SKINTEST Skin Test Christina P. Linton 1. A middle-aged, diabetic woman presents with 6. What is the estimated 5-year survival rate for well-demarcated, yellow-brown, atrophic, telangiectatic melanoma that has spread beyond the original area plaques with a raised, violaceous border on her shins. of involvement to the nearby lymph nodes (but What is the most likely diagnosis? not to distant nodes or organs)? a. Lipodermatosclerosis a. 25% b. Pyoderma gangrenosum b. 41% c. Necrobiosis lipoidica c. 63% d. Erythema nodosum d. 87% 2. Which of the following types of fruit is most likely 7. What is another name for leprosy? to cause phytophotodermatitis? a. von Recklinghausen’s disease a. Pineapple b. MuchaYHabermann disease b. Grapefruit c. Schamberg’s disease c. Kiwi d. Hansen’s disease d. Peach 8. Which of the following is not an expected 3. Hypothyroidism can cause several changes to the skin extracutaneous finding in patients with and skin appendages including all of the following, HenochYScho¨ nlein purpura? except: a. Abdominal pain a. Hyperpigmentation b. Hematuria b. Easy bruising c. Shortness of breath c. Thin, brittle nails d. Arthralgias d. Dry, coarse skin 9. When the term ‘‘papillomatous’’ is used to describe 4. In a patient with neurofibromatosis, which sign refers a skin lesion, it means that the lesion is to the presence of bilateral axillary freckling? a. characterized by multiple fine surface projections. a. Auspitz sign b. erupting like a mushroom or fungus. b. Crowe sign c. characterized by fine fissures and cracks in the skin. c. Russell sign d. sieve like and contains many perforations. d. Gorlin sign 10. Which systemic medication can cause whip-like, linear, 5. Which of the following keratinization disorders is erythematous wheals that are similar in appearance inherited in an autosomal recessive fashion? to shiitake dermatitis? a. Darier disease a. Pimecrolimus b. Ichthyosis vulgaris b. Bleomycin c. HaileyYHailey disease c. Dapsone d. Lamellar ichthyosis d. Cyclosporine Readers are encouraged to submit Skin Test questions to be considered for future issues. Please submit as many or as few questions as you would like (with answers and references) to [email protected]. Thank you. VOLUME 7 | NUMBER 6 | NOVEMBER/DECEMBER 2015 373 Copyright © 2015 Dermatology Nurses' Association. Unauthorized reproduction of this article is prohibited. SKINTEST ANSWERS 3. a. Hyperpigmentation. Hyperpigmentation is not associated with hypothyroidism, but localized and 1. c. Necrobiosis lipoidica. Necrobiosis lipoidica be- generalized hyperpigmentation can occur in individ- gins with brownish-red papules and nodules that uals with hyperthyroidism. Individuals with hypo- slowly evolve and flatten to form well-demarcated, thyroidism often have hair that grows slowly and yellow-brown, atrophic plaques in which telangiec- tends to be dull, coarse, and brittle. In addition, af- tasias are often visible. These lesions have a raised, fected individuals may experience alopecia on the violaceous, irregular border and are described as ap- lateral third of their eyebrows. Nail changes associ- pearing glazed or glistening. The pretibial region is ated with hypothyroidism include thin, brittle, striated most commonly affected. Other sites of predilection nails; slow growth rate; and rarely, onycholysis. Other include the ankles, calves, thighs, and feet. Involve- cutaneous manifestations of hypothyroidism include ment of the trunk and upper extremities is rare but dry, rough, coarse skin; cold, pale skin; myxedema; possible. Most lesions are asymptomatic. About 60% yellow discoloration (carotenemia); and easy bruis- of affected individuals also have diabetes, and women ing. In contrast, cutaneous manifestations of hyper- are three times more commonly affected than men. thyroidism include velvety, smooth skin; warm, moist The course of necrobiosis lipoidica is often indolent skin because of increased sweating; hyperpigmen- and unresponsive to treatment. Erythema nodosum tation; pruritis; onycholysis; and mild, diffuse alopecia. is the most common panniculitis and the prototyp- Bolognia, J. L., Jorizzo, J. L., & Schaffer, J. V. (2012). Dermatology (3rd ed.). ical septal panniculitis. It presents with an eruption St. Louis, MO: Elsevier/Mosby. of bilateral, symmetrical, deep, tender nodules and 4. b. Crowe sign. Crowe sign refers to the bilateral ax- plaques 1Y10 cm in diameter, usually on the pretibial illary freckling that is seen in neurofibromatosis. Auspitz area and lateral shins. It is an acute condition that sign refers to the appearance of pinpoint areas of can result from various medications, infections, or bleeding when scale is removed from psoriatic plaques. other precipitating factors. Lipodermatosclerosis Russell sign refers to erosions and sometimes thickening (also called sclerosing panniculitis) is characterized of the metacarpophalangeal and interphalangeal joints by indurated, woody plaques with erythema, edema, on the dorsum of the hand as seen in patients with telangiectasia, and hyperpigmentation involving the lower legs with a stocking distribution. It is a anorexia bulimia nervosa. Gorlin sign refers to the ability to touch the tip of the nose with the tip of the chronic disorder usually associated with chronic ve- tongue and is associated with EhlersYDanlos syndrome. nous insufficiency. Pyoderma gangrenosum is a rare inflammatory disease of unknown etiology that is Ko, J., Hawryluk, E., & Taylor, C. R. (2011). Part II: High-yield dermatologic characterized by neutrophilic infiltration of the der- signs. Journal of Drugs in Dermatology, 10(2), 197Y198. mis and tissue destruction. The clinical appearance 5. d. Lamellar ichthyosis.Lamellarichthyosisisinher- is highly variable and can generally be categor- ited through an autosomal recessive pathway. Af- ized as being either ulcerative, bullous, pustular, or fected neonates are encased in a collodion membrane vegetative. with underlying erythroderma that is gradually re- James, W. D., Berger, T. G., & Elston, D. M. (2011). Andrews’ diseases of placed by large scales. Lamellar ichthyosis persists un- the skin: Clinical dermatology (11th ed.). Philadelphia, PA: Saunders/ remittingly throughout life and is characterized by Elsevier. large, dark-brown, and plate-like scales that form a Wolff, K., Goldsmith, L. A., Katz, S. I., Gilchrest, B. A., Paller, A. S., & Leffell,D.J.(2008).Fitzpatrick’s dermatology in general medicine (7th ed.). mosaic or bark-like pattern with minimal-to-no ery- New York, NY: McGraw-Hill Medical. throderma. Darier’s disease is an autosomal domi- nantly inherited condition that begins with small, 2. b. Grapefruit. Phytophotodermatitis is a reaction firm papules that are almost the color of normal caused by the combination of a topical photosen- skin. Over time, these lesions darken, develop a greasy sitizing agent and subsequent exposure to the ap- gray-brown-colored crust, and tend to coalesce into propriate wavelength of ultraviolet radiation. This patches. Commonly affected areas include the neck, combination results in an inflammatory reaction con- shoulders, face, extremities, front of the chest, and sisting of erythema, with or without blistering, and midline of the back. Ichthyosis vulgaris is inherited delayed hyperpigmentation. Foods that belong to in an autosomal semidominant manner with many the plant families most likely to cause phytophoto- cases of incomplete penetrance. Affected individuals dermatitis include celery, fennel, parsnip, parsley, usually develop dry skin and mild-to-moderate scal- wild rhubarb, grapefruit, some limes, some oranges, ing in early childhood that is most prominent on the and some lemons. extensor surfaces of the extremities. Other cutaneous Bolognia, J. L., Jorizzo, J. L., & Schaffer, J. V. (2012). Dermatology (3rd ed.). findings often include accentuated skin markings and St. Louis, MO: Elsevier/Mosby. hyperkeratosis of the palms, keratosis pilaris, and 374 Journal of the Dermatology Nurses’ Association Copyright © 2015 Dermatology Nurses' Association. Unauthorized reproduction of this article is prohibited. SKINTEST atopic changes. HaileyYHailey disease (also called triggers for HSP include a viral or streptococcal pha- familial benign chronic pemphigus) is an autosomal ryngitis, bacterial infections, foods, drugs, and dominant dermatosis characterized by a persistently lymphoma. In about 40% of cases, the cutaneous recurrent bullous and vesicular dermatitis on the sides manifestations are preceded by mild fever, joint of the neck, axillae, and intertriginous areas. The symptoms, and abdominal pain for up to 2 weeks. lesions usually develop during the second or third Arthralgias occur in 74%Y84% of cases and often decade but may be delayed until the fourth or fifth progress to periarticular swelling around the knees decade. The initial lesion is a flaccid vesicle on ery- and ankles. Abdominal pain occurs in 61%Y76% of thematous or normal skin that ruptures easily and is affected individuals, and complications such as gas- therefore often overlooked. The blisters give rise to trointestinal bleeding, paralytic ileus, vomiting, and macerated or crusted erosions, which tend to spread distension may occur. Renal disease occurs in 44%Y47% peripherally, producing a circinate or figurate border of cases, and about 25% of patients have microscopic with crusts and small vesicles. or gross hematuria. Progressive glomerular disease and renal failure may develop in a small percentage Bolognia, J. L., Jorizzo, J. L., & Schaffer,