Self-Assessment Self-Assessment examination of the American Academy of Dermatology* Identification No. 892-201 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 1-5 A 19-year-old college student had alopecia of the left eyebrow and scaly red plaques on the left side of the forehead, left cheek, and neck of 9 months' du- ration (Fig. 1). Biopsy specimens of lesional skin from the forehead and neck showed similar changes (Figs. 2 and 3). Results of complete blood cell count and renal and hepatic chemistries were normal. 1. The most likely diagnosis is (Choose single best response.) a. alopecia mucinosa b. tuberculoid leprosy c. allergic contact dermatitis d. polymorphous light eruption e. subacute cutaneous lupus erythematosus 2. Patients with this disorder are at increased risk for the development of (Choose single best response.) a. lepromatous leprosy b. cutaneous T-cell lymphoma c. Wegener's granulomatosis d. lymphomatoid granulomatosis e. systemic lupus erythematosus 3. Attributes that portend a good prognosis include (Choose as many as apply. All, some, or none of the choices may be correct.) 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. Tomecki, MD, chairman, Bur- ton S. Belknap, MD, Mary R. Buchness, MD, Ponciano D. Cruz, MD, C. Ralph Daniel III, MD, Gary R. Kantor, MD, Francisco A. Kerdel, MD, Melinda B. Musick, MD, Tobi B. Richman, MD, The- odore Rosen, MD, Robert A. Schwartz, MD, and Ronald G. Wheeland, MD. a. young age of onset b. lack of epidermotropism c. absence of lesions below the neck d. absence of lymphadenopathy e. normal complete blood cell count and hepatic and renal chemistries 4. Which initial approach to therapy is most reasonable for this patient? (Choose single best response.) a. Topical tretinoin b. Topical triamcinolone c. Topical nitrogen mustard d. Topical psoralens plus UVA radiation e. No treatment; assure patient of the benignity of the disorder 497
Transcript
Self-Assessment
Self-Assessment examination of theAmerican Academy of Dermatology* Identification No. 892-201
Learning objectives: At the conclusion of this self-assessment learning activity, physician participants should be able toassess their own diagnostic and patient management skills with respect to those of their colleagues in the field, use theresults of the self-assessment to help determine personal learning needs that can be addressed through subsequent CMEinvolvement, and enhance their ability to comply with the requirements for certification in the specialty ofdermatology.
Instructions for Category I CME credit appear in the front advertising section. See last page of Contents for page number.
Instructions: In answering each question, refer to the specific directions provided. Because it is often necessary to provideinformation in questions occurring later in a series that give away answers to earlier questions, please answer the questions in each series in sequence.
QUESTIONS 1-5
A 19-year-old college student had alopecia of theleft eyebrow and scaly red plaques on the left side ofthe forehead, left cheek, and neck of 9 months' duration (Fig. 1). Biopsy specimens of lesional skinfrom the forehead and neck showed similar changes(Figs. 2 and 3). Results of complete blood cell countand renal and hepatic chemistries were normal.
1. The most likely diagnosis is (Choose single bestresponse.)a. alopecia mucinosab. tuberculoid leprosyc. allergic contact dermatitisd. polymorphous light eruptione. subacute cutaneous lupus erythematosus
2. Patients with this disorder are at increased risk for thedevelopment of (Choose single best response.)a. lepromatous leprosyb. cutaneous T-cell lymphomac. Wegener's granulomatosisd. lymphomatoid granulomatosise. systemic lupus erythematosus
3. Attributes that portend a good prognosis include(Choose as many as apply. All, some, or none ofthechoices may be correct.)
The Self-Assessment examination is supported in part by aneducational grant from the Procter & Gamble Company,Cincinnati, Ohio.
*Members of the Self-Assessment Committee of the American Academy of Dermatology are: Kenneth J. Tomecki, MD, chairman, Burton S. Belknap, MD, Mary R. Buchness, MD, Ponciano D. Cruz,MD, C. Ralph Daniel III, MD, Gary R. Kantor, MD, Francisco A.Kerdel, MD, Melinda B. Musick, MD, Tobi B. Richman, MD, Theodore Rosen, MD, Robert A. Schwartz, MD, and Ronald G.Wheeland, MD.
a. young age of onsetb. lack of epidermotropismc. absence of lesions below the neckd. absence of lymphadenopathye. normal complete blood cell count and hepatic and
renal chemistries
4. Which initial approach to therapy is most reasonablefor this patient? (Choose single best response.)a. Topical tretinoinb. Topical triamcinolonec. Topical nitrogen mustardd. Topical psoralens plus UVA radiatione. No treatment; assure patient of the benignity of
the disorder
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5. Three months later, the patient returns with onlyslight improvement. Previous lesions are essentiallyunchanged and new lesions have developed on the leftleg. A biopsy specimen of lesional skin on the left legreveals the same histologic changes. Reasonabletherapeutic options now include (Choose as many asapply. All, some, or none of the choices may be correct.)a. oral etretinateb. oral isotretinoinc. oral psoralens plus UVAd. topical nitrogen mustarde. intramuscular triamcinolone
QUESTIONS 6-10
A 45-year-old Hispanic woman had itching anda rash-annular, urticarial plaques-for 5 weeks,which began on her neck and axillae and later spreadto the trunk (Fig. 4) and extremities (Fig. 5).
6. Which dermatologic category is least likely in thiscase? (Choose single best response.)a. Viral exanthemb. Figurate erythemac. Urticarial eruptiond. Blistering disordere. Papulosquamous dermatitis
7. A biopsy specimen from perilesional skin (Fig. 6) ismost consistent with which one of the followingdiagnoses? (Choose single best response.)a. Bullous pemphigoidb. Herpes gestationisc. Dermatitis herpetiformis
d. Familial benign pemphiguse. Epidermolysis buUosa dystrophica
8. Fig. 7 shows direct immunofluorescence of skin fromthe same biopsyspecimen. Among those listed, whichdiagnosis is least consistent with this result? (Choosesingle best response.)a. Bullous pemphigoidb. Herpes gestationisc. Dermatitis herpetiformisd. Linear IgA bullous dermatosise. Epidermolysis bullosa acquisita
9. The immunoglobulin deposits shown in Fig. 7 provedto be IgA. The best therapy for this condition is(Choose single best response.)a. dapsoneb. oral retinoidsc. oral glucocorticoidsd. topical glucocorticoidse. gluten-free diet
10. This disorder is associated with an increased risk of(Choose single best response.)a. glomerulonephritisb. arthritis and serositisc. gastrointestinal lymphomad. similar disease in newborn if the patient becomes
pregnante. none of the above
QUESTIONS 11-15
A 47-year-old white woman has many asymptomatic, scaly, papules, each 1 to 5 mm in diameter,
on the dorsal aspect of the hands and feet (Fig. 8).Her skin disease began 18 years ago.
11. The least likely diagnosis is (Choose single bestresponse.)a. porokeratosisb. eccrine poromac. stucco keratosisd. acrokeratoelastoidosise. focal acral hyperkeratosis
12. Fig. 9 shows histology from a lesional skin biopsy.The best diagnosis is (Choose single best response.)a. porokeratosisb. stucco keratosisc. acrokeratoelastoidosisd. acrokeratosis verruciformis of Hopfe. hyperkeratosis lenticularis persians
13. The likely explanation for this disorder is (Choosesingle best response.)a. autosomal dominant inheritanceb. chronic arsenic intoxicationc. repetitive vibratory traumad. prolonged sun exposuree. hypovitaminosis A
14. Known characteristics of this disorder include which
of the following? (Choose as many as apply. All,some, or none ofthe choices may be correct.)a. Onset after 30 years of ageb. Greater predilection for womenc. Mucosal involvementd. Association with internal malignancye. Degeneration into squamous cell carcinoma
15. Reasonable topical treatment includes (Choose asmany as apply. All, some, or none ofthe choices maybe correct.)a. tretinoinb. salicylic acidc. a-hydroxy lactic acidd. nitrogen mustarde. glucocorticoids
QUESTIONS 16-20
A 29-year-old black woman had numerous fleshcolored and waxy papules and nodules along thetarsal edge of the eyelids, nasal vestibule, and lips(Fig. 10). She also had verrucous papules andplaques on the extensor aspects of forearms and elbows (Fig. 11), the dorsal phalanges, and nailfolds
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(Fig. 12). Histologic features are shown in Figs. 13,14, and 15.
16. On the basis of the clinical appearance and biopsymaterial, the best diagnosis is (Choose single best response.)a. amyloidosisb. Fabry's diseasec. lipoid proteinosisd. basal cell nevus syndromee. multicentric reticulohistiocytosis
17. Clinical features consistent with this disorder include(Choose as many as apply. All, some, or none ofthechoices may be correct.)
a. hoarseness at birthb. disabling arthritisc. pitted facial scarsd. dental abnormalitiese. intracranial calcification
18. Endocrine disorders associated with this disorder include (Choose as many as apply. All, some, or noneof the choices may be correct.)a. hypogonadismb. hypoadrenalismc. hypothyroidismd. diabetes mellituse. diabetes insipidus
19. Potentially life-threatening consequences of this disorder include (Choose as many as apply. All, some,or none of the choices may be correct.)a. uremiab. asphyxiac. seizuresd. cardiac failuree. internal malignancy
20. The hyaline deposit surrounding vessels and sweatglands is (Choose single best response.)a. periodic acid-Schiff (PAS}-positiveb. diastase-resistantc. diastase-sensitived. Congo red-positivee. alcian blue-positive at pH 2.9
QUESTIONS 21-30
A 78-year-old man has an asymptomatic perianalplaque (Fig. 16), which his physician discoveredduring a scheduled annual examination. Thought tobe and treated as intertrigo a year earlier, the plaquehas slowly enlarged despite topical therapy with antifungal preparations.
21. On the basis of the history, clinical appearance, andbiopsy findings (Fig. 17), the best diagnosis for thisplaque is (Choose single best response.)
22. The most likely pathogenesis of this lesion is (Choosesingle best response.)a. a mycobacterial infectionb. a malignant neoplasm of glandular originc. an insect bited. a granulomatous response to a Candida infectione. UV light-induced carcinogenesis
23. The best therapy for this plaqueis (Choose single bestresponse.)a. dapsoneb. wide local excision with regional lymph node dis-
sectionc. systemic antifungal therapyd. chemotherapy with local palliatione. Mohs micrographic surgery
24. Ifa simple local excision is done, the likely outcomewould be (Choose single best response.)a. distant metastasesb. cellulitisc. local recurrenced. unchanged
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e. local regression with regional lymph node metastases eventually
25. Histologically, the cytoplasm of the atypical cells(Choose single best response.)a. contains PAS-positive neutral mucopolysaccha
rides not removed by diastaseb. contains PAS-positive neutral mucopolysaccha-
rides removed by diastasec. does not stain with PASd. does not stain with colloidal irone. does not stain with mucicarmine
26. The atypical cells in this disorder tend to (Choosesingle best response.)a. lie in or above the basal layerb. lie at the dermoepidermal junctionc. be PAS negative and dopa positived. be PAS negative and dopa negativee. show cerebriform calcifications
27. With immunohistologic studies that use standardperoxidase-antiperoxidase techniques, the neoplasmexhibits (Choose single best response.)a. antibodies directed against all cytokeratinsb. antibodies against carcinoembryonic (CEA) anti
genc. antibodies against S-100 proteind. antibodies directed against keratin and 8-100
proteine. antibodies against CEA antigen and S-l00 protein
28. The atypical cells in this disorder (Choose single bestresponse.)a. always contain melaninb. occasionally contain melaninc. never contain melanind. contain a dopa-positive pigment that is not mela
nine. contain a pigment (lipofuscin) that may resemble
melanin.
29. A patient with this disorder deserves an evaluation for(Choose single best response.)a. lung cancerb. multiple primary melanomasc. anogenital tract cancerd. diabetes mellituse. cytophagic histiocytic panniculitis
30. Serial sectioning of the perianal plaque may reveal(Choose single best response.)a. an underlying adnexal carcinomab. origin of the tumor in the clear cells of the outer
root sheath of the hair folliclec. the presence of mycobacteriad. atypical melanocytes proliferating into the papil
lary dermise. atypical keratinocytes proliferating into the papil
