Item 1

Answer: (A)
Interferon and ribavirin
Educational Objective: Select the appropriate therapy for hepatitis Cassociated vasculitis
!his patient with hepatitis Cassociated vasculitis probably has essential "i#ed
cryo$lobuline"ia% despite the ne$ative results of cryo$lobulin testin$ !he best therapy for this
patient&s vasculitis and early chan$es of cirrhosis is interferon and ribavirin Althou$h vasculitis
"ay be treated with prednisone% "ethotre#ate% a'athioprine% and cyclophospha"ide% the use
of these dru$s "ay increase the viral load and result in pro$ression of the liver disease
(ethotre#ate has been used for so"e patients with s"all)vessel vasculitis% but it has been
associated with the possible develop"ent of cirrhosis and is certainly not indicated in this
patient% even with folic acid Cyclophospha"ide and intravenous i""uno$lobulin are therapies
that are far too a$$ressive for s"all)vessel vasculitis
*iblio$raphy
+,eichard O% -or.rans /% 0ryden A% *raconier 12% Sonnerbor$ A% 3eiland O ,ando"ised%
double)blind% placebo)controlled trial of interferon alpha)4b with and without ribavirin for
chronic hepatitis C !he Swedish Study /roup 5ancet +66789:+:79);
4(c2utchison 1/% /ordon SC% Schiff E,% Shiff"an (5% 5ee 3(% ,ust$i <=% et al Interferon
alfa)4b alone or in co"bination with ribavirin as initial treat"ent for chronic hepatitis C
2epatitis Interventional !herapy /roup - En$l 1 (ed +6678996:+>7:)64

Item 2
Answer: (A)
Aller$ic contact der"atitis
Educational Objective: ,eco$ni'e the clinical "anifestations of an acute aller$ic contact
der"atitis% and differentiate it fro" other acute vesiculobullous diseases
!his patient&s tense vesicles and bullae on a bac.$round of erythe"a are typical of a contact
der"atitis In so"e areas% the eruption assu"es a linear confi$uration% characteristic of an
e#o$enous e#posure to an anti$en or irritant Aller$ic contact der"atitis is al"ost always
pruritic *iopsy of a lesion shows spon$iosis with intraepider"al vesicle for"ation *ullous
pe"phi$oid is an autoi""une disease of elderly patients that is characteri'ed by a pruritic
eruption% which usually develops $radually !he lesions are tense bullae on erythe"atous or
nor"al)appearin$ s.in !he co""on sites of involve"ent are the $roin% a#illae% and fle#ural
areas !he blisters are subepider"al in location and are acco"panied by an eosinophilic
infiltrate ?irect and indirect i""unofluorescent studies show a linear band of I$/ and C9
deposited alon$ the base"ent "e"brane 'one
?er"atitis herpetifor"is is a chronic% intensely pruritic disorder that usually occurs in adults
and is characteri'ed clinically by clustered s"all vesicles sy""etrically located on the e#tensor
surfaces% particularly the elbows% .nees% and buttoc.s !he vesicles are subepider"al% with a
neutrophilic infiltrate in the upper der"is ?irect i""unofluorescent studies show $ranular
deposition of I$A alon$ the base"ent "e"brane 'one
2erpesvirus infection is typically locali'ed to a s"all area (herpes si"ple# virus infection) or a
der"ato"e (herpes 'oster infection)% and it is not widespread and bilaterally distributed li.e
the lesions in this patient I"peti$o@cellulitis usually does not occur in healthy adults It is
rarely widespread and bilateral% and it is characteri'ed by pustules (i"peti$o) or confluent
ede"atous erythe"a (cellulitis)
*iblio$raphy
+5eun$ ?A% ?ia' 5A% ?e5eo <% Soter -A Aller$ic and i""unolo$ic s.in disorders 1A(A
+66;84;7:+6+>)49
4*elsito ?< A sherloc.ian approach to contact der"atitis ?er"atol Clin +6668+;:;B:)+9
9=rasteva (% =ehren 1% ?uclu'eau (!% Saya$ (% Cacciapuoti (% A.iba 2% et al Contact
der"atitis I Cathophysiolo$y of contact sensitivity Eur 1 ?er"atol +66686:D:);;
>=rasteva (% =ehren 1% Saya$ (% ?uclu'eau (!% ?upuis (% =anita.is 1% -icolas 10 Contact
der"atitis II Clinical aspects and dia$nosis Eur 1 ?er"atol +66686:+>>):6

Item 3
Answer: (C)
!opical tretinoin
Educational Objective: Select the best therapeutic approach for co"edonal acne
!reat"ent for acne is best directed at its various co"ponents Catients with co"edones% which
are the do"inant feature in this patient% benefit fro" therapy with a topical retinoid% such as
tretinoin !retinoin in a "icrosphere delivery syste"% adapalene% and ta'arotene are newer
retinoid alternatives -or"ali'ation of follicular .eratini'ation follows retinoid use% which
results in e#trusion of plu$$ed sebaceous "aterial
!opical erythro"ycin is an appropriate therapy for patients with "ild to "oderate
infla""atory acne% but it has little effect on co"edones !opical ben'oyl pero#ide is also
pri"arily beneficial for patients with "ild infla""atory lesions% but the effect on co"edones
would be far less than that achieved with a topical retinoid Syste"ic tetracycline is best used
for patients with "ore si$nificant infla""atory acne Syste"ic therapy with oral isotretinoin is
$enerally reserved for patients with the "ost severe for"s of acne that are resistant to
traditional therapies
*iblio$raphy
+!hiboutot ?( An overview of acne and its treat"ent Cutis +66D8:;(+ Suppl):7)+4

Item 4
Answer: (C)
2is son should be referred to a der"atolo$ist for "onitorin$ with yearly s.in e#a"inations
Educational Objective: Choose the best "ana$e"ent strate$y for patients with dysplastic
nevi
?espite the nor"al appearance of the ;)year)old son&s "oles% he has the dysplastic nevus
syndro"e In the fa"ily settin$ described% it is usual for patients with the syndro"e to
develop "oles at an earlier a$e than would be e#pected for co""on acEuired nevi In patients
with this syndro"e% "oles not only appear early in life% but also occur in increased nu"bers
and in locations not ordinarily seen with co""on acEuired "oles% such as the scalp% $enital
re$ion% dorsu" of the feet% and breasts (in wo"en) Althou$h the appearance and si'e of
these lesions "ay be clinically indistin$uishable fro" those of routine "oles at this a$e% the
"orpholo$y usually rese"bles that of classic dysplastic nevi when the patient reaches late
adolescence
!he "ost appropriate course of action is to advise the patient that his child is afflicted with the
dysplastic nevus syndro"e and to educate the parent about the i"portance of havin$ the child
avoid sun e#posure% as well as about the deleterious effects of sunburns Aearly co"plete s.in
e#a"inations are reco""ended
If none of the "oles is clinically suspicious for "elano"a% a biopsy is not indicated !he
dia$nosis of fa"ilial dysplastic nevus syndro"e is a clinical one% and% in the settin$ described%
there is no Euestion about the dia$nosis Si"ilarly% there is no co"pellin$ need to re"ove the
e#istin$ nor"al)appearin$ "oles in this youn$ster It is i"portant that he start a lifeti"e sun)
protection pro$ra" and have suspicious lesions re"oved% but wholesale re"oval is not
warranted 0ree'in$ any .ind of "ole is inappropriate treat"ent
*iblio$raphy
+*rod.in ,2% Alt"an E( Controllin$ "ali$nant "elano"a A focus on pediatricians A" 1 ?is
Child +6698+>;:7;:)7+
42alpern AC% /uerry ? >th% Elder ?E% !roc. *% Synnestvedt (% 2u"phreys ! -atural history
of dysplastic nevi 1 A" Acad ?er"atol +669846::+);

Item 5
Answer: (*)
?er"atitis herpetifor"is
Educational Objective: Correlate the clinical findin$s with the specific blisterin$ disorder
!he clinical findin$s of pruritic lesions on the elbows and buttoc.s associated with chronic
$astrointestinal sy"pto"s stron$ly su$$est the dia$nosis of der"atitis herpetifor"is
0reEuently% these vesicles rupture fro" local scratchin$ and "ay appear only as $rouped
crusts !here is a stron$ association of der"atitis herpetifor"is with $luten)sensitive
enteropathy and "alabsorption% which e#plain this patient&s chronic $astrointestinal
sy"pto"s !he lesions of porphyria cutanea tarda and linear I$A bullous der"atosis are not
pruritic% and these disorders are not associated with $astrointestinal disease Althou$h the
dia$nosis of paraneoplastic pe"phi$us could be possible in a patient with wei$ht loss and
$astrointestinal sy"pto"s% these patients usually have si$nificant oral erosions and
nonpruritic poly"orphic s.in lesions ,ecurrent herpes si"ple# lesions are $rouped% but they
would not be e#pected to be pruritic or sy""etrical
*iblio$raphy
+,eunala !% Collin C ?iseases associated with der"atitis herpetifor"is *r 1 ?er"atol
+66;8+9D:9+:)7

Item 6
Answer: (?)
Cer"ethrin :F
Educational Objective: Crescribe appropriate therapy for patients with scabies
Cer"ethrin :F and lindane are the "ainstays of therapy for patients with scabies 3hen used
properly% both a$ents are safe% but lindane has the $reatest potential for adverse reactions if it
is not used properly !o#icity fro" lindane poisonin$ usually ta.es the for" of sei'ures
Concerns about the neuroto#icity of lindane% particularly in children and in patients who are
prone to sei'ures% have brou$ht per"ethrin to the therapeutic forefront for scabies% and it is
currently the treat"ent of choice for all a$e $roups Alternative scabicides include crota"iton
+BF% and DF to +BF sulfur oint"ents !hese preparations are considerably less effective% and
they "ust be applied on a daily basis for : to +B days !he "essiness and offensive odor of
sulfur also li"it patient co"pliance *en'yl ben'oate has been widely used to treat scabies in
developin$ countries% especially in ani"als% but it is rarely used in the Gnited States because it
is not as effective as per"ethrin
*iblio$raphy
+Schult' (3% /o"e' (% 2ansen ,C% (ills 1% (enter A% ,od$ers 2% et al Co"parative study of
:F per"ethrin crea" and +F lindane lotion for the treat"ent of scabies Arch ?er"atol
+66B8+4D:+D;);B
40ran' !1% 5eh"an CA% 0ran' S0% /uin 1? Co"parative percutaneous absorption of lindane
and per"ethrin Arch ?er"atol +66D8+94:6B+):

Item 7
Answer: (*)
Chleboto"y
Educational Objective: Choose the appropriate therapy for hepatitis Crelated porphyria
cutanea tarda
!his patient has hepatitis C virus infection% which was probably caused by blood transfusions
durin$ one of his "any trips to the hospital e"er$ency roo" when he was a child% and
hepatitis Crelated porphyria cutanea tarda 2epatoto#ic a$ents should be avoided !he
porphyria should be treated first% followed by treat"ent of the hepatitis C virus infection to
perhaps prevent the develop"ent of cirrhosis and possibly hepatocarcino"a !he best
treat"ent for this patient is phleboto"y% to reduce the iron stores Sodiu" bicarbonate will
al.alini'e the urine% but this older therapy is rarely effective for the porphyria Interferon% with
or without ribavirin% is effective for hepatitis C virus infection and "ay prevent the
develop"ent of pro$ressive liver disease or cancer of the da"a$ed liver% but it should be used
only after the porphyria has been controlled
*iblio$raphy
+En$lish 1C 9rd% Cea.e (0% *ec.er 5E 2epatitis C and porphyria cutanea tarda Cutis
+66D8:;:>B>)7
42errero C% 5echa ( (ana$e"ent of patients with porphyria cutanea tarda Chotoder"atol
Chotoi""unol Choto"ed +6678+>:D>):
9,o"eo ,% Col S% *erthelot C% *rechot C Eradication of hepatitis C virus ,-A after alpha)
interferon therapy Ann Intern (ed +66>8+4+:4;D);

Item 8
Answer: (C)
?er"atophytosis
Educational Objective: ?ia$nose cutaneous disease based on laboratory results
!he potassiu" hydro#ide preparation shows the septate hyphae dia$nostic of a der"atophyte
infection ?er"atophyte infection of the feet "ay produce infla""atory and vesicular lesions
that "ay be difficult to distin$uish fro" other infections or infla""atory disorders Candidiasis
produces intertri$inous infection and is rarely vesicular A scrapin$ fro" a lesion of candidiasis
shows abundant buddin$ yeast for"s or short hyphae that are not septate !inea versicolor is
an infection caused by (alasse'ia furfur that typically presents with hypopi$"ented or
hyperpi$"ented scaly "acules on the trun. and pro#i"al e#tre"ities A potassiu" hydro#ide
preparation of scale fro" a lesion shows short hyphae and yeast for"s (so)called spa$hetti
and "eatballs) 2erpesvirus infection is unusual on the sole of the foot A scrapin$ of a herpes
vesicle stained with 3ri$ht)/ie"sa stain would show dia$nostic acantholytic ballooned and
"ultinucleated cells A s"ear fro" a lesion of i"peti$o would contain clu"ps of $ra")positive
cocci
*iblio$raphy
+(asri)0ridlin$ /? ?er"atophytosis of the feet ?er"atol Clin +66D8+>:99)>B
4!aplin ?% (ein.in$ !5 Scabies% lice% and fun$al infections Cri" Care +6768+D:::+);D

Item 9
Answer: (E)
Cre$nancy test
Educational Objective: ,eco$ni'e the terato$enic potential of oral isotretinoin therapy
A wo"an receivin$ isotretinoin therapy should have re$ular laboratory "onitorin$% includin$
pre$nancy testin$ At least "onthly pre$nancy testin$ is reEuired because of the terato$enic
potential of this "edication (even if the patient is appropriately followin$ a pre$nancy
prevention pro$ra" by usin$ two for"s of effective contraception)
A co"plete blood count would not be part of standard "onitorin$ for patients receivin$
isotretinoin therapy% althou$h very rare he"atolo$ic abnor"alities have been reported with
the use of this dru$ 5iver function testin$ is part of the "onitorin$ pro$ra"8 however%
abnor"alities are not co""only found One of the "ajor e"phases in the develop"ent of
isotretinoin to differentiate it fro" oral vita"in A was to reduce the ris. of hepatoto#icity
Althou$h tri$lyceride deter"inations are i"portant because of the tendency for so"e patients
to develop si$nificant elevations% cholesterol deter"inations are not routinely reEuired
Isotretinoin "ay have so"e effect on the cholesterol level8 however% this effect is ephe"eral%
and it would not have the sa"e short)ter" conseEuences as a dra"atic elevation in the seru"
tri$lyceride level Grinalysis would not be part of the "onitorin$ of patients receivin$
isotretinoin therapy% because isotretinoin has ne$li$ible ris.s of renal to#icity
*iblio$raphy
+!hiboutot ?( An overview of acne and its treat"ent Cutis +66D8:;(+ Suppl):7)+4
4Strauss 1S% ,apini ,C% Shalita A,% =onec.y E% Cochi CE% Co"ite 2% E#ner 12 Isotretinoin
therapy for acne: results of a "ulticenter dose)response study 1 A" Acad ?er"atol
+67>8+B:>6B)D

Item 10
Answer: (E)
2er "oles increase her chances of developin$ a "elano"a
Educational Objective: ,eco$ni'e that lar$e nu"bers of Hnor"alI acEuired "oles carry an
increased ris. for "elano"a
5ar$e nu"bers of co""on acEuired "oles confer a "odest or "oderate increase in ris. for
"elano"a !he level of ris. depends on the total nu"ber of "oles present (ore than 4:
"oles by a$e 4B years confer a "odest increase in ris.8 "ore than :B "oles confer an even
$reater ris. !he dan$er is not $rave% nor do the "oles i"ply an early onset of "elano"a
Con$enital nevi in offsprin$ are unrelated to the nu"ber of nor"al acEuired "oles in parents
Si"ilarly% lar$e nu"bers of "oles in parents do not confer increased ris. for "elano"a in their
children
As the na"e i"plies% acEuired nevi are not present at birth but develop so"eti"e durin$ late
childhood !hese nevi tend to be located in sun)e#posed areas and are believed to be
secondary to e#posure to the ultraviolet radiation in sunshine !he nu"ber and anato"ic
distribution of these "oles on the e#tre"ities and trun. are related to the freEuency and
intensity of sun e#posure 5i.e frec.les% solar lenti$ines% and dysplastic nevi% acEuired nevi are
thou$ht to be caused by clonal e#pansion of "utated "elanocytes in response solar)induced
?-A da"a$e As inter"ediate end points in the develop"ent of cancer% they are "ar.ers of
patients with a $reater tendency to develop "elano"a
AcEuired nevi function as "ar.ers for those patients at increased ris. for developin$
"elano"a% but so"e nevi "ay actually be precursors of "elano"a So"e apparently nor"al
"oles chan$e in si'e% color% or border confi$uration and prove to be "elano"a on biopsy !he
Euestion is whether they have always been anaplastic or pro$ressed to that state fro" a
beni$n precursor "ole In either case% individuals with "ore than 4: "oles by a$e 4B years
should be "ade aware they are at increased ris. for developin$ a "elano"a Such patients
should adhere to a sun)protection pro$ra"% do s.in self)e#a"inations% and report any
chan$in$ "oles or newly developin$ "oles with the irre$ular features of the A*C? "elano"a
criteria (asy""etry% border irre$ularity% color varie$ation% and dia"eter J D "")
*iblio$raphy
+*ataille <% *ishop 1A% Sasieni C% Swerdlow A1% Cinney E% /riffiths =% Cu'ic. 1 ,is. of
cutaneous "elano"a in relation to the nu"bers% types and sites of naevi: a case)control
study *r 1 Cancer +66D8;9:+DB:)++
4/alla$her ,C% (c5ean ?I% Aan$ CC% Cold"an A1% Silver 2=% Spinelli 11% *ea$rie ( Suntan%
sunburn% and pi$"entation factors and the freEuency of acEuired "elanocytic nevi in children
Si"ilarities to "elano"a: the <ancouver (ole Study Arch ?er"atol +66B8+4D:;;B)D
92arth A% 0ried"an)*irnbau" ,% 5inn S Influence of cu"ulative sun e#posure on the
prevalence of co""on acEuired nevi 1 A" Acad ?er"atol +66484;:4+)>
>2arrison S5% *uettner C/% (ac5ennan , *ody)site distribution of "elanocytic nevi in youn$
Australian children Arch ?er"atol +6668+9::>;):4
:=elly 13% ,ivers 1=% (ac5ennan ,% 2arrison S% 5ewis AE% !ate *1 Sunli$ht: a "ajor factor
associated with the develop"ent of "elanocytic nevi in Australian schoolchildren 1 A" Acad
?er"atol +66>89B:>B)7

Item 11
Answer: (*)
Ceriodic recurrence in the sa"e area
Educational Objective: ,eco$ni'e the various clinical presentations of herpes si"ple# virus
and herpes 'oster virus infections
A characteristic feature of herpes si"ple# virus infection is that% followin$ the pri"ary infection
of the s.in or "ucous "e"branes% the virus establishes a latent or dor"ant state within
neuronal cells in the $an$lia 3ith reactivation% the virus travels down the nerve fiber to
produce recurrent s.in infection Cri"ary infection is "ore severe than recurrent disease
<esicles and painful ulcers occur in "ucocutaneous areas ("outh and pharyn#% cervi# and
e#ternal $enitalia)8 they "ay be locali'ed but are often widespread% involvin$ the entire "outh
or lar$e areas of the $enitalia Acco"panyin$ syste"ic sy"pto"s% such as "alaise and fever%
are co""on with pri"ary infection ,ecurrent herpes si"ple# virus infection is usually
heralded by prodro"al tin$lin$% burnin$% or dysesthesias% followed by the appearance of
clustered vesicles and pustules ,ecurrences occur in the sa"e area of the s.in Occasionally%
herpes si"ple# virus "ay assu"e a so"ewhat der"ato"al distribution
2erpes 'oster is locali'ed disease characteri'ed by unilateral radicular pain and a vesicular
eruption that is $enerally li"ited to the der"ato"e innervated by a sin$le spinal or cranial
sensory $an$lion It is the result of reactivation of virus that persisted in latent for" within
$an$lia followin$ earlier infection with varicella Crodro"al pain and paresthesia in the involved
der"ato"e usually precede the eruption by several days
A distinctive feature of herpes 'oster is the locali'ation and distribution of the eruption% which
is al"ost always unilateral% does not cross the "idline% and is $enerally li"ited to the area of
s.in innervated by a sin$le sensory $an$lion 3idespread disease "ay occur in
i""unoco"pro"ised patients *oth herpes si"ple# virus and herpes 'oster virus infections
are characteri'ed by the presence of "ultiple vesicles
*iblio$raphy
+Cohen 1I% *runell CA% Straus SE% =rause C, ,ecent advances in varicella)'oster virus
infection Ann Intern (ed +6668 +9B:644)94
4(cCrary (5% Severson 1% !yrin$ S= <aricella 'oster virus 1 A" Acad ?er"atol +6668>+:+)
+>
9Cereira 0A 2erpes si"ple#: evolvin$ concepts 1 A" Acad ?er"atol +66D89:::B9)4B

Item 12
Answer: (C)
(ultiple childhood sunburns
Educational Objective: Gnderstand the i"portance of childhood sunburns in the patho$enesis
of "elano"a
!he develop"ent of s.in cancer is "ost stron$ly correlated with e#posure to the ultraviolet
radiation in sunli$ht E#posure to fluorescent li$ht has never been proved to cause the
develop"ent of "elano"a !here is a prolon$ed la$ period between the actual e#posure to
ultraviolet radiation and the develop"ent of "elano"a !he types of e#posure listed in the
options% other than the "ultiple childhood sunburns% would be insufficient on their own to
cause s.in cancer
Several aspects of the relationship between "elano"a and ultraviolet radiation have been
pu''lin$ 3hy do so"e patients develop a "elano"a% whereas others develop a basal cell or
sEua"ous cell carcino"aK 3hy do the tu"ors occur on the trun. in so"e patients and on the
head and nec. of other patientsK 3hy do s.in cancers appear in the third or fourth decade in
so"e patients and not until the seventh or ei$hth in other patientsK A paradi$" has been
developed to help answer "any of these Euestions It appears that several variables play a
role:
L !he $enetic "a.e)up of patients in ter"s of their response to ultraviolet radiation:
co"ple#ion% ability to tan% tendency to burn
L !he ti"in$ of the e#posure to ultraviolet radiation: childhood or adulthood
L !he intensity of the e#posure: stron$ enou$h to result in a sunburn (redness% erythe"a) or
less intense (suberythe"al)
L 0reEuency of the ultraviolet radiation e#posure: chronic% such as that in outdoor wor.ers% or
inter"ittent% such as that occurrin$ durin$ wee.end recreation or once)a)year vacations in
sunny cli"ates
L !he s.in areas e#posed: the usually e#posed s.in of the face% nec.% and lower ar"s or the
inter"ittently e#posed s.in of the chest% bac.% and shoulders
L !he two predo"inant cells in the epider"is e#posed to ultraviolet radiation: .eratinocytes
and "elanocytes
Actinic .eratoses and sEua"ous cell carcino"a are derived fro" the actively replicatin$
.eratinocytes that reside in the basal layer of the epider"is% just above the base"ent
"e"brane separatin$ the epider"is fro" the der"is !hese tu"ors are believed to be caused
by chronic e#posure to ultraviolet radiation of s.in that is usually e#posed to the sun% includin$
the head% nec.% and upper e#tre"ities !he tu"ors appear late in life (si#th% seventh% and
ei$hth decades) Gltraviolet radiation da"a$es the ?-A of the .eratinocytes% resultin$ in
characteristic thy"ine di"ers If the cells are heavily da"a$ed% p:9 tu"or suppresser $enes
(and "ost li.ely% other tu"or $enes) be$in apoptotic seEuences and re"ove the irreparable
cell 2owever% if da"a$e is not so severe% p:9 tu"or suppresser $enes slow the cell cycle until
e#cision repair of the faulty ?-A strands can be acco"plished !he nor"al cell then re)enters
the proliferative pool or differentiates toward .eratin production% "oves up the epider"is% and
dies as it for"s part of the stratu" corneu" 2owever% with continued chronic e#posure to
ultraviolet radiation% so"e "utations in the ?-A% especially in the p:9 tu"or suppresser $ene
itself% occur and accu"ulate Glti"ately% with clonal e#pansion% a sEua"ous cell in situ (actinic
.eratosis) is for"ed% which "ay or "ay not pro$ress to an invasive sEua"ous cell carcino"a
(elano"as are derived fro" the "uch less nu"erous "elanocytes% which also reside in the
basal layer of the epider"is !hey provide the "elanin pi$"ent that $ives persons their
co"ple#ion and the ability to tan in response to sun e#posure !hese cells nor"ally do not
divide% and protectin$ the" fro" destruction is a priority ConseEuently% with heavy ultraviolet
radiation e#posure% considerable ?-A da"a$e is done
*iblio$raphy
+/ilchrest *A% Eller (S% /eller AC% Aaar ( !he patho$enesis of "elano"a induced by
ultraviolet radiation - En$l 1 (ed +66689>B:+9>+)7

Item 13
Answer: (*)
S.in biopsy for routine processin$
Educational Objective: Order an appropriate test to evaluate a patient with central facial
erythe"a
In patients with central facial erythe"a% it "ay be difficult to distin$uish relatively beni$n
cutaneous disorders% such as rosacea% fro" diseases with potential syste"ic conseEuences%
such as syste"ic lupus erythe"atosus (S5E) and der"ato"yositis !he characteristic central
facial papules and pustules usually allow for a clinical dia$nosis of rosacea% and a s.in biopsy
is not necessary 2owever% if S5E or der"ato"yositis cannot be distin$uished fro" rosacea on
der"atolo$ic e#a"ination% a routine s.in biopsy with subseEuent histolo$ic e#a"ination by a
co"petent der"atopatholo$ist can reveal interface chan$e% which is hi$hly su$$estive of
either S5E or der"ato"yositis !hese conditions could then be evaluated "ore fully as
appropriate 2istolo$ic interface chan$e would not be found in patients with rosacea
?irect i""unofluorescence "icroscopy is less useful% because false)positive results can occur
in patients with rosacea% and this test can be positive in patients with S5E or der"ato"yositis
An antinuclear antibody test can be positive in patients with S5E or der"ato"yositis8 however%
as "any as 4:F to 9BF patients older than D: years have positive antinuclear antibody
deter"inations A co"plete blood count could reveal he"atolo$ic abnor"alities in patients
with S5E% but this would not be a specific findin$ !he seru" creatine .inase level could be
elevated in patients with der"ato"yositis% but it would not be helpful in distin$uishin$ S5E
fro" rosacea
*iblio$raphy
+2el" =0% (en' 1% /ibson 5E% ?ic.en C2 A clinical and histopatholo$ic study of
$ranulo"atous rosacea 1 A" Acad ?er"atol +66+84:(Ct +):+B97)>9
45erner EA% 5erner (, 3hither the A-AK Arch ?er"atol +67;8+49:9:7)D4
9-un'i E% ,ebora A% 2a"erlinc. 0% Cor"ane ,2 I""unopatholo$ical studies on rosacea *r 1
?er"atol +67B8+B9::>9):+

Item 14
Answer: (C)
Cush on an intact blister to see if it can be e#tended
Educational Objective: Correlate the clinical findin$s of autoi""une blisterin$ diseases with
the level of patholo$ic process in the s.in
!his D7)year)old "an has bullous pe"phi$oid% which is a subepider"al blisterin$ disorder !he
response to the bedside dia$nostic "aneuver of pressin$ on the intact blister ed$e allows
discri"ination between an intraepider"al blisterin$ process and a subepider"al process In
this patient with bullous pe"phi$oid% it would be e#pected that the blister would not advance
with application of pressure% because its patholo$ic location is subepider"al Althou$h a s.in
biopsy is necessary% the results of this test ta.e days A !'anc. test is helpful for identifyin$
$iant cells in herpes viral infections% and rubbin$ nor"al s.in or culturin$ for atypical
"ycobacteria has no dia$nostic si$nificance
*iblio$raphy
+Scott 1E% Ah"ed A, !he blisterin$ diseases (ed Clin -orth A" +667874:+496)79
4=or"an -1 *ullous pe"phi$oid !he latest in dia$nosis% pro$nosis% and therapy Arch
?er"atol +6678+9>:++9;)>+

Item 15
Answer: (*)
Csoriasis
Educational Objective: ,eco$ni'e and distin$uish arthritis that "ay be associated with
cutaneous disease
(any co""on for"s of arthritis are associated with s.in disease ,eco$nition of the cutaneous
findin$s of arthritis "ay be helpful in establishin$ the dia$nosis !his patient has characteristic
nail and joint findin$s of psoriatic arthritis Onset of arthritis is usually insidious% and "ost
patients "anifest a peripheral asy""etric oli$oarthritis that involves the s"all joints of the
hands and feet% the lar$e joints of the le$s% or a co"bination of both Onychodystrophy%
onycholysis% nail pittin$% and subun$ual .eratosis are "ore stron$ly associated with arthritis
than with psoriasis alone 2yperurice"ia "ay occur in patients with psoriasis /outy tophi
appear late in the course of $out !hey occur in the olecranon bursa% infrapatella% Achilles
tendon% subcutaneous tissues on the e#tensor surface of the forear"% and overlyin$ joints and
occasionally around the heli# of the ear -ail chan$es are not seen in $out -ail disease caused
by der"atophyte infection (onycho"ycosis) "ay rese"ble psoriatic nail chan$es% with
subun$ual hyper.eratosis% thic.enin$% and onycholysis8 however% there is no joint disease in
this condition !he dia$nosis of onycho"ycosis can be confir"ed with nail clippin$s that are
e#a"ined with potassiu" hydro#ide or with fun$al cultures ,heu"atoid arthritis "ay be
associated with rheu"atoid nodules in 4:F to :BF of patients8 they tend to occur when the
disease is "ost active ,heu"atoid vasculitis and pyoder"a $an$renosu" also "ay be seen in
association with rheu"atoid arthritis -ail chan$es typically do not occur !he joints "ost
co""only affected by sarcoidosis are the .nees% an.les% elbows% wrists% and s"all joints of the
hands Affected joints are swollen% war"% tender% and painful S.in lesions include lupus pernio
(violaceous indurated lesions with a predilection for the nose% ears% lips% and face)% s.in
plaEues% papules% subcutaneous nodules% and erythe"a nodosu" -ail chan$es are not seen
*iblio$raphy
+/lad"an ?? Csoriatic arthritis ,heu" ?is Clin -orth A" +66784>:746)>>
4(c/ona$le ?% Cona$han C/% E"ery C Csoriatic arthritis: a unified concept twenty years on
Arthritis ,heu" +6668 >4:+B7B)D
9Espino'a 5,% van Solin$en ,% Cuellar (5% An$ulo 1 Insi$hts into the patho$enesis of
psoriasis and psoriatic arthritis A" 1 (ed Sci +66789+D:4;+)D
>,oss E5% ?&Cru' ?% (orrow 31 Catho$enic "echanis"s in psoriatic arthritis 2osp (ed
+6678:6::9>)7

Item 16
Answer: (E)
2ot bevera$es
Educational Objective: ,eco$ni'e that in$estin$ hot liEuids is an i"portant cause of flushin$
in patients with rosacea
0lushin$ can be a particularly disablin$ "anifestation of rosacea All of the sti"uli "entioned%
includin$ alcohol% caffeine% spicy foods% sun e#posure% and hot bevera$es% have been
i"plicated in "a.in$ flushin$ worse Studies have shown that overheatin$ of the oral cavity%
such as with hot liEuids% perhaps throu$h sti"ulation of the carotid sinus% can reliably produce
flushin$ E#posure to caffeinated bevera$es and to other sti"uli did not readily produce
flushin$ if te"perature was controlled !his is relevant fro" the therapeutic standpoint%
because rapid coolin$ of the oral cavity% such as with ice chips% can abort the flushin$ that
follows drin.in$ hot bevera$es
*iblio$raphy
+3il.in 1= Oral ther"al)induced flushin$ in erythe"atotelan$iectatic rosacea 1 Invest
?er"atol +67+8;D:+:)7
43il.in 1= Effect of nadolol on flushin$ reactions in rosacea 1 A" Acad ?er"atol
+67684B(Ct +):4B4):

Item 17
Answer: (*)
?ru$)induced linear I$A bullous der"atosis
Educational Objective: ,eco$ni'e the causes of dru$)induced autoi""une blisterin$
diseases
!his 47)year)old wo"an has developed cellulitis as a co"plication of her atopic der"atitis !he
initiation of vanco"ycin therapy followed by the onset of a blisterin$ disorder stron$ly
su$$ests the dia$nosis of linear I$A bullous der"atosis *ullous i"peti$o is hi$hly unli.ely%
because the patient was treated with vanco"ycin Acute contact der"atitis fro" the hospital
bed sheets would be a hi$hly unli.ely cause of a locali'ed blisterin$ reaction when lar$e s.in
surface areas are e#posed Atopic der"atitis is not e#acerbated by vanco"ycin Ce"phi$us is
an intraepider"al blisterin$ process% and thus% it would be e#pected that the patient&s blisters
could be advanced with application of pressure
*iblio$raphy
+*aden 5A% Apovian C% I"ber (1% ?over 1S <anco"ycin)induced linear I$A bullous
der"atosis Arch ?er"atol +6778+4>:++7D)7
4Carpenter S% *er$ ?% Sidhu)(ali. -% 2all ,C 9d% ,ico (1 <anco"ycin)associated linear I$A
der"atosis A report of three cases 1 A" Acad ?er"atol +66484D:>:)7
9-ousari 2C% =i"yai)Asadi A% Caeiro 1C% Anhalt /1 Clinical% de"o$raphic% and
i""unohistolo$ic features of vanco"ycin)induced linear I$A bullous disease of the s.in
,eport of 4 cases and review of the literature (edicine (*alti"ore) +6668;7:+)7

Item 18
Answer: (C)
,esolve
Educational Objective: Gnderstand that the level of i""unosuppression correlates with 2I<)
associated s.in disease and that hi$hly active antiretroviral therapy (2AA,!) "ay reverse
these "anifestations
S.in lesions in patients with 2I< infection correlate with the level of i""unosuppression% and
effective therapy can result in a HspontaneousI healin$ of the lesions In this case% the patient
presented with "olluscu" conta$iosu" that was associated with a hi$h level of
i""unosuppression 0ortunately% with the newer for"s of therapy% viral loads and the level of
i""une dysfunction "ay be reversed% and uncontrollable cutaneous disorders% includin$ viral
infections% "ay resolve or "ay be controlled "ore easily
*iblio$raphy
+/oldstein *% *er"an *% Su.eni. E% 0ran.el S1 Correlation of s.in disorders with C?>
ly"phocyte counts in patients with 2I<@AI?S 1 A" Acad ?er"atol +66;89D:4D4)>
4Spach ?2% Colven , ,esolution of recalcitrant hand warts in an 2I<)infected patient treated
with potent antiretroviral therapy 1 A" Acad ?er"atol +6668>B:7+7)4+
9,ich 1?% (ylona.is E% -ossa ,% Chapnic. ,( 2i$hly active antiretroviral therapy leadin$ to
resolution of porphyria cutanea tarda in a patient with AI?S and hepatitis C ?i$ ?is Sci
+6668>>:+B9>);
>2ic.s C*% (yers SA% /iner 1 ,esolution of intractable "olluscu" conta$iosu" in a hu"an
i""unodeficiency virusinfected patient after institution of antiretroviral therapy with
ritonavir Clin Infect ?is +66;84>:+B49):

Item 19
Answer: (?)
Caraneoplastic pe"phi$us
Educational Objective: ,eco$ni'e the clinical presentation% histopatholo$ic characteristics%
and i""unofluorescence findin$s of paraneoplastic pe"phi$us
Caraneoplastic pe"phi$us is a recently described entity that occurs "ost often in patients with
a history of ly"pho"a or who currently have ly"pho"a So"e patients have been described
in who" there is no evidence of "ali$nancy% but in such patients% it is reasonable to search for
a possible neoplas" !his "an&s lesions are characteristic of pe"phi$us% and the presence of a
positive i""unofluorescence study on rat bladder is hi$hly su$$estive of the paraneoplastic
variant I"peti$o "ay "anifest si"ilar s.in lesions but not intraoral lesions !he
histopatholo$ic and i""unopatholo$ic findin$s are not those of cutaneous lupus
erythe"atosus% which would include an interface der"atitis and $ranular deposition of
i""uno$lobulin alon$ the der"al)epider"al junction Sweet&s syndro"e is "anifested by
cellulitic)appearin$ plaEues !he $luca$ono"a syndro"e "i$ht be associated with wei$ht loss
and an an$ular cheilitis% but the s.in lesions are an intertri$inous erosive der"atitis
*iblio$raphy
+Gdey (C% Stanley 1, Ce"phi$usMdiseases of antides"oso"al autoi""unity 1A(A
+6668474::;4)D
4,obinson -?% 2ashi"oto !% A"a$ai (% Chan 5S !he new pe"phi$us variants 1 A" Acad
?er"atol +6668>B:D>6);+
9-ousari 2C% ?eterdin$ ,% 3ojtc'ac. 2% Aho S% Gitto 1% 2ashi"oto !% Anhalt /1 !he
"echanis" of respiratory failure in paraneoplastic pe"phi$us - En$l 1 (ed +66689>B:+>BD)
+B

Item 20
Answer: (A)
!etracycline and niacina"ide
Educational Objective: !reat patients with autoi""une blisterin$ disorders
!his 7B)year)old "an has characteristic clinical and histopatholo$ic findin$s of bullous
pe"phi$oid *ecause of the relatively beni$n presentation of his illness and his nu"erous
syste"ic proble"s% includin$ insulin)dependent diabetes "ellitus and hypertension% the
initiation of tetracycline and niacina"ide therapy should be considered first before usin$
prednisone or prednisone plus a'athioprine !he co"bination of tetracycline and niacina"ide
alone has proved effective in the treat"ent of so"e patients with bullous pe"phi$oid
(ethotre#ate is not particularly effective in the treat"ent of bullous pe"phi$oid% and
diclo#acillin has no effect on this disorder
*iblio$raphy
+*er. (A% 5orinc' A5 !he treat"ent of bullous pe"phi$oid with tetracycline and niacina"ide
A preli"inary report Arch ?er"atol +67D8+44:D;B)>
42ornschuh *% 2a"" 2% 3ever S% 2ashi"oto !% Schroder G% *roc.er E*% Nilli.ens ?
!reat"ent of +D patients with bullous pe"phi$oid with oral tetracycline and niacina"ide and
topical clobetasol 1 A" Acad ?er"atol +66;89D:+B+)9

Item 21
Answer: (*)
Cri"ary syste"ic a"yloidosis
Educational Objective: ,eco$ni'e the cutaneous features of pri"ary syste"ic a"yloidosis
!his patient has pri"ary syste"ic a"yloidosis% "anifested by HpinchI purpura !his condition
is associated with the widespread deposition of a"yloid in "ultiple tissues% includin$ the s.in%
as de"onstrated by the findin$s on s.in biopsy Cri"ary syste"ic a"yloidosis is associated
with "ultiple "yelo"a in al"ost all instances% and this patient de"onstrated a "onoclonal
paraprotein on seru" protein electrophoresis Actinic purpura is "anifested by ecchy"oses on
the ar"s and is caused by capillary fra$ility Idiopathic thro"bocytopenic purpura presents as
petechiae% not "acular purpura S"all)vessel vasculitis is "anifested as palpable purpura%
"ost often on the le$s =aposi&s sarco"a "ay occur in 2I< infection as a "acular% purpuric
lesion but would not have occurred followin$ strainin$ durin$ defecation
*iblio$raphy
+=yle ,A% /ert' (A Cri"ary syste"ic a"yloidosis: clinical and laboratory features in >;>
cases Se"in 2e"atol +66:894:>:):6
4=yle ,A SeEuence of testin$ for "onoclonal $a""opathies Arch Cathol 5ab (ed
+6668+49:++>)7
9?aoud (S% 5ust 1A% =yle ,A% Cittel.ow (, (onoclonal $a""opathies and associated s.in
disorders 1 A" Acad ?er"atol +6668>B::B;)9:

Item 22
Answer: (?)
?iscontinue tri"ethopri")sulfa"etho#a'ole% and hospitali'e the patient for intravenous
i""uno$lobulin therapy
Educational Objective: !reat a patient with to#ic epider"al necrolysis
!his youn$ wo"an has the early si$ns and sy"pto"s of to#ic epider"al necrolysis secondary
to her antibiotic therapy !he approach to treat"ent is to discontinue the "edications and
be$in intravenous i""uno$lobulin therapy% which bloc.s the apoptotic activity of the 0as
li$and on .eratinocytes and inhibits epider"al necrosis !he use of prednisone in such patients
continues to be controversial and is often associated with increased "orbidity
*iblio$raphy
+<iard I% 3ehrli C% *ullani ,% Schneider C% 2oller -% Salo"on ?% et al Inhibition of to#ic
epider"al necrolysis by bloc.ade of C?6: with hu"an intravenous i""uno$lobulin Science
+6678474:>6B)9
4Sanwo (% -wadiu.o ,% *eall / Gse of intravenous i""uno$lobulin in the treat"ent of
severe cutaneous dru$ reactions in patients with AI?S 1 Aller$y Clin I""unol +66D8 67(Ct
+):+++4):

Item 23
Answer: (?)
!ria"cinolone acetonide
Educational Objective: Select the best initial therapy for ec'e"a of the hands
!he "ainstay of treat"ent for ec'e"atous eruptions is the use of topical $lucocorticoids As
with "ost therapeutic "edications% an a$ent "ust be present in an effective concentration at
the site of the patholo$ic condition !herefore% topical $lucocorticoids are not useful for
subcutaneous diseases% such as erythe"a nodosu"% or for deeper der"al infla""atory
conditions% such as urticaria !hey are ideally suited for superficial infla""atory conditions%
such as ec'e"atous eruptions% in which the histopatholo$ic chan$es are confined to the upper
der"is and epider"is It is also i"portant to e#clude infla""atory conditions that produce
secondary epider"al infla""ation but that would be "ade worse by topical $lucocorticoids%
such as infections with der"atophytes or Candida !opical calcipotriene is a relatively new
treat"ent that has proved to be effective in the "ana$e"ent of patients with psoriasis It is
$enerally co"bined with topical $lucocorticoid therapy to achieve both a rapid response fro"
the $lucocorticoid and a "ore sustained benefit fro" the calcipotriene !opical retinoids (such
as tretinoin or the newer ta'arotene) have been used in the treat"ent of co"edonal acne but
also have been used "ore recently in the treat"ent of psoriasis% playin$ "uch the sa"e role
as calcipotriene -eosporin should be avoided because of contact der"atitis% which is a
particular ris. on s.in that is already ec'e"ati'ed Catients with ec'e"ati'ed s.in often
beco"e aller$ic to the -eosporin and "ay develop a contact der"atitis !his causes dia$nostic
and therapeutic confusion in a patient with a pre)e#istin$ ec'e"atous condition !he
co"bination product clotri"a'olebeta"ethasone dipropionate should be avoided because of
the potency of the $lucocorticoid and the absence of fun$al infection reEuirin$ clotri"a'ole
*iblio$raphy
+,u'ic.a ! Atopic ec'e"a between rationality and irrationality Arch ?er"atol
+6678+9>:+>D4)6
40eld"an S,% Clar. A, Csoriasis (ed Clin -orth A" +667874:++9:)>>

Item 24
Answer: (C)
2istory and physical e#a"ination
Educational Objective: Gnderstand the role of laboratory studies in the "ana$e"ent of
"elano"a
!he "ost critical issue for patient survival once the dia$nosis of "elano"a is established is
whether "etastases have occurred before the pri"ary cutaneous lesion was successfully
e#cised In appro#i"ately 4BF of clinical sta$e I and II disease (local disease)% patients are
harborin$ undetectable "icro"etastases in the ly"ph nodes or in distant or$ans !o date% the
*reslow thic.ness has been the best pro$nostic indicator for survival% with the ris. of
"icro"etastases correlated with increasin$ thic.ness In prospective studies% elective ly"ph
node dissection was shown to be costly% associated with considerable "orbidity% and ineffective
in i"provin$ survival 5y"phatic "appin$ and selective or sentinel node biopsy are bein$
investi$ated as a less "orbid and less e#pensive way to classify patients with "elano"a It is
hoped that when "icro"etastases are found in the sentinel node% subseEuent full ly"ph node
dissection and adjuvant therapy when the tu"or burden is low will i"prove survival Si"ilarly%
it is hoped that when the sentinel node is ne$ative for tu"or% patients will re"ain tu"or)free
*oth hypotheses have not yet been proved
In the "eanti"e% it has beco"e evident that neither the ine#pensive tests% such as the seru"
lactate dehydro$enase level and chest radio$raphy% nor the "ore costly studies% such as C!%
(,I% and positron e"ission to"o$raphy% have the ability to identify s"all foci of tu"ors cells
ConseEuently% the "ain purpose of freEuent follow)up visits is to chec. for local recurrences%
chec. for new lesions% and perfor" a co"plete history and physical e#a"ination 5aboratory
studies should be ordered as a function of the clinical sy"pto"s and findin$s 3ith freEuent
follow)up visits% clinically detected "etastases should be found as early as possible% and
appropriate therapy should be rendered when it is "ost effective One pro"isin$ blood test is
the tu"or)associated anti$en !A)6B i""une co"ple# assay It "ay be useful for sta$in$ and
for postoperative "onitorin$ for tu"or recurrence Creli"inary data indicate that elevated
preoperative levels of !A)6B i""une co"ple# are associated with decreased survival and that
persistent elevated levels postoperatively are si"ilarly o"inous
*iblio$raphy
+2uan$ C5% Crovost -% (ar$hoob AA% =opf A3% 5evin 5% *art ,S 5aboratory tests and i"a$in$
studies in patients with cutaneous "ali$nant "elano"a 1 A" Acad ?er"atol +667896:>:+)
D9
43eiss (% 5oprin'i C5% Crea$an E!% ?alton ,1% -ovotny C% O&0allon 1, Gtility of follow)up tests
for detectin$ recurrent disease in patients with "ali$nant "elano"as 1A(A +66:84;>:+;B9)
:
9!erhune (2% Swanson -% 1ohnson !( Gse of chest radio$raphy in the initial evaluation of
patients with locali'ed "elano"a Arch ?er"atol +6678+9>::D6);4
>=elley (C% 1ones ,C% /upta ,=% Aee ,% Stern S% 3ane. 5% (orton ?5 !u"or)associated
anti$en !A)6B i""une co"ple# assay predicts subclinical "etastasis and survival for patients
with early sta$e "elano"a Cancer +667879:+9::)D+

Item 25
Answer: (?)
2I< infection
Educational Objective: ,eco$ni'e persons at ris. for severe infestation with scabies
I""unoco"pro"ised patients (particularly those with AI?S) and institutionali'ed patients
"ay develop widespread scabies with e#tensive scalin$ that "ay not itch !his unco""on
variant% crusted scabies% also .nown as -orwe$ian scabies% is often "isdia$nosed as ec'e"a%
psoriasis% or ichthyosis It is associated with a vast nu"ber of "ites and is hi$hly conta$ious
Crusted scabies does not occur with any freEuency in patients with the other diseases listed
Cutaneous lesions associated with acute "yelo$enous leu.e"ia include leu.e"ic infiltrates in
the s.in% plaEues of Sweet&s syndro"e% and less specific petechiae and purpura Catients with
cystic fibrosis have increased a"ounts of electrolytes in the sweat% which leads to e#cessive
s.in wrin.lin$ when the pal"s and soles are i""ersed in water !he only definitive
"ucocutaneous lesion attributed to Epstein)*arr virus infection is oral hairy leu.opla.ia
Catients with Epstein)*arr virus infection who receive antibiotic therapy% particularly a"picillin%
are prone to develop a widespread pruritic "orbillifor" eruption !here is no increased
incidence of scabies in patients with psoriasis
*iblio$raphy
+Or.in ( Scabies in AI?S Se"in ?er"atol +6698+4:6)+>

Item 26
Answer: (?)
,osacea
Educational Objective: ,eco$ni'e the clinical appearance of rosacea% and distin$uish it fro"
other infla""atory facial lesions
!his patient&s history and clinical appearance are characteristic of rosacea% a chronic
der"atosis of "iddle)a$ed and older patients ,osacea be$ins insidiously with transient
erythe"a% followed by telan$iectasias% papules% pustules% and% rarely% nodules ,hinophy"a% a
late seEuela% is "ore co""on in "en Catients often $ive a history of facial flushin$ followin$
in$estion of hot liEuids or alcohol ?er"atophytosis involvin$ the face (tinea faciei) is an
unco""on but often "issed fun$al infection 5esions are asy""etric% erythe"atous% and
so"eti"es annular A potassiu" hydro#ide e#a"ination of surface scale shows dia$nostic
hyphae Aller$ic contact der"atitis is "anifested as a pruritic papular and vesicular eruption%
occurrin$ at the site of anti$en e#posure It typically be$ins abruptly and clears in a few
wee.s ?iscrete papules and pustules are not typical of aller$ic contact der"atitis An irritant
contact der"atitis is produced by repetitive e#posure to a harsh che"ical and typically results
in confluent erythe"a with lichenification% scale% and fissurin$ 0acial eruptions associated with
syste"ic lupus erythe"atosus "ay be difficult to differentiate fro" rosacea Sy""etric "alar
"acular erythe"a is seen in syste"ic lupus erythe"atosus8 sharply de"arcated
erythe"atous% hyperpi$"ented and hypopi$"ented plaEues on the scalp and sun)e#posed
areas are typical of cutaneous discoid lupus erythe"atosus lesions ?iscrete s"all papules and
pustules typical of rosacea are not seen in syste"ic lupus erythe"atosus Chotosensitivity%
syste"ic sy"pto"s% and a positive antinuclear antibody titer are other "anifestations of
syste"ic lupus erythe"atosus Seborrheic der"atitis is a chronic cutaneous disorder that
appears as well)de"arcated% confluent% "acular erythe"a with $reasy scale 5esions are "ost
pro"inent on the scalp% eyebrows% beard area% nasolabial creases% and central chest
*iblio$raphy
+2i$$ins E% du <ivier A Alcohol inta.e and other s.in disorders Clin ?er"atol +6668+;:>9;)
>+
43il.in 1= Gse of topical products for "aintainin$ re"ission in rosacea Arch ?er"atol
+6668+9::;6)7B

Item 27
Answer: (A)
!each her how to do "onthly s.in self)e#a"inations
Educational Objective: (ana$e a patient at hi$h ris. for developin$ "elano"a
!his patient&s "elano"a was relatively thin and had no other characteristics that would
increase the li.elihood of "etastases (for e#a"ple% ulceration or re$ression) !he ris. that she
is harborin$ clinically undetectable "icro"etastases is low% and there is a $reater than 6:F
chance that she will be cured !he i"portance of freEuent follow)up e#a"inations is to detect
any local% re$ional% or distant recurrences as early as possible% when pro"pt intervention
would be "ost beneficial In addition% this patient has a relative ris. of 7: of developin$
another "elano"a About ;:F of new "elano"as occur in a different anato"ic re$ion than
the initial "elano"a 0reEuent surveillance allows very early detection of new "elano"as%
when they are readily curable
S.in self)e#a"ination is another strate$y for early detection of new "elano"as Catients can
be tau$ht the essentials of doin$ total s.in e#a"inations usin$ a co"bination of wall)"ounted
and hand)held "irrors Catients should be instructed to report any new "oles% any chan$in$
"oles% or any lesions that have any of the A*C? chan$es associated with "elano"a
(asy""etry% border irre$ularity% color varie$ation% and dia"eter J D "") (onthly s.in self)
e#a"ination has been shown to be an effective "ethod of early tu"or detection In addition% it
focuses patients& attention on their propensity to for" s.in tu"ors and hei$htens their
co"pliance with a sun)protection pro$ra"
5aboratory studies and even sophisticated dia$nostic "odalities such as (,I and C! have not
been effective in detectin$ "icro"etastases Sentinel node biopsy is not reco""ended for
early% thin "elano"a Sentinel node biopsy is an interventional sta$in$ techniEue that would
have an e#tre"ely low benefit in tu"ors less than + "" in thic.ness Si"ilarly% adjuvant
therapy with interferon is not warranted in this low)ris. patient Althou$h this patient would
benefit fro" education on appropriate sun)avoidance techniEues% for"al psycholo$ic
counselin$ is not reEuired
*iblio$raphy
+*erwic. (% *e$$ C*% 0ine 1A% ,oush /C% *arnhill ,5 Screenin$ for cutaneous "elano"a by
s.in self)e#a"ination 1 -atl Cancer Inst +66D877:+;)49
4(iller ?,% /eller AC% 3yatt S3% 2alpern A% 2owell 1*% Coc.erell C% et al (elano"a
awareness and self)e#a"ination practices: results of a Gnited States survey 1 A" Acad
?er"atol +66D89>:6D4);B
91ohnson !(% 2a"ilton !% 5owe 5 (ultiple pri"ary "elano"as 1 A" Acad ?er"atol
+667896:>44);
>(ar$hoob AA% Slade 1% =opf A3% Salope. !/% ,i$el ?S% *art ,S ,is. of developin$ "ultiple
pri"ary cutaneous "elano"as in patients with the classic atypical)"ole syndro"e: a case)
control study *r 1 ?er"atol +66D8+9::;B>)++

Item 28
Answer: (E)
A fi#ed)dru$ eruption
Educational Objective: ,eco$ni'e the clinical findin$s of a fi#ed)dru$ eruption
Althou$h the anato"ic area of the eruption su$$ests a recurrent herpes si"ple# reaction% this
patient has the characteristic history and physical findin$s of a fi#ed)dru$ eruption 0i#ed)dru$
eruption "ay represent a locali'ed variant of erythe"a "ultifor"e Infla""atory lesions with
residual hyperpi$"entation recur at the sa"e site with each e#posure to the offendin$ dru$
!he patholo$ic "echanis" of a fi#ed)dru$ eruption is poorly understood% but the patholo$ic
process occurs at the junction of the epider"is and der"is% often resultin$ in the deposition of
epider"al "elanin in the upper der"is% which causes a brown)$ray color at the site of the
reaction !he area is too locali'ed for a contact der"atitis fro" laundry deter$ent% and a
recurrent herpes si"ple# infection would be e#pected to present as $rouped vesicles It would
be very unusual for recurrent urticaria to occur at the sa"e site% and persistin$
dyspi$"entation would not be e#pected A fun$al infection should present as a scalin$ "acule
and usually would not resolve without treat"ent
*iblio$raphy
+3olverton SE Gpdate on cutaneous dru$ reactions Adv ?er"atol +66;8+9:D:)7>
4<ervloet ?% ?urha" S Adverse reactions to dru$s *(1 +66789+D:+:++)>

Item 29
Answer: (A)
!opical clobetasol
Educational Objective: ,eco$ni'e that syste"ic $lucocorticoids are relatively contraindicated
in patients with psoriasis
!he develop"ent of $enerali'ed pustular psoriasis is one of the "ost i"pressive co"plications
of der"atolo$ic illness Althou$h this condition can occur de novo% it often follows the
discontinuation of a syste"ic $lucocorticoid 0or this reason% "ost der"atolo$ists believe that
the use of syste"ic $lucocorticoids in patients with psoriasis is relatively contraindicated
!herefore% topical clobetasol% a superpotent $lucocorticoid% is the therapy of choice for this
patient with locali'ed disease 0or this reason% patients who reEuire syste"ic $lucocorticoids
for other conditions% such as syste"ic lupus erythe"atosus% autoi""une bullous diseases (for
e#a"ple% bullous pe"phi$oid)% and psoriasis% are particularly difficult to "ana$e Oral
prednisone in a 4)wee. taper is the preferred "ethod of treatin$ $enerali'ed rhus der"atitis
in patients who do not have psoriasis !he "ethylprednisolone dose pac.% althou$h so"eti"es
effective% is associated with rebound owin$ to the short duration of therapy Oral prednisone
tapers produce a s"oother taper than intra"uscular dosin$ with depocorticosteroids !his is
because of less predictable absorption with the intra"uscular route of ad"inistration
-onsedatin$ antihista"ines such as loratadine have no role in the treat"ent of rhus der"atitis
because the pruritus is not pri"arily hista"ine)"ediated
*iblio$raphy
+0eld"an S,% Clar. A, Csoriasis (ed Clin -orth A" +667874:++9:)>>
4*a.er 2 Corticosteroids and pustular psoriasis *r 1 ?er"atol +6;D86>(Suppl +4):79)7

Item 30
Answer: (A)
,efer hi" to a der"atolo$ist for a biopsy of the lesion
Educational Objective: ,eco$ni'e lenti$o "ali$na% and understand that it is a precursor of
"elano"a
!his patient has a lenti$o "ali$na% which is an in situ sta$e of "elano"a Althou$h co"pletely
flat% it is asy""etric% the border is notched% and there is varie$ation of color% all of which are
characteristic warnin$ si$ns of "elano"a !he "ost appropriate option in "ana$in$ this
patient is to perfor" a biopsy of the lesion for histolo$ic confir"ation of the dia$nosis
,e"ovin$ a pi$"ented lesion with liEuid nitro$en or a laser without a dia$nosis is
inappropriate !here are no laboratory tests other than biopsy that would be of any help
5enti$o "ali$na usually develops in elderly patients in the seventh or ei$hth decade who have
other si$ns of chronic sun e#posure It typically e#pands slowly and develops as a pi$"ented
lesion in a sun)e#posed location (for e#a"ple% the head and nec.) 5ess than 4BF of lenti$o
"ali$na develop on sites other than the head and nec. (usually on the e#tre"ities of wo"en
and on the trun. of "en) !he lesion often re"ains "acular (flat) for "any years before it
beco"es invasive and palpable tu"or is evident !he la$ ti"e before invasion occurs is
unpredictable% but it is usually several years !he accepted ran$e of pro$ression fro" lenti$o
"ali$na to lenti$o "ali$na "elano"a is fro" +:F to 9BF So"e authorities believe that
$iven enou$h ti"e% "ost lenti$o "ali$na would pro$ress to lenti$o "ali$na "elano"a% but
because of the incidence in the elderly population% "any patients die before invasion occurs
Once invasion occurs% the pro$nosis of lenti$o "ali$na "elano"a depends on the thic.ness of
the tu"or and is si"ilar to that of co"parable superficial spreadin$ and nodular "elano"as of
the sa"e thic.ness !here has been a lin$erin$ "isconception that lenti$o "ali$na "elano"a
has a "ore beni$n clinical course
!he clinical presentation of lenti$o "ali$na has all the si$ns associated with "elano"a%
includin$ asy""etry8 irre$ular% blurred% or notched borders8 lar$e si'e8 and often dra"atic
varie$ation of color Colors ran$e fro" shades of tan and brown to red and blue !he si'e "ay
vary fro" less than + c" to several centi"eters and "ay cover lar$e areas of the chee.%
forehead% or scalp If palpable areas are present% a presu"ptive dia$nosis of lenti$o "ali$na
"elano"a should be "ade !he treat"ent of lenti$o "ali$na is sur$ical e#cision !he entire
lesion should be re"oved to prevent recurrence and to analy'e the entire speci"en for foci of
invasion !he latter would chan$e the pro$nosis dra"atically 5enti$o "ali$na has no
associated "ortality rate% whereas the survival of patients with lenti$o "ali$na "elano"a
depends on tu"or thic.ness and level of invasion (ohs& "icro$raphic sur$ery is the procedure
used to treat lenti$o "ali$na "elano"a% with cure rates approachin$ 6;F ,outine sur$ical
e#cision% cryosur$ery% and radiation therapy are associated with recurrence rates of about ;F
to +BF ,adiation therapy is an alternative to sur$ery and "ay be a reasonable choice in
infir" elderly patients who are not able to under$o sur$ery 0or so"e lar$e% flat lesions%
radiation therapy "ay be better than e#tensive e#cision% which "ay result in cos"etic or
functional defor"ity
Solar lenti$o and seborrheic .eratosis fi$ure pro"inently in the differential dia$nosis of lenti$o
"ali$na Solar lenti$ines (liver spots or sun spots) are usually s"all (O + c")% evenly
pi$"ented% tan to brown lesions with a re$ular border !hey occur "ost often on sun)da"a$ed
s.in of the bac. of the hands% te"ple% forehead% and scalp 5ar$er% dar.er lesions "ay cause
so"e confusion with lenti$o "ali$na Seborrheic .eratoses are also li$ht tan to dar. brown but
usually are palpable and have a scaly surface and sharply de"arcated borders 5enti$o
"ali$na is not a "ar.er of any internal or syste"ic diseases
*iblio$raphy
+Cohen 5(% (cCall (3% Na# ,2 (ohs "icro$raphic sur$ery for lenti$o "ali$na and lenti$o
"ali$na "elano"a A follow)up study ?er"atol Sur$ +66784>:D;9);
4/eara 0*% An$ == ,adiation therapy for "ali$nant "elano"a Sur$ Clin -orth A"
+66D8;D:+979)67
9Co# -2% Aitchison !C% (ac=ie ,( E#trafacial lenti$o "ali$na "elano"a: analysis of ;+
cases and co"parison with lenti$o "ali$na "elano"a of the head and nec. *r 1 ?er"atol
+6678+96:>96)>9

Item 31
Answer: (*)
5ithiu"
Educational Objective: ,eco$ni'e "edications that "ay e#acerbate psoriasis
Of the dru$s listed% lithiu" is the only one associated with an e#acerbation of psoriasis
Csoriasis is a co""on disease8 patients with psoriasis often reEuire syste"ic "edications for
conco"itant disorders It is i"portant to reali'e that "any dru$s "ay a$$ravate e#istin$
disease or even precipitate pro$ression to pustular psoriasis !he dru$s "ost freEuently
i"plicated in the e#acerbation of psoriasis include beta)receptors (particularly propranolol)%
lithiu"% synthetic anti"alarial a$ents (Euinacrine hydrochloride and chloroEuine)% nonsteroidal
anti)infla""atory dru$s (phenylbuta'one% indo"ethacin% and ibuprofen)% an$iotensin)
convertin$ en'y"e inhibitors (captopril)% and interferon)alfa -one of these "edications is
absolutely contraindicated in patients with psoriasis% but patients should be warned that their
s.in disease "ay worsen !he other "edications that this patient is ta.in$ $enerally do not
worsen psoriasis
*iblio$raphy
+!san.ov -% =a'andjieva 1% ?renovs.a = ?ru$s in e#acerbation and provocation of psoriasis
Clin ?er"atol +6678+D:999):+
4Abel EA% ?iCicco 5(% Orenber$ E=% 0ra.i 1E% 0arber E( ?ru$s in e#acerbation of psoriasis 1
A" Acad ?er"atol +67D8+:(Ct +):+BB;)44

Item 32
Answer: (?)
Celvic ultrasono$raphy
Educational Objective: Evaluate a >:)year)old wo"an with der"ato"yositis
!his patient presents with the classic features of der"ato"yositis (ali$nancy is co""on in
patients with der"ato"yositis but occurs "ore freEuently in older patients Althou$h this
wo"an is >: years old% she should have an evaluation for a possible "ali$nancy A li.ely site
for a cancer in such a patient would be the pelvis Ovarian cancer appears to be over)
represented in "ost recent case studies8 therefore% the test "ost li.ely to detect a "ali$nancy
in this patient is pelvic ultrasono$raphy *ariu" ene"a would be a correct answer if the
patient were older than DB years of a$e Althou$h it could possibly detect "etastatic disease%
a brain scan would not be useful in this patient !hyroid cancer is not over)represented in
these patients% and thus% a thyroid scan would not be useful Carcinoe"bryonic anti$en (CEA)
is a nonspecific test and is not useful for cancer screenin$ in this patient
*iblio$raphy
+?avis (?% Ah"ed I Ovarian "ali$nancy in patients with der"ato"yositis and poly"yositis:
a retrospective analysis of fourteen cases 1 A" Acad ?er"atol +66;89;:;9B)9
4Si$ur$eirsson *% 5indelof *% Edha$ O% Allander E ,is. of cancer in patients with
der"ato"yositis or poly"yositis A population)based study - En$l 1 (ed +664894D:9D9);
9(arie I% 2atron CA% 5evesEue 2% 2achulla E% 2ellot (0% (ichon)Casturel G% et al Influence of
a$e on characteristics of poly"yositis and der"ato"yositis in adults (edicine (*alti"ore)
+6668;7:+96)>;

Item 33
Answer: (*)
?iscontinue phenytoin% and continue cefta'idi"e
Educational Objective: Identify the early si$ns of phenytoin hypersensitivity reaction
!his patient is developin$ the early si$ns of phenytoin hypersensitivity reaction% which often
presents as fever% a $enerali'ed erythe"atous "acular or papular eruption% periorbital or facial
ede"a% ly"phadenopathy% abnor"al liver function tests% and leu.ocytosis with eosinophilia
*ecause there is still a Euestion about a possible infection% it is best to discontinue the
phenytoin but "aintain antibiotic covera$e until the results of the cultures are .nown In
addition% the possibility of infection would preclude the i""ediate use of intravenous
"ethylprednisolone sodiu" succinate Carba"a'epine can cross)react with phenytoin8
therefore% it is an inappropriate antisei'ure a$ent in this patient
*iblio$raphy
+Shear -2% Spielber$ SC Anticonvulsant hypersensitivity syndro"e In vitro assess"ent of
ris. 1 Clin Invest +677874:+74D)94
4Chopra S% 5evell -1% Cowley /% /il.es 11 Syste"ic corticosteroids in the phenytoin
hypersensitivity syndro"e *r 1 ?er"atol +66D8+9>:++B6)+4
9(oss ?(% ,udis (% 2enderson SO Cross)sensitivity and the anticonvulsant hypersensitivity
syndro"e 1 E"er$ (ed +6668+;::B9)D

Item 34
Answer: (?)
Seborrheic .eratosis
Educational Objective: ,eco$ni'e the distin$uishin$ features of beni$n and "ali$nant
pi$"ented tu"ors
*ecause of the public&s increasin$ awareness about s.in cancer and the i"portance of early
detection and treat"ent% patients freEuently inEuire about new or chan$in$ pi$"ented lesions
!he lesion shown is a classic e#a"ple of a seborrheic .eratosis% which is a co""on beni$n
tu"or of .eratinocytes Seborrheic .eratoses are 4)"" to 4)c" papules or plaEues with an
irre$ular% papillated surface covered with sli$ht% $reasy scale Seborrheic .eratoses are sharply
de"arcated fro" nor"al adjacent s.in and have a stuc.)on appearance !hey are usually
pi$"ented% but the de$ree of pi$"entation "ay vary considerably fro" lesion to lesion and
even within an individual lesion Seborrheic .eratoses are unco""on in childhood and
increase in nu"ber with a$e Althou$h they are usually asy"pto"atic% lesions occasionally
beco"e infla"ed% with acco"panyin$ tenderness and pruritus Seborrheic .eratoses "ust be
differentiated fro" other pi$"ented cutaneous tu"ors 3hen there is doubt about the
dia$nosis% a biopsy should be done to e#clude "ali$nancy
A con$enital "elanocytic nevus is present at birth% occurrin$ in appro#i"ately +F of
newborns 5esions vary in si'e fro" very s"all to lar$e (coverin$ a lar$e area of the body) A
con$enital nevus has a s"ooth surface% occasionally with out$rowths of coarse ter"inal hairs
(ali$nant "elano"a "ay be difficult to distin$uish fro" a seborrheic .eratosis A "elano"a is
"orpholo$ically characteri'ed by the A*C?s (asy""etry% border irre$ularity% color varie$ation%
and a dia"eter J D "") (ost basal cell carcino"as contain little or no "elanin8 however% a
pi$"ented variant e#ists It can be distin$uished fro" a seborrheic .eratosis by its
translucent% pearly border% with telan$iectasias% central ulceration% and s"ooth surface !he
pi$"ent in a basal cell carcino"a tends to be stippled rather than evenly dispersed Solar
lenti$o is a "acular tan)brown lesion that develops in sun)e#posed s.in% but it usually is not
confused with a seborrheic .eratosis
*iblio$raphy
+Cariser ,1 *eni$n neoplas"s of the s.in (ed Clin -orth A" +667874:+47:)9B;

Item 35
Answer: (A)
S.in biopsy for routine processin$
Educational Objective: Select the test "ost li.ely to confir" a dia$nosis of cutaneous lupus
erythe"atosus in a patient with nonscarrin$ cutaneous disease
!his patient has subacute cutaneous lupus erythe"atosus !his is a photosensitive eruption
that "ay be preceded by a history of a poly"orphous li$ht eruptionli.e rash Althou$h so"e
investi$ators in Scandinavia believe that poly"orphous li$ht eruption and subacute cutaneous
lupus erythe"atosus can coe#ist% it is the belief of "ost authorities in the Gnited States that
the lesions of poly"orphous li$ht eruption that occurr prior to dia$nosis of subacute cutaneous
lupus erythe"atosus are probably forerunners of the condition% rather than a separate
condition Subacute cutaneous lupus erythe"atosus is best dia$nosed by the presence of an
interface der"atitis on routine histolo$ic study !he patient "ay have a positive result on
direct i""unofluorescence% but this test "ay be falsely ne$ative in about >BF of patients with
subacute cutaneous lupus erythe"atosus and "ay be falsely positive when e#posed s.in is
tested Antinuclear antibodies are freEuently abnor"al in patients with subacute cutaneous
lupus erythe"atosus (J 6BF)% but the presence of a positive test in a >7)year)old wo"an can
also be false)positive !he anti),o (SS)A) antibody has been closely lin.ed to subacute
cutaneous lupus erythe"atosus% but it "ay occur in other conditions% includin$ Sj$ren&s
syndro"e and rheu"atoid arthritis% and even in so"e nor"al individuals !he presence of a
positive test in a patient such as the one presented in this case would be hi$hly su$$estive%
but often on a sin$le testin$% the freEuency of positivity is only >BF to :BF So"e patients
with subacute cutaneous lupus erythe"atosus will also have Sj$ren&s syndro"e% but a
Schir"er&s test is not part of the routine evaluation and would not be helpful dia$nostically
*iblio$raphy
+Sonthei"er ,? S.in disease in lupus erythe"atosus 5upus +66;8D:;:)4+;
45ee 5A% 0arris A? Chotosensitivity diseases: cutaneous lupus erythe"atosus 1 Investi$
?er"atol Sy"p Croc +6668>:;9)7

Item 36
Answer: (?)
!ri"ethopri")sulfa"etho#a'ole
Educational Objective: ,eco$ni'e the ris. involved in the use of low)dose wee.ly
"ethotre#ate therapy for the treat"ent of severe psoriasis
Catients treated with wee.ly low)dose pulse "ethotre#ate therapy can have dra"atic
i"prove"ent in their Euality of life in ter"s of both their psoriatic arthritis% if it is present% and
their e#tensive psoriatic cutaneous lesions Close laboratory "onitorin$ is reEuired% and
vi$ilance "ust be continuous Sudden chan$es in renal function can produce dra"atic
"ethotre#ate to#icity caused by reduced renal clearance of the dru$ A nu"ber of dru$s can
have a si"ilar effect !ri"ethopri")sulfa"etho#a'ole causes a particularly severe dru$
interaction% with potentially dra"atic elevation of blood levels of "ethotre#ate All nonsteroidal
anti)infla""atory dru$s (-SAI?s) are notorious for both reducin$ renal clearance of
"ethotre#ate and unbindin$ "ethotre#ate fro" its carrier protein 2owever% this proble"
usually beco"es a crisis with -SAI?s only if renal function deteriorates for so"e other reason%
whereas it is a proble" with tri"ethopri")sulfa"etho#a'ole even in patients with nor"al
renal function
Itracona'ole has been associated with rare to#ic hepatitis and can even produce neutropenia
2owever% it would not predispose patients to "ethotre#ate to#icity% which occurred in this
patient Crednisone therapy is relatively contraindicated in patients with psoriasis because of
the ris. of rebound after taper% but it would not account for the to#icity in this patient
Cropranolol and other beta)bloc.ers can e#acerbate psoriasis% but a$ain% they would not
predispose patients to the hepatic% he"atolo$ic% or $astrointestinal to#icity of "ethotre#ate
(inocycline can be associated with nausea It produces pancytopenia and liver function test
abnor"alities only very rarely and would not account for the "ethotre#ate to#icity in this
patient
*iblio$raphy
+/reaves (3% 3einstein /? !reat"ent of psoriasis - En$l 1 (ed +66:8994::7+)7
4!ho"as ?,% ?over 1S% Ca"p ,? Cancytopenia induced by the interaction between
"ethotre#ate and tri"ethopri")sulfa"eth)o#a'ole 1 A" Acad ?er"atol +67;8+;:+B::)D

Item 37
Answer: (?)
!reat individual lesions with liEuid nitro$en% followed by a course of topical :)0G crea"
Educational Objective: Select the appropriate "ana$e"ent for patients with actinic
.eratoses
*ecause actinic .eratoses represent an early sta$e in the biolo$ic continuu" to sEua"ous cell
carcino"a% der"atolo$ists believe that actinic .eratoses are not trivial or cos"etic lesions and
should be treated to prevent the develop"ent of sEua"ous cell carcino"a In addition% actinic
.eratoses "ay be painful or beco"e irritated and bleed !he preferred treat"ent is destruction
of the lesions by liEuid nitro$en (+6: PC)% either by direct application with a cotton)tipped
applicator or by spray with a special spray cannister !his free'es the tissue to :B PC and
destroys the cells !he techniEue involves frostin$ the lesion and the i""ediate surroundin$
"illi"eter of nor"al s.in for several seconds Crolon$ed free'in$% such as that used for
treatin$ warts% is not necessary *lister for"ation should be avoided !he fro'en area
i""ediately beco"es reddened and stin$s !his lasts for about a day SubseEuently% the
actinic .eratosis crusts and disappears% leavin$ a well)healed area *ecause the actinic
.eratosis process is totally intraepider"al% scarrin$ is avoided if the proper a"ount of liEuid
nitro$en is applied
Cryosur$ery is the treat"ent of choice for individual lesions8 so"e thic.er lesions "ay reEuire
retreat"ent In "any patients% it suffices as a "onotherapy 2owever% when there are "any
lesions% as in this patient% co"bination therapy with liEuid nitro$en initially for discrete lesions
and individual lar$e or thic. actinic .eratoses% followed by a course of topical :)fluorouracil (:)
0G) for about 4 wee.s% is often the best course of action Intralesional :)0G has been used
successfully for the treat"ent of .eratoacantho"a and recalcitrant warts% but not actinic
.eratoses Chotodyna"ic therapy with a topical photosensiti'er (a"inolevulinic acid) that
binds preferentially with the abnor"al actinic .eratosis cells co"bined with laser li$ht has
recently been approved by the 0ood and ?ru$ Ad"inistration% but it is still very new and
reEuires sophisticated eEuip"ent
!opical :)0G would also be a $ood "onotherapy% but it has si$nificant drawbac.s It is a potent
contact irritant in "ost patients% and about +BF of patients develop a contact hypersensitivity
reaction% si"ilar to the reaction caused by poison ivy *oth conditions translate to an increased
incidence of local irritation% redness% swellin$% weepin$% oo'in$% crustin$% pain% and tenderness
(any patients do not co"plete a course of treat"ent% and co"pliance is a proble" !o avoid
these side effects% atte"pts to vary the dosin$ with inter"ittent pulse treat"ent (three ti"es
a wee.% + wee. out of >) or co"binin$ :)0G with topical $lucocorticoids (such as
hydrocortisone or tria"cinolone) is often helpful
*iblio$raphy
+0eld"an S,% 0leischer A* 1r% 3illiford C(% 1ori''o 15 ?estructive procedures are the
standard of care for treat"ent of actinic .eratoses 1 A" Acad ?er"atol +6668>B:>9);
4Epstein E ?oes inter"ittent HpulseI topical :)fluorouracil therapy allow destruction of actinic
.eratoses without si$nificant infla""ationK 1 A" Acad ?er"atol +667897:;;)7B
9Abadir ?( Co"bination of topical :)fluorouracil with cryotherapy for treat"ent of actinic
.eratoses 1 ?er"atol Sur$ Oncol +67986:>B9)>
>=urwa 2A% Aon$)/ee SA% Seed C!% (ar.ey AC% *arlow ,1 A rando"i'ed paired co"parison
of photodyna"ic therapy and topical :)fluorouracil in the treat"ent of actinic .eratoses 1 A"
Acad ?er"atol +6668>+(Ct +):>+>)7

Item 38
Answer: (C)
2ydrochlorothia'ide
Educational Objective: Identify hydrochlorothia'ide as a cause of subacute cutaneous lupus
erythe"atosus
!his patient has subacute cutaneous lupus erythe"atosus that "i$ht have been induced by
her use of hydrochlorothia'ide Althou$h she has adult acne and is ta.in$ "inocycline% s.in
lesions rarely acco"pany the lupus)li.e disease that is associated with "inocycline
2ydrala'ine also has been associated with dru$)induced syste"ic lupus erythe"atosus% but
the clinical "anifestation is usually a serositis% not a s.in rash *oth the "inocycline)induced
disease and hydrala'ine)induced disease have been associated with antihistone antibodies%
and the "inocycline)induced disease has been lin.ed to a positive pA-CA !he role of estro$en
in patients with syste"ic lupus erythe"atosus is not clear% but it has not been lin.ed to the
develop"ent of dru$)induced cutaneous lupus erythe"atosus Etidronate has not been lin.ed
to dru$)induced syste"ic lupus erythe"atosus or to dru$)induced cutaneous lupus
erythe"atosus
*iblio$raphy
+,eed *,% 2uff 1C% 1ones S=% Orton C3% 5ee 5A% -orris ?A Subacute cutaneous lupus
erythe"atosus associated with hydrochlorothia'ide therapy Ann Intern (ed +67:8+B9:>6):+
4Crowson A-% (a$ro C( Subacute cutaneous lupus erythe"atosus arisin$ in the settin$ of
calciu" channel bloc.er therapy 2u" Cathol +66;847:D;);9
9Stur.enboo" (C% (eier C,% 1ic. 2% Stric.er *2 (inocycline and lupusli.e syndro"e in acne
patients Arch Intern (ed +6668+:6:>69);
>Cra"atarov =? ?ru$)induced lupus erythe"atosus Clin ?er"atol +6678+D:9D;);;

Item 39
Answer: (?)
!halido"ide
Educational Objective: Select an appropriate therapy for a patient with refractory cutaneous
lupus erythe"atosus
,ecently% thalido"ide has beco"e available for off)label use in patients who have refractory
cutaneous lupus erythe"atosus !halido"ide is effective in relatively low doses and "ay be
used over a lon$ period with "ini"al to#icity Concern for the possible develop"ent of
neuropathy should be discussed with the patient prior to therapy% but the use of nerve
conduction studies before and durin$ therapy is not clear *ecause this patient is
post"enopausal% a pre$nancy prevention pro$ra" is not needed% but the co"pany that
supplies thalido"ide has desi$ned a pro$ra" for its safe use
Althou$h prednisone is useful for the treat"ent of syste"ic lupus erythe"atosus% its
effectiveness for cutaneous lesions has been Euestioned and it has "any side effects% "a.in$
its use less than desirable for patients who reEuire lon$)ter" therapy Carba"a'epine has not
been reported to be effective in lupus erythe"atosus Althou$h both intravenous
i""uno$lobulin and "ycophenolate "ofetil have been reported to be beneficial to so"e
patients% their costs are too e#pensive for their selection at this ti"e
*iblio$raphy
+?uon$ ?1% Spi$el /!% (o#ley ,! 9rd% /aspari AA A"erican e#perience with low)dose
thalido"ide therapy for severe cutaneous lupus erythe"atosus Arch ?er"atol
+6668+9::+B;6)7;
4Callen 1C (ana$e"ent of anti"alarial)refractory cutaneous lupus erythe"atosus 5upus
+66;8D:4B9)7

Item 40
Answer: (C)
Ce"phi$us vul$aris or paraneoplastic pe"phi$us with antibodies a$ainst des"o$lein 9 or
des"o$lein + and 9 and the pla.in proteins% respectively
Educational Objective: ,eco$ni'e the clinical findin$s of pe"phi$us and its variants and their
associated anti$ens
!his older patient has an intraepider"al blisterin$ disorder% which is deter"ined clinically by
e#tension of an intact blister with application of pressure !he "ost li.ely dia$nosis is
pe"phi$us vul$aris or paraneoplastic pe"phi$us% in which the anti$ens are des"o$lein 9 or
des"o$lein + and 9 and the pla.in proteins% respectively Althou$h lichen planus can
so"eti"es present as a bullous eruption% its patholo$ic site is subepider"al as is that of
bullous pe"phi$oid A thia'ide)induced reaction would not be e#pected to be associated with
circulatin$ autoi""une antibodies
*iblio$raphy
+Anhalt /1 (a.in$ sense of anti$ens and antibodies in pe"phi$us 1 A" Acad ?er"atol
+6668>B(Ct +):;D9)D
4Scott 1E% Ah"ed A, !he blisterin$ diseases (ed Clin -orth A" +667874:+496)79
9*ystryn 1C% Stein"an -( !he adjuvant therapy of pe"phi$us An update Arch ?er"atol
+66D8+94:4B9)+4

Item 41
Answer: (C)
Arran$e for e#cision of the entire lesion
Educational Objective: Gnderstand the ris. of "elano"a in con$enital nevi
!his patient "ost li.ely has a "elano"a developin$ within a "ediu")si'ed con$enital nevus
!he $ray hairs "ay or "ay not be related to the anaplastic process% but the nodule for"ation
and notchin$ of the "edial border certainly are 3ith such a hi$h level of suspicion% e#cision of
the entire tu"or is warranted ,e"ovin$ the entire lesion not only insures that an appropriate
histolo$ic dia$nosis can be "ade% but also facilitates identifyin$ the *reslow thic.ness and
Clar. level invasion !he latter two para"eters are the "ost i"portant variables in predictin$
the ris. of "etastases 0ull)thic.ness incisional biopsy has been advocated as a "eans of
"onitorin$ bu"ps and nodules that develop within lar$e% unresectable con$enital nevi
2owever% althou$h a tan$ential biopsy of the nodule would identify "elano"a% it would
actually interfere with an assess"ent of tu"or thic.ness and level of invasion !he chan$es in
this lesion are dra"atic% and observation or reassurance would be inappropriate "ana$e"ent
options for this patient 5y"phatic "appin$ in co"bination with sentinel node biopsy can be
done% if warranted% at the ti"e of wide local e#cision (that is% after a dia$nosis of "elano"a is
established and pro$nostic variables have been obtained)
Con$enital nevi are present in appro#i"ately + in +BB babies born in the Gnited States (ost
of these con$enital nevi are s"all% but about + in 4B%BBB are lar$e or $iant Con$enital nevi
have been arbitrarily divided into s"all (O +: c")% "ediu")si'ed (+: to +66 c")% and lar$e
(J 4B c")% accordin$ to the si'e they will attain in adulthood !he last are also referred to as
hairy% $iant% or bathin$ trun. nevi% dependin$ on their location and confi$uration !he lar$e
nevi are the "ost worriso"e *esides bein$ cos"etically disfi$urin$% they have a :F to +BF
chance of developin$ "elano"a !his is a concern durin$ childhood% because "ore than :BF
of "elano"as develop before : years of a$e% whereas ;BF develop by +B years of a$e
Intervention should be done as early as possible
!he ris. of "elano"a in s"all and "ediu")si'ed tu"ors is dra"atically different% bein$ no
hi$her than that in the $eneral population Althou$h there are no lifeti"e prospective studies%
the incidence of "elano"a developin$ in the lar$er "ediu")si'ed nevi is very low (less than
>F)% and when "elano"a does occur% it is always in adulthood% as in this patient !herefore%
unless s"all or "ediu")si'ed lesions have unusual features (for e#a"ple% a notched border or
nodules)% are in difficult)to)observe areas% such as the scalp% or are cos"etically unappealin$%
lifeti"e observation is adeEuate 2owever% when si$nificant chan$e does occur% such as nodule
for"ation% notchin$ of the border% areas of re$ression% or sy"pto"s such as bleedin$% pain% or
itchin$% biopsy is reEuired
*iblio$raphy
+Sahin S% 5evin 5% =opf A3% ,ao *=% !riola (% =oeni$ =% et al ,is. of "elano"a in "ediu")
si'ed con$enital "elanocytic nevi: a follow)up study 1 A" Acad ?er"atol +667896:>47)99
4Swerdlow A1% En$lish 1S% Qiao N !he ris. of "elano"a in patients with con$enital nevi: a
cohort study 1 A" Acad ?er"atol +66:894::6:)6
9E$an C5% Oliveria SA% Elenitsas ,% 2anson 1% 2alpern AC Cutaneous "elano"a ris. and
phenotypic chan$es in lar$e con$enital nevi: a follow)up study of >D patients 1 A" Acad
?er"atol +667896:649)94
>(ar$hoob AA% Schoenbach SC% =opf A3% Orlow S1% -ossa ,% *art ,S 5ar$e con$enital
"elanocytic nevi and the ris. for the develop"ent of "ali$nant "elano"a A prospective
study Arch ?er"atol +66D8+94:+;B):

Item 42
Answer: (A)
5ichen planus
Educational Objective: ,eco$ni'e lichen planusli.e eruptions as a "anifestation of $raft)
versus)host disease
!he cutaneous eruption associated with chronic $raft)versus)host disease followin$ allo$eneic
bone "arrow transplantation "ost closely rese"bles lichen planus It is of interest that lichen
planus is a prototypic disease "anifestin$ histolo$ic apoptosis 5y"phocytes can be seen
adjacent to dyin$ .eratinocytes% as would be e#pected in a $raft)versus)hostli.e reaction
Cityriasis roseali.e eruptions can occur in patients with a hypersensitivity to "edications
("ost typically $old salts) but are not a "anifestation of $raft)versus)host disease Althou$h
so"e lichen planusli.e eruptions "ay rese"ble psoriasis clinically% in that both are
papulosEua"ous diseases% the der"atolo$ic reactions in $raft)versus)host disease rese"ble
lichen planusli.e eruptions% both clinically and histopatholo$ically Atopic der"atitis is not a
"anifestation of chronic $raft)versus)host disease !inea corporis% li.e lichen planus% pityriasis
rosea% and psoriasis% is a papulosEua"ous eruption with lesions be$innin$ as papules with fine
scale% but it should not be confused with the lichen planusli.e eruptions of $raft)versus)host
disease It can be e#cluded by e#a"ination of potassiu" hydro#ide preparations and by fun$al
culture of scale obtained fro" a lesion
*iblio$raphy
+*oyd AS% -eldner =2 5ichen planus 1 A" Acad ?er"atol +66+84:::69)D+6
4Cribier *% 0rances C% Chosidow O !reat"ent of lichen planus An evidence)based "edicine
analysis of efficacy Arch ?er"atol +6678+9>:+:4+)9B

Item 43
Answer: (?)
?o#ycycline
Educational Objective: ,eco$ni'e the ris.s associated with usin$ tannin$ beds in patients
ta.in$ photosensiti'in$ dru$s
Catients are often warned to avoid sun e#posure when they are prescribed a photosensiti'in$
"edication Chotosensitive reactions to dru$s are usually related to e#posure to ultraviolet A
radiation (94B to >BB n") !he enhanced percenta$e of ultraviolet A radiation% as opposed to
shorter)wavelen$th ultraviolet * radiation% in tannin$ beds actually "a.es that e#posure of
even $reater ris. than sunli$ht for producin$ photosensitive reactions to "edications
?o#ycycline% a rin$ed "olecule in the tetracycline fa"ily% has often been i"plicated as a
photosensiti'in$ dru$
Colchicine has not produced photosensitive reactions 2ydro#ychloroEuine is often used to
treat photosensitive diseases% such as syste"ic lupus erythe"atosus% but it is not a
photosensiti'er *eta)carotene has been reported to benefit patients with photosensitivity
diseases such as poly"orphic li$ht eruption and erythropoietic protoporphyria% but it does not
produce photosensitive reactions itself A'athioprine is an i""unosuppressive "edication that
has been used to treat patients with photosensitivity diseases such as syste"ic lupus
erythe"atosus and chronic actinic der"atitis% but it does not by itself produce photosensitive
reactions
*iblio$raphy
+(iranda (A Assess"ent of the phototo#icity ris. of new dru$s Arch !o#icol Suppl
+66;8+6:4>6):7

Item 44
Answer: (C)
Choliner$ic urticaria
Educational Objective: ?ia$nose choliner$ic urticaria
!his patient has sy"pto"s of choliner$ic urticaria induced by heat% activity% and e"otional
stress -ot unco""only% patients with active urticaria also de"onstrate der"o$raphis"
(i""ediate wheal and flare reaction with trau"a to the s.in)% as is the case in this patient
!his is different fro" pressure)induced urticaria% in which a painful whealin$ reaction occurs
hours after local s.in pressure or trau"a Choliner$ic urticaria is often difficult to co"pletely
eli"inate% but it can be effectively "ana$ed by the use of antihista"ines and by havin$ the
patient avoid e#cessive heat% physical activity% and stress Antihista"ines are usually effective
in controllin$ the si$ns and sy"pto"s of der"o$raphis"
*iblio$raphy
+Nuberbier !% Althaus C% Chantraine)2ess S% C'arnet'.i *( Crevalence of choliner$ic urticaria
in youn$ adults 1 A" Acad ?er"atol +66>89+:6;7)7+
42u"phreys 0% 2unter 1A !he characteristics of urticaria in 96B patients *r 1 ?er"atol
+6678+97:D9:)7

Item 45
Answer: (C)
,ely pri"arily on protective clothin$ and hats
Educational Objective: 5earn the co"ponents of a co"prehensive Hsun)protectionI pro$ra"
!his professional $olfer will be unable to totally avoid sun e#posure 2owever% he can "odify
his behavior to li"it his e#posure Schedulin$ tee ti"es durin$ tourna"ents is out of his
control% but he can arran$e practice rounds early or late in the day% when the sun is not
overhead Avoidin$ outdoor activities durin$ the ti"es of "ost intense ultraviolet radiation
e#posure% between +B:BB A( and >:BB C( (dependin$ on the ti"e of year and latitude)%
reduces the total lifeti"e e#posure si$nificantly 2i$h)ris. behaviors such as suntannin$ or
$oin$ to a tannin$ salon should be avoided A Hsun)savvyI attitude is also helpful% for
e#a"ple% wal.in$ on the shady side of the street% usin$ a sun u"brella at the beach or when
spendin$ ti"e at outdoor sportin$ events% and purchasin$ tic.ets on the shady side of the field
for outdoor sportin$ events !his patient can stand in the shade or under an u"brella when his
partners are on the puttin$ $reen
Crotective clothin$ is probably the best line of defense for this patient when sun avoidance is a
proble" Clothin$ should li"it e#posure to hi$h)ris. portions of the e#posed s.in that are
prone to photoa$in$ and s.in cancers !hese include the scalp% ears% nec.% forear"s% and the
< of the nec. In $eneral% re$ular use of wide)bri""ed hats and lon$)sleeved shirts and
blouses help acco"plish this $oal !hese articles of clothin$ and hats with wide bri"s or nec.)
protective e#tensions are readily available and fashionable enou$h for any outdoor activity
Sunscreen use can be added as the final strate$y in a co"prehensive sun)s"art approach to
life ,e$ular and proper application of hi$h)potency and wide)spectru" sunscreens
supple"ents the effects of sun avoidance and protective clothin$ 2i$h)ris. areas such as the
nose% ears% scalp% and nec. can be covered Euic.ly and easily !he three strate$ies of sun
avoidance% protective clothin$% and sunscreens are i"portant !ailorin$ their proportional use
to a specific lifestyle is critical !his patient "ust rely on protective clothin$ as a pri"ary
strate$y% with sunscreen an i"portant adjunct Over a lifeti"e% payin$ attention to sun
avoidance saves hours of cu"ulative ultraviolet radiation e#posure !annin$ salons play no role
in a sun)s"art pro$ra" !his patient cannot select where and when he wants to play
*iblio$raphy
+/uercio)2auer C% (acfarlane ?0% ?eleo <A Chotoda"a$e% photoa$in$ and photoprotection
of the s.in A" 0a" Chysician +66>8:B:94;)94% 99>
45oescher 51% *uller (=% *uller ?*% E"erson 1% !aylor A( Cublic education projects in s.in
cancer !he evolution of s.in cancer prevention education for children at a co"prehensive
cancer center Cancer +66:8;:(4 Suppl):D:+)D

Item 46
Answer: (C)
3ear a >)inch broad)bri""ed cloth hat
Educational Objective: Appreciate the protective effect of wearin$ a hat
!he >)inch broad)bri""ed hat is the best for" of "obile shade and is effective in protectin$
the ears% nec.% and face% includin$ the nose !he only disadvanta$e is its un$ainliness for
so"e physical activities% such as swin$in$ a $olf club !he cap with flaps that drape over the
ears and nec. would be a $ood choice if it protected the chee.s and nose "ore effectively It
provides cover for all the areas at ris.% e#cept the nose% and provides shade for the eyes !he
plain baseball cap does not cover the ears and nec.% althou$h it protects the scalp and
forehead adeEuately It is the "ost popular for" of recreational head$ear% but it does not
protect the wearer fro" sunli$ht co"in$ in fro" either side of the front bri" !he fenestrated
straw hat and other types of "eshed hats are cooler% but they allow sunli$ht throu$h the wide
holes and $ive a false sense of protection In $eneral% clothin$% in this case in the for" of a
hat% is better protection a$ainst ultraviolet radiation than sunscreens
2ats are the "ost i"portant article of clothin$ when it co"es to sun protection 0or "en% the
ears are especially prone to overe#posure Ei$hty)five percent of s.in cancers occur on the
ears If worn properly% a hat offers "obile shade for these areas A >)inch broad)bri""ed hat
is the "ost effective% because it provides the best protection for all the areas at ris.% especially
the te"ples% chee.s% and nose durin$ the "iddle of the day% re$ardless of the person&s an$le
to the sun It has been esti"ated that each inch of bri" on a hat reduces the incidence of s.in
cancer by +BF
*ibliol$raphy
+?iffey *5% Cheese"an 1 Sun protection with hats *r 1 ?er"atol +6648+4;:+B)4

Item 47
Answer: (*)
5ichenification
Educational Objective: Identify the clinical features of chronic ec'e"atous eruptions
All types of ec'e"atous eruptions are associated with histolo$ic spon$iosis% which represents
ede"a within and around epider"al cells 5ichenification% however% is the characteristic clinical
feature of chronic ec'e"atous eruptions !his thic.enin$ of the outer layers of the s.in is
e#acerbated by chronic rubbin$ It "anifests clinically as an e#a$$eration of s.in "ar.in$s
with thic.enin$% which is often acco"panied by scale and dyspi$"entation
<esicles are a definin$ feature of acute ec'e"atous eruptions !he =oebner pheno"enon (the
tendency of eruptions to spread into sites of trau"a) is seen with several papulosEua"ous
diseases% such as psoriasis and lichen planus% but it does not occur in chronic ec'e"atous
eruptions ?er"al ede"a occurs in "any conditions but is particularly characteristic of
urticarial eruptions An annular or rin$li.e confi$uration is seen with "any erythe"atous
eruptions% especially erythe"a "i$rans seen in patients with 5y"e disease% but it is not a
feature of chronic ec'e"atous eruptions
*iblio$raphy
+(ac=en'ie)3ood A,% 0ree"an S Gnclassified endo$enous ec'e"a Contact ?er"atitis
+6668>+:+7)4+

Item 48
Answer: (?)
SEua"ous cell carcino"a
Educational Objective: ,eco$ni'e actinic .eratoses as an early clinical sta$e in the
pro$ression of sEua"ous cell carcino"a
!here is now co"pellin$ epide"iolo$ic% histopatholo$ic% and "olecular biolo$ic evidence that
actinic .eratosis and sEua"ous cell carcino"a are different sta$es of an oncolo$ic continuu"
that ran$es fro" dysplastic preclinical chan$e% throu$h actinic .eratosis% to invasive sEua"ous
cell carcino"a% and% finally% to "etastatic sEua"ous cell carcino"a It is accepted that
ultraviolet radiation fro" sun e#posure da"a$es the ?-A of the .eratinocytes% which are the
pri"ary cell line of the s.in ?a"a$ed cells either die throu$h apoptosis or survive with
co"plete or faulty repair of the ?-A Cells that survive persist as "utations and lead to clonal
e#pansion and clinical lesions reco$ni'ed as actinic .eratoses after they receive further
e#posure to ultraviolet radiation So"e actinic .eratoses persist as an inter"ediate end point
in the cancer spectru"% so"e re$ress% and others pro$ress to invasive sEua"ous cell
carcino"a Appro#i"ately DF to +BF of actinic .eratoses pro$ress to sEua"ous cell
carcino"a
Credictin$ which actinic .eratoses will pro$ress to sEua"ous cell carcino"a is i"possible
clinically !herefore% treat"ent of actinic .eratoses is dee"ed i"portant in the prevention of
sEua"ous cell carcino"a 5i.ewise% it is i"portant to do a co"plete s.in e#a"ination on
patients with actinic .eratoses to detect lesions that "ay have already pro$ressed to or are
suspicious for sEua"ous cell carcino"a because they are lar$er or thic.er than the other
actinic .eratoses
Actinic .eratoses act as a dose "eter% "easurin$ the patient&s uniEue susceptibility to
ultraviolet li$ht radiation% as well as the cu"ulative ultraviolet li$ht radiation e#posure% and
they identify patients at ris. for basal cell carcino"a and% to a lesser e#tent% "elano"a
=eratoacantho"a is another type of s.in cancer related to sEua"ous cell carcino"a It is
believed to be an abortive variety of sEua"ous cell carcino"a% in which the tu"or $rows
rapidly to a si'e of + to 4 c" over a >) to D)wee. period% re"ains Euiescent for a short ti"e%
and then re$resses over a period of > to D wee.s
*iblio$raphy
+?odson 1(% ?eSpain 1% 2ewett 1E% Clar. ?C (ali$nant potential of actinic .eratoses and the
controversy over treat"ent A patient)oriented perspective Arch ?er"atol +66+8+4;:+B46)
9+
4(oon !E% 5evine -% Cart"el *% *an$ert 15% ,odney S% ?on$ Q% et al Effect of retinol in
preventin$ sEua"ous cell s.in cancer in "oderate)ris. subjects: a rando"i'ed% double)blind%
controlled trial Southwest S.in Cancer Crevention Study /roup Cancer Epide"iol *io"ar.ers
Crev +66;8D:6>6):D
9Salasche S1 Epide"iolo$y of actinic .eratoses and sEua"ous cell carcino"a 1 A" Acad
?er"atol 4BBB8>4(Ct 4):>);
>/uenthner S!% 2urwit' ,(% *uc.el 51% /ray 2, Cutaneous sEua"ous cell carcino"as
consistently show histolo$ic evidence of in situ chan$es: a clinicopatholo$ic correlation 1 A"
Acad ?er"atol +6668>+(Ct +):>>9)7
:Nie$ler A% 1onason AS% 5effell ?1% Si"on 1A% Shar"a 23% =i""el"an 1% et al Sunburn and
p:9 in the onset of s.in cancer -ature +66>89;4:;;9)D

Item 49
Answer: (*)
Avoid $oin$ to the tannin$ salon entirely
Educational Objective: Gnderstand the futility and har"ful effects of obtainin$ a Hbase tanI at
a tannin$ salon
!here is a popular "isconception that because naturally dar.)s.inned people are less li.ely to
sunburn or develop a "elano"a% a Hbase tanI for li$ht)co"ple#ioned people will provide the
sa"e protection !his is a fallacy at several levels 0irst% the process of obtainin$ a tan i"plies
that da"a$e has been done to the ?-A of epider"al cells !annin$ is a defensive respone by
the s.in to ultraviolet radiation *ecause it is epider"al cell injury that initiates the process of
"elano$enesis% there is no such thin$ as a healthy tan Second% a tan is not very protective A
Hbase tan%I however obtained% "ay increase the sun protective factor (SC0) of fair s.in fro" a
baseline of B: to only 9 A product that would offer an SC0 of only 9 would hardly be worth
applyin$ to the s.in% as it would only triple the a"ount of ti"e so"eone could stay out in the
sun without burnin$ 0or a fair)s.inned redhead% this "ay "ean an increase in protected ti"e
of only about a half hour !his is not co""ensurate with the widely presu"ed belief that the
base tan allows for e#tra ti"e in the sun without further protection
0inally% the indoor tannin$ industry% a R4 billion per year con$lo"erate% once clai"ed that
tannin$ is har"less and healthy ,ecently% the 0ederal !rade Co""ission ruled that the
industry could no lon$er "a.e health and safety clai"s% only clai"s for cos"etic
enhance"ent 0urther"ore% to decrease the ti"e reEuired on the tannin$ bed% tannin$ salon
owners have added ultraviolet * wavelen$ths to co"ple"ent the HsafeI ultraviolet A rays 3ith
this addition% burns have occurred% and the ris. of s.in cancers is increased In addition% the
tans produced are not protective% as lenti$o)li.e lesions have been produced% and an increase
in the incidence of non"elano"atous s.in cancer has been reported
*iblio$raphy
+Spencer 1(% A"onette ,A Indoor tannin$: ris.s% benefits% and future trends 1 A" Acad
?er"atol +66:899(Ct +):477)67
4Spencer 1(% A"onette , !annin$ beds and s.in cancer: artificial sun S old sol T real ris.
Clin ?er"atol +6678+D:>7;):B+
93esterdahl 1% Olsson 2% (asbac. A% In$var C% 1onsson -% *randt 5% et al Gse of sunbeds or
sunla"ps and "ali$nant "elano"a in southern Sweden A" 1 Epide"iol +66>8+>B:D6+)6
>Autier C% ?ore 10% 5ejeune 0% =oel"el =0% /effeler O% 2ille C% et al Cutaneous "ali$nant
"elano"a and e#posure to sunla"ps or sunbeds: an EO,!C "ulticenter case)control study in
*el$iu"% 0rance and /er"any EO,!C (elano"a Cooperative /roup Int 1 Cancer
+66>8:7:7B6)+9

Item 50
Answer: (?)
,efer her to a der"atolo$ist for patch testin$ to a nu"ber of co""on anti$ens% includin$
rubber additives
Educational Objective: ?ifferentiate i""ediate late# aller$ic reactions fro" delayed reactions
caused by rubber additives
!his patient has s.in chan$es of a chronic aller$ic (delayed) contact der"atitis !he dia$nostic
approach is to perfor" patch testin$ to rubber additives% which are the "ost co""on cause of
this reaction ,adioaller$osorbent (,AS!) and s.in)pric. tests to late# anti$ens would test for
the presence of I$E% which is not relevant to this patient&s reaction A s.in biopsy would not
provide a specific answer to the cause of the reaction% and inhalation challen$es for patients
with I$E antibodies to late# could be fatal
*iblio$raphy
+3arshaw E( 5ate# aller$y 1 A" Acad ?er"atol +667896:+)4> 6799;+:B
43yss (% Elsner C% 3uthrich *% *ur$ / Aller$ic contact der"atitis fro" natural late# without
contact urticaria Contact ?er"atitis +669847:+:>)D

Item 51
Answer: (*)
Sunscreens should be applied about a half hour before $oin$ into the sun
Educational Objective: Gnderstand the i"portant aspects of selectin$ and usin$ sunscreens
!oday&s refined sunscreens represent a "ajor develop"ent in the battle a$ainst s.in cancer
and photoa$in$ !here is now convincin$ evidence that they can help prevent the acute
da"a$e of sunburn and the a$in$ effects of chronic sun e#posure Evidence also shows that
sunscreens can reduce the incidence of actinic .eratoses and non"elano"atous s.in cancers
!o be effective% a sunscreen "ust be capable of bloc.in$ wavelen$ths of ultraviolet radiation
across the entire solar spectru" and of sufficient sun protective factor (SC0) stren$th to
prevent ultraviolet radiation fro" reachin$ the s.in *oth the stren$th and width of the
spectru" covered by a sunscreen "ust account for the co"bination of a patient&s response to
the sun% the latitude where the patient lives% and the scope of the outdoor activities pursued
!hey "ust be used properly and in sufficient Euantity to cover e#posed areas (any people do
not use sunscreens in sufficient stren$th or Euantity and do not reapply sunscreen durin$
prolon$ed sun e#posure% and they have a false sense of security !hey will not adhere to sun
avoidance techniEues or wear protective clothin$% and they stay out in the sun lon$er than
they should In these instances% the opposite of the desired $oal will occurM"ore s.in cancers
will develop
*iblio$raphy
+(c5ean ?I% /alla$her , Sunscreens Gse and "isuse ?er"atol Clin +6678+D:4+6)4D
4?iffey *5% /rice 1 !he influence of sunscreen type on photoprotection *r 1 ?er"atol
+66;8+9;:+B9):
9-aylor (0% *oyd A% S"ith ?3% Ca"eron /S% 2ubbard ?% -eldner =2 2i$h sun protection
factor sunscreens in the suppression of actinic neoplasia Arch ?er"atol +66:8+9+:+;B):
>!ho"pson SC% 1olley ?% (ar.s , ,eduction of solar .eratoses by re$ular sunscreen use -
En$l 1 (ed +6698946:++>;):+
:,obinson 1=% ,ade"a.er A3 Sun protection by fa"ilies at the beach Arch Cediatr Adolesc
(ed +6678+:4:>DD);B

Item 52
Answer: (*)
!i$htness of the weave of the fabric
Educational Objective: Identify the properties of clothin$ fabric that add to or detract fro" its
ability to protect a$ainst ultraviolet radiation
Clothin$ is obviously an i"portant ele"ent in sun protection Si"ple "aneuvers such as
wearin$ lon$)sleeved shirts rather than short)sleeved shirts si$nificantly reduce ultraviolet
radiation e#posure to the forear"s Si"ilarly% buttonin$ shirts up to the top button and turnin$
up the collar do the sa"e for the anterior chest and nec.
-ot all fabrics are eEually effective in bloc.in$ ultraviolet radiation 0or e#a"ple% widely
available tee shirts "ay offer protection (si"ilar to the sun protection factor USC0V of a
sunscreen)% ran$in$ fro" an SC0 as low as D to 7 to one as hi$h as +D to 4B Several variables
e#plain these differences% includin$ the type of fiber used in the fabric% how the fabric is
desi$ned and woven% and the color of the fabric !he "ost i"portant sun)protective property
of a cloth is how ti$htly it is woven !he tiny holes created by the weave or .nit allow so"e
sunli$ht to pass throu$h !he ti$hter this weave% the s"aller the holes and the "ore
protection it affords 2oldin$ a $ar"ent up to li$ht $ives a $ood indication of the protection
the $ar"ent would provide fro" the sun =nit polo shirts are the least effective sun)protective
shirts !he shirt&s hole si'e is also affected by how ti$htly the $ar"ent is stretched over the
s.in Snu$ly fittin$ clothes stretch over the shoulders and upper bac.% widenin$ the interstices
of the weave and lowerin$ the SC0 !he difference in SC0 of the tail of a shirt "ay be double
the portion stretched over the shoulders Sweatin$ soa.s a $ar"ent and $reatly reduces the
SC0 of a fabric All the holes beco"e filled with water% which acts as a "a$nifyin$ $lass%
allowin$ trans"ission of the sun&s rays 2owever% washin$ a tee shirt for the first ti"e in hot
water si$nificantly increases the SC0% because the $ar"ent shrin.s and the intervenin$ holes
beco"e s"aller
Other characteristics of clothin$ are also i"portant in protectin$ the s.in fro" the sun%
especially the thic.ness or density of the "aterial 3ith ti"e and repeated wash and wear
cycles% the fabric thins% and the SC0 decreases So"e "aterials% such as cotton% contain
li$nins% which are ultraviolet radiation)absorbin$ pi$"ents Gsin$ bleach in the wash cycle can
ne$ate the protective effect of these li$nins 2owever% so"e fluorescent whitenin$ a$ents
actually absorb lon$)wave ultraviolet A radiation and increase the SC0 So"e "anufacturers
add ultraviolet)absorbin$ co"pounds durin$ the "anufacturin$ process to decrease
photode$radation !hese co"pounds% such as ,ayosan,% also increase the SC0 of the
$ar"ent 5astly% the dar.er shades of so"e ultraviolet)absorbin$ dyes are "ore effective
protective aids than the li$hter shades of the sa"e dye
Althou$h wearin$ lon$)sleeved shirts and lon$ pants "a.es sense% the challen$e has been to
desi$n co"fortable% loose)fittin$% li$htwei$ht fabrics that provide adeEuate protection a$ainst
ultraviolet radiation !he new boutiEue hi$h)SC0 clothin$ ta.es advanta$e of all these
properties% but it is "ore e#pensive than routinely available articles of clothin$
*iblio$raphy
+Ada" 1 Sun)protective clothin$ 1 Cutan (ed Sur$ +66789::B)9
4Sayre ,(% 2u$hes S Sun protective apparel% advance"ents in sun protection S.in Cancer
l66987:>+);
9Stanford ?/% /eor$ouras =E% Cailthorpe (! Sun protection by a su""er)wei$ht $ar"ent:
the effect of washin$ and wearin$ (ed 1 Aust +66:8+D4:>44):
>O&Quinn ,C% 3a$ner ,0 1r Gnusual patterns of chronic photoda"a$e throu$h clothin$ Cutis
+6678D+:4D6);+
:(enter 1(% 2ollins !?% Sayre ,(% Ete"adi AA% 3illis I% 2u$hes S- Crotection a$ainst G<
photocarcino$enesis by fabric "aterials 1 A" Acad ?er"atol +66>89+(Ct +):;++)D

Item 53
Answer: (C)
5a#ity
Educational Objective: ,eco$ni'e s.in chan$es attributable to intrinsic chronolo$ic a$in$ as
opposed to s.in chan$es related to injury
All of the s.in chan$es listed e#cept la#ity are caused by photoda"a$e !wo processes lead to
cutaneous chan$es associated with a$in$ E#trinsic a$in$ is related to environ"ental
influences% such as ultraviolet radiation% s"o.in$% wind% and che"ical e#posure Cersistent
e#posure to ultraviolet li$ht is the "ost si$nificant cause of e#trinsic a$in$% resultin$ in s.in
coarseness% actinic@solar .eratoses% lenti$ines% fine lines% and telan$iectasias Intrinsic
chronolo$ic a$in$ is lar$ely $enetically deter"ined Intrinsic chan$es include the natural
effects of $ravity (sa$$in$@la#ity)% furrow or e#pression lines% and atrophy of the der"is and
subcutis that often leads to the $aunt appearance of old a$e ?aily use of a broad)spectru"
sunscreen with a hi$h sun protective factor (SC0) or a sunscreen that co"bines a ultraviolet *
and ultraviolet A bloc. helps prevent ultraviolet da"a$e and pre"ature e#trinsic photoa$in$
*iblio$raphy
+!aylor C,% Sober A1 Sun e#posure and s.in disease Annu ,ev (ed +66D8>;:+7+)6+
4=a"inester 52 Current concepts Chotoprotection Arch 0a" (ed +66D8::476)6:
9*enedetto A< !he environ"ent and s.in a$in$ Clin ?er"atol +6678+D:+46)96
>Castanet 1% Ortonne 1C Ci$"entary chan$es in a$ed and photoa$ed s.in Arch ?er"atol
+66;8+99:+46D)6