Skin Test Christina P

SKINTEST Skin Test Christina P. Linton

1. What is the typical rate at which the eruption of 6. Which of the following growths is not classified as cutaneous larva migrans progresses? a hamartoma? a. About 0.5 cm per day a. Trichofolliculoma b. About 2 cm per day b. Nevus sebaceous c. About 1 cm per week c. Dermatofibroma d. About 5 cm per week d. Chondroid syringoma

2. Under which of the following circumstances do 7. By what age does the marked freckling associated pruritic urticarial papules and plaques of pregnancy with xeroderma pigmentosum most commonly (PUPPP) most commonly occur? occur? a. Primagravida, first trimester a. 9 months old b. Multigravida, first trimester b. 2 years old c. Primagravida, third trimester c. 5 years old d. Multigravida, third trimester d. 10 years old

3. Approximately what percentage of hair follicles 8. Which of the following medications is least likely to are in the active growth (anagen) phase on a place patients at risk for developing StevensYJohnson normal scalp? syndrome or toxic epidermal necrolysis? a. 30% a. Furosemide b. 50% b. Sulfamethoxazole c. 70% c. Allopurinol d. 90% d. Carbamazepine

4. Which of the following sutures is associated with 9. What is the appropriate term for describing excessive the least intense tissue inflammatory response? longitudinal ridging of the nails? a. Nylon a. Beau’s lines b. Catgut b. Koilonychia c. Silk c. Muehrcke’s lines d. Cotton d. Trachyonychia

5. In a patient with psoriatic arthritis, which of the 10. In which condition would a positive Nikolsky sign following features would be an expected finding? not be expected? a. Symmetrical joint involvement a. Porphyria cutanea tarda b. All of the joints in one digit are affected b. Staphylococcal scalded-skin syndrome c. Initial involvement of five or more joints c. Pemphigus vulgaris d. Affected joints are swollen without erythema d. Toxic epidermal necrolysis

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ANSWERS James, W. D., Berger, T. G., & Elston, D. M. (2011). Andrews’ diseases of the skin: Clinical dermatology (11th ed.). Philadelphia, PA: Saunders/Elsevier. Y 1. b. About 2 cm per day. In cutaneous larva 3. d. 90%. Approximately 90% 93% of scalp follicles migrans, the life cycle of the parasites begins when are in the active growth (anagen) phase, which lasts Y eggs are passed from animal feces into warm, for 2 8 years. Catagen is the involution stage in moist, sandy soil, where the larvae hatch and molt between the anagen and telogen phases. During this twice before the infective third stage. By using phase, massive keratinocyte apoptosis leads to in- their proteases, larvae penetrate through follicles, volution of the lower two thirds of the hair follicle, Y Y fissures, or intact skin of the new host where they shortening scalp follicles from 2 5mmto0.25 0.5 mm. shed their natural cuticle and begin migration Most follicles that are not in the anagen phase are in within a few days. In animal hosts, the larvae are the resting (telogen) phase in which the hairs are able to penetrate into the dermis and are transported prepared for expulsion. Approximately 1% of the to the lungs where they break through into the telogen follicles are in the exogen phase, meaning alveoli, migrate to the trachea, are swallowed, and that they are shedding their hair shafts. mature sexually in the intestine, and their eggs are Goldsmith, L. A., Katz, S. I., Gilchrest, B. A., Paller, A. S., Leffell, D. J., & then excreted. Within humans, the larvae lack the Wolff, K. (2012). Fitzpatrick’s dermatology in general medicine (8th ed.). New York, NY: McGraw-Hill Medical. collagenase needed to penetrate the basement membrane and invade the dermis; therefore, the 4. a. Nylon. Sutures made from natural products like larvae remain limited to the skin. The larvae are silk, catgut, and cotton are associated with high tis- acquired through activities such as going barefoot at sue reactivity (the degree of the tissue’s inflamma- the beach, playing in sandboxes, carpentry or tory response to the suture). Most other sutures are plumbing under homes, and gardening. The most made from synthetic fibers and cause low amounts commonly affected areas are the feet, buttocks, of tissue reactivity, including nylon (Ethilon, genitals, and hands. Shortly after inoculation, Dermalon, Nurolon, Surgilon), polypropylene slightly pruritic papules appear, and as the larvae (Prolene, Surgilene, Surgipro), and polyester (Dacron, begin to burrow, they create thin, linear, twisting, Mersilene, Ethibond) sutures. winding lines. The tortuous linear lesions are often New Zealand Dermatological Society Incorporated. (2012). Suture materials. interrupted by papules that mark the site of resting Retrieved from http://www.dermnetnz.org/procedures/sutures.html; larvae. Migration generally begins 4 days after Goldsmith, L. A., Katz, S. I., Gilchrest, B. A., Paller, A. S., Leffell, D. J., & Wolff, K. (2012). Fitzpatrick’s dermatology in general medicine (8th ed.). inoculation, although the larvae may remain quies- New York, NY: McGraw-Hill Medical. cent for several days or months. The larvae progress at a rate of about 2 cm per day, and as the eruption 5. b. All of the joints in one digit are affected. Psoriatic advances, old parts tend to fade. If left untreated, the arthritis typically manifests with asymmetric joint larvae usually die in 2Y8 weeks, with resolution of involvement and commonly affects all of the joints the eruption, although rarely it has been reported to in one digit whereas the others remain free of ar- persist for up to 1 year. thritis. It is an inflammatory arthritis that typically manifests with swelling and overlying erythema of James, W. D., Berger, T. G., & Elston, D. M. (2011). Andrews’ diseases of the skin: Clinical dermatology (11th ed.). Philadelphia, PA: Saunders/ the affected joints. Psoriatic arthritis has a gradual Elsevier; Robles, D. T. (2011). Cutaneous larva migrans. Retrieved from onset and usually begins as an oligoarthritis (four or http://emedicine.medscape.com/article/1108784-overview fewer joints) that may progress to a polyarticular 2. c. Primagravida, third trimester. The term ‘‘pru- (more than four joints) disease. About half of the ritic urticarial papules and plaques of pregnancy’’ affected individuals experience morning stiffness (PUPPP) was first used by Lawley et al in 1979. that lasts for more than 60 minutes and gets better The eruption is characterized by erythematous with activity. Enthesitis (inflammation at the site of papules and plaques that begin as 1- to 2-mm tendon or ligament insertion into the bone) is pres- lesions within the abdominal striae. They then ent in up to 42% of patients and most commonly spread over the course of a few days to involve the involves the attachment of the Achilles tendon or the abdomen, buttocks, thighs, and in some cases, plantar fascia to the calcaneus. Dactylitis (uniform arms and legs. The lesions coalesce to form swelling of a digit, also called ‘‘sausage digit’’) urticarial plaques, and intense pruritis is charac- occurs in up to 49% of individuals and results from teristic. Most cases occur in primagravidas and simultaneous involvement of all three joints and rarely recur with subsequent pregnancies. Onset is tenosynovitis of the involved digit. generally late in the third trimester, and delivery Garg, A., & Gladman, D. (2010). Recognizing psoriatic arthritis in the results in resolution. Fetal and maternal outcomes dermatology clinic. Journal of the American Academy of Dermatology, are not affected. 63(5), 733Y748.

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6. c. Dermatofibroma. Dermatofibromas are detachment. Drugs that are considered to have a fibrohistiocytic tumors, which, unlike hamartomas, high risk for developing this type of reaction are considered a neoplastic growth. Hamartomas include allopurinol, sulfamethoxazole, sulfadiazine, are benign proliferations composed of cellular ele- sulfapyridine, sulfadoxine, sulfasalazine, carba- ments, normal to a given site, in aberrant propor- mazepine, lamotrigine, phenobarbital, phenytoin, tion. Hamartomas can be congenital, such as nevus phenylbutazone, nevirapine, oxicam, Nonsteroidal sebaceous, or acquired, such as trichofolliculoma anti-inflammatory drugs, and thiacetazone. or chondroid syringoma. Goldsmith, L. A., Katz, S. I., Gilchrest, B. A., Paller, A. S., Leffell, D. J., & Wolff, K. (2012). Fitzpatrick’s dermatology in general medicine (8th ed.). Bolognia, J. L., Jorizzo, J. L., & Schaffer, J. V. (2012). Dermatology (3rd ed.). New York, NY: McGraw-Hill Medical. St. Louis, MO: Elsevier/Mosby. 7. b. 2 years old. In most patients with xeroderma 9. d. Trachyonychia. The term trachyonychia is used pigmentosum, marked freckling of sun-exposed to describe rough, often thin, nails because of ex- areas usually occurs before 2 years old. More than cessive longitudinal ridging. If all nails are affected, half of the individuals with this condition have a the term ‘‘twenty nail dystrophy’’ is often used. history of acute sunburn reaction with blistering Causes include lichen planus, alopecia areata, or persistent erythema after minimal ultraviolet psoriasis, and dermatitis. Beau’s lines are transverse exposure. Ophthalmologic involvement in xeroderma depressions or grooves that move distally with nail pigmentosum is almost as common as the cutaneous growth. They occur because of the temporary abnormalities, with the onset of symptoms at around interruption of nail matrix activity. Involvement of 4 years old. About 30% of patients with xeroderma a single nail usually indicates trauma, whereas pigmentosum experience progressive neurologic de- multiple nail involvement indicates a systemic cause generation. The earliest clinical signs of neurologic such as severe or febrile illness, erythroderma, or involvement are diminished or absent deep tendon certain medications. The term koilonychia refers to reflexes and high-frequency hearing loss. These may thin, concave, spoon-shaped nails that are usually occur in infancy or be delayed until the second decade physiologic in children and occupational or associ- of life. Other neurologic findings include microceph- ated with iron deficiency anemia in adults. aly, progressive intellectual deterioration, spasticity, Muehrcke’s lines are paired, narrow, white trans- ataxia, or seizure. Xeroderma pigmentosum is an verse bands, separated from each other and the example of accelerated photoaging, and among lunula by strips of pink nail. They are an abnor- affected individuals who are 20 years old or younger, mality of the nail bed that is associated with there is a greater than 1,000-fold increased risk of hypoalbuminemia and chemotherapy and do not cutaneous basal cell carcinoma, squamous cell carci- grow out with the nail. noma, or melanoma. Patients with this condition also Linton, C. P. (2012). Describing nail abnormalities. Journal of the Dermatology have an approximately 10- to 20-fold increase in Nurses’ Association, 4(2), 149Y150. internal malignancies, including cancer of the brain, 10. a. Porphyria cutanea tarda. The vesicles and lungs, hematopoietic system, kidney, and gastroin- bullae of porphyria cutanea tarda result from a testinal tract. More severely affected patients tend to subepidermal process and are not associated with die of neoplastic complications by 20 years old. a positive Nikolsky sign. Nikolsky sign is positive Chantorn,R.,Lim,H.W.,&Shwayder,T.A.(2012).Photosensitivity when lateral pressure on normal-appearing skin at disorders in children: Part II. Journal of the American Academy of Dermatology, 67(6), 1113.e1Y1113.e15. the periphery of active lesions results in shearing away of the epidermis. This easy detachment of 8. a. Furosemide. Although furosemide has been im- the epidermis is noted in blistering disorders in plicated in a few case studies as a potential cause of which the pathology is above the basement StevensYJohnson syndrome or toxic epidermal membrane zone. These conditions include staph- necrolysis, it is not considered to be a high-risk ylococcal scalded-skin syndrome, pemphigus medication. These two severe drug reactions are vulgaris, and toxic epidermal necrolysis. characterized by erythematous macules of the skin Goldsmith, L. A., Katz, S. I., Gilchrest, B. A., Paller, A. S., Leffell, D. J., & and mucous membranes that evolve progressively Wolff, K. (2012). Fitzpatrick’s dermatology in general medicine (8th ed.). into confluent flaccid blisters that lead to epidermal New York, NY: McGraw-Hill Medical.

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