corporis
c. Leprosy, lepromatous
d. Chronic mucocutaneous candidiasis
Tuberculoid Leprosy

Lesions are solitary, few & asymmetrical

Lesion: large erythematous plaque w/ sharply elevated border & atrophic center

Sensory: anesthetic or hyposthetic & anhidrotic

Nerve involvement: early, superficial peripheral nerves are enlarged, tender or both
30. How will you manage this patient?
a. Topical Ketoconazole, applied BID for 2 weeks
b. Rifampin 600 mg once a month for 6 months and Dapsone 100mg OD x 6 months
c. Rifampin 600mg and Clofazimine 300mg once a month and Dapsone 100 mg and Clofazimine 50mg OD x 12
months
d. Oral Fluconazole 150mg once a week
WHO Protocol for Hansens Disease:

Single lesion Paucibacillary

Single dose: Rifampin 600mg, Ofloxacin 400mg & Minocycline 100mg (ROM)

Paucibacillary [(Indeterminate, Tuberculoid Leporsy (TT)]

Rifampin 600mg once a month x 6 months

Dapsone 100mg OD x 6 months

31. Which statement is NOT true about exfoliative dermatitis?
a. It may be caused by a preceding eczematous disease
b. It may be caused by preceding systemic disease (SLE)
c. It may occur as an idiopathic entity (without a preceding dermatitis or systemic disease)
d. None of the above
Exfoliative Dermatitis:

a.k.a. Erythroderma

Inflammatory skin disease in which erythema and scaling is widespread/generalized (GED = generalized
exfoliative dermatitis)

Due to a preceding skin or systemic disease

SKIN Diseases= Eczematous dermatitis, Psoriasis, superficial fungal infections (dermatophytosis),

scabies

SYSTEMIC Diseases = Cancers (leukemia, lymphoma, rectal CA, lungCA), HIV infection

Drugs implicated

DRUGS = allopurinol, NSAIDS, anticonvulsants/ psychotropic drugs(Carbamezapine, Phenytoin,

Lithium), antibiotics (penicillin, trimethoprim, sulfonamides, sulfonyureas, INH/Rifampicin, etc.)

May occur as an idiopathic entity w/o preceding dermatitis or systemic disease

32. Drugs commonly implicated in Exfoliative dermatitis
a. Allopurinol
b. NSAIDs
c. Anticonvulsants
d. A and B only
e. A, B, and C
Refer to #31
33. This result in previously sensitized skin
a. Irritant contact dermatitis
b. Allergic contact dermatitis
c. Contact dermatitis
d. Atopic dermatitis
Allergic Contact Dermatitis:

Results when an allergen comes into contact with previously sensitized skin

Results from a specific acquired hypersensitivity of the delayed type a.k.a. cell-mediated immunity or cellmediated hypersensitivity

May be induced upon a sensitized area of skin when an allergen is taken internally
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Patient may have exposure to an allergen for years before developing hypersensitivity e.g. hair dyes, rubber,
cosmetics, insecticides

34. Also known as eruptive psoriasis and can be triggered by a prior infection
a. Guttate psoriasis
b. Inverse psoriasis
c. Psoriasis vulgaris
d. Pustular psoriasis
Guttate Psoriasis (guttate = droplike)

a.k.a.eruptive psoriasis (sudden/acute onset)

Trunk and proximal extremities most affected

35. Coin-shaped eczema also known as
a. Seborrheic dermatitis
b. Nummular dermatitis
c. Contact dermatitis
d. Stasis dermatitis
*From 2010 Tranx
Nummular Dermatitis:

Characterized by circular or oval coin-like lesions

Begin as small edematous papules that become crusted and scaly

Unknown etiology, but dry skin is a contributing factor

Common locations: trunk or the extensor surfaces of the extremities, particularly on the pretibial areas or
dorsum of the hands

Occurs more frequently in men

Most commonly seen in middle age

Treatment is similar to that of atopic dermatitis

36. Which is a major criteria for atopic dermatitis
a. Xerosis
b. Early age of onset
c. Pruritus
d. Elevated serum IgE
Atopic Dermatitis:

A chronic, relapsing inflammatory skin disease affecting up to 20% of the population

A multigenic disorder = the genetics of atopy are complex

Has a serious impact on the quality of life of patients and their families

Increasing prevalence worldwide noted due to

1. Environmental factors : house dust mites, airborne allergens, poor air quality, poorly-ventilated homes
2. Western lifestyle factors: Increased urbanization, increasing industrialization in dev. countries stress,
dietary changes, travel to new environments, new microbial environment, most time spent indoors, more
pets

Diagnosis is arrived at by history taking and clinical criteria (based on Clinical criteria as guidelines for dx of AD
by Rajka and Hanifin):
A. Major criteria (3 or more):
1. Pruritus
2. Typical morphology and distribution
- Adults: Flexural lichenification
- Children: Facial and Extensor involvement
3. Chronic or chronically relapsing dermatitis
4. Personal/Family Hx of ATOPY (asthma, allergic rhinitis aka hay fever, atopic dermatitis,
allergic conjunctivitis, GI allergy)
B. Minor features (3 or more):
1. Xerosis (dry skin)
2. Ichthosis/palmar hyperlinearity/ keratosis pilaris
3. Immediate(type I) skin test reactivity
4. Elevated serum IgE
5. Early age of onset
6. Tendency towards skin infections(esp. S.aureus & Herpes simplex) / impaired cellmediated immunity
7. Tendency towards nonspecific hand or foot dermatitis
8. Nipple eczema
9. Cheilitis
10. Recurrent conjunctivitis
11. Dennie-Morgan infraorbital folds
12. Keratoconus
13. Anterior subcapsular cataracts
14. Orbital darkening
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15.
16.
17.
18.
19.
20.
21.
22.
23.

Facial pallor/erythema
Pityriasis alba
Anterior neck fold
Itch when sweating
Intolerance to wool and lipid solvents
Perifollicular accentuation
Food intolerance
Course influenced by environemental and emotional factors
White dermographism

37. Which statement is true regarding phototherapy

a. It is used for eczematous disease only
b. It is only used for psoriasis patients
c. It is used for exfoliative dermatitis
d. All of the above
Eczema Treatment:

Topical Regimen

Steroids hydrocortisone, dexamethasone, mometasone, methylprednisolone, triamcinolone,

betamethasone, clobetasol, fluocinolone

Antibiotics gram-positive coverage, broad-spectrum

Immunomodulatory drugs tacrolimus

Emollients / Moisturizers /hypoallergenic cleansers

Systemic Drugs

Antihistamines sedating/ non-sedating

Antibiotics

Steroids prednisone, methylprednisolone, hydrocortisone

Immunomodulatory drugs cyclosporine, methotrexate, azathioprine

Phototherapy

Use of ultraviolet light:

1. UVA-1 atopic dermatitis
2. Narrow-band UVB

Intralesional injections of corticosteroids

Psoriasis Treatment:

TOPICAL Treatment = applied to skin

Glucocotricosteroids

Vitamin D3 analogues: calcipotriol

Topical retinoid: Tazarotene

Tar

Anthralin

Emollients/ Moisturizers: eg. Petroleum jelly commonly used because cheap but greasiness is
uncomfortable

SYSTEMIC Treatment (oral/IM/ IV)

Methotrexate

Cyclosporine

Retinoids (Vit A derivatives)= etretinate, acitretin

Biologicals : genetically engineered medication from a living organism (e.g. virus), gene or protein
injected or infused intravenously = e.g. etanercept , infliximab

PHOTOTHERAPY - Treatment with ultraviolet (UV) light

Photochemotherapy : PUVA = a photosensitizer (methoxypsoralen) is ingested and the patient is subjected

to UVA light

UVB light = broad band UVB

= narrow band UVB
Exfoliative Dermatitis Treatment:

Exfoliative dermatitis commonly resists therapy until the underlying disease is treated (eg. phototherapy,
systemic medications in psoriasis).*
*External Source
38. Which is NOT true about psoriasis?
a. It occurs at any age
b. Most cases have a positive family history
c. It peaks at age 16-22 years old
d. It peaks at 55-60 years old
*The answer indicated was A, but according to the ppt, all of them are characteristics of psoriasis, so the answer should be
none of the above.
Psoriasis:

A chronic, relapsing disease characterized by red, scaling skin lesions of variable forms

Affects about 2% of population

(+) Genetic predisposition

1/3 of patients have (+)family history

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Occurs at ANY AGE

PEAKS at 2 age groups:

16-22 y/o and 55-60 y/o

39. Which is NOT a distribution pattern of seborrheic dermatitis

a. Scalp
b. Eyebrows
c. Extensor surfaces
d. Flexor surfaces
*From 2010 Tranx
Seborrheic Dermatitis:

Common, chronic disorder characterized by greasy scales overlying erythematous patches or plaques with
variable pruritis

Most common location: scalp (recognized as severe dandruff)

Seborrheic distribution: Eyebrows, nasolabial folds, eyelids, glabella, post-auricular area, periorbital, upper
back, flexural areas

May also be seen in central chest, axilla, groin, submammary folds, and gluteal cleft

Age of onset 2 peaks

Infancy (within 1st 3 months) evident in scalp cradle cap yellow, greasy, adherent scales
th th

4 -7 decade

Epidemiology:

Male > Female

85% patients with AIDS

No racial predilection
40. Which area is NOT commonly affected in psoriasis vulgaris
a. Lower back
b. Cheeks
c. Scalp
d. Retroauricular areas
Psoriasis Vulgaris:

Circular plaques predominantly on scalp (particularly) retroauricular areas , elbows & knees, lower back (lumbar
area)

Chronic stationary psoriasis months/yrs.

41. Standard precautions should be applied to which of the following admitted patients
a. A 3month old baby girl with fever and rash
b. A 12year old boy who sustained a leg fracture
c. A 37year old pregnant mother with vaginal bleeding
d. A 60year old diabetic man complaining of severe chest pain
e. All of the above
Standard Precautions:

Primary strategy for successful prevention and control of healthcare-associated infections

Designed for the care of ALL patients in hospitals, REGARDLESS of their diagnosis or presumed infection status

Goals:
1. Reduce the risk of transmission of bloodborne pathogens
2. Reduce the risk of transmission of pathogens from moist body substances (ie. Blood, all body fluids except
sweat, non-intact skin, mucous membranes)
42. A 35 year old engineer was admitted for 1 month intermittent fever, anorexia, and cough which initially was dry but
later productive of greenish, blood-streaked sputum. What isolation precautions should be done for this patient?
a. Admission in a single room
b. Wearing of gloves when taking his blood pressure
c. Asking the patient to wear N95 respirator mask all the time
d. Separating the patients utensils
e. All of the above
Airborne Precautions:

Airborne transmission occurs when droplet nuclei (<5 microns) are disseminated in the air and inhaled by a
susceptible host

Droplet nuclei can remain suspended in the air for long periods of time and can be carried on air currents over
long distances.

Recommendations

Isolation room/special ventilation room

Negative air-pressure ventilation, HEPA filtered air if re-circulated

Keep the door closed at ALL times

Patient should wear a mask when transported out of room

Healthcare Worker (HCW) should wear fitted respirator mask (N95 mask)
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43. Contact precautions should be observed in patients with the following conditions EXCEPT
a. Scabies
b. Herpes zoster
c. HIV-AIDS
d. Hepatitis A
e. Shigella
Contact Precautions:

Contact transmission is the most frequent means of transmitting healthcare-associated infections

Direct-contact vs indirect-contact transmission

Apply to specified patients known or suspected to be infected or colonized with epidemiologically important
organisms transmitted primarily by the contact route

Infections Requiring Contact Precautions:

Multidrug-Resistant Bacteria (MRSA, VRSA)

C. difficile diarrhea, Enteroviruses, Shigella, Hepatits A

Viral and Hemorrhagic Conjunctivitis

Cutaneous Diphtheria

Herpes simplex virus, Herpes zoster, Varicella

Impetigo, Major non-contained abscesses

Scabies

S. Aureus Cutaneous Infection

Private room, cohorting permissible

Clean, nonsterile gloves at all times

Handwashing after glove removal

Gowns at all times, unless px is continent and contact of clothing with px or environmental surfaces is NOT
anticipated

Remove gloves and gowns before leaving px room

44. The most effective way of preventing the spread of healthcare associated infections is
a. Admission of infected patients in single rooms
b. Administration of prophylactic antibiotics to persons exposed to infected patients
c. Adherence to hand hygiene
d. Wearing of personal protective equipment when caring for patients
e. All of the above
*From 2009 Tranx:

Contact transmission is the most frequent means of transmitting healthcare-associated infections

Health Care Workers Hands are probably the most common means by which spread of infection by direct
contact can occur, so hand hygiene is most important to adhere to.
45. In healthcare facility where single rooms are limited, patients with respiratory infections transmitted through droplets
may be cohorted in a multi-bed ward as long as the beds are maintained at what distance from each other
a. 3 feet
b. 5 feet
c. 7 feet
d. 10 feet
Droplets do not remain suspended in the air and travel only short distances (3 feet or less).
46. Which healthcare associated infection is the most frequently seen in the hospitals today
a. Ventilator-associated pneumonia 13%
b. Catheter-related UTI 34%
c. Surgical site infection 17%
d. Vascular device-related infection 14%
e. Infected pressure sores
47. In assessing an infection related to a vascular access device, what is the most appropriate mode of doing cultures?
a. Obtain two peripheral blood cultures
b. Obtain cultures from each access port of the suspected line
c. Obtain two cultures peripherally from two separate sites with semiquantitative cultures of the catheter
tip
d. Obtain a culture of skin form the exit site of the central venous catheter
Culture:

Recovery of the same species of microorganisms from peripheral-blood cultures

Semiquantitative cultures of the vascular tip

Pathogens: Coagulase-negative Staphylococcus, S. aureus, enterococci, gram-negative bacilli, Candida

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48. Which of the following risk factors will contribute most significantly to the development of healthcare associated
pneumonia in a 65 year old male admitted stuporous for a massive stroke?
a. Uncontrolled blood pressure
b. Feeding through nasogastric tube
c. Depressed sensorium
d. Mechanical ventilation
e. Age
*Both C and E can be possible answers since they are both listed as risk factors. Since the cause of his stroke is not
indicated and there is no indication of use of mechanical ventilation or a nasogastric tube, A, B, and D are the less likely
answers.
Risk Factors:

Events that increase the risk of colonization by potential pathogens

e.g. prior antimicrobial therapy, contaminated ventilatory equipment, low gastric pH

Increased risk of aspiration of oropharyngeal contents into the lower respiratory tract

intubation, decreased level of sensorium

Reduced host defense mechanisms in the lung that permit overgrowth of aspirated pathogens

e.g. COPD, old age

49. Administration of prophylactic antibiotics to prevent surgical site infections should be
a. 1 hour before surgery
b. 24 hours before surgery
c. End after 3 days
d. End on day 7 post-surgery
e. Given during first incision
Administer prophylactic antibiotics within 1 hour before surgery; discontinue within 24 hours.
50. Which pathogen is most commonly isolated in bloodstream infections related to the use of vascular catheters
a. Pseudomonas aeruginosa
b. Escherichia coli
c. Candida
d. Staphylococcus aureus
e. Streptococcus viridians
*From 2009 Tranx:

Most Common Pathogens:

1. Coagulase Negative Staphylococci
2. S. Aureus
3. Enterococci
4. Nosocomial Gram-negative Bacilli
5. Candida

Many pathogens, especially staphylococci, produce extracellular polysaccharide biofilms that facilitate
attachment to catheters and provide sanctuary from antimicrobial agents

Therapy for vascular access-related infection is directed at the pathogen directed at the pathogen recovered
from the blood and/or infected site.

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