The Skin

17

A 14-year-old boy presents with a 6-month history of

erythematous papules on his face. Physical examination
reveals numerous blackheads over the forehead and cheeks.
Which of the following bacteria is associated with the development of these lesions?
(A) Clostridium sp.
(B) Lactobacillus sp.
(C) Propionibacterium sp.
(D) Staphylococcus sp.
(E) Streptococcus sp.

18

A 30-year-old man presents with flat-topped papules that have

appeared gradually on the flexor surfaces of his wrists. White
streaks and patches are also found on the buccal mucosa of
the patients mouth. Histologically, the lesions showed hyperkeratosis, thickening of the stratum granulosum, and a bandlike infiltrate of lymphocytes and macrophages in the upper
dermis, disrupting the basal layer of the epidermis. Lymphocytes were mostly of the CD4+ immunophenotype. Which of
the following is the appropriate diagnosis?
(A) Dermatitis herpetiformis
(B) Erythema multiforme
(C) Erythema nodosum
(D) Hypersensitivity angiitis
(E) Lichen planus

19

A 66-year-old woman presents with a 5-year history of erythematous, scaly patches on her buttocks. Physical examination reveals plaques with telangiectases, atrophy, and
pigmentation. Biopsy of lesional skin shows that the epidermis
and papillary dermis are expanded by an extensive infiltrate
of atypical lymphocytes. These infiltrating lymphocytes most
likely express which of the following cluster of differentiation cell surface markers?

(A)
(B)
(C)
(D)
(E)

CD4
CD9
CD15
CD20
CD31

20

A 30-year-old woman with chronic hepatitis B presents

with numerous red skin lesions that she has had for 5 days.
Physical examination reveals multiple, purpuric, 2- to
4-mm papules on the skin (shown in the image). The papules did not blanch under pressure. Biopsy of lesional skin
shows necrotizing leukocytoclastic venulitis. Immunofluorescence studies disclose immune complex deposition in
vascular walls. Which of the following is the most likely
diagnosis?

(A)
(B)
(C)
(D)
(E)
21

279

Allergic contact dermatitis

Dermatitis herpetiformis
Erythema multiforme
Erythema nodosum
Hypersensitivity angiitis

A 20-year-old man presents to his family physician for treatment of itching after exposure to poison ivy. The patients
hands and arms appeared red and were covered with oozing
blisters and crusts (shown in the image). Which of the following represents the most important step in the pathogenesis of
the sensitization phase of injury in this patient?

(A)
(B)
(C)
(D)
(E)

Development of spongiosis
Infiltration of the epidermis by neutrophils
Migration of Langerhans cells into dermal lymphatics
Rapid increase in vascular permeability
Separation of the epidermis from the dermis mediated by
eosinophils

The Skin
of the epidermis are thickened several-fold in the rete pegs and
are frequently thinner over the dermal papillae. The capillaries
of the papillae are dilated and tortuous. Neutrophils emerge
at their tips and migrate into the epidermis above the apices
of the papillae. Neutrophils may become localized in the epidermal spinous layer or in small Munro microabscesses in the
stratum corneum. The dermis below the papillae exhibits a
varying number of mononuclear inflammatory cells (choices
A and E) around the superficial vascular plexuses.
Diagnosis: Psoriasis
9

10

11

The answer is C: Epidermolysis bullosa (EB). EB comprises

a heterogeneous group of disorders loosely bound by their
hereditary nature and by a tendency to form blisters at sites of
minor trauma. EB simplex has been attributed to mutations of
genes encoding cytokeratin intermediate filaments. The clinical spectrum of the disease ranges from a minor annoyance to
a widespread, life-threatening blistering disease. These blisters are almost always noted at birth or shortly thereafter. The
classification of these disorders is based on the site of blister formation in the basement membrane zone. Although epidermolytic EB is cosmetically disturbing and sometimes debilitating,
it is not life threatening. Blisters seen in bullous pemphigoid
(choice A) and pemphigus vulgaris (choice E) are associated
with immunoglobulin deposits that are visualized by direct
immunofluorescence microscopy. Dermatitis herpetiformis
(choice B) occurs at a later age and is associated with gluten
hypersensitivity. In ichthyosis vulgaris (choice D), scaly skin
results from increased cohesiveness of the stratum corneum.
Diagnosis: Epidermolysis bullosa
The answer is B: Desmoglein-3. Pemphigus vulgaris is an
autoimmune disease caused by autoantibodies to a keratinocyte antigen. The characteristic lesion is a large, easily ruptured
blister that leaves extensive denuded or crusted areas. Suprabasal dyshesion results in a blister that has an intact basal layer
as a floor and the remaining epidermis as a roof. The blister
contains a moderate number of lymphocytes, macrophages,
eosinophils, and neutrophils. Distinctive, rounded keratinocytes (termed acantholytic cells) are shed into the vesicle
during the process of dyshesion. Circulating IgG antibodies
in patients with pemphigus vulgaris react with an epidermal
surface antigen called desmoglein-3, a desmosomal protein.
Antigenantibody union results in dyshesion, which is augmented by the release of plasminogen activator and, hence,
the activation of plasmin. This proteolytic enzyme acts on the
intercellular substance and may be the dominant factor in dyshesion. None of the other choices are related to the pathogenesis of pemphigus vulgaris.
Diagnosis: Pemphigus vulgaris
The answer is A: Basal cell carcinoma (BCC). BCC is the
most common malignant tumor in persons with pale skin.
Although it may be locally aggressive, metastases are exceedingly rare. BCC usually develops on the sun-damaged skin of
people with fair skin and freckles. The tumor is composed of
nests of deeply basophilic epithelial cells with narrow rims
of cytoplasm that are attached to the epidermis and protrude
into the subjacent papillary dermis. Basaloid keratinocytes are
rarely seen in squamous cell carcinoma (choice D) and are not
encountered in the other choices.
Diagnosis: Basal cell carcinoma

281

12

The answer is E: Human papillomavirus. Verruca vulgaris,

also known as the common wart, is an elevated papule with
a verrucous (papillomatous) surface. The warts may be single
or multiple and are most frequent on the dorsal surfaces of
the hands or on the face. Several human papillomavirus types,
including types 2 and 4, have been demonstrated in verruca
vulgaris. No malignant potential is recognized. The other
choices do not induce papillomas.
Diagnosis: Verruca vulgaris

13

The answer is D: Erythema nodosum (EN). EN is a cutaneous

disorder that manifests as self-limited, nonsuppurative, tender
nodules over the extensor surfaces of the lower extremities.
It is triggered by exposure to a variety of agents, including
drugs and microorganisms (bacteria, viruses, and fungi), and
occurs in association with a number of benign and malignant
systemic diseases. The early neutrophilic inflammation suggests that EN may be a response to the activation of complement, with resulting neutrophilic chemotaxis. The subsequent
appearance of chronic inflammation, foreign body giant cells,
and fibrosis is secondary to necrosis of adipose tissue. The
other choices do not feature this distinctive histology.
Diagnosis: Erythema nodosum

14

The answer is B: Bullous pemphigoid (BP). BP is a common,

autoimmune, blistering disease with clinical similarities to
pemphigus vulgaris (thus, the term pemphigoid) but in which
acantholysis is absent. Complement-fixing IgG antibodies are
directed against two basement membrane proteins, BPAG1 and
BPAG2. In contrast to pemphigus vulgaris (choice E), immunofluorescent studies demonstrate linear deposition of C3 and
IgG along the epidermal basement membrane zone. The other
choices do not feature antibasement membrane antibodies.
Diagnosis: Bullous pemphigoid

15

The answer is B: IgA deposits in dermal papillae. Dermatitis herpetiformis is an intensely pruritic cutaneous eruption related to gluten sensitivity, which is characterized by
urticaria-like plaques and vesicles over the extensor surfaces
of the body. Genetically predisposed patients may develop
IgA antibodies to components of gluten in the intestines. The
resulting IgA complexes then gain access to the circulation and
are deposited in the skin. The release of lysosomal enzymes by
inflammatory cells cleaves the epidermis from the dermis. The
other choices are not typical histologic findings in dermatitis
herpetiformis.
Diagnosis: Dermatitis herpetiformis

16

The answer is C: Granular distribution of immune complexes in

the basement membrane zone. The patient exhibits signs and
symptoms of systemic lupus erythematosus (SLE), a disorder
characterized by a variety of autoantibodies and other immune
abnormalities indicating B-cell hyperactivity. Epidermal cellular damage initiated by light or other exogenous agents causes
the release of a large number of antigens, some of which may
return to the skin in the form of immune complexes. Immune
complexes are also formed in the skin by a reaction of local
DNA with antibody that may also be deposited beneath the
epidermal basement membrane zone. The other choices are
not features of SLE.
Diagnosis: Systemic lupus erythematosus