M C e o d n i t ca in l u CONTINUING MEDICAL EDUCATION Ed in u g c at io n

Objectives Differentiating 1) To provide a systematic approach to examining and Dermatological treating inflamma - tory skin conditions Diagnosis and 2) To discuss the most common skin conditions seen in Treatment the podiatric practi - tioner’s office

The authors present a systematic approach to 3) To discuss the examining and treating inflammatory skin first line treatment for inflammatory conditions. skin disorders

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By Tracey C. Vlahovic, DPM, FAPWCA tice the color, shape, and size in ad - be used to describe the rash appro - and Michelle Oliver, BA dition to laterality of the lesions on priately, both in the chart and in correspondence to other physi - patient first presenting with cians. When looking at the shape a red, scaly, itchy foot or leg of the lesions, it is helpful to deter - Acan prove to be a challenge Plaque psoriasis mine if they were self-induced by to diagnose and manage. When the patient (excoriation by a finger - faced with a patient with an in - presents as nail) or naturally caused (a plantar flammatory in the heel fissure). One should document office, the podiatric physician an erythematous if the lesions are plantar foot, dor - should have a systematic approach plaque with a sal foot, or proximal on the lower to arrive at a baseline differential leg. Nail involvement should be diagnosis: observe, ask, and apply silvery scale. noted. Finally, the fingernails and an algorithm. dorsum and palmar aspects of the hands should be examined as many Observe skin dermatoses mirror the pedal Upon entering the treatment the lower extremity. Primary and involvement there. room, the practitioner should no - secondary lesions (Table 1) should Continued on page 176 www.podiatrym.com APRIL/MAY 2010 • PODIATRY MANAGEMENT 175 n g o in ti u a n c the dermis from a pathology per - ostasis, trans-epidermal water loss, ti u Differentiating... n d o E spective. and prevents entry of foreign parti - C al ic Ask Other questions to consider ask - cles and pathogens into the body. d e Questions that will help form ing patients are the color of socks Trans-epidermal water loss is the M differential diagnoses should be they wear (azo dyes in blue socks newest target in the dermatological asked while completing the physi - can be a potential allergen), occu - pharmaceutical armamentarium in pation, and any associated daily order to reduce skin flares and com - hazards. Also, one fort the patient should ask about with an inflam - TABLE 1 both over-the- matory skin der - counter and Trans-epidermal water matosis. Primary Skin Lesions: homeopathic or Macule natural treatment loss is the newest Apply an Patch options they have Algorithm Plaque tried. In order to target in the To begin for - Nodule plan for a possi - dermatological mulating a differ - Vesicle ble in-office biop - ential diagnosis, Bullae sy during that pharmaceutical there is a basic al - Wheal visit, it is impor - gorithm to follow Telangiectasia tant to ask what armamentarium in for treating the Secondary Skin Lesions: the natural pro - order to reduce skin most common Ulcer gression of the le - skin disorders en - Atrophy sions has been flares and comfort the countered in the Scale and where the office: is it a Crust newest crops of patient with an plaque, scale, or Erosion lesions are. inflammatory skin zebra? (Table 2) A Excoriation Now that well-defined and Scar basic observation dermatosis. geometric shaped Lichenification and questioning plaque is often have occurred, psoriasis, but it’s important to eczema and cal exam of the skin. Often, the pa - delve more deeply into the chief lichen planus also must be consid - tient will answer a question that complaint and examine the skin ered. Circular, serpiginous scales are will help direct the diagnosis. Be - fully. Common skin signs of in - most often tinea but xerosis should yond asking the history of present flammation are calor (heat), rubor be ruled out. Remember that tinea illness, past medical history and (redness), tumor (swelling) and pru - pedis is KOH positive and may in - family history, the podiatric physi - ritis (itching), which ultimately volve both the interspaces and the cian should consider asking if there point to skin barrier dysfunction. plantar foot. Any papules, vesicles is a personal or family history of al - The skin barrier, which is stratum or other skin markings are consid - lergic rhinitis, sensitive skin, asth - corneum with the lipid-enriched ered “zebras” for this algorithm’s ma or skin cancer. The patient extracellular matrix surrounding purpose. should be asked if he has ever seen the corneocytes, is the body’s pro - Following the above algorithm, a dermatologist before and if he has tective wall and regulates home - the most common inflammatory any skin lesions or “rashes” any - skin conditions the where else on the body that may or podiatric practition - may not be similar to what is seen er will encounter are on the feet. TABLE 2 as follows: Unfortunately, most patients do not correlate what is happening on Algorithm Plaque the rest of the body to what is man - Plaque psoria - ifesting on the plantar aspect of the Plaque —® Consider psoriasis, lichen planus, sis presents as an feet. It is the physician’s responsi - eczema erythematous plaque bility to ask the questions in order with a silvery scale. to make that connection. It is help - Scale —® Consider xerosis, tinea pedis, These lesions are ge - ful to ask if the skin has ever been ichythosis, non-inflamed to mildly inflamed ographic, bilateral, biopsied (for example, “did you psoriasis and eczema and symmetrical, have a piece of skin removed and and typically occur Zebra —® Blisters? Bullous diabeticorum, then have stitches?”). A skin scrap - pemphigus, drug reaction on the extensor sur - ing for KOH that was completed by Target lesions? faces. The plaques another physician does not count minor, drug reaction can also be pruritic as a proper biopsy to base the diag - and affect joints as nosis on, as a biopsy of inflamma - well as the nails dur - tory skin disorders should include Continued on page 177

176 PODIATRY MANAGEMENT • APRIL/MAY 2010 www.podiatrym.com M C e o d n i t Wickham’s stri - ca in Differentiating... l u Ed in ae, which is the fine u g c ing the progression of the disease. white lacy overlay on at io Psoriasis can develop either in the plaques, may also be n childhood or as an adult. Besides seen. This skin condition can plaque psoriasis, pustular psoriasis be so pruritic that activities of appears as sterile pustules on the daily living may be compromised. plantar foot. It may also affect the toenails, ap - Plantar pearing anywhere from a proximal plaque and subungual onychomycosis-like pre - pustular pso - Figure 4: Nail involvement in lichen sentation to a thinning of the nail riasis are fre - planus with a ‘wing’ of skin or pteryigium quently mis - pointing distally (Figure 4). 1 Nail diagnosed as arthritic component of psoriasis involvement should be treated im - either vesicu - which may manifest in dactylitis of lar or moc - the digits (sausage toes), enthesitis Figure 1: Nail disease casin tinea of the Achilles tendon, and distal in psoriasis pedis. Due to interphalangeal joint involvement. the fissuring that often accompanies psoriatic Case Example #1 plaques, it has also been misdiag - A young male patient presented nosed as xerosis. If the patient’s to the clinic with a pruritic and current treatment consists of either scaly plantar rash (Figures 2-3) that an oral or topical antifungal, and was mis-diagnosed as tinea pedis at isn’t improving the skin condition the emergency department. He had within the appropriate time frame, presented there for painful fissures Figure 5: Pedal lichen planus a biopsy of the skin, in order to de - on his feet that prevented him termine if a should from walking properly. He was mediately as it can irreversibly scar be used, is warranted. Upon exami - given oral ketoconazole at the ED the nail unit. Lichen planus can nation of one patient, the hands and then presented to the office. A also form lesions in the mouth. 2 were also involved. A skin biopsy of punch biopsy was taken confirming the plantar foot lesion revealed pso - the clinical suspicion of psoriasis, Case Example #2 riasis, and the patient was started and topical therapy A young male presented with was implemented. The patient numerous small plaques and healed unevent - papules that were fully from the extremely pruritic acute flare and (Figure 5). He had presents periodi - Lichen planus been diagnosed cally for mainte - with tinea pedis, nance treatment. is characteristic of and had tried If the patient over-the-counter presents with cir - the “P’s”: plentiful, antifungals with Figure 2: Psoriasis upon first presenta - cular papules or pruritic, purple, no improvement. tion plaques with little During his office or no polished, popular and visit, the extent of on first-line therapy: scale planar lesions that involvement of topical . that the nails and oral Also, if the patient extend are bilateral cavity were noted only presents with ony - proxi - and a diagnosis of chomycosis-like nail in - mally and symmetrical. lichen planus was volvement and has not from made. responded to oral anti - the In addition to fungals, a diagnosis of foot, psoriasis and psoriatic nail disease the differential diagno - lichen planus, a scaly erythematous should be considered. sis of psoriasis that rash with fissures could also be an Another clue to aid in should be considered is eczematous reaction pattern. De - the diagnosis of psoriat - lichen planus. Lichen fined plaques may or may not be ic nails includes exam - planus is characteristic present, but eczema should be a dif - ining for the presence of of the “P’s”: plentiful, ferential diagnosis when consider - erythema peri-ungually, pruritic, purple, pol - ing psoriasis. An eczematous reac - onycholysis, and pitting Figure 3: Psoriasis upon ished, popular and pla - tion that is often seen is atopic der - (Figure 1). 1 Patients may one month of using topi - nar lesions that are bi - matitis. This is usually inherited, as also present with the cal steroid therapy lateral and symmetrical. Continued on page 178 www.podiatrym.com APRIL/MAY 2010 • PODIATRY MANAGEMENT 177 n g o in ti u a n c plantar feet and doesn’t have to be removed from the patient’s regi - ti u Differentiating... n d o E bilateral and symmetrical. men, and topical steroids were C al ic patients will present with a given. The patient’s inflamed skin d e personal or family history of Patch Test resolved in four M asthma, hay fever, and skin rash The patch test weeks. appropriate for their age. It is often done in an aller - described as an “ that gets a gist’s or dermatol - Scale rash” and can’t be described as hav - ogist’s office will Asteatotic eczema Xerotic, or ing a primary lesion as is the case assist in pin-point - is also seen in dry skin, should with psoriasis and lichen planus. 3 ing the allergen have scales pre - Atopic , like the other causing the reac - patients with sent within the forms of eczema, can be described tion. When pa - skin lines on the as having an acute, sub-acute, and tients have a his - dementia who plantar foot. Moc - chronic stage of the disease. During tory of chronic ve - bathe frequently. casin tinea pedis, the acute phase, patients experi - nous insufficiency on the other ence intense pruritus with an ery - with skin that be - hand, usually pre - thematous scaling and oozing skin comes indurated, sents with small rash. Clinically, this can also ap - inflamed, and serpiginous scales pear as dry skin eczema, contact pruritic, venous is plantarly. The most common form dermatitis, stasis dermatitis or even the standard diagnosis. Since stasis of dry skin that is KOH negative en - a dermatophyte infection. Sub- dermatitis is the most common countered on the lower extremity is acute forms of cause of an id reaction on the present with less pruritus, erythe - palmar aspect of the hand, it is ma, scaling, and fissured skin rash. important for the physician to Chronic eczema presents with examine the hands to aid in pruritus, hyper- and hypopigmented the diagnosis. Lastly, plaques of previous inflamed skin, dyshidrotic eczema is a specific scaly and lichenified skin. Due to the condition that should not be severe skin barrier disruption in all an overall term applied to any forms of atopic dermatitis, these pa - inflamed skin condition. Con - tients are susceptible to secondary trary to its name, it is not bacterial infec - linked to tions and this sweat gland Figure 6: Allergic should be consid - dysfunction. ered in the treat - Dyshidrotic termed asteatotic or xerotic eczema. ment plan. Over - Since stasis dermatitis eczema (pom - It can also be termed erythema all, differential di - is the most common pholyx) character - craquele. This is commonly known agnosis for atopic istically has prurit - as “winter itch” due to its increased dermatitis include: cause of an id reaction ic tapioca pud - severity especially during the win - tinea pedis, con - ding-like blisters ter months in the northern part of tact dermatitis, on the palmar aspect on the palmar as - the United States. lichen simplex of the hand, it is pect of the hands Asteatotic eczema commonly chronicus (chron - with minimal foot presents on the anterior aspect of the ic form of atopic) important for the involvement. 4 This and dyshidrosi - physician to examine can be a self-limit - form eczema. ing condition; If the patient the hands to aid in however, most pa - doesn’t fit into tients have debili - having the the diagnosis. tating pain and fis - “triad” of atopic suring that can be dermatitis, other difficult to treat. types of eczema should be considered. Allergic con - Case Example #3 tact dermatitis can occur when a A female patient presented with patient has developed sensitivity to denuded and inflamed skin on the a product (detergent, soap, glue, anterior tibia (Figure 6). She report - dye) after using it for a length of ed that this began after the use of time. Allergic contact dermatitis is a triple ointment. Upon Figure 7: keratoderma climacterum result of an antigen-antibody reac - further history and examination of tion that presents eight to twenty- the patient, a working diagnosis of leg as pruritic, annular, scaling eight days after initial introduction allergic contact dermatitis to the patches. This condition is frequently to the allergen. Contrary to belief, a preservatives in triple antibiotic misdiagnosed as tinea corporis, but is contact dermatitis can occur on the ointment was made. The drug was Continued on page 179

178 PODIATRY MANAGEMENT • APRIL/MAY 2010 www.podiatrym.com M C e o d n i t arch with no underlying erythema These are tender lesions ca in Differentiating... l u Ed in (Figure 8). A biopsy helped to diag - and are usually Nikolsky’s u g c KOH negative. Asteatotic eczema is nose her with psoriasis and the ap - sign positive. at io also seen in patients with dementia propriate therapy commenced. If patients have target lesions n who bathe frequently. Patients can with three zones of color (center le - also develop dry, cracked heels plan - Zebra sion surrounded by a clear zone, tarly which is known as keratoderma If vesicles, bulla, or other skin le - and followed by a red border) asso - climacterum (Fig - sions are present, ciated with circular papules and/or ure 7). the podiatric plaques with mild scaling; one In addition to physician should must consider erythema multi - these environ - consider several forme minor. This is associated mental causes of Dyshidrotic eczema other diagnoses. A after a manifestation of herpes sim - dry skin, the (pompholyx) charac- diabetic patient plex (recent cold sore or genital le - most common in - who presents with sion) and the target lesions may herited form is teristically has pruritic tense blisters that present on the feet. 6 Drug reactions ichthyosis vul - tapioca pudding-like seem to appear may also present as target-like le - garis. These pa - overnight, most sions with less defined target zones tients present blisters on the palmar likely has bullosis of color on the lower extremity. with fish scale- diabeticorum. 5 like dryness that aspect of the hands Bullosis diabetico - First-Line Treatment Options may improve with minimal foot rum may have lit - When treating a condition that with age. tle inflammation is fungal, bacterial, or inflammato - Ichthyosis vul - involvement. present and may ry in nature, the podiatric practi - garis can also be heal uneventfully tioner should use the appropriate acquired and may if the patient does - drug, but if one is unsure of the be associated n’t pop or scratch cause, a biopsy of the skin lesion with diabetes, renal disease, and them. Bullous pemphigoid, com - should be completed. Inflammato - various types of cancer. monly seen in older adults in nurs - ry skin conditions often warrant Circular scales with serpiginous ing homes, will present with subepi - topical corticosteroid therapy as a dermal blisters first line method that originally in treatment. were urticarial It is useful to plaques that avoid combina - turned into tense A diabetic patient who tion steroid-anti - bullae. These le - presents with tense fungal drugs or sions are located methylpred - widespread blisters that seem to nisolone dose throughout the appear overnight, packs as these body on flexural may create a surfaces. most likely has quick fix, but ulti - Nikolsky’s mately can cause sign, or exfolia - bullosis diabeticorum. frustration for the tion of the upper Pemphigus vulgaris is dermatological Figure 8: Psoriatic Scale plantarly layers of epider - patient. The re - mis upon rubbing a chronic disease bound effect from borders are often diagnosed as tinea of the skin, is the dose pack can pedis, but other skin conditions negative and affecting adults which be potentially de - that present as small circular, scaly these lesions can can be life-threatening bilitating by caus - rimmed lesions are pityriasis rosea crust, pigment, ing a dermatitis and secondary syphilis. There have but not scar un - due to its lesions that is worse than also been instances of plantar psori - less excoriated the original reac - asis presenting as scaly skin with no into an ulcer. beginning in the tion, and the dose erythema. Pemphigus vul - mouth and affecting pack itself isn’t garis is a chronic the same as pre - Case Example #4 disease affecting the oro-pharyngeal scribing a true A female patient presented to adults which can area. prednisone taper. the clinic for a second opinion. She be life-threaten - When in had been previously diagnosed as ing due to its le - doubt, the first line having xerosis, but continued to sions beginning therapy for an in - have extreme pruritus that was not in the mouth and affecting the oro- flammatory skin dermatosis should be a controlled by any topical medica - pharyngeal area. Flacid bullae then topical steroid and a skin moisturizer or tion. Her plantar feet had a local - progress to the face, neck, chest, keratolytic (such as urea or lactic acid). ized plaque with scale in the medial groin and intertriginous areas. Continued on page 180 www.podiatrym.com APRIL/MAY 2010 • PODIATRY MANAGEMENT 179 n g o in ti u a n c should be added to decrease trans- References ti u Differentiating... n d 1 Zaiac MN and Daniel CR: “Nails in o l E epidermal water loss and decrease C a 7 ic The stage (acute, sub-acute, flares. If the patient is in the sub- Systemic Disease,” Dermatol Ther, vol d e and 15, 2002, pg 99-106. M 2 chron - Bolognia JL, Jorizzo JL, Rapini RP. Dermatology. Volumes 1 and 2, 1st edi - ic) of TABLE 3 tion, 2003. the skin 3 Brenninkmeijer EE, Schram ME, disorder Topical Steroid Classes Leeflang MM, Bos JD, Spuls PI. Diagnos - and the tic criteria for atopic dermatitis: a sys - length tematic review. Br J Dermatol. Apr of time Class I: Ultra potent 2008;158(4):754-65. the con - Class II: Potent 4 Lofgren SM, Warshaw EM. dition Class III: Upper mid-strength : epidemiology, clinical presents characteristics, and therapy. Dermatitis. Class IV: Mid-strength will aid Dec 2006;17(4):165-81 5 Cantwell AR Jr, Martz W. Idiopathic in the Class V: Lower-mid strength Class VI: Mild bullae in diabetics. Bullosis diabeticorum. level of Arch Dermatol. Jul 1967;96(1):42-4. topical Class VII: Least potent (hydrocortisone) 6 Huff JC. Erythema multiforme and steroid latent herpes simplex infection. Semin which Adapted from the National Psoriasis Foundation Topical Steroids Potency Dermatol. Sep 1992;11(3):207-10. should Chart 7 Cork MJ, Danby S. Skin barrier be used. breakdown: a renaissance in emollient For therapy. Br J Nurs. Jul 23-Aug 12 the severe, acute inflammatory skin acute or chronic stage and a topical 2009;18(14):872, 874, 876-7. concerns, Class 1 drugs should be steroid is warranted for the level of used for two weeks consecutively. irritation and pruritus present, the Some examples of Class 1 steroids practitioner should prescribe the include: clobetasol (Clobex, Olux, appropriate steroid class (Table 3). When in doubt, Temovate), betamethasone (Dipro - The goal in treating inflamma - lene), diflorasone (Psorcon), halobe - tory conditions is to ultimately the first line therapy tasol (Ultravate), fluocinonide have the patient use little to no for an inflammatory (Vanos). topical steroid, and use the previ - In the author’s experience, no ously mentioned skin moisturizers skin dermatosis refills are given due to the side-ef - as maintenance, if possible. If the fects of using a Class I steroid for patient does not respond to the should be a topical longer than four - topical steroid as steroid and a skin teen days. Side- predicted, further effects include consideration of moisturizer or skin thinning or other diagnoses atrophy which Side-effects of using a should be given keratolytic can lead to Class I steroid for and a biopsy (such as urea stretch marks, should be telangiectasias, longer than fourteen planned. If this is or lactic acid). and hypopig - not within the mentation, to days include skin comfort zone of name a few. It is thinning or atrophy the practitioner, helpful to titrate he should then down from a which can lead to refer the patient Class 1 steroid to stretch marks, for a dermatology a mid-potency consult. preparation after telangiectasias, and Overall, in - that initial two flammatory skin week period. hypopigmentation. dermatoses can be For example, challenging and one could have frustrating for the patient use a both the practi - Class 1 steroid on Monday, tioner and patient. By doing a thor - Wednesday, and Friday with the ough history and skin exam, the as - Dr. Vlahovic is an Associate Profes - mid-potency topical steroid for the tute practitioner can create a work - sor at Temple University School of Podi - days in between. ing list of differential diagnoses atric Medicine. The fairly new skin barrier pro - that can be further changed by Ms. Oliver is a fourth year student at tection emollient moisturizers (Im - both reaction to treatment and, of Temple University School of Podiatric pruv lotion, Mimyx, Atopiclair) course, a biopsy result. I Medicine, Philadelphia, PA.

180 PODIATRY MANAGEMENT • APRIL/MAY 2010 www.podiatrym.com M C e o d n i t ca in l u Ed in EXAMINATION u g c at io n See answer sheet on page 183 .

1) All of the following are an ID reaction is: 11) Which of the following is a primary lesions EXCEPT: A) Atopic dermatitis Class 1 steroid?: A) macule (eczema) A) Psorcon (diflorasone) B) bulla B) Irritant contact dermatitis B) Cortaid (hydrocortisone) C) tumor C) Stasis dermatitis C) Aclovate (aclometasone) D) scale D) D) Kenalog (triamcinolone)

2) In plaque psoriasis, which of 7) Which of the following 12) Contact dermatitis: the following best describes the doesn’t the patient need to have A) is bilateral and lesion?: to diagnose of atopic dermatitis symmetrical A) plaque with silver scale (eczema)? B) intensity varies on each B) plaque with yellow scale A) paronychia of great toe limb C) plaque with pustules B) personal history of C) only involves vesicles D) plaque with peeling inside asthma, runny nose, skin rash D) never edge C) pruritis D) chronic relapsing course 13) Dyshidrosic eczema 3) The pustules in palmar/ (pompholyx): plantar psoriasis are filled 8) Asteatotic Eczema (Eczema A) is linked to sweat with: craquele) is associated with: glands A) sterile fluid A) children B) occurs mostly on the B) staph aureus B) high humidity hands C) pseudomonas C) frequent bathing C) first appears as pustules D) strep D) hyperhidrosis D) is a drug reaction

4) Lichen planus can be 9) Bullosa diabeticorum 14) One of the side-effects of described by all of the following (diabetic bullae) usually appear using a Class 1 topical steroid EXCEPT: as ____ blisters on the lower consecutively over the initial A) Peachy extremity. two-week period is: B) Pruritic A) tense A) lichenification C) Purple B) flaccid B) scar formation D) Papular C) pus-filled C) atrophy D) hemorrhagic D) hyperkeratosis 5) The best differential diagnosis for plantar psoriasis is: 10) Pemphigus vulgaris lesions 15) Which of the following is a A) atopic dermatitis most commonly begin in this secondary skin lesion? B) herpes simplex location: A) telangiectasia C) erythema multiforme A) Pretibial B) scale D) neurotic excoriations B) Soles C) papule C) Thighs D) patch 6) The most common cause of D) Mouth Continued on page 182 www.podiatrym.com APRIL/MAY 2010 • PODIATRY MANAGEMENT 181 n g o in ti u a n c ti u n d o E EXAMINATION PM ’s C al ic ed (cont’d) M CPME Program Welcome to the innovative Continuing Education 16) The new skin barrier moisturizers help to Program brought to you by Podiatry Management reduce flare by: Magazine . Our journal has been approved as a A) decreasing trans-epidermal water loss sponsor of Continuing Medical Education by the B) increasing trans-epidermal water loss Council on Podiatric Medical Education. C) decreasing T-cell lymphocyte involvement Now it’s even easier and more convenient D) increasing T-cell lymphocyte to enroll in PM’s CE program! involvement You can now enroll at any time during the year and submit eligible exams at any time during your enrollment period. 17) The target lesion in erythema multiforme PM enrollees are entitled to submit ten exams minor has __ zone(s) of color: published during their consecutive, twelve–month A) 1 enrollment period. Your enrollment period begins B) 2 with the month payment is received. For example, C) 3 if your payment is received on September 1, 2006, D) 4 your enrollment is valid through August 31, 2007. If you’re not enrolled, you may also submit any 18) A differential diagnosis for tinea pedis exam(s) published in PM magazine within the past would be: twelve months. CME articles and examination A) pityriasis rosea questions from past issues of Podiatry Man - agement can be found on the Internet at B) erythema multiforme minor http://www.podiatrym.com/cme. Each lesson C) nevi is approved for 1.5 hours continuing education con - D) stretch mark tact hours. Please read the testing, grading and pay - ment instructions to decide which method of partici - 19) Dyshidrotic eczema has vesicles that can pation is best for you. be described as: Please call (631) 563-1604 if you have any ques - A) grapefruit-like tions. A personal operator will be happy to assist you. B) tapioca-like Each of the 10 lessons will count as 1.5 credits; C) peau d’orange-like thus a maximum of 15 CME credits may be earned during any 12-month period. You may se - D) raspberry-like lect any 10 in a 24-month period.

20) The latest treatment for inflammatory skin The Podiatry Management Magazine CME dermatoses involves prescribing: program is approved by the Council on Podiatric A) a topical steroid and a moisturizer Education in all states where credits in instruction - B) a topical steroid and an NSAID al media are accepted. This article is approved for C) a topical steroid and sunscreen 1.5 Continuing Education Contact Hours (or 0.15 D) a topical steroid and diphenhydramine CEU’s) for each examination successfully completed.

Home Study CME credits now See answer sheet on page 183 . accepted in Pennsylvania

182 PODIATRY MANAGEMENT www.podiatrym.com £ M C e o d n i t ca in l u Ed in Enrollment/Testing Information u g c at io and Answer Sheet n Note: If you are mailing your answer sheet, you must complete exam during your current enrollment period. If you are not en - all info. on the front and back of this page and mail with your rolled, please send $20.00 per exam, or $139 to cover all 10 exams credit card information to: Podiatry Management , P.O. Box (thus saving $61* over the cost of 10 individual exam fees). 490, East Islip, NY 11730. Facsimile Grading To receive your CPME certificate, complete all information and TESTING, GRADING AND PAYMENT INSTRUCTIONS fax 24 hours a day to 1-631-563-1907. Your CPME certificate will (1) Each participant achieving a passing grade of 70% or be dated and mailed within 48 hours. This service is available for higher on any examination will receive an official computer form $2.50 per exam if you are currently enrolled in the annual 10-exam stating the number of CE credits earned. This form should be safe - CPME program (and this exam falls within your enrollment period), guarded and may be used as documentation of credits earned. and can be charged to your Visa, MasterCard, or American Express. (2) Participants receiving a failing grade on any exam will be If you are not enrolled in the annual 10-exam CPME pro - notified and permitted to take one re-examination at no extra cost. gram, the fee is $20 per exam. (3) All answers should be recorded on the answer form below. For each question, decide which choice is the best an - Phone-In Grading swer, and circle the letter representing your choice. You may also complete your exam by using the toll-free ser - (4) Complete all other information on the front and back of vice. Call 1-800-232-4422 from 10 a.m. to 5 p.m. EST, Monday this page. through Friday. Your CPME certificate will be dated the same day (5) Choose one out of the 3 options for testgrading: mail-in, you call and mailed within 48 hours. There is a $2.50 charge for fax, or phone. To select the type of service that best suits your this service if you are currently enrolled in the annual 10-exam needs, please read the following section, “Test Grading Options”. CPME program (and this exam falls within your enrollment peri - od), and this fee can be charged to your Visa, Mastercard, Ameri - TEST GRADING OPTIONS can Express, or Discover. If you are not currently enrolled, the fee Mail-In Grading is $20 per exam. When you call, please have ready: To receive your CME certificate, complete all information 1. Program number (Month and Year) and mail with your credit card information to: 2. The answers to the test Podiatry Management 3. Your social security number P.O. Box 490, East Islip, NY 11730 4. Credit card information There is no charge for the mail-in service if you have already In the event you require additional CPME information, enrolled in the annual exam CPME program, and we receive this please contact PMS, Inc., at 1-631-563-1604 .

ENROLLMENT FORM & ANSWER SHEET

Please print clearly...Certificate will be issued from information below.

Name ______Soc. Sec. #______Please Print: FIRST MI LAST Address______City______State______Zip______Charge to: _____Visa _____ MasterCard _____ American Express Card #______Exp. Date______Note: Credit card is the only method of payment. Checks are no longer accepted. Signature______Soc. Sec.#______Daytime Phone______State License(s)______Is this a new address? Yes______No______

Check one: ______I am currently enrolled. (If faxing or phoning in your answer form please note that $2.50 will be charged to your credit card.) ______I am not enrolled. Enclosed is my credit card information. Please charge my credit card $20.00 for each exam submitted. (plus $2.50 for each exam if submitting by fax or phone). ______I am not enrolled and I wish to enroll for 10 courses at $139.00 (thus saving me $61 over the cost of 10 individual exam fees). I understand there will be an additional fee of $2.50 for any exam I wish to submit via fax or phone. Over, please 183 £ t’d) con ( www.podiatrym.com EET SH s i s o n g a i D exam SWER ) r n? this l a c e N v i ed l t n lesso i g o A e O l o the #4/10 m t t a & complet d n a M a e N r A m r c i you T X IO complete E d e D v o RM _____ to date g n a h a l the you n i t 2010 FO V ( educational T LUA A EV a i t cate take n T its it : indi all ON e r le eve e did at hi c ir ease APRIL/MAY ESS me ac L Pl C • ti f f i D lesson? ____Well his t ENT lesson exams: much LLM EN ______s ______minutes s _____ thi ______Not assign d How future RO di hour for you MANAGEM at well well Y uld EN ions ______

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