Dermatology

Blueprint Physician Assistant Board Review

Eczematous Eruptions
-Contact Dermatitis

-delayed hypersensitivity reaction
-well demarcated plaques of erythema and edema
-may have some vesicles (acutely)
-Subacute/Chronic-may have some plaques of erythema, dry scales, or desquamation
-May have plaques of lichenification
-Treatment-to remove offending agent if able to isolate
-Topical steroids in mild cases
-Severe cases may require systemic corticosteroids for 2 weeks (tapered)
-Burrows solution on wet dressing may be helpful

-Atopic Dermatitis

-Type I Hypersensitivity reaction

-Lesions may be present for months to years
-Poorly defined erythematous patches
-Chronically the lesions may have some lichenification with excoriation marks
-Fissured areas with painful areas are possible
-May have associated allergic rhinitis or asthma
-Topical anti itch lotions are helpful
-Patients may need low potency steroid ointment at times
-Wet dressings
-UVA and UVB light may be helpful for chronic and subacute

-Dyshidrosis

-sweating does not play a role
-rash presents as vesicles in clusters in early phases
-later phases scaling and painful fissures and crusting
-80% on hands and feet
-Treatment involves high potency topical glucocorticoids for 1-2 weeks
-Burrows solution maybe helpful with wet dressings in early stages
-For severe cases systemic glucocorticoids is necessary over 1-2 weeks (tapered)

-Lichen Simplex Chronicus


-Predilection of the skin that responds to trauma by epidermal hyperplasia
-Skin becomes hypersensitive and nerves and epidermis proliferate
-Itches
-Solid plaque of of lichenification from a confluence of small papules
-Scaling is minimal
-Skin feels thickened
-Areas of distribution scalp, ankles, lower thighs, exterior forearms, vulva, neck , scrotum and groin
-Occlusive dressings are helpful
-Can inject with triamcinolone
-Combination of crude tar in zinc oxide and topical glucocorticoids is helpful


Papulosquamous Diseases
-Drug Eruptions-

-Exact mechanism is unknown but likely a delayed hypersensitivity reaction
-In a previously sensitized patient, eruption starts within 2-3 days of given the drug
-Peak incidence is approximately 9 days after administration of the medication
-Very pruritic lesions and painful
-Macules and papules on lower legs and may progress to the whole body
-Lesions are bright red color
-Meds that can cause: penicillins, sulfa, NSAIDS, Barbiturates, Nitrofurantoin, Isoniazid,
Benzodiazepines, Phenothiazines, Carbamazepine, Allopurinol, Gold Salts
-Need to stop the medication

-Oral antihistamines
-Oral or IV Glucocorticoids
-Potent Topic Glucocorticoids can help prevent the spread of the rash
-Label patient as allergic to that medication and or class of medications

-Lichen Planus

-idiopathic in most cases
-Also caused by drugs (gold), or infection (HCV) results in cell mediated immunity
-Lesions last months to years
-The 5 Ps of Lichen Planus-Purple
-Polygonal
-Papules
-Pruritic
-Planar

-Topical corticosteroids or intra-lesional injection with triamcinolone
-Cyclosporin mouth wash may be helpful for those with oral lesions
-Systemic corticosteroids or cyclosporin for severe cases
-Systemic retinoids & PUVA if needed

-Pityriasis Rosea


-Herald patch precedes the exanthem phase
-Fine papules and plaques dull tawny oval exanthem that are scattered
-Christmas tree pattern
-Etiology unknown but Herpes 7 is suspected
-May last 6-12 weeks
-Oral antihistamines and topical glucocorticoids
-Short course of glucocorticoids may help

-Psoriasis-



-there is an overproduction of epidermal cells by 28 times normal
-Salmon pink papules and plaques sharply marginated with silvery scale
-Can be bilateral and symmetrical
-Psoriatic arthritis incidence 5-8%
-Topical treatment with fluorinated glucocorticoids in ointment base
-Small plaques triamcinolone aqueous suspension
-Vitamin D Analogues
-Topical retinoid Tazarotene
-When there is >10% TBSA PUVA or UVB therapy is indicated
-Scalp-Clobetasol lotion
-Methotrexate for more severe cases and cyclosporin or immune modulators
Desquamation
-Erythema Multiforme


-Etiology
-Infection (HSV most common) and mycoplasma
-Drugs (PCN, Sulfonamides, Dilantin, and Allopurinol)
-Connective tissue disease
-Physical agents
-Pregnancy
-Malignancy
-Idiopathic is actually the most common etiology

-Target shaped lesions are classic
-Lesions are most common on the face and extremities

-Ranges from mild (EM minor) to severe (EM major)
-Minor-little or no mucus membrane involvement, vesicles but no systemic symptoms. Likes extensor
surfaces of extremities with target shaped lesions
-Erythema Multiform Major-most commonly from a drug reaction. Has mucus membrane involvement,
tendency for lesions to become confluent and bullous, fever, may have conjunctivitis, and ulcerations in
larynx and trachea.
-Maximal Variant-life-threatening

-Stevens-Johnson Syndrome


-Consider a severe form of erythema Multiforme
-Lesions are more diffuse
-10% or less epidermal detachment
-Effects the mucus membranes (eyes, mouth, genitalia)
-Most often seen in children and young adults
-Usually preceded by URI symptoms
-Etiologies-50% are associated with drug exposure (sulfa, allopurinol, carbamazepine, penicillins, cephalosporins,
vancomycin, rifampin, ibuprofen, naproxen, and fluoroquinolones. Etiologies in not clear)
-chemicals
-infections- mycoplasma, viral infections, and immunizations
-Definitive diagnosis is skin biopsy
-Management-admit to burn center and ICU, IV Fluid replacement, Parkland Formula, Corticosteroids
may or not be helpful, immunoglobulins, deride necrotic skin

-Toxic Epidermal Necrolysis (TEN)

-Full thickness loss of epidermis
-Usually greater than 30% of body surface are and dermal detachment
-Tends to involve mucus membranes
-Patients should be in a burn unit
-Risk of infection
-Electrolyte disturbance
-Fatalities are common
-80% of cases related to medication however 5% report no med use

-Chemicals can cause

-Also infections mycoplasma, viral infections and immunizations
-Management-admit to burn center and ICU, IV Fluid replacement, Parkland Formula, Corticosteroids
may or not be helpful, immunoglobulins, deride necrotic skin


Vesicular Bullae
-Bullous Pemphigoid

-comes from interaction of the autoantibody with bullous pemphigoid antigen on the surface of the
keratinocytes
-Bullous lesion comes from multiple molecules released from mast cells and eosinophils
-prefers the axillae, medial aspects of the thighs, groin, abdomen, arms and legs (flexor surfaces)
-Diagnosis is made by skin biopsy
-Treatment-Prednisone 50-100 mg daily until clear combined with azathoprine 150 mg daily
-Tetracycline have been effective in some cases


Acneiform Lesions
-Acne Vulgaris

-results from a change in keratinization pattern in the hair follicle. The secretion of sebum is then blocked
-lesions are complex interaction between hormones and bacteria
-When the follicle has a portal of entry at the skin a semisolid mass protrudes and this is called a
blackhead

-Prefers sites of face, neck, upper arms, trunks and buttocks

-Mild acne-topical antibiotics (Clindamycin), Benzoyl Peroxide, and Topical Retinoids (Tretinoin)
-Moderate Acne-oral antibiotics (Minocycline) is added to above it treatment fails. Females can add
high does of estrogens
-Severe acne-isotretinoin inhibits sebaceous gland function and keratinization










-Rosacea

-patients usually have a long history of reddening of the face with increases of temperature in response to
heat stimuli in the mouth
-Exposure to heat may cause exacerbations
-Acne may precede the onset of rosacea

-Stage I-Persistent erythema with telangiectases
-Stage II-Persistent erythema with telangiectases, papules and tiny pustules
-Stage III-Persistent deep erythema, dense telangiectases, papules, pustules, nodules, and solid edema

-Treatment-Topical metronidazole gel or cream. Sodium Sulfacetamide. Topical erythromycin
-Systemic-Tetracycline or minocycline
-oral isotretinoin maybe helpful for refractory cases


Verrucous Lesions

-Actinic Keratosis


-Single or multiple discrete dry rough, adherent scaly lesions on sun exposed areas.
-Occurs in adults
-Treatment is removal. 5 FU ointment also helpful.

-Seborrheic Keratosis:

-Usually see after the age of 30
-Early Stages-barely elevated papule
-Treatment is removal if patient is bothered by them


Infections/Parasites
-Lice


-two types of lice that are obligate parasites in humans: pediculus humanus and phithirius pubis
-commonly spread by direct contact between individuals or indirectly by contact with bedding, brushes or
clothing.
-body lice is associated with poor socioeconomic conditions
-pubic lice is typically transmitted sexually
-pubic lice may not be transmitted sexually also. Transmitted from pubic lice in hair on head and back
-itches and excoriations can get infected.
-Pediculosis Capitis-lice infection of the scalp
-Pediculosis Pubis-pubic lice
-Treatment avoid contact with contaminated items, environment should be vacuumed. Permethrin,
Malathion, Lindane

-Scabies

-caused by Sarcoptes scabei
-hypersensitivity reaction of both immediate and delayed types occur in the development of lesions other
than burrows
-persons with their first infection, sensitization takes several weeks to develop. If it is a re-infection,
itching may occur within twenty four hours
-lesions usually prefer the webspace and spare the head and neck
-Treatment-Permetherin 5% cream, Lindane


-Spider Bites


-can easily be confused with a MRSA infection
-most spiders are harmless except brown recluse spider and the black widow spider
-can cause rashes from mild urticaria to full blown necrosis
-the black widow spider venom has a neurotoxin producing reactions at the bite site to varying degrees of
systemic reactions
-mild rash locally is usually a maculopapular exanthem
-systemic reactions may cause fever, headache, arthralgias, nausea, and vomiting
-most are sensitive to bactrim or doxycycline (cover for MRSA)


Neoplasms
-Basal Cell Carcinoma

-Four Clinical Types-

-Nodular
-Ulcerating
-Sclerosing
-Superficial Pigmented

-can be isolated but multiple lesions are not infrequent
-80% are on the head and neck
-excision is the goal. Cryosurgery and electrosurgery are options. Mohs surgery is sometimes needed
-Topical treatments can be used for superficial basal cell carcinomas but only for those that are below the
neck.
-Erivedge now available for metastatic basal cell carcinoma and locally recurrent basal cell carcinoma.
Once daily oral chemo agent
-Basal Cell Nevus Syndrome (BCNS) or Gorlin's Syndrome patients may have hundreds of basal cell
lesions throughout their body

-Kaposi Sarcoma

-multisystem vascular neoplasia
-mucocutaneous violaceous lesions and edema and can involve any organ
-many individuals are immunocompromised, especially those with HIV
-lesions may be widespread or localized.
-lesions almost always occur on feet, legs, or hands
-goal of management is control of symptoms of disease, not a cure.
-responds to radiotherapy of involved sites
-responds to systemic chemotherapy
-local therapy is usually directed at lesions that are individually cosmetically disruptive

-Melanoma


-Lentigo Maligna Melanoma
-Average onset is 45 greater in fair males
-Causes: Sun burn and Heredity
-Grows radial and extends deep only 0.5 mm
-Makes up 5% of melanomas and has best prognosis
-Lesions are dark in color with irregular border larger than an eraser head and flat
-Seen in sun exposed areas

-Superficial spreading melanoma
-70% of melanomas
-Favors back, legs
-Prognosis is fair because of a moderate radial growth phase

-Nodular Melanoma
-Grows deep
-Worst kind 16%
-Black bumps
-Head neck and trunk favored
-Metastatic Melanoma
-A lesion with a blacked colored kidney shaped area in the lesion

-Treatment-surgical excision is the goal. May need concomitant chemo or radiation if metastatic

-Squamous Cell Carcinoma


-Appears as a sharply demarcated scaling or hyperkeratotic macule, papule or plaque
-Solitary lesions are often pink with small erosions or crusted
-Increase incidence in males over 60 with fair complexion
-Keratinizing Epidermal cells
-Ultraviolet rays cause cancer. HPV can also cause
-Sun exposed areas rolled border with crust in the center
-Can form cutaneous horn
-Surgical excision is the goal. Cryotherapy or 5 FU topically can also be used


Hair and Nails
-Alopecia


-Several different types-Alopecia Areata is considered an autoimmune disease. Causes patches of hair loss over weeks to
months. Some may have spontaneous regrowth
-Alopecia Universalis is global loss of hair, eyebrows, lashes, beard and all body hair.
-Androgenic Alopecia-the most common progressive hairless that occurs through the combined effect of
genetic predisposition and the action of androgen on the hair follicles of the scalp.
-Treatment for androgenic alopecia involves oral finasteride, topical minoxidil, and anti androgens


-Onychomycosis

-chronic infection of the nail apparatus caused by dermatophytes most commonly.
-Also can be caused by candidia and molds
-80% occur on the feet
-a white patch is usually noted at distal nail. Progressive infection the nail becomes opaque, thickened

cracked, and yellow. Raised by underlying hyperkeratotic debris in nail bed.

-Treatment involves debridement or systemic agents Terbinafine

-Paronychia

-inflammation of the nail fold produces erythema, swelling, and throbbing pain and extend into the
proximal nail fold and the eponychium
-purulent material accumulates and often requires surgical incision and drainage
-antimicrobial coverage with bactrim and cephalexin is necessary

Viral Diseases
-Condyloma Acuminatum

-may occur in the oral or genital epithelium
-HPV is the causative organism

-They can present from oral gentile contact and usually present flat papillomatous plaques or nodules with
a glandular surface
-early lesions can be visualized by using 5% acetic acid
-lesions more advanced have a cauliflower appearance

-Exanthems-an infections generalized skin eruption associated with a primary systemic infection.
-most common they are viral in nature, but can be associated with bacteria and parasites.
-Examples of Exanthems-Rubella
-Measles
-Hand Foot and Mouth Disease
-Erythema Infectiosum

-Rubella

-erythematous macules and papules appearing initially on the face and then inferiorly to the trunk and
extremities
-Usually takes about 24 hours
-posterior auricular lymph node and posterior cervical lymph nodes can be enlarged
-see in patients not immunized

-Measles


-highly contagious childhood viral infection
-presents with fever, coryza, cough, congestion, conjunctivitis, and Koplik spots
-see in patients that are not immunized
-caused by measles virus and paramyxovirus
-erythematous papules appear on the face and neck where they spread to the trunk and arms

-Hand Foot and Mouth Disease

-multiple superficial erosions and small vesicles surrounded by erythematous halo.
-lesions are painful

-occur on the hands, feet, and mouth (herpetic gingivostomatitis)

-caused mainly by cocksackie virus
-very contagious

-Erythema Infectiosum (Fifth's Disease)

-caused by the Parvovirus
-get diffuse erythema and edema to the cheeks
-get a "slapped cheek" appearance
-prodrome of fever, malaise, headache, coryza, and sore throat
-management is symptomatic

-Herpes Simplex Virus

-transmission is skin to skin, skin to mucosa
-presents as grouped vesicles on a erythematous base usually initially
-can have isolated lesions and varying degrees of ulceration
-HSV1-oral mucosal
-HSV2-genital
-Diagnosis is made my clinical suspicion confirmed with viral culture or antigen detection
-Treatment-acyclovir, valacyclovir, and famciclovir

-Molluscum Contagiosum

-a self limited epidermal viral infection
-characterized by skin colored papules that are often umbilicated
-can occur in children
-In HIV infected individuals can occur on the face
-caused by poxvirus
-contagious can be transferred from skin to skin contact
-Aldara cream applied qHS 3 times a week for up to 1-3 months can help

-Varicella

-highly contagious primary infection caused by the herpes zoster virus
-characterized by crops of pruritic vesicles that evolve to pustules, crusts, and ulcers.
-the infection can have mild constitutional symptoms of fever, malaise and URI symptoms
-also called chicken pox
-acyclovir can shorten duration of illness of started early

-Herpes Zoster-

-is a dermatomal infection caused with reactivation of the varicella zoster virus characterized by
unilateral pain in vesicular or bullous eruption limited to a dermatomal distribution
-major complication is post herpetic neuralgia
-acyclovir and antivirals can shorten duration of symptoms if started in the first 48 hours

-Verrucae

-they are cutaneous human papilloma virus infections
-firm papules 1-10 mm are hyperkeratotic, cleft surface, and have vegetations
-Verruca Plantaris (Plantar Warts)
-Verruca Plana (Flat Warts)
-can treat with salicylic acid or lactic acid
--Imiquimod cream can help
-Cryosurgery or electrosurgery for larger lesions


Bacterial Infections

-Cellulitis

-has similar features to erysipelas but extends to the deep subcutaneous tissues
-cellulitis lesions are not raised
-demarcation from uninvolved skin is distinct
-tissue is red, warm, and painful to palpation
-most common organism is staph aureus and group A streptococcus
-treatment parenteral-vancomycin and zosyn. oral-cephalexin and bactrim or doxycycline

-Erysipelas

-basically a superficial cellulitis with marked dermal lymphatic vessel involvement
-painful
-bright red, raised, edematous, indurated plaque with advance borders
-usually caused by group A beta hemolytic streptococcus
-can by caused by staph aureus
-treatment parenteral-vancomycin and zosyn. oral-cephalexin and bactrim or doxycycline

-Impetigo

-crusted golden yellow stuck on erosions that become confluent
-usually on nose, cheek, lips, and chin

-Caused by Group A Streptococcus

-Can be caused by staph
-Treatment usually with cephalexin, but should add bactoban, bactrim or doxycycline for MRSA coverage


Fungal Infections
-Candidia-can be oral, genital, intertrigo, cutaneous , or balanoposthitis
-treatment dependent on site

-Oral Candidia

-also called thrush
-get white creamy plaques on tongue or in mouth
-can be caused by dentures, oral inhaled steroids, diabetes, or immunosuppression
-common in infants
-treatment with nystatin swish and spit solution

-Vaginal Candidia

-common in diabetics, recent antibiotic use
-diagnosed with KOH prep
-treatment with oral diflucan or anti fungal vaginal suppositories


-Balanoposthitis


-transmitted in sexually active males by sexual contact
-causes burning itching and redness
-Azoles/imidazoles are more effective then nystatin
-can cause discrete pustules on the glans penis and the inner aspect of the foreskin
-can be mistaken for herpes

-Intertrigo Candidiasis

-predisposing factors are obesity, diabetes, hyperhidrosis, heat
-initially pustules on erythematous base become eroded and confluent
-usually in the axillae, groin, perineal, inter-gluteal cleft
-treat by keeping area dry. Topical treatment with topical anti fungal nystatin, and can use systemic oral
anti fungal

-Cutaneous Candidia

-vesicles, pustules, and papules become confluent in the folds
-can be treated with topical anti fungal or systemic for more severe cases


-Dermatophyte Infections
-Tinea Pedis

-dermatophyte infection of the feet
-causes redness, scaling, and maceration and or bullae formation
-often breaks up the integrity of the epidermis
-also known as athletes foot
-management use shoes while bathing. Topical anti fungal for mild to moderate infections. Oral anti
fungal for more severe infection

-Tinea Manuum

-dermatophyte infection of the hand. Most commonly on the dominant hand
-Topical anti fungal for mild to moderate infections. Oral anti fungal for more severe infection
-may see a raised well demarcated border

-Tinea Corporis-

-raised well demarcated border
-refers to a dermatophyte infection of the trunks, legs, arms, and neck
-Topical anti fungal for mild to moderate infections. Oral anti fungal for more severe infection















-Tinea Capitis

-Dermatophyte infection involving the hair follicles
-get a large circular area of missing patch of hair
-topical anti-fungals are ineffective
-oral anti-fungal necessary for several weeks. Griseofulvin

-Tinea Barbae is a tinea infection of the beard


-Acanthosis Nigricans

-diffuse thickening and hyperpigmentation of the skin
-usually the axillae or body folds
-can be associated with hereditary, obesity, endocrine problems, meds, or malignancy
-caused by hyper secretion of pituitary peptide or non specific growth effect of hyperinsulinemia
-treatment is targeted at treating underlying disorder

-Burns
-Rule of 9's



-9% for the head and neck
-18% for the front torso
-18% for the back torso and buttocks
-9% for each lower extremity on front
-9% for each lower extremity on back portion
-9% for each arm
-1% for genitals

-Parkland Formula- to determine fluid needs for the first 24 hours in a burn victim

4 x weight in kg x TBSA burn = fluid requirements for the first 24 hours.

Give first half over the first 8 hours and give the second half over the last 16 hours. Simple divide the
total over the amount of hours necessary to give the fluids and that gives you the hourly rate.

-Classification of Burns
-First degree Burn:

-Includes only the outer layer of skin, the epidermis
-Skin is usually red and very painful
-Equivalent to superficial sunburn without blisters
-Dry in appearance
-Healing occurs in 3-5 days, injured epithelium peels away from the healthy skin

-Second degree: Can be classified as partial or full thickness.

-Partial thickness
-Blisters can be present
-Involve the entire epidermis and upper layers of the dermis
-Wound will be pink, red in color, painful and wet appearing
-Wound will blanch when pressure is applied
-Should heal in several weeks (10-21 days) without grafting, scarring is usually minimal

-Full thickness
-Can be red or white in appearance, but will appear dry.
-Involves the destruction of the entire epidermis and most of the dermis
-Sensation can be present, but diminished
-Blanching is sluggish or absent
-Full thickness will most likely need excision & skin grafting to heal


-Third degree:

-All layers of the skin is destroyed
-Extend into the subcutaneous tissues
-Areas can appear, black or white and will be dry
-Can appear leathery in texture
-Will not blanch when pressure is applied
-No pain

-Fourth degree: Full thickness that extends into muscle and bone.

-Hidradenitis Suppurativa

-chronic suppurativa often cicatricial disease of the apocrine gland axillae and the anogenital regain
-sometimes associated with nodulocystic acne and pilonidal sinuses
-unknown cause
-there is keratinous plugging of the apocrine duct, dilation of the hair follicle, and severe inflammatory
changes of the single apocrine gland.
-Bacterial growth causes dilated duct
-ruptured duct or gland causes extension of inflammation or infection which cause tissue destruction and
then this leads to ulceration, fibrosis and sinus tract formation
-treatment is incision and drainage and to excise recurrent fibrotic nodules and tracts

-Lipoma

-benign subcutaneous tumors that are rounded, lobulated, and moveable over the overlying skin
-many are small but can be greater than 6 cm
-occur mainly on the neck, trunk and extremities
-most of the time just observe. Rarely excise unless causing pain or discomfort

-Epithelial Inclusion Cyst

-occurs secondary to traumatic implantation of the epidermis within the dermis.
-traumatically grafted epidermis grows in the dermis with accumulation of keratin within the cyst cavity
-treatment is excision

-Melasma

-an acquired light or dark brown hyperpigmentation that occurs in the exposed areas to sunlight
-can be associated with pregnancy, oral contraceptives, or idiopathic
-pathogenesis is unknown
-treatment 3% hydroquinone solution in combination of tretinoin gel or 4% hydroquinone solution and
glycolic acid
-need to use high SPF sunblock

-Pilonidal Disease

-Pilonidal disease is a chronic infection of the skin in the region of the buttock crease
-The condition results from a reaction to hairs embedded in the skin, commonly occurring in the cleft
between the buttocks.
-The disease is more common in men than women and frequently occurs between puberty and age 40. -It
is also common in obese people and those with thick, stiff body hair.
-Treatment is incision and drainage with antibiotics. Usually poly-microbial
-Definitive treatment is excision

-Pressure Ulcers


-develop over body support surfaces over bony prominences as a result of the external compression of the
skin, shear forces, or friction which produce ischemic changes or necrosis
-treatment is prevention. Reposition patient every 2 hours. Pad ulcer prone areas and massage them
-clean areas and keep free of urine and feces
-mobilize patient if possible

-Stages of Pressure UlcersStage I: Non-blanchable erythema
Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly
pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area
may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to
detect in individuals with dark skin tones.

Stage II: Partial thickness
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without
slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled
blister.Presents as a shiny or dry shallow ulcer without slough or bruising. This category should not be
used to describe skin tears, tape burns, incontinence associated dermatitis, maceration or excoriation.

Stage III: Full thickness skin loss

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed.
Slough may be present but does not obscure the depth of tissue loss. May include undermining and
tunneling. The depth of a Stage III pressure ulcer varies by anatomical location. The bridge of the nose,
ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Stage III ulcers can be shallow.
In contrast, areas of significant adiposity can develop extremely deep Stage III pressure ulcers.
Bone/tendon is not visible or directly palpable.

Stage IV: Full thickness tissue loss
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often
includes undermining and tunneling. The depth of a Stage IV pressure ulcer varies by anatomical location.
The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these
ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia,
tendon or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible
or directly palpable.

-Urticaria

-IgE mediated complement mediated to physical stimuli
-acute urticaria is less than 30 days.
-chronic urticaria-greater than 30 days
-management is steroids, H1 and H2 blockers. Subcutaneous epinephrine for hypotension, airway
compromise. Albuterol for bronchospasm. Consider observation for severe systemic symptoms

-Vitiligo

-characterized by development of totally white macules and the complete absence of melanocytes
-associated with thyroid disease and many other medical conditions
-management sunscreens and cosmetic coverup
-Regimentation- topical steroids, UVA, systemic UVADermatology Board Review Questions

1. Which of the following organism are responsible for causing the disease pictured below in the
photograph?

A. Cocksackie Virus
B. Parvovirus
C. Herpes Zoster

I. Ebstein Barr Virus







2. Which of the following is the best treatment for the condition listed below in the photograph?

A. Griseofulvin
B. Nizoral Shampoo
C. Nystatin
D. Lamisil


3. Your patient is a 34 year old female that presents with first and second degree burns to her entire head
and neck, entire right arm and her anterior torso. She weighs 110 kilograms. What should be the patients
IV fluid rate for the first 8 hours?

A. 990 mL/hr
B. 660 mL/hr
C. 495 mL/hr
D. No IV Fluids are necessary




4. Which of the following skin disorders has less than 10% of epidermal detachment?

A. Toxic Epidermal Necrolysis
B. Steven Johnson Syndrome
C. Scalded Skin Syndrome
D. Pityriasis Rosea


5. Which of the following skin disorders has an association with asthma and allergic rhinitis?

A. Contact Dermatitis
B. Psoriasis
C. Erythema Multiforme
D. Atopic Dermatitis


6. Which of the following are not considered part of the excepted treatment of acneiform vulgaris?

A. Cleocin T

B. Isotretinoin
C. Birth Control Pills
D. Cyclosprorin










7. Your patient is a 51 year old male that presents with a lesion in the picture listed below. He indicates
he has not seen a doctor in over 30 years. Which of the following is the best test to order (other than
biopsy) to help look for a potential etiology of this disease?

A. VDRL
B. Western Blot Test
C. Hepatitis C Surface Antigen
D. Culture patient for HSV








8. Which of the following skin cancers has the worse prognosis?

A. Lentigo Maligna Melanoma
B. Superficial Spreading Melanoma
C. Basal Cell Carcinoma
D. Nodular Melanoma


9. Your patient is an 18 year old female recently started on bactrim for a UTI. She comes in with the rash
depicted below and shortness of breath and diffuse wheezing. She is starting having trouble swallowing.
You have ordered albuterol aerosol, solumedrol, and zantac IV. Her vitals are as follow: BP 75/43,
Pulse-112, O2 Sat 91% on 100% NRB. Which of the following is the most important therapeutic
intervention?

A. Diphenhydramine IV
B. Epinephrine
C. Ipatroprium Bromide Aerosol
D. Zantac Drip


10. Which organism has been implicated in the rash listed below in the photograph?

A. Cocksackie Virus
B. Poxvirus
C. Parvovirus
D. HSV


11. Which of the following is not an etiology of Erythema Multiforme?

A. Connective Tissue Disease
B. HSV
C. Idiopathic
D. Oral Contraceptives




12. Your patient is a 54 year old female that presents with the rash in the photograph below. All of the
following are recognized treatments for this condition except:

A. Acyclovir
B. Prednisone
C. Tetracycline
D. Azathoprine








13. Your patient is a 45 year old female with the rash in the photograph below. She notes it is
exacerbated by being in hot environments. All of the following are accepted treatments for this condition
except:


A. Metronidazole Gel
B. Topical Erythromycin
C. Minocycline
D. Triamcinolone Cream









14. Which of the following organisms are responsible for the rash listed below:

A. Pediculus Humanus
B. Phithirius Pubis
C. Sarcoptes Scabei
D. Borrelia burgdorferi








15. Which of the following is not true regarding Basal Cell Carcinoma?

A. 80 percent involve the head and neck
B. Basal Cell Nevus Syndrome or Gorlin's Syndrome patients may have hundreds of basal cell lesions
throughout their body
C. Erivedge is an oral chemotherapy agent approved for use
D. Topical treatments can be used but for lesions that are above the neck


16. What is the best treatment for the condition depicted below in the photograph?

A. Lamisil cream
B. Lamisil orally
C. Prednisone
D. Lotrisone






17. Which condition listed below has Koplik Spots?

A. Rubella
B. Measles
C. Molluscum Contagiosum
D. Roseola


18. Your patient is a 58 year old that presents with the rash listed below in the photograph. The rash is
painful and started yesterday. Which of the following is the best therapeutic intervention?

A. Acyclovir Orally
B. Acyclovir Topically
C. Prednisone
D. Triamcinolone


19. Which organism is known to cause the rash listed below:

A. Poxvirus
B. Parvovirus
C. Herpes Simplex Virus
D. Human Papilloma Virus


20. Which of the following is not a difference between full thickness and partial thickness burns?

A. Full thickness burns are wet and partial thickness burns are dry
B. Deep full thickness burns (3rd degree or greater) will not have any sensory input
C. Full thickness burns are dry and partial thickness burns are wet
D. Full thickness burns have evidence of penetration to the deeper tissues



21. Your patient is a 83 year old female that presents to the ER with the skin ulcer listed below. Please
choose the most correct stage of the ulcer listed below:

A. Stage I
B. Stage II
C. Stage III
D. Stage IV




22. Which of the following is not true of vitiligo?

A. It is characterized by the development of white macules and the complete presence of melanocytes
B. Management includes sunscreens and cosmetic cover up
C. Repigmentation can be attempted with topical steroids, UVA and systemic UVA
D. It can be associated with thyroid disease


23. Which of the following medical conditions have not been implicated in the skin condition listed
below in the photograph?

A. Hyperinsulinemia
B. Obesity
C. Malignancy
D. Sunburn









24. What is the best management option for the skin disorder depicted in the photograph listed below?

A. Acyclovir
B. Bactrim
C. Triamcinolone cream
D. Acyclovir cream


25. Which of the following are not one of the 5 P's of Lichen Planus?

A. Pain

B. Purple
C. Pruritic
D. Polygonal





26. Which of the following statements regarding Pityriasis Rosea is incorrect?

A. Possibility of being caused by the Herpes 7 Virus
B. May last for 6-12 weeks
C. Exanthem phase precedes herald patch
D. Tends to occur in a "Christmas Tree" pattern


27. What is the best management option of the lesion listed below in the photograph?

A. Bactroban Ointment
B. Bactrim
C. Observation
D. Excision


28. What is the best management option for the skin condition depicted below?

A. Permethrin
B. Griseofulvin
C. Nizoral Shampoo
D. Prednisone


29. Which of the following is not true regarding spider bites?

A. Black Widow Spiders and Brown Recluse Spiders tend to be the most harmful of all spiders
B. The Black Widow Spider venom has a neurotoxin that produces reactions at the side with systemic
reactions
C. These bites are best treated with Amoxicillin
D. Systemic reactions include fever, headache, arthralgias, nausea, and vomiting.


30. Which of the following is the best treatment option for the skin condition depicted below in the
photograph?

A. Zithromax IV
B. Prednisone
C. TED Hose
D. Zosyn IV
31. Your patient is a 45 year old female that presents with this painless freely moveable lesion depicted
in the photograph below. Which of the following is the best management option?

A. Incision and Drainage
B. Observation
C. Biopsy
D. Place of cephalexin for 10 days


32. Which of the following is not true regarding Melasma?

A. It is an acquired dark brown or light brown hyperpigmentation that occurs in the exposed areas to
sunlight
B. The mainstay of treatment is UVA and UVB
C. The mainstay of treatment is SPF sunblock
D. It is associated with pregnancy, oral contraceptives, or can be idiopathic






33. What is the best management option for the disease depicted the the photograph below?

A. Keflex 500 mg QID
B. Bactrim DS one PO BID
C. Warm Compresses
D. Incision and Drainage


34. How long does urticaria have to persist before it is considered chronic urticaria?

A. Greater than 15 days
B. Greater than 30 days
C. Greater than 60 days
D. Greater than 90 days





35. Which of the following is the best management option for the condition depicted below in the
photograph?

A. Hydrocortisone Cream
B. Prednisone tapered for 2 weeks
C. Acyclovir
D. Benadryl
36. Which of the following is not a treatment for the skin condition depicted below?

A. Combination of crude tar in zinc oxide
B. Topical Steroids
C. Intra-lesion injections with triamcinolone
D. Lotrisone Cream


37. What is the incidence of arthritis associated with psoriasis?

A. 1-2%
B. 5-8%
C. 10-12%
D. 15-20%







38. Which of the following is the best management option for the skin condition depicted below?

A. Skin biopsy
B. Topical Triamcinolone
C. Intra-lesion injection of triamcinolone
D. Removal with cautery or surgery






39. Which of the following is the best management option for the skin disorder pictured in the photograph
below?

A. Bactroban Ointment
B. Bactrim
C. Prednisone
D. Permethrin









40. Which of the following would be definitive treatment for the skin condition listed below?

A. Skin Biopsy
B. Warm soaks
C. Incision and Drainage
D. Topical Bactroban


41. Which of the following is not true regarding Condyloma Accuminatum?

A. Can occur on oral or genital epithelium
B. Early lesions can be visualized with 5% acetic acid
C. It is caused by HSV
D. Lesions more advanced have a cauliflower appearance


42. What is the organism that causes the rash depicted in the photograph below?

A. Poxvirus
B. Parvovirus
C. HPV
D. Cocksackie Virus


43. Which of the following is not true regarding Molluscum Contagiosum?

A. It is contagious and can be transferred from skin to skin contact
B. Patients with HIV can get lesions on their face
C. Aldara cream can help the rash
D. It is caused by a obligate parasite
44. Your patient is 14 year old that presents with the rash depicted below in the photograph. Which of
the following is the best management option?

A. Acyclovir
B. Clindamycin
C. Keflex and bactoban ointment
D. Prednisone

















45. Which of the following is the best treatment for the condition depicted below in the photograph?

A. Nystatin
B. Diflucan

C. Chlorhexidine mouthwash
D. Prednisone









46. What is the best management option for the rash depicted below in the photograph?

A. Diflucan
B. Miconazole Topical
C. Triamcinolone
D. Prednisone















47. What degree of burn is the depicted in the photograph below?

A. First Degree Burn
B. Second Degree Burn
C. Third Degree Burn
D. Forth Degree Burn


48. Which of the following is not true regarding hidradenitis suppurativa?

A. It is a disease of the apocrine gland of the axillae and the anogenital region

B. Its cause is unknown

C. There is keratinous plugging of the apocrine duct, dilation of the hair follicle, and severe inflammatory
changes of the apocrine ducts, and the bacterial growth causes a dilated duct
D. These patients rarely need surgery





49. Which of the following is the pathogenesis of epithelial inclusion cyst formation?

A. It is formed by an infected hair
B. It is formed from an infected sebaceous cyst
C. Occurs secondary to traumatic implantation of the epidermis within the dermis and causes keratin
within the cyst cavity
D. It is from an infected apocrine gland


























50. Which of the following is not part of the accepted treatment of the skin condition listed below?

A. Prednisone

B. Zantac
C. Benadryl
D. Protonix


1. Choice B is the correct answer. This child has Fifth's Disease or Erythema Infectiosum. This caused
by the Parvovirus. It is characterized by a slapped cheek appearance. It often has a prodrome of fever,
coryza, malaise, headache and sore throat. Cocksackie is the virus that causes hand foot and mouth
disease. Herpes zoster is the virus that causes chicken pox.


2. Choice A is the correct answer. Tinea Capitis is treated most effectively orally. Topical preparations
such as nizoral shampoo or nystatin are not effective. Lamisil is used for onychomycosis.


3. Choice A is the correct answer. The patient has 36% TBSA burns. She weighs 110 kg. So this
applied to the Parkland Formula you get 4 x 110 kg x 36 = 15, 840 mL for the first 24 hours. Divide this
by 2 and this gives you 7920 mL for the first 8 hours. When you divide 7920/8 you get the correct answer
of 990 mL/hr.


4. Choice B is the correct answer. Steven Johnson Syndrome has less than 10% of epidermal
detachment. Toxic Epidermal Necrolysis has greater than 30% of epidermal detachment. Pityriasis
Rosea does not involve epidermal detachment. Scalded Skin Syndrome is caused by certain strains of
staphylococcus infections. Toxins are produced that cause damage to the skin.


5. Choice D is the correct answer. Atopic Dermatitis does have an association with allergic rhinitis and
asthma. It is a a Type I Hypersensitivity reaction. Lesions are typically present over months to years.
Treated with low potency steroid creams and wet dressings. UVA and UVB can be helpful. Contact
dermatitis, Psoriasis, and Erythema Multiforme do not have an association with asthma and allergic
rhinitis.
6. Choice D is the correct answer. Acne Vulgaris results from as changed in the keratinization pattern in
the hair follicle. The secretion is blocked. Lesions are a result of interaction between bacteria and
hormones. Cleocin T helps kill this bacteria. Isotretinoin inhibits sebaceous gland function and
keratinization. The estrogen in the birth control pills help interfere with interaction between the bacteria
and the hormones. The immunosuppressor cyclosporin has no role in treatment of acne.


7. Choice B is the correct answer. This patient has HIV until proven otherwise. This picture is of a
patient with Kaposi Sarcoma. VDRL is a test for syphillis and this has not been implicated in relation to
Kaposi Sarcoma. Hepatitis C and HSV have not been implicated in this disorder either.


8. Choice D is the correct answer. Nodular Melanoma has the worse prognosis because it grows deep.
It makes up about 16% of melanomas. Lentigo Maligna Melanoma has the best prognosis of the
melanomas because it grown radially and does not extend deep. The most common type of melanoma is

superficial spreading melanoma and this makes up 70% of all melanomas. Basal Cell Carcinoma is the
slowest growing skin cancer and in general has the best prognosis.


9. Choice B is the correct answer. This patient is hypotensive and exhibiting signs of her airway
swelling. This is one of the major indications for epinephrine. The alpha antagonist epinephrine will
help reduce the swelling and increase the patients blood pressure. These cytokines that cause this are
released from the mast cells. Diphenhydramine is indicated but will not help the patient immediately.
There is no evidence to suggest that ipatroprium or a Zantac drip will show benefited patient outcomes.
10. Choice B is the correct answer. Molluscum Contagiosum is caused by the poxvirus. Cocksackie
Virus causes hand, foot and mouth disease. Fifth's disease is caused by Parvovirus. HSV is the virus the
causes herpes simplex


11. Choice D is the correct answer. Most commonly erythema multiforme is idiopathic. The most
common infection causing erythema multiforme is HSV. Connective tissue disease, pregnancy,
malignancy, physical agents, and medications (PCN, Sulfonamides, Dilantin and Allopurinol) are all
cause of Erythema Multiforme.


12. Choice A is the correct answer. This is Bullous Pemphigoid. It comes from an interaction of the
autoantibody with bullous pemphigoid antigen on the surface of keratinocytes. The bullous lesions come
from molecules released from mast cells. Prednisone and azathoprine have been shown to be helpful with
this mechanism. Tetracycline has also been shown to be helpful but the mechanism is unknown.
Acyclovir is not an accepted treatment regarding this.


13. Choice D is the correct answer. This patient has Rosacea. Metronidazole Gel, Topical
Erythromycin, and Minocycline are accepted treatments. Triamcinolone cream is best used for steroid
response dermatoses.


14. Choice C is the correct answer. Sarcoptes Scabei is the organism that causes scabies. Pediculus
Humanus is the parasite that causes Pediculus Capitis (Scalp Lice). Phithirius Pubis is the parasite that
causes pubic lice. Borrelia burgdorferi is the bacteria that causes lyme disease.


15. D is the correct answer. Topical treatments can be used on lesions that are below the neck and not
above. These lesions tend to be less aggressive. Eighty precent of the lesions are on the head and neck
the most sun exposed areas. BCNS or Gorlin's syndrome is a genetic disorder where there is hundreds of
basal cell lesions on the body.


16. Choice B is the correct answer. Onychomycosis responds best to systemic treatment with oral anti
fungal agents such as lamisil. Topical treatments such as lamisil cream or combination anti fungal and
steroid creams such as lotrisone are not effective. Prednisone dose not help in the treatment of
Prednisone.



17. Choice B is the correct answer. Measles is a condition that has Koplik spots. Rubella has
erythematous macules that appear initially on the face and work their way inferiorly. It can have posterior
auricular and posterior cervical lymphadenopathy. Molluscum has raised pigmented papules.


18. Choice A is the correct answer. This is rash is painful and vesicular which is consistent with
shingles. This is an infection that travels along the dermatome and requires systemic treatment.
Acyclovir topically can be used but will not be as effective. Prednisone and triamcinolone will not be
effective.


19. Choice D is the correct answer. Verruca Plana (Flat Warts) and Verruca Plantaris (Plantar Warts) are
caused by the Human Papilloma Virus. They can be treated with salicylic acid, lactic acid topically,
cryosurgery, or electrosurgery. Herpes Simplex does not cause warts. Parvovirus causes Fifth's Disease.
Poxvirus causes Molluscum.
20. Choice A is the correct answer. Full thickness burns will have a dry appearance and partial
thickness burns will not. Partial thickness burns will be wet and maintain their sensory innervation. Full
thickness burns will have evidence of penetration to the burns to the deeper tissues such as muscle and
bone exposed.


21. Choice B is the correct answer. Stage I ulcers just have non blanchable erythema with no skin
breakdown. Stage II ulcers have some loss of the dermis with an open wound and have a red area in the
center. There is no slough. Stage III is full thickness. There maybe subcutaneous tissue visible but there
is no muscle, bone, or tendons visible. Stage IV ulcers are full thickness ulcers with bone, muscle, and
tendons exposed.


22. Choice A is the correct answer. Vitiligo is actually characterized by the complete absence of
melanocytes. This is what causes the white macules. Management is with topical steroids, UVA and
systemic UVA. It is associated with thyroid disease and other medical conditions.


23. Choice D is the correct answer. Acanthosis Nigricans, a diffuse thickening and hyperpigmented area
of skin is caused by hyperinsulinemia, obesity, endocrine disorders, and malignancy. Usually on the
axillae and bodily folds. It is caused by a over active secretion of pituitary peptide or non specific
growth effect of hyperinsulinemia


24. Choice C is the correct answer. Dishidrotic eczema in acute phase can have a vesicular appearance.
It differs from herpes in that it is not on an erythematous base and typically herpetic ulcers are more pink.
Acyclovir and acyclovir cream would be appropriate for herpetic infections. Bactrim would be
appropriate for bacterial infections especially staph infections. Triamcinolone would be most
appropriate in this case.


25. Choice A is the correct answer. The five P's of Lichen Planus are: planar, polygonal, pruritic,
purple, and papular


26. Choice C is incorrect. The herald patch precedes the exanthem of pityriasis rosea and occurs in a
Christmas Tree pattern. It can last for up to 6-12 weeks. The etiology is actually is unknown but it is
possible caused by the Herpes 7 virus.


27. Choice D is the correct answer. Actinic Keratosis are managed best when they can be removed. 5
FU topically can be used. Bactrim or Bactroban ointment would be appropriate if this lesion was
infected. Actinic Keratosis tend to occur in sun exposed areas


28. Choice A is the correct answer. Permethrin is the treatment of choice for scalp lice. Griseofulvin
and Nizoral are appropriate to be used together for Tinea Capitis. Prednisone would not be helpful in
either condition.


29. Choice C is the correct answer. These bites are best treated with bactrim or doxycycline. There is a
high incidence of MRSA associated with these spider bites. The remainder of the answers are true.




30. Choice D is the correct answer. Zosyn is the treatment of choice for circumferential cellulitis such as
this. Zithromax has poor skin penetration. Prednisone would be helpful if this was a contact dermatitis.
TED hose will help with any edema but will not fix the cellulitis


31. Choice B is the correct answer. This presentation is typical for lipomas. They are typically round,
painless, and freely movable. These typically are not removed unless they bother the patient. Biopsy
would be necessary if the diagnosis. Lipomas typically occur on the neck, trunk, and extremities.
Cephalexin would be appropriate if there was a question of a soft tissue infection but this lesion is
painless so this is not likely.


32. Choice B is the correct answer. The hyperpigmentation is exacerbated by exposed areas of light. The
patients with Melasma need to have high SPF sunblock over sun exposed areas. It is associated with
pregnancy, oral contraceptives, or can be idiopathic.


33. Choice D is the correct answer. Incision and drainage is needed for definitive treatment of a
pilonidal abscess, Keflex, bactrim, and warm compresses each would help but not definitively treat
pilonidal abscess.


34. Choice B is the correct answer. Acute urticaria persists for less than 30 days. Chronic urticaria lasts
greater than 30 days.





35. Choice B is the correct answer. This case of contact dermatitis is too severe for topical treatment
with hydrocortisone. In addition, it is low potency steroid. Benadryl would help help with the symptoms
but not do much for the underlying disorder. Shingles is not in the differential because this lesion crosses
the midline so acyclovir is not indicated.


36. Choice D is the correct answer. Lichen Simplex Chronicus is a predilection of the skin that responds
to trauma by epidermal hyperplasia. It has no fungal properties so lotrisone is not indicated. It can be
treated with a combination of crude tar and zinc oxide, topical steroids, intra-lesion injections of
triamcinolone, or occlusive dressings.


37. Choice B is the correct answer. Psoriatic arthritis has an incidence of about 5-8 percent.


38. Choice D is the correct answer. Seborrheic keratosis are benign skin lesions that occur after the age
of 30. Skin biopsy is not necessary. Topical or intra-lesion injection of triamcinolone would not be
helpful. Removal is definitive treatment.


39. Choice D is the correct answer. Lesion lesion occur between the web spaces consistent with
scabies. Bactroban ointment and bactrim would be appropriate if an infection is suspected. Prednisone
would be over treatment is this was suspected to be contact dermatitis. There is only a couple of lesions
and this could be treated with topical steroids if it was contact dermatitis.




40. Choice C is the correct answer. This is a paronychia which is an accumulation of purulent material
around the nail apparatus. This needs incision and drainage for definitive treatment. Skin biopsy is not
indicated. Warm soaks would help but not provide definitive treatment. Topical bactroban may help but
will not provide definitive treatment. The patient after incision and drainage should be on cephalexin and
bactrim or doxycycline pending cultures.


41. Choice C is the correct answer. Condyloma is caused by the the HPV not HSV. It does occur on oral
or genital epithelium. Advance lesions resemble cauliflower appearance. Early lesions can be
visualized with 5% acetic acid


42. Choice C is the correct answer. Cocksackie virus is the causative organism in hand foot and mouth
disease. Parvovirus cause Fifth's disease. HPV causes condyloma. Poxvirus cause molluscum
contagiousum


43. Choice D is the correct answer. Molluscum is caused by the poxvirus. It is very contagious and
spread by contact. It is a self limited epidermal infection that causes skin colored papules.



44. Choice C is the correct answer. Impetigo is best treated with keflex and bactroban. This helps with
strep and staph coverage both. It also will help with MRSA. Some clinicians add bactrim to this.
Clindamycin is effective against strep and staph but there is some degree of resistance when treating
MRSA. Prednisone and acyclovir are not indicated here.


45. Choice A is the correct answer. Nystatin is the treatment of choice for thrush. Prednisone can
exacerbate it or make it worse. It can also be caused by dentures, oral inhaled steroids, diabetes, or
immunosuppression. It is common in infants.


46. Choice B is the correct answer. Tinea corporis with an isolated lesion is best treated with
Miconazole. If systemic treatment is needed, griseofulvin is indicated. This rash has a mycotic
appearance and has a raised well demarcated border. This rash does not look like a steroid responsive
dermatoses.


47. Choice C is the correct answer. First degree burns included the outer layer of skin and is similar to
sunburn without blisters. Second degree involves the entire epidermis and upper layers of the dermis.
Third degree involves all layers of the skin and extends to subcutaneous tissue. There is no exposed
muscle and bone. Forth degree is down to the bone and muscle.


48. Choice D is the correct answer. These patients frequently need incision and drainage and to excise
recurrent fibrotic nodules and tracts. Ruptured duct gland causes extension and inflammation or infection
which causes tissue destruction and then leads to ulceration, fibrosis, and sinus tract formation.



49. Choice C is the correct answer. Epithelial inclusion cysts occur secondary to implantation of the
epidermis within the dermis and there is accumulation of the keratin in the cyst cavity.



50. Choice D is the correct answer. Steroids, H1 blockers, H2 Blockers, Albuterol (for bronchospasm)
and epinephrine (for life threatening systemic symptoms) are part of the accepted treatment of urticaria.