Skin Test Christina P

SKINTEST Skin Test Christina P. Linton

1. The development of Sweet’s syndrome is most 6. Notalgia paresthetica characteristically occurs in commonly associated with which of the following which anatomic location? conditions? a. Base of the skull a. Upper respiratory infection b. Lateral, posterior thigh b. Hematologic malignancies c. Ulnar wrist c. Pregnancy d. Border of the scapula d. Inflammatory bowel disease 7. A 54-year-old man explains that when his feet get too 2. Which of the following terms is used to describe the warm, they turn bright red and feel like they are patches of white hair that can occur in individuals burning. What is the most likely diagnosis? with vitiligo? a. Erythema ab igne a. Ophiasis b. Erythromelalgia b. Schizotrichia c. Erythema marginatum c. Poliosis d. Erythroderma d. Madarosis 8. Which of the following diagnostic maneuvers is utilized to test for Asboe-Hansen sign? 3. In normal skin, how long does it take for a keratinocyte a. The skin is stroked firmly with a blunt object. to migrate from the basal cell layer to the surface of b. A pencil eraser is twisted against the skin. the stratum corneum? c. Firm pressure is applied to a flaccid bulla. a. 10 days d. The skin is pricked with a sterile needle. b. 14 days c. 20 days 9. Freckles are also known as ______d. 28 days a. Maculae ceruleae. b. Rhytides. 4. All of the following conditions are typically caused by c. Perl2che. a herpetic viral strain except ______d. Ephelides. a. Roseola infantum. b. Hand-foot-and-mouth disease. 10. Which of the following statements is not true regarding c. Kaposi sarcoma. the use of prednisone during pregnancy and lactation? d. Infectious mononucleosis. a. Use in the first trimester is linked to an increased risk of oralYfacial clefts. 5. In which of the following conditions would you b. Approximately 30% of the maternal dose is expect histologic evaluation to reveal cornoid lamella? transferred to her breast milk. a. Porokeratosis c. Use during pregnancy may cause premature delivery, b. Superficial erythema annulare centrifugum intrauterine growth retardation, and preeclampsia. c. Parapsoriasis d. Peak levels are found in breast milk within 1 hour d. Pityriasis lichenoides chronica of maternal ingestion.

Readers are encouraged to submit Skin Test questions to be considered for future issues. Please submit as many or as few questions a you would like (with answers and references) to [email protected]. Thank you.

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ANSWERS

Kolarsick, P. A. J., Kolarsick, M. A., & Goodwin, C. (2011). Anatomy and 1. a. Upper respiratory infection. Most Sweet’s syn- physiology of the skin. Journal of the Dermatology Nurses’ Association, drome cases are preceded by an upper respiratory 3(4), 203Y213. infection. Other documented associations include 4. b. Hand-foot-and-mouth disease. Hand-foot-and- nonrespiratory infections, inflammatory bowel disease, mouth disease has been linked to several nonpolio hematologic malignancies or solid tumors, preg- enteroviruses, although the most commonly identi- nancy, and certain medications. The primary lesion fied cause is coxsackievirus A or B. Affected in- of Sweet’s syndrome is a sharply marginated, rapidly dividuals are generally 1Y4 years old and present extending, tender, erythematous or violaceous, pain- with fever, malaise, and a characteristic exanthema, Y ful, elevated plaques 2 10 cm in diameter. Lesions which consists of gray-white vesicular lesions on the may appear indurated or intensely edematous and palms and soles. In addition, painful vesicles and typically involve the face, neck, upper trunk, and ex- erosions are typically present on the buccal surfaces, tremities. More than three quarters of affected in- palate, tongue, uvula, gingivae, and anterior tonsil- dividuals have systemic symptoms such as fever, lar pillars that may cause anorexia or dehydration. arthritis, arthralgias, myalgias, conjunctivitis, epis- The course of hand-foot-and-mouth disease is gen- cleritis, or oral lesions. Many also have an elevated erally benign, and treatment is supportive. Roseola sedimentation rate, neutrophilia, leukocytosis, and infantum is a common cause of sudden, unexplained a left shift. The standard treatment is systemic cor- high fever in children 6Y36 months old that is as- ticosteroids. When associated with an upper respi- sociated with human herpesvirus-6 and human ratory infection, Sweet’s syndrome generally lasts herpesvirus-7. The fever remains consistently high, Y 3 6 weeks and then resolves. Persistent cases have with morning remission, until the fourth day, when been reported to last several years. Because of the it falls precipitously to normal, coincident with the association with internal malignancies, attempts appearance of a morbilliform eruption consisting of should be made to identify the underlying cause, small blanchable pink macules and papules, 1Y5 especially in persons over the age of 50 years and mm in diameter, on the trunk and neck that may those with anemia, thrombocytopenia, or lesions remain discrete or become confluent. The buttocks, that are bullous or necrotic. face, and extremities may be affected, and often, James, W. D., Berger, T. G., & Elston, D. M. (2011). Andrews’ diseases of the there is a blanched halo around the lesions. The skin: Clinical dermatology (11th ed.). Philadelphia, PA: Saunders/Elsevier. course is self-limited, and resolution occurs within Y 2. c. Poliosis. The term ‘‘poliosis’’ refers to circum- 1 2 days with only symptomatic management. scribed patches of white or gray hair. These Kaposi sarcoma is a multifocal, systemic tumor of patches may be associated with several syndromes endothelial origin caused by human herpes virus-8. including vitiligo, regressing melanoma, and alo- The routes of human herpes virus-8 transmission pecia areata. Migrating patches without hair loss are not completely known, although it has been may represent a forme fruste presentation of confirmed that transmission occurs during sexual alopecia areata. The term ‘‘ophiasis’’ is used to activities, and it is widely assumed that contact with describe confluent hair loss along the temporal and saliva and blood or blood products can also transmit occipital scalp and is usually a feature of alopecia the infection. The early lesions of classic Kaposi areata. Madarosis refers to a loss of eyelashes and/ sarcoma appear most commonly on the toes or soles or eyebrows, and schizotrichia is used to describe as reddish, violaceous, or bluish-black macules and hairs that are splitting at their distal ends. patches that spread and coalesce to form rubbery nodules or plaques. The course is slowly progressive, Linton, C. P. (2012). Describing the hair and related abnormalities. and the lesions generally respond well to chemother- Y Journal of the Dermatology Nurses’ Association, 4(3), 207 208. apy and radiation. Infectious mononucleosis is 3. d. 28 days. The migration of keratinocytes from the caused by the EpsteinYBarr virus, which is a gamma basal layer to the cornified layer of the epidermis herpesvirus. This viral strain infects human mucosal takes at least 14 days, and the transit through the cells and B-lymphocytes. The infection persists for the cornified layer to the surface of the stratum corneum life of the host, often transitioning between latent and requires another 14 days. During this journey to the productive phases many times. Initial exposure surface, the keratinocytes proceed through a synthet- generally occurs through contact with oral secretions ic and then degradative differentiation process called during childhood or early adulthood, and about keratinization. 95% of the population has been infected by their

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early 20s. Cutaneous and mucous membrane lesions hypertension, or diabetes mellitus. Childhood are present in about 10% of patients, and exanthems erythromelalgia often appears without an underlying occur in 15%Y30% of affected children. Treatment is cause, and an autosomal dominant inheritance has generally supportive. been identified. Symptoms can be relieved by support- Goldsmith, L. A., Katz, S. I., Gilchrest, B. A., Paller, A. S., Leffell, D. J., & Wolff, K. ive measures such as elevation of the extremity or im- (2012). Fitzpatrick’s dermatology in general medicine (8th ed.). New York, mersion in cold water. Erythema ab igne is a persistent NY: McGraw-Hill Medical. condition produced by long exposure to direct, James,W.D.,Berger,T.G.,&Elston,D.M.(2011).Andrews’ diseases of the skin:Clinicaldermatology(11th ed.). Philadelphia, PA: Saunders/Elsevier. moderate heat such as fireplaces, space heaters, heating pads, and laptop computers. Erythema ab 5. a. Porokeratosis. Porokeratosis is a chronic, prog- igne begins as a mottling caused by local hemostasis ressive disorder of keratinization characterized and progresses into a reticulated erythema. Multiple clinically by hyperkeratotic papules or plaques sur- colors are simultaneously present in an active patch, rounded by a thread-like, elevated border that ex- varying from pale pink to old rose or dark purplish- pands centrifugally. This border corresponds to the brown. After the cause is removed, the pigment tends cornoid lamella, which is a distinctive histopatho- to disappear gradually, although in some cases, it logic feature. Several variants have been described, may be permanent. Erythema marginatum is an some with overlapping features. Superficial erythe- indicator of rheumatic fever that manifests with a ma annulare centrifugum presents with one or more spreading patchy erythema that migrates peripherally lesions that begin as erythematous macules or urti- and often forms polycyclic configurations that appear carial papules that enlarge by peripheral extension for only a few hours or days on the trunk or proximal to form ringed, arcuate, or polycyclic figures with an extremities. Erythroderma, also known as exfoliative indistinct border and trailing scale. Parapsoriasis dermatitis, presents with extensive erythema and scal- generallyoccursasovalorirregularly shaped patches ing, which progresses until the entire body surface is or very thin plaques that are usually discrete and dull scarlet and covered by small, laminated scales occur mainly on the trunk. These lesions are light red- that exfoliate profusely. Erythroderma usually occurs brown or salmon pink, asymptomatic, or mildly because of a preexisting generalized dermatosis such pruritic and may persist for years with little change in as psoriasis or atopic dermatitis, certain medications, clinical appearance. Pityriasis lichenoides chronica is internal malignancy, erythrodermic mycosis fungoides, characterized by recurrent crops of erythematous or S2zary syndrome. scaly papules that spontaneously regress over several James, W. D., Berger, T. G., & Elston, D. M. (2011). Andrews’ diseases weeks to months. of the skin: Clinical dermatology (11th ed.). Philadelphia, PA: Saunders/ Wolff,K.,Goldsmith,L.A.,Katz,S.I.,Gilchrest,B.A.,Paller,A.S.,&Leffell,D.J. Elsevier. (2008). Fitzpatrick’s dermatology in general medicine (7th ed.). New York, NY: McGraw-Hill Medical. 8. c. Firm pressure is applied to a flaccid bulla. Asboe-Hansen sign refers to the extension of a blister 6. d. Border of the scapula. Notalgia paresthetica is to adjacent unblistered skin when firm pressure is characterized by focal, intense pruritus over the applied to the surface of a flaccid bulla. Nikolsky sign medical scapular borders. It can occasionally be ac- is present when the twisting or rubbing of unblistered companied by pain, paresthesias, or hyperesthesias. skin causes intact epidermis to shear away from the This condition is thought to be a sensory neuropa- underlying dermis. Both of these signs show that the thy that may involve spinal nerve impingement. The extent of microscopic vesiculation can be more overlying skin is often unaffected, although there significant than is evident by simple inspection. They may be hyperpigmentation or lichenification be- are useful when evaluating the severity of pemphigus cause of chronic rubbing of the area. vulgaris and severe bullous drug reactions. A positive Bolognia, J. L., Jorizzo, J. L., & Schaffer, J. V. (2012). Dermatology (3rd ed.). Darier’s sign is elicited when skin that is firmly St. Louis, MO: Elsevier/Mosby. stroked with a blunt object becomes erythematous, 7. b. Erythromelalgia. Erythromelalgia is a rare form edematous, and pruritic. This urticarial reaction is of paroxysmal vasodilation of the feet that is usually indicative of cutaneous mastocytosis. Pathergy test- triggered by an increase in environmental tempera- ing is a nonspecific diagnostic tool that is not com- ture. Episodes can last for a few minutes or several monly utilized in clinical settings. It is performed days and manifest with burning, localized pain, by pricking the skin with a sterile needle and ob- redness, and high skin temperature. This can be a serving the area over the next few days for the ap- primary condition or secondary to diseases such as pearance of a papule, pustule, or ulceration at the polycythemia vera, thrombotic thrombocytopenic site of the injury. Pathergy testing is often positive purpura, thrombocytopenia, peripheral neuritis, mye- in Behc¸et disease, pyoderma gangrenosum, and litis, multiple sclerosis, systemic lupus erythematosus, Sweet’s syndrome.

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James, W. D., Berger, T. G., & Elston, D. M. (2011). Andrews’ diseases of the baseline risk is only 1 in 1,000 live births. Prednisone skin: Clinical dermatology (11th ed.). Philadelphia, PA: Saunders/Elsevier. also may result in premature delivery, premature New Zealand Dermatological Society Incorporated. (2011). Pathergy. Retrieved from http://www.dermnetnz.org/reactions/pathergy.html membrane rupture, intrauterine growth retardation, gestational diabetes, hypertension, preeclampsia, 9. d. Ephelides. Freckles are also known as ephelides. and eclampsia. For these reasons, many clinicians They are small, well-circumscribed pigmented mac- recommend that prolonged use be limited to 7.5 mg/ ules found only on the sun-exposed skin of in- day and that doses of 20 mg/day or higher be avoided. dividuals with fair skin. Rhytides is another name The American Academy of Pediatrics considers 2 for wrinkles, and perl che is another name for systemic corticosteroids ‘‘usually compatible’’ with angular cheilitis. Maculae ceruleae are blue- or slate- lactation and recommends prednisone or predniso- colored macules that can appear on the sides of the lone over other options. One study found that, for trunk and inner thighs of individuals with pedicu- mothers with doses between 10 and 80 mg, relative losis pubis. infant doses ranged from 0.002 to 0.059 mg, which Bolognia, J. L., Jorizzo, J. L., & Schaffer, J. V. (2012). Dermatology (3rd ed.). represents G10% of the infant’s endogenous cortisol St. Louis, MO: Elsevier/Mosby. level. The published literature fails to show adverse James,W.D.,Berger,T.G.,&Elston,D.M.(2011).Andrews’ diseases of the skin: Clinical dermatology (11th ed.). Philadelphia, PA: Saunders/Elsevier. effects in lactating infants, although these studies include modest maternal doses (between 5 and 10 mg 10. b. Approximately 30% of the maternal dose is daily). In an effort to minimize exposure and avoid transferred to her breast milk. Of the systemic the peak levels that occur 1 hour after maternal inges- corticosteroids, prednisone is the preferred choice tion, it is recommended that mothers do not breast- because placental enzymes limit passage to the feed for at least 4 hours after taking prednisone. embryo. Prednisone use during pregnancy has been Murase, J. E., Heller, M. M., & Butler, D. C. (2014). Safety of dermatologic associated with a three-fold increase in the risk of medications in pregnancy and lactation: Part I. Pregnancy. Journal of the orofacial clefts when it is taken during the 4 weeks American Academy of Dermatology, 70(3), 401.e1Y401.e14. Murase, J. E., Heller, M. M., & Butler, D. C. (2014). Safety of dermatologic before conception or up to 12 weeks after conception. medications in pregnancy and lactation: Part II. Lactation. Journal of the However, the absolute risk still remains low as the American Academy of Dermatology, 70(3), 417.e1-417.e10.

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