Self-Assessmen! II I l l III Illl I II I II

Serf-Assessment examination of the American Academy of Dermatology* Identification No. 891-20t

Learning objectives: At the conclusion of this self-assessment learning activity, physician participants should be able to assess their own diagnostic and patient management skills with respect to those of their colleagues in the field, use the results of the self-assessment to help determine personal learning needs that can be addressed through subsequent CME involvement, and enhance their ability to comply with the requirements for certification in the specialty of dermatology.

Instructions for Category I CME credit appear in the front advertising section. See last page of Contents for page num- ber.

Instructions: In answering each question, refer to the specific directions provided. Because it is often necessary to provide information in questions occurring later in a series that give away answers to earlier questions, please answer the ques- tions in each series in sequence.

QUESTIONS 1-11

A healthy 36-year-old woman had many itchy red papules and a few small plaques on the chest and lateral aspects of the arms and forearms 2 days af- ter playing golf on a sunny afternoon in late spring (Fig. 1). She had a similar episode the previous year during a trip to the Caribbean in early summer. Her only medication is an oral contraceptive, which she has taken regularly for the past 6 years; she takes no other medication and regularly uses a sunscreen (sun protector factor [SPF] 29) whenever outdoors.

1. The most likely diagnosis is (Choose single best response.) a. systemic lupus erythematosus b. polymorphous light eruption (PMLE) c. solar urticaria d. photocontact dermatitis e. sunburn

2. The woman has PMLE. Nevertheless, the treating physician should exclude which of the following dis- eases? (Choose single best response.) a. Lupus erythematosus b. Secondary syphilis c. Lyme disease d. Dermatitis herpetiformis e. Eosinophilic pustular foUiculitis

O The Self-Assessment examination is supported in part by an educational grant from the Procter & Gamble Company, Cincinnati, Ohio.

*Members of the Self-Assessment Committee of the American Acad- emy of Dermatology are: Kenneth J. Tomec/d, MD, chairman, C. Ralph Danid III, MD, Richard A. Johnson, MD, Melinda B. Mu- sick, MD, Warren W. Piette, MD, Robert A. Schwartz, MD, and Ronald G. Wheeland, MD.

3. To exclude lupus erythematosus, evaluation should include (Choose two best responses.) a. skin biopsy for histology b. skin biopsy for direct immunofiuorescence c. skin (prick) testing d. patch testing e. chest x-ray

4. Serologic testing should include (Choose two best re- sponses.) a. serologic test for syphilis b. antinuclear antibody c. anti-Ro (SSA) antibody d. human immunodeficiency virus (HIV) antibody e. none of the above

5. Morphologically, PMLE may exhibit (Choose as many as apply. All, some, or none o f the choices may be correct.) a. erythema b. papules or papulovesiclea c. plaques d. purpura e. bullae

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Volume 24 Number 1 January 1991 Self-Assessment examination 157

6. Histologic changes of PMLE are nonspecific but should include (Choose two best responses.) a. acanthosis and spongiosis b. epidermal atrophy c. lymphocytic perivascular infiltrate in the dermis d. foci of hemorrhage e. thickened basement membrane

7. Initial therapy typically includes (Choose two best responses.) a. topical corticoste~roids b. sunscreens c. aspirin d. systemic antibiotics e. none of the above

8. Adjunctive therapy may include (Choose single best response.) a./~-carotene b. photochemotherapy (PUVA) c. UVB phototherapy d. antimalarials e. all of the above

9. Each of the following is true of PMLE except (Choose single best response.) a. it is an idiopathic reaction to UV light, usually

UVA. b. most patients are young adults. c. disease occurs more commonly in women. d. disease usually occurs 1 to 2 days after sun expo-

sure. e. disease can ocour in non-sun-exposed areas of the

body.

10. Each of the following statements about PMLE is true except (Choose single best response.) a. papular PMLE is the most common presentation. b. PMLE has a patchy distribution with spared ar-

eas adjacent to lesional skin. c. scarring is rare. d. with avoidance or discontinuation of sun exposure,

disease resolves within a week. e. regular use of sunscreens (SPF 15 or higher) will

prevent disease.

11. PMLE primarily occurs after exposure to which of the following? (Choose single best response.) a. UVA radiation b. UVB radiation c. UVC radiation d. Visible light e. Alpha particles

QUESTIONS 12-20

A 25-year-old white man has a 3-year history of draining ulcers and scar formation in his groin,

perianal area, and axillae (Fig. 2). H e is otherwise healthy.

12. The most likely diagnosis is (Choose single best response.) a. hidradenitis suppurativa b. tuberculosis c. cat-scratch disease d. actinomycosis e. lymphogranuloma venereum

13. Suggested diagnostic laboratory tests for this disor- der include (Choose single best response.) a. VDRL b. computed tomographic scanning c. liver function tests d. HLA typing e. none of the above

14. Histologic examination of a lesion of hidradenitis suppurativa would likely reveal all of the following except (Choose single best response.) a. fibrosis and scarfing of the pflosebaeeous unit in

late lesions b. infiltration of the apocrine gland with atypical

lymphocytes c. keratin plugging of apocrine ducts and associated

hair follicles d. infiltration of the apocrine gland with neutrophils e. bacteria around apocrine glands

15. Hidradenitis suppurativa is associated with each of the following except (Choose single best response.) a. obesity b. occurrence in apocrine gland-bearing areas c. onset before puberty d. genetic predisposition to ache e. chronic, relapsing course

16. Other conditions associated with hidradenitis suppu- rativa include each of the following except (Choose single best response.) a. rheumatoid arthritis

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b. pilonidal cyst c. dissecting ceUulitis of the scalp d. spondyloarthropathy e. aene conglobata

Each of the following medical therapies is of at least occasional benefit in hidradenitis suppurativa except (Choose single best response.) a. isotretinoin b. intralesional steroid injections e. topical or systemic antibiotics d. Goeckerrnan regimen e. antiandrogen hormones

Surgical treatment is often nece~ary for patients with severe disease. Each of the following is a true statement about such surgery except (Choose single best response.) a. adequate excision of apoerine gland-bearing skin

often leaves a defect too large for primary closure. b. recurrence rates are lowest in the axillae and

perianal areas and highest in the submammary area .

e. most local recurrences appear within 3 months of surgery.

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d. acceptable means of closure after excision include split-thickness skin grafting, myocutaneous flaps, and healing by secondary intention.

e. follow-up studies indicate that most patients are pleased with surgical results.

Possible complications of hidradenitis suppurativa include each of the following except (Choose single best response.) a. ache fulminans b. squamous cell carcinoma arising at the si te of

chronic lesions c. secondary systemic amyloidosis d. psychosocial difficulties arising from cosmetic al-

terations e. sinus tract and fistula formation

Another occlusive disease that has been reported in association with hidradenitis suppurativa is (Choose single best response.) a. Fox-Fordyce disease b. hidradenoma papilliferum c. Fordyce condition d. nevus sebaceus e. tubular apocrine adenoma