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SKINTEST Skin Test Christina P. Linton

1. What is the primary function of desmosomes within 6. Nevus of Ota generally occurs in which anatomic the stratum spinosum? region? a. Initiate apoptosis among keratinocytes in the upper a. Supraclavicular layers b. Perioral b. Transfer melanin from melanocytes to keratinocytes c. Lumbosacral c. Recognize foreign invaders and signal the innate d. Periorbital immune response d. Form intercellular attachments between keratinocytes 7. Ocular symptoms are common among all of the following conditions except 2. Which of the following medications is most likely to a. Behc¸et disease be responsible for causing a fixed drug eruption? b. Dermatomyositis a. Hydrochlorothiazide c. Rosacea b. Tetracycline d. Linear immunoglobulin A disease c. Omeprazole d. Methotrexate 8. Which of the following conditions is generally the most pruritic? 3. Old World leishmaniasis is endemic in which of the a. Lichen amyloidosis following countries? b. Lichen striatus a. India c. Lichen nitidus b. Brazil d. Lichen spinulosus c. Australia d. Puerto Rico 9. Cafe´ au lait spots are associated with all of the following conditions except 4. Which of the following injectable anesthetics is an ester? a. Tuberous sclerosis a. Prilocaine b. Ataxia telangiectasia b. Bupivacaine c. Incontinentia pigmenti c. Procaine d. Neurofibromatosis d. Lidocaine 10. Which of the following statements most accurately 5. Which of the following over-the-counter topical describes classic Kaposi sarcoma? products is not recommended for use during pregnancy? a. Incidence is most common among African men. a. Salicylic acid b. Initial lesions typically present on the trunk. b. Minoxidil c. The initial furuncles progress to eroded c. Selenium sulfide ulcerations. d. Benzoyl peroxide d. Progression to disseminated disease is generally slow.

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ANSWERS tified throughout large portions of the world. Al- though sand flies are found in the United States as far north as upstate New York and visceral 1. d. Form intercellular attachments between keratinocytes. leishmaniasis has been identified in foxhounds in a Desmosomes are intercellular attachment plates formed wide geographic distribution in the United States, by bundles of keratin. They promote mechanical virtually, no human transmission is believed to coupling between the keratinocytes of the epidermis occur in most of the United States. and provide resistance to physical stresses. Desmo-

somes are abundant in the intercellular spaces be- Stark, C. G. (2014). Leishmaniasis. Retrieved from http://emedicine.medscape. tween the squamous cells of the stratum spinosum, com/article/220298-overview and the spine-like appearance of these desmosomes along the cell margins is where the stratum spinosum 4. c. Procaine. Local anesthetics are structurally com- derives its name. As the cells progress outward, des- posed of three subunits: a hydrophobic aromatic mosomes undergo proteolytic degradation, which ring, a hydrophilic amine group, and an interven- contributes to the shedding of corneocytes during ing group that connects these two units. The region desquamation. connecting the hydrophilic and hydrophobic units may be either an amide group or an ester group. Kolarsick, P. A. J., Kolarsick, M. A., & Goodwin, C. (2011). Anatomy and physiology of the skin. Journal of the Dermatology Nurses’ Association, The intermediate ester or amide linkage determines 3(4), 203Y213. anesthetic metabolism and propensity for hyper- sensitivity. Ester anesthetics, which include procaine, 2. b. Tetracycline. The drugs most commonly asso- benzocaine, tetracaine, and cocaine, are metabolized ciated with fixed drug eruption are sulfonamides, nonsteroidal anti-inflammatory drugs, barbitu- by plasma pseudocholinesterase and are excreted renally. Amide anesthetics, which include lidocaine, rates, tetracyclines, and carbamazepine. The initial prilocaine, bupivacaine, and mepivacaine, are me- manifestation of a fixed drug eruption generally tabolized in the liver through dealkylation and hy- develops 1Y2 weeks after exposure to the respon- drolysis by microsomal enzymes. sible medication. With subsequent exposures, the eruption occurs in the same site within 24 hours. Goldsmith,L.A.,Katz,S.I.,Gilchrest,B.A.,Paller,A.S.,Leffell,D.J.,& Classic fixed drug eruption appears in the form of Wolff, K. (2012). Fitzpatrick’s dermatology in general medicine (8th ed.). New York, NY: McGraw-Hill Medical. one or a few round, sharply demarcated erythem- Roenigk, R. K., Ratz, J. L., & Roenigk, H. H. (2007). Roenigk’s dermatologic atous and edematous plaques, sometimes with a surgery: Current techniques in procedural dermatology (3rd ed.). New York, NY: Informa Health Care. dusky, violaceous hue; central blister; or detached epidermis. The lesions can arise anywhere on the body but favor the lips, face, hands, feet, and genitalia. 5. b. Minoxidil. There have been case reports of car- The lesions fade over several days and often leave diac, neurodevelopmental, gastrointestinal, renal, postinflammatory hyperpigmentation. and limb malformations with topical minoxidil use during pregnancy. Because there are no conclusive Bolognia, J. L., Jorizzo, J. L., & Schaffer, J. V. (2012). Dermatology (3rd ed.). St. Louis, MO: Elsevier/Mosby. studies, minoxidil use is not recommended during pregnancy. Topical benzoyl peroxide is considered 3. a. India. Leishmaniasis is a disease caused by an safe for acne and rosacea therapy during pregnancy. intracellular protozoa parasite transmitted by the Interestingly, when benzoyl peroxide is absorbed by bite of a female sand fly. Old World leishmaniasis is the skin, it is metabolized within the skin to benzoic caused by Leishmania species found in Africa, Asia, acid, a food additive, and exposure to benzoic acid the Middle East, the Mediterranean, and India. New in the diet is greater than exposure from topical World leishmaniasis is caused by Leishmania spe- application. Although salicylism has occurred using cies found in Central America and South America. methyl salicylate ointments and high concentrations Old World leishmaniasis produces cutaneous or of salicylic acid on widespread areas of hyperker- visceral disease, whereas New World leishmaniasis atotic skin, there are no known cases resulting from produces cutaneous, visceral, and mucocutaneous acne or wart products containing salicylic acid. It is diseases. The global incidence of leishmaniasis has generally accepted that the use of over-the-counter increased in recent years because of increased inter- salicylic acid on localized areas for limited periods national leisure and military-related travel, human during pregnancy is considered safe. Likewise, local alteration of vector habitats, and concomitant fac- application of selenium sulfide for a limited period tors that increase susceptibility, such as infection with is acceptable. human immunodeficiency virus and malnutrition. Murase, J. E., Heller, M. M., & Butler, D. C. (2014). Safety of dermatologic With the exception of Australia, the Pacific Islands, medications in pregnancy and lactation. Journal of the American Academy and Antarctica, Leishmania species have been iden- of Dermatology, 70(3), 401.e1Y401.e14.

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6. d. Periorbital. Nevus of Ota occurs predominantly 8. a. Lichen amyloidosis. Lichen amyloidosis is char- in more darkly pigmented individuals, especially acterized by the appearance of paroxysmally pru- Blacks and Asians. Lesions are most commonly ritic lichenoid papules. The primary lesions are small, present at birth or develop within the first year of brown, discrete, slightly scaly papules that group to life, although in some individuals, Nevus of Ota form large, infiltrated, moniliform plaques. The most appears during puberty. Nevus of Ota is generally common presentation is on the bilateral shins. Less characterized by a confluence of individual macules commonly, the thighs, forearms, and upper back may varying from pinhead size to several millimeters in be affected. Treatment is often unsatisfactory and diameter, which gives an overall appearance of an must include efforts to reduce chronic rubbing of the irregularly demarcated, mottled patch. The colora- skin. Lichen striatus is a fairly common self-limited tion varies from shades of tan and brown to gray, eruption that is seen primarily in children. Lesions blue, black, and purple because of the presence of begin as 1- to 3-mm papules that are erythematous melanin-producing melanocytes in the dermis. The and slightly scaly. These papules coalesce to form overall lesion size may be a few centimeters, or there a 1- to 3-cm-wide continuous or interrupted band may be extensive unilateral or bilateral involvement. that, over a few weeks, progresses down the ex- Nevus of Ota favors the distribution of the first two tremity or around the trunk, following the lines of branches of the trigeminal nerve and typically in- Blaschko. The lesions are usually asymptomatic and volves the periorbital area, temple, forehead, malar last for an average of 1 year. Lichen nitidus is a chronic area, earlobe, preauricular and postauricular areas, inflammatory disease characterized by minute, shiny, nose, and conjunctivae. In about two thirds of pa- flat-topped, pale, exquisitely discrete, uniform papules tients, there is involvement of the ipsilateral sclera. that are rarely larger than a pinhead. Initially, lesions There may also be involvement of other ocular struc- are localized, chiefly on the penis and lower abdomen, turesaswellastheoralmucosa, pharynx, nasal the inner surfaces of the thighs, and the flexor aspects mucosa, and tympanum. of the wrists and forearms. The condition is usually asymptomatic, and the course is slowly progressive Bolognia, J. L., Jorizzo, J. L., & Schaffer, J. V. (2012). Dermatology (3rd ed.). St. Louis, MO: Elsevier/Mosby. with a tendency for remission. Lichen spinulosus is a disease chiefly of children that is characterized by 7. b. Dermatomyositis. Dermatomyositis is not com- minute filiform horny spines that protrude from folli- monly associated with ocular symptoms. Approxi- cular openings independent of any papules. The spines mately 50% of patients with linear immunoglobulin are discrete, grouped, and symmetrically distributed A disease have eye symptoms such as dry eyes, foreign over the trunk, limbs, and buttocks with a predilec- body sensation, burning, and/or discharge. Slit lamp tion for the neck, buttocks, abdominal wall, popli- evaluation reveals conjunctival scarring and sub- teal spaces, and extensor surfaces of the arms. Little conjunctival fibrosis with some secondary corneal or no itching is present, and the lesions tend to clouding that can cause a long-term decline of vision. involute at puberty. Y Ocular manifestations occur in 70% 85% of Behc¸et James, W. D., Berger, T. G., & Elston, D. M. (2011). Andrews’ diseases of disease cases. Early eye involvement is unilateral with the skin: Clinical dermatology (11th ed.). Philadelphia, PA: Saunders/ two thirds of patients progressing to bilateral eye Elsevier. disease. Up to 25% of patients with eye involvement 9. c. Incontinentia pigmenti. Incontinentia pigmenti develop blindness within 5 years of the onset of ocular is an X-linked, dominant condition that appears in symptoms. Therefore, prompt evaluation by an oph- girls during the first weeks after birth. In most cases, thalmologist is essential for all patients with Behc¸et vesicular and verrucous lesions occur before the onset disease. More than 50% of rosacea cases have ocular of pigmented macules arranged in streaks, sprays, involvement, which occurs independent of skin se- splatters, and whorls that follow the lines of Blaschko. verity. Objectively, redness and telangiectasia can be Typical cafe´ au lait spots are not an expected finding seen on the eyelid with blepharitis, hordeola, and in this condition. Tuberous sclerosis is an autosomal chalazia along the eyelid margin. Patients also com- dominantly inherited condition in which affected in- monly complain of dry eyes, ocular pain, burning, and dividuals may experience adenoma sebaceum, mental foreign body sensation. Any symptomatic eye involve- deficiency, and epilepsy. Cutaneous manifestations in- ment should prompt an ophthalmology referral. clude periungual fibromas, shagreen plaques, oral

Bolognia, J. L., Jorizzo, J. L., & Schaffer, J. V. (2012). Dermatology (3rd ed.). papillomatosis, ash-leaf hypomelanotic macules, skin St. Louis, MO: Elsevier/Mosby. fibromas, and cafe´ au lait spots. Ataxia telangectasia Horner,M.E.,Abramson,A.K.,Warren,R.B.,Swanson,S.,&Menter,M.A. is a rare autosomal recessive disorder in which af- (2014). The spectrum of oculocutaneous disease: Part I. Infections, inflammatory and genetic causes of oculocutaneous disease. Journal of fected individuals experience neurologic decline that the American Academy of Dermatology, 70(5), 795.e1Y795.e25. usually results in wheelchair dependency by the early

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teenage years. Cutaneous manifestations include tel- acquired-immunodeficiency-syndrome-related KS. angiectasias, cafe´ au lait patches, hypopigmented The typical patient with classic KS is a Caucasian macules, seborrheic dermatitis, premature graying, and man in his 60s with a Mediterranean or Jewish sparsity of the hair and progeroid features. Neurofi- background. The tumors usually start on the skin bromatosis is an autosomal dominantly inherited syn- of the distal portions of the lower extremities as drome manifested by developmental changes in the unilateral or bilateral bluish-red (hematoma-like) nervous system, bones, and skin. The presence of six macules that slowly progress both horizontally or more cafe´ au lait macules of more than 5 mm in and vertically and into firm plaques and eventu- greatest diameter in prepubertal individuals or more ally nodules. During the tumor’s progression, the than 15 mm in greatest diameter in postpubertal indi- color changes to brownish, and the skin overlying viduals should raise suspicion for neurofibromatosis. the tumor becomes hyperkeratotic and may ulcer- ate. There is frequently pitting edema surrounding Bolognia, J. L., Jorizzo, J. L., & Schaffer, J. V. (2012). Dermatology (3rd ed.). St. Louis, MO: Elsevier/Mosby. the tumor that may evolve into fibrosis. Classic KS James, W. D., Berger, T. G., & Elston, D. M. (2011). Andrews’ diseases of usually runs a rather benign course, and after several the skin: Clinical dermatology (11th ed.). Philadelphia, PA: Saunders/ Elsevier. years of proximal tumor progression, dissemination frequently occurs to other body sites, such as the 10. d. Progression to disseminated disease is generally lymph nodes, mucous membranes, and internal organs. slow. Kaposi sarcoma (KS) is a multifocal, systemic This dissemination is rarely symptomatic, and patients tumor of endothelial origin that results from in- may live with the slowly progressing disease for decades. fection with human herpes virus 8. There are four Goldsmith, L. A., Katz, S. I., Gilchrest, B. A., Paller, A. S., Leffell, D. J., & clinical variants: classic KS, endemic African KS, KS Wolff, K. (2012). Fitzpatrick’s dermatology in general medicine (8th ed.). associated with immunosuppressive therapy, and New York, NY: McGraw-Hill Medical.

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