USMLE Step 2 CK Medical Subject Review: Internal: Dermatology

28-year-old man presents with a pruritic rash on his arms and legs that started 3 days ago. He has tried topical diphenhydramine cream with no change in symptoms. He reports that he was seen 1 week ago for blister-like lesions on his penis. He was given an antiviral medicine and those lesions resolved. He denies fevers or recent travel, but he has a history of a similar rash on two previous occasions. Physical exam is remarkable for a pink-to-red papular rash on the backs of the hands and feet and extensor surfaces of the arms and legs. The individual lesions have a red center surrounded by a pale ring and another outer ring of red inflamed tissue. What drug is most effective at preventing this man's current symptoms?

Acyclovir

20-year-old man with a past medical history of moderate acne has undergone 1 month of second-line acne therapy. He now presents with skin that looks worse; including more inflammation and the development of cysts. What is the most appropriate next step?

Add oral isotretinoin after stopping medication for 2 weeks.

28-year-old male presents to the office with bilateral cervical lymphadenopathy of 2 cm with mild fever and sore throat for 1 week. He also complains of nausea and decreased appetite. On examination, there is hepatosplenomegaly and palatal petechiae. A new intern diagnoses him with streptococcal throat infection and prescribes antibiotics. The patient comes back the next day with a painless, itchy rash all over his body. The antibiotic that was most likely given to this patient is

Amoxicillin

35-year-old woman presented with intensely pruritic red papules over the anterior wrists. On close examination, the papules are shiny with a flat surface and occasional central umbilication. A red plaque is seen along the scratch line at the anterior forearm. What laboratory test may be most revealing in this patient?

Anti-HCV antibody

5-year-old boy presents with an erythematous skin rash associated with intense itching. The boy's mother has noticed that her son's rash has been recurrent, with 3-4 episodes per year. The itching and rash increases after consumption of certain foods. On examination, erythematous raised papules are seen on the cheek, trunks, and upper arms. What is most likely associated with the boy's condition?

Asthma

20-year-old African-American woman presents with very itchy rashes on her arms. She reports that they have been recurrent for as long as she can remember. She is an asthmatic and on ventolin (salbutamol) inhaler. On examination, you note erythematous maculopapular lesions with hyperpigmentation and lichenification in the antecubital fossae bilaterally. What is the most likely diagnosis?

Atopic dermatitis

An 8-year-old girl presents with an itchy rash. The mother says she has observed the child itch off and on over the last 4 months. "She'd be fine if I could just get her to stop itching," the mother says. The child is on no medications; she is well positioned on the growth curve, and she is otherwise healthy except for occasional bouts of exercise-induced asthma. Physical exam reveals generally dry skin and areas of mild erythema and excoriation, largely confined to the antecubital and popliteal fossae. As the doctor prepares to step outside, the mother asks if the fact that she was treated for syphilis prior to her pregnancy with this child could have anything to do with this. What condition does the girl most likely have?

Atopic dermatitis

23-year-old woman presents with itchy, scaly patches on both her knees and lower legs. The patches were initially penny-sized, but have recently increased in size and are mildly itchy now. There is no history of infection, drug intake, or insect bites. However, she says that she has been under extreme stress over the last month due to family issues. On examination, you note whitish, irregular, slightly raised plaques on the knees and legs. Scraping the scales leads to multiple bleeding points. What clinical finding have you elicited?

Auspitz sign

59-year-old fair-skinned Caucasian woman presents with a lesion on her eyelid that has been growing slowly for the past 6 months. She reports that she has been an avid gardener most of her life. On examination, you find a nontender nodule with a pearly border on her right lower eyelid. What is the most likely diagnosis?

Basal cell carcinoma

A 55-year-old man presents with a non-healing, inflamed 'pimple' on his cheek. It has been present for 5 months, and it has recently started to bleed when he shaves. On physical examination, you note that he has fair skin, blue eyes, and a ruddy complexion. There is a raised lesion on the left cheek measuring 2.5 cm in diameter that appears rolled, with pearly pink borders and telangiectasias. Image 6-1 (courtesy John Hendrix, MD) depicts the lesion. What is your preliminary diagnosis?

Basal cell carcinoma

A 65-year-old man presents to the outpatient clinic with a non-healing ulcer on his face. He gives a history of a nodule appearing on his face 7 months ago that enlarged slowly, then ulcerated and failed to heal regardless of the special care he gave it. The man is a farmer and is otherwise healthy. The following photo shows the lesion. What is the most likely diagnosis?

Basal cell carcinoma

A 60-year-old woman presents for evaluation of a hyperpigmented lesion on the left side of her face; the lesion has increased in size over the past 6 months. On physical examination, the lesion is non-uniform in color; it has an asymmetry configuration, and it measures approximately 11 mm in diameter. The image provides a depiction of the lesion. What histologic characteristic of this diagnosis is the best prognostic indicator?

Breslow depth

66-year-old woman presents with a rash that has developed over the last 3 weeks; it has been getting worse. She states that her legs began to itch and became red with blisters, she noted that the same thing was occurring on her abdomen about 1 week ago. On physical examination, you note urticarial, inflammatory plaques, as well as papules with blister formation. On her abdomen, you note inflammatory plaques surmounted by tense blisters. What is your initial diagnosis?

Bullous pemphigoid

30-year-old woman presents with lower abdominal pain; she is thought to have pelvic inflammatory disease (PID). She reports being a sex worker and recreational drug use. Labs on admission reveal blood glucose of 260 mg/dL, a positive HIV screen, and a non-reactive RPR. Aside from the abdominal/pelvic pain, the admitting physical is notable for moderate obesity, absence of pronounced lymphadenopathy, and an erythematous macerated rash in the intertriginous distribution. The patient reports her rash is "really itchy and wet all the time," and it began within the last 3 months; it is now at its worst. She reports intense itching of the vulva over the last few weeks. The intertriginous rash is most likely a manifestation of what condition?

Candidiasis

17-year-old boy presents with acne; he has had acne since age 10. The patient says he does not eat chocolate or greasy foods. He washes his face 2 times a day with a popular acne soap, but nothing seems to be helping. On physical exam, the clinician notes that the acne covers his face, neck, chest, and some on his shoulders and back. After taking a careful history to rule out acnegenic factors and more serious endocrine abnormalities, the clinician inquires about his family history. It is positive for his father also having acne. His social history is non-contributory. What type of acne does the client most likely have?

Comedo

15-year-old boy presents with a complaint of small red itchy blisters on his feet and ankles. The blisters began early in the summer when he was attending band camp. He denies taking medication. On clinical exam, there are red papules with some dry scales. The area affected is limited to the foot and ankle area. What is the most likely diagnosis?

Contact dermatitis

36-year-old man presents with an itchy rash that has developed on his left hand. The rash appears to be on the sides of the fingers and on the palm. The lesions are vesicular in nature and have a tapioca-like color to them. What is the appropriate treatment for this patient?

Course of tapered prednisolone

A 67-year-old man presents concerned with 2 asymptomatic skin lesions on the underside of his penis; the lesions are shown in the image. He has a 20-year history of hypertension; it is well-controlled with diet and hydrochlorothiazide (HCTZ). He is a retired automobile sales manager, and he has been faithfully married for 40 years. There is no history of sexually transmitted infections, and he has not been sexually active for the past 2 years. He has no history of skin cancer; he does not smoke tobacco, drink alcohol, or have a history of illicit drug use. What does appropriate management include?

Cryospray and curettage

57-year-old man presents for a routine checkup; he is concerned about a lesion on his head. He appears healthy and has a rustic, tanned complexion. The patient has been a 1-pack/day smoker for more than 30 years, and he consumes alcohol on a daily basis. He has a crusted, rough, yellow-brown solitary lesion on the middle forehead at the hairline. He does not use any type of SPF protection and has had major sunburns throughout life; he spends the weekends on his sailboat whenever possible. What would be an appropriate treatment for this patient?

Cryosurgery

The nurse taking care of a 76-year-old woman at a nursing home notices an ulcer on the left lateral malleolus. The woman is mostly confined to bed due to severe disabling bilateral hip osteoarthritis. She has been a diabetic for the past 10 years, is on insulin, and has been recently diagnosed with depression. Examination reveals a 2x3 cm ulcer over the left lateral malleolus. There is full-thickness loss of tissue with exposure of subcutaneous fat. There is a large amount of slough in the ulcer, but there is no undermining. Sensations are intact in all dermatomes of the lower extremities. Dorsalis pedis, popliteal, and femoral arteries are bilaterally palpable. Examination of the back and lower limbs reveals another similar ulcer on the left greater trochanter of the femur. What is the most likely diagnosis?

Decubitus ulcer

35-year-old woman notices a change in the appearance of a mole on her neck. Physical examination reveals that the lesion is an irregular nodular superficial mass with a variegated appearance. Biopsy demonstrates a primary malignant tumor. What characteristic of the malignant skin lesion is most predictive of the patient's long-term prognosis?

Depth

75-year-old white man came with a black nodule on the back of his hand. The surface is irregular, the edges are not well defined and the surface shows ulceration. This nodule has always been there as a small nevus which recently grew rapidly to assume this shape. What is the most important prognostic factor of this lesion?

Depth

56-year-old woman presents for a routine physical exam. She has been myopic since childhood, and she has visited her ophthalmologist routinely in the past. At the present checkup, she is able to read Snellen chart at 20 feet without her glasses. She has no other significant medical history. Her medication history includes daily calcium supplements; she has been taking the supplements for 3 years. The etiology for her change in vision is similar to what other condition?

Dermal aging

A 67-year-old man presents with protrusions from his skin at his armpits. On general examination, the patient is obese. Skin examination shows small, furrowed papules; they are slightly darker in color than skin. He is diagnosed with skin tags. What is the most common association with this patient's diagnosis?

Diabetes mellitus

5-year-old girl presents with a rash. The girl's mother states that she took the child to an urgent care center over the previous weekend; the patient was diagnosed with a urinary tract infection. The child was started on a 7-day course of sulfamethoxazole/trimethoprim and currently only has one more dose to take. The mother states the child has never taken this type of medication before. The rash in question was first noticeable 2 days ago; it has spread, worsened, and intensified, prompting the mother to bring the child in today. She denies any recent fevers, irritability, itching, or other significant symptoms. Her previous UTI symptoms have resolved. On physical examination, you note scattered lesions on the child. Each lesion appears to have three concentric circles of color change. Making note of the characteristic target lesions this patient displays, what treatment should be recommended?

Discontinue sulfamethoxazole/trimethoprim; monitor symptoms.

A 65-year-old woman initiates carbamazepine for a head trauma-related seizure disorder. A few weeks later, she develops a facial rash and arthritis. She has no new paresthesias or other neurological symptoms, and she has not had any additional seizures. No ulcers, pleuritis, chest pain, bruising, hematuria, or gastrointestinal symptoms are noted. On physical examination, her temperature is 98.6°F; her blood pressure is 120/80 mm Hg, and her pulse is 80 beats per minute. She has a malar rash, and the remainder of her examination is normal. Labs are as follows: Anti-double-stranded antibodies Negative Antihistone antibodies Positive Hemoglobin 13.5 g/dL Serum creatinine 0.7 mg/dL Urinalysis No protein, no blood, no cells, no glucose, no casts White blood cell count 5 x 103 cells/mm3 What is the most likely diagnosis?

Drug-induced lupus

A 27-year-old man came to the outpatient clinic presenting with a red itchy patch on his right arm, as seen in the image. The patient gave a history of falling while playing tennis 2 weeks ago. His arm had an abrasion that almost healed before the appearance of this new rash. What is the most likely diagnosis?

Erysipelas

19-year-old woman presents with a 2-week history of rash. Other than a sore throat that she had last week, she reports being in good health; her sore throat was treated with penicillin. She does not believe that she has come in contact with any type of irritants or any individuals who are sick. On physical examination, you note several target-like lesions on the palms of her hands that are bilateral and symmetric. She indicates that she is on birth control medication. What is the most likely diagnosis?

Erythema multiforme

A 3-year-old girl is brought to the emergency department by her parents. They noticed the abrupt onset of a rash that began on her trunk and extended to her extremities symmetrically. The rash has been accompanied by fever, and her parents note that she napped longer than usual today. She has no chronic medical conditions, but her mother states that she did have a cold sore recently. On examination, the following is seen. Refer to the image. What is the most likely diagnosis?

Erythema multiforme

39-year-old man presents with swollen body parts. He states that he had a tooth extraction procedure yesterday and the swelling started afterwards. The patient's face, hands, arms, genitalia, and legs are swollen. What is the most important management step to take at this point?

Examine the patient for respiratory obstruction.

53-year-old Caucasian man presents due to a bleeding mole on his left cheek that has been present for the past several years. In the last 3 months, it has started to spontaneously bleed. The patient denies any other moles with the same characteristics, and he just wants it taken care of so it is not as bothersome. The patient denies weight loss, night sweats, or fevers; he has no recent changes in his appetite or sleeping issues. He is a farmer, and he owns over 100 acres that he plants and harvests yearly; he has done so for the last 25 years. Physical examination reveals a 4 cm macule with irregular borders, at least 3 different shades of color, and small ulcer in the middle. Considering the most likely diagnosis for this patient, what diagnostic study is most crucial to confirm this pathology?

Excisional biopsy

A 56-year-old woman has had multiple skin issues over the years. She has been on long-term treatment with methotrexate for psoriasis vulgaris, with occasional topical steroid application. She also has increased sensitivity to sunlight. She has a questionable lesion pictured below. The lesion is shown in the image. What is the next step in management?

Excisional biopsy

50-year-old man presents because of a mole his hairdresser noticed on the back of his neck. The patient says that he had felt some itchiness in the area of this mole over the past few weeks. He also has multiple other moles on his back, arms, and legs. He spends most of the work week indoors, but he typically spends his weekends gardening. The rest of his personal and family history is not contributing. Physical examination is within normal limits, except for a presence of 1.7 x 2.3 cm pigmented mole on the back of his neck. What will be your next step in the diagnosis?

Excisional biopsy with narrow margins

65-year-old Caucasian man presents due to losing 15 lb over the past 6 months; he is also experiencing postprandial fullness, hematemesis, abdominal pain, and melena. He also has a 35-year history of daily alcohol intake and smoking. On examination, the patient is found to have pallor and several hyperpigmented velvety papillomatous plaques on the back of his neck and axilla, as shown in the image. What condition is suspected based on patient's signs and symptoms?

Gastric carcinoma

A 60-year-old man with a history of recurrent sinus infections presents with hemoptysis and hematuria. Physical examination shows a temperature of 101°F, a blood pressure of 145/85 mm Hg, decreased breath sounds on his right lower lobe, and palpable purpura on his bilateral lower legs. No warm or swollen joints were noted. Anti-neutrophil cytoplasmic antibody (ANCA) Positive Anti-double-stranded DNA (dsDNA) Negative Anti-Glomerular Basement Antibody (GBM) Negative Erythrocyte sedimentation rate 50 mm/hour Hemoglobin 11 g/dL Serum creatinine 1.5 mg/dL Serum potassium 5 meq/L Serum chloride 21 meq/L Urinalysis 1.020, pH 6, numerous red cells, 500 mg albumin/g creatinine, red blood cell casts Chest X-ray Right lower lobe effusion What is the most likely diagnosis?

Granulomatosis with polyangitis (GPA, Wegener's granulomatosis)

46-year-old HIV-positive man presents with skin changes. You find a painful ulcer on his face and in his mouth and bluish-red and purple bumps on the skin of his thighs, arms, and hands. What is the cause of the disease in this patient?

HHV8 infection

62-year-old man presents to the outpatient clinic with a severe burning pain on his back and left side. On examination, the patient shows grouped vesicles along a dermatome unilaterally that are tense and deep-seated. The regional lymph nodes are tender and swollen. The patient states that his pain came before the onset of the rash. What is the most likely diagnosis?

Herpes zoster

21-year-old woman presents with recurrent painful nodules that form in her armpits. On physical examination, you note red inflammatory nodules that are very tender to palpation. Also noted are open comedones that seem to be paired. The patient indicates that these areas ultimately break down and drain a foul-smelling purulent material. What is the most likely diagnosis?

Hidradenitis suppurativa

65-year-old man with a fair complexion presents with a 8-mm hyperkeratotic, erythematous plaque on the right jaw. On physical examination, there is no regional lymphadenopathy appreciated. A skin biopsy shows a poorly differentiated squamous cell carcinoma (SCC) of skin; there is evidence of perineural invasion. What feature makes the risk of metastasis high?

Histologic features

24-year-old man presents with a painful ulcer on the left leg and systemic symptoms. The lesion started 1 week ago as a small pustule that developed at the site of a mosquito bite and rapidly developed into a painful ulcer. The patient describes the pain as "stabbing" and debilitating. He develops symmetrical joint pain, muscle pain, fever, and malaise. Past medical history is significant for ulcerative colitis, currently in remission. On examination, there is a deep exudative ulceration with a well-defined violet border and a worn erythematous indurated edge. There are signs of pathergy. What should be recommended in addition to meticulous wound care?

Immunosuppressant (systemic corticosteroids)

6-year-old boy attended the outpatient clinic with his mother complaining of a yellow crust on his face. The boy stated that he had a scratch on that area 2 weeks ago. On examination, a honey-yellow adherent crusted plaque of 1.5cm size with minimal surrounding redness was observed on the lower left buccal area. Left cervical lymph nodes were mildly enlarged and tender with no signs of pharyngitis. What is the most likely diagnosis?

Impetigo

7-year-old boy presents with a rash on both legs. The rash started several days ago while he was summer camping. He tells you that some of his friends had similar changes on their skin, but they were not as extensive as he has now. His past medical history is significant for atopic dermatitis that was never put under complete control. On examination, you find several vesicles on his ankles, a few honey brown crusted lesions with an erythematous bases, and several other lesions in various stages of crusting and oozing. Some of them itch. The rest of the examination, including local lymph nodes status, is normal. What is the most likely diagnosis?

Impetigo

A 3-year-old boy presents with 'an itchy and ugly' rash on his elbow that his mother noticed 3 days ago. He has no fever, eats well, and sleeps normally. He has been playing and active and goes to daycare everyday. He has had swimming lessons three times during the last week at the community swimming pool. He has been vaccinated according to the recommended schedule and has no medical history. Upon examination, there is the indicated rash and similar smaller red spots on his face and other arm; he also has slightly swollen lymph nodes. What is the most probable diagnosis?

Impetigo

A patient comes to your office complaining of blisters on his hands. He has noticed that the blisters occur often after he bumps his hand on a hard surface. He tells you that other members of his family have also experienced this problem. He appears to have the Weber-Cockayne form of epidermolysis bullosa. You explain that this disease affects proteins called keratins. Where are these proteins found?

Intermediate filaments

An 18-year-old man presents with lesions on his face. They have been present for the past several years, but they have increased in number and have become more painful since he began taking medications for a cough. He works at a construction site where he has to wear a helmet every day. On examination, you find numerous papules, pustules, and nodules on his face, neck, chest, and upper back. What medication may have worsened his skin condition?

Isoniazid

79-year-old Italian man presents with a 6-month history of lesions on his legs. He is not taking any medications. On examination, you note that he has multiple painless purple papules on his lower limbs. What is the most likely diagnosis?

Kaposi's sarcoma

50-year-old German woman presents with multiple tiny swellings on the dorsum of her left hand. On examination, there are 3 flesh-colored dome shaped swellings measuring between 0.5 to 1 cm. Close examination reveals keratin plugs in the swelling. Microscopically, the biopsy taken from the swelling shows a keratin-filled crater with tongues of epithelium growing downwards. The epithelium shows cytological atypia and abrupt keratinization. What is the most likely diagnosis?

Keratoacanthoma

38-year-old woman presents with a skin rash. She indicates that she has a history of psoriasis, but she has not had a serious outbreak for several years. You note salmon-pink papular lesions involving the flexor surfaces of the patient's wrist. The patient has no other lesions. The lesions appear to follow a linear pattern of distribution. She indicates that the lesion has been present about 3 days. You ask her if she was exposed to any type of agent, and she tells you that she scratched the area and then the lesions appeared the next days upon awakening. What is this lesion called?

Koebner phenomenon

15-year-old male school student presents with white spots on his back that are sometimes itchy. He said that he got them from his soccer teammate at school as they exchanged shirts. On examination, the boy had dark skin color generally. Locally, hypopigmented spots with fine scales were seen on his upper trunk and of variable sizes. The diagnosis was confirmed by KOH test. What is the cause of the hypopigmentation in this case?

Lack of tanning in some areas

30-year-old woman presents with a 2-week history of itchy pimples on her wrist. On examination, there are violaceous papules with a network of gray lines on their surface; they are found on the medial aspect of her right wrist. What is the most likely diagnosis?

Lichen planus

A 65-year-old man presents to the outpatient clinic with a non-healing ulcer on his face. He gives a history of a nodule appearing on his face 7 months ago that enlarged slowly, then ulcerated and failed to heal regardless of the special care he gave it. The man is a farmer and is otherwise healthy. The following photo shows the lesion. What is the best treatment option?

Local excision

17-year-old boy presents with pain in his wrists, elbows, and knees bilaterally. He has felt fatigued, and he has been unable to work his summer job as a cashier and bagger in his family's community grocery store for the past 2 weeks. He also reports intermittent fevers and a large rash on his back in the area of his right shoulder. All of these symptoms have emerged in the last 4 weeks after a week-long backpacking trip in upper state New York. He has no significant past medical history. His only medication is acetaminophen daily for joint pain. He does not use tobacco, alcohol, or illicit drugs. He has no known allergies. Physical examination reveals a thin male adolescent in no acute distress. Temp 99.1°F, P 100 bpm, RR 14, BP 120/70 mm Hg. Small non-tender mobile lymph nodes are palpable in the neck and axilla bilaterally. There is a large warm erythematous patch with central clearing at the patient's posterior right shoulder region; it extends across the arm and axilla and measures approximately 25 cm in diameter. There is limited range of motion in his right wrist and left elbow. There were no gross focal neurologic deficits. What is the most likely cause of these symptoms?

Lyme disease

77-year-old man presents with a rash. The patient states that the rash began a few months ago as several small reddish-brown spots on his shoulders. Over time, the spots became bigger, with some of them growing together to form large well-defined patches. The surrounding skin is not affected. He denies any fever, and he states that he has never had this before. His past medical history is significant for hypertension and obesity. He is otherwise healthy, and he denies any other symptoms. On physical exam, he is a well-developed obese man in no acute distress. He has large areas of well-defined patches that have various shades of brown. Examination of skin scrapings under a microscope shows hyphae. This condition is usually caused by what organism?

Malassezia

13-year-old boy is very self-conscious and refuses to participate in gym class during summer school because he has areas of blotchy paleness on his upper trunk. The areas affected are scaly and vary in color from white to light tan. A skin scraping is performed and evaluated by a KOH preparation, revealing a "spaghetti and meatballs" pattern. What is the cause of the abnormal pigmentation?

Malassezia furfur

42-year-old male presented with a slightly pruritic rash, which he had had for at least 2 months. He complained that the affected skin did not tan normally. He was otherwise in good health and denied any recent travel or illness. Physical exam revealed a well-developed, well-nourished man in no acute distress. He had a rash that consisted of macules of varying colors that were found mainly on his back and chest. In some areas, the macules had become large patches. Tinea versicolor is suspected. What is the most common cause of this patient's condition?

Malassezia furfur

59-year-old Caucasian woman presents with a 1-month history of a lesion on her face. She reports a tendency to sunburn ever since her youth. She is not taking any medications and she exercises regularly. On examination, there is a brown irregularly-shaped macule 3 cm in diameter on her right cheek. It has darker brown spots scattered irregularly within it. What is the most likely diagnosis?

Malignant melanoma

65-year-old man presents for a retirement physical. The physical examination is unremarkable except for a lesion on his upper back. It is a flat, blue-gray, pigmented lesion; it measures 1 x 2 cm and has irregular borders. The patient tells you that it has been there "for a while" and bleeds occasionally. What is the most likely diagnosis?

Malignant melanoma

15-year-old girl with a recent history of epilepsy presents 1 week following the evaluation by a neurologist for prophylactic anti-seizure medication. She was placed on phenytoin by the neurologist at that time. Today, she complains of a 3-day history of fever, myalgias, nonproductive cough, sore throat, and several episodes of nonbilious vomiting. She also states that a nonpruritic rash has developed, first at her hands and feet, but has now begun to "move up her arms and legs." The rash is pictured in the supporting image. What is an additional expected clinical manifestation in this patient?

Mucosal erosions

55-year-old man is a paraplegic due to a spinal cord injury. He is bed bound and has a stage 4-pressure wound on his right trochanter. The wound is 30mm x 35mm x 6 mm. His vital signs are: temperature 101 F, pulse 85/min, and BP 145/80 mm Hg. You refer the patient to a wound care team, and they decide to do sharp debridement and bone biopsy. What kind of surgery is more appropriate for him?

Musculocutaneous flap

21-year-old woman presents with a 3-month history of a black mole on her right calf. She tells you that the lesion is enlarging and expanding. It began to itch about 3 weeks ago, and it has bled 2 times. She has no significant past medical history. She works as a model, occasionally using a tanning booth. There is no family history of skin cancer. Exam is significant for fair complexion. There is a dark brown-black nodule on the right calf 1 cm in diameter with a tiny area of crusting. There are no hairs. The nodule is asymmetrical, with a sharply demarcated border; the color is uniform, and the elevation is regular. There is a narrow (1-2 mm) rim of erythema. There is no lymphadenopathy. What is the most likely diagnosis?

Nodular melanoma

50-year-old Caucasian man presents with an itchy lesion on his left leg. He reports that it has been recurrent for several years, always appearing at the same site. On examination, a coin-shaped, crusted lesion is noted on his left pretibial surface. What is the most likely diagnosis?

Nummular dermatitis

24-year-old man diagnosed 10 years ago with insulin-dependent diabetes mellitus comes to the clinic presenting with pain in his tongue and white patches that bleed if removed. On examination, the following picture was seen. A swab was taken and culture was done. The plate showed white large colonies. What is the most likely diagnosis?

Oral candidiasis

2-year-old boy is brought to your office by his mother after she noticed that he often scratches his head. She also notes patchy loss of hair on the top of his head. She has been sending him to a daycare center for the past 2 months. On examination, you note patchy loss of hair in the right parietal area and another area of "black dot" alopecia about 4 cm lateral to it. The area of hair loss shows a grayish ring-shaped scaly lesion. A KOH preparation demonstrates branching hyphae and spores. What is the best treatment for this condition?

Oral griseofulvin

49-year-old woman presents with a 1-month history of a rash on her right breast. She reports that it has not been responding to the creams that she has been applying and she is having some burning and itching at the rash. On examination, she has an erythematous area that is sharply demarcated with scaling and vesicles over her right areola and nipple. There is a nontender lump in the upper outer quadrant. Her left breast is normal. What is the most likely diagnosis?

Paget's disease

A 27-year-old man came to the outpatient clinic presenting with a red itchy patch on his right arm, as seen in the image. The patient gave a history of falling while playing tennis 2 weeks ago. His arm had an abrasion that almost healed before the appearance of this new rash. What is the most suitable line of treatment?

Penicillin

46-year-old woman presents with recurrent erysipelas and a chronic ulcer on her right lower leg. The patient has no history of liver disease, diabetes, or immunosuppression; however, her medical history is significant for obesity and a 2-year history of chronic ulcer of the right leg. She had been well until approximately 2 days earlier, at which point she abruptly developed severe pain, swelling, and tenderness of the right leg. Other symptoms include fever, chills, and malaise. Physical examination reveals an obese woman in moderate distress. Her temperature is 99.6°F; her respiratory rate is 18 breaths/min; her pulse is 110 beats/min; and her blood pressure is 104/60 mm Hg. The patient is alert and oriented. Findings from the patient's heart, lung, and abdomen are unremarkable. There is an ulcer on the lower right leg measuring approximately 3 x 2.5 cm, with elevated margins and surrounding erythema. There is swelling of the entire leg and tenderness to palpation. What is true regarding this patient's condition?

Penicillin is the drug of choice.

60-year-old woman presents with long-standing changes on nails on her feet. Changes started 3 years ago when both her big toes were severely injured during a hiking trip in the mountains. She contributed the extent of the injury to "not so comfortable boots" and long-distance walks. However, her nails never recovered; over the next few years, her nails started to look worse, and the problem spread to other nails. Now they look thick, pitted, ridged and crumble. Routine cutting and thinning of the nails did not help. She feels depressed because of her cosmetically embarrassing condition, and she has stopped wearing open shoes, sandals, and flip-flops. 6 months ago she was diagnosed with Diabetes mellitus type 2 and despite diet and regular physical activity, her blood sugar and HbA1c remain high (fasting blood sugar 140 mg/dL and HbA1c 9 giving the value of average blood sugar around 212 mg/dL). Her BMI is 29. She has no other complaints. On examination, you find discoloration in the form of whitish-yellow growth under and on the nails towards their tip (subungual hyperkeratosis), with rough surface areas and onycholysis in all nails. Skin of the soles and interdigital webs are normal. What will be your first step in the management of her problems?

Perform potassium hydroxide (KOH) test

4-year-old boy presents with a rash on his feet, ankles, wrists, and gluteal areas; the rash is accompanied by severe itching, particularly at night. His 6-month-old sister has a similar rash on her neck and head. On examination, you find pruritic erythematous papular and papulopustular skin changes between the web spaces of the fingers; changes are also seen on the flexor aspects of the wrists and in the genital and gluteal areas. On superficial epidermis, you find several short elevated red tortuous lines; they have a small vesicle at the tip. What treatment you will suggest?

Permethrin cream

12-year-old girl presents with a 1-week history of a rash on her trunk. The patient has not been ill or exposed to anyone ill. On examination, there are scattered lesions on her trunk; they look like they form a Christmas tree. The girl states that the lesions are itchy at times, but they are generally not bothersome. What is the most likely diagnosis?

Pityriasis rosea

20-year-old African-American woman presents with itchy rashes on her hands. She reports that they have been persistent for the past 2 years. On examination, deep-seated vesicles with scaling on her palms are noted bilaterally. What is the most likely diagnosis?

Pompholyx

14-year-old African American boy presents to your clinic with a several-week-long history of the appearance of spots on his face; they produce pus when he squeezes them. Over the past week, he has also noticed similar spots on his back. He recently began smoking cigarettes. His 17-year-old brother has similar spots on his face. What is not a pathogenic factor associated with his condition?

Poor hygiene

21-year-old man presents with itchy skin changes. He works as a lifeguard. About a week ago, he noticed a round red patch on his belly that spread to his trunk and legs. He denies recent infections, allergies, and illnesses; he does not take any medications, and he admits that he occasionally smokes marijuana. The rest of his personal and family history is non-contributory. On examination, you find round annular scaly pruritic papulosquamous changes on his torso and legs. There are no changes on his mucosa, and the rest of physical examination is within normal limits. What is the next step in making the diagnosis?

Potassium hydroxide preparation

59-year-old man presents with a 1-day history of severe burning pain on his back and left side. On examination, the patient shows grouped vesicles distributed unilaterally along a dermatome that are tense and deep-seated. The regional lymph nodes are tender and swollen. What is the proper management in this case?

Prescribe a systemic antiviral.

13-year-old boy presents at his physician's office with multiple skin lesions on his face and neck. He states that he began having mild symptoms about 1 year ago, but the condition worsened significantly over the past 2 or 3 months. He had been very healthy and denied any recent travel. Physical examination reveals a well-developed, well-nourished young boy in no acute distress. His face was erythematous and covered with papules and pustule in various stages of healing. Comedones were distributed liberally on his face and neck. The lesions were non-tender and there was no lymphadenopathy. The rest of his exam was within normal limits. The organism most likely to cause this condition is

Propionibacterium acnes

30-year-old man presents with a facial outbreak. He indicates that it comes and goes, and he says that he was not concerned until he thought it was getting worse and spreading. The outbreak is localized to his jaw area and upper neck. He does not shave every day and the outbreak seems to get worse when his beard grows back. On physical examination, you note papules and pustules that are located to the side of the hair follicles. What is your initial diagnosis?

Pseudofolliculitis

35-year-old obese man presents with a 6-month history of itchy rash. He was referred to you by his primary care physician, who treated him for tinea cruris over a period of 4 months with limited success. A brief history reveals the patient is bipolar on lithium, does not smoke, and takes no other medications aside from the terbinafine (Lamisil) tablets prescribed by the primary physician. On physical examination, the rash is located primarily in the intertriginous areas of the groin, but it can also be seen in the axillary and sacral regions. The morphology is variable, but it is largely consistent with that of erythematous plaques. Scaling is widely observed, except for in the groin, where the plaques are moist and more confluent. The dermatologist does a KOH preparation of the scrapings and finds no hyphae. What is the most likely diagnosis?

Psoriasis

14-year-old Caucasian girl presents with a painless nodular lesion on her right cheek. She states that, about 2 months ago, she noted a pimple on her cheek that grew rapidly over several weeks to the size of the small blueberry. The bump irritates her. Because it bled several times when she did so, she tries not to pick at it. The girl is otherwise healthy. On examination, you find a sessile, reddish-brown nodule of around 5 mms in diameter; it is moderately firm and covered by a crust. Biopsy shows a proliferation of capillaries, with endothelial cells embedded in gelatinous stroma in a lobular configuration. What is the next step in the management of this condition?

Pulsed-dye laser therapy

17-year-old boy presents with velvety-brown spots on his chest, nape, and back that are sometimes itchy. On examination, hyperpigmented spots with fine scales of variable sizes are seen on his upper trunk and back. He is diagnosed with tinea versicolor and prescribed 1 dose of oral ketoconazole 400 mg. After 1 month, the patient states he has not improved at all; he took the drug just as prescribed; when he played sports, he showered and dried himself well. Why was the ketoconazole inefficient?

Random shower

32-year-old man attended the outpatient clinic complaining of papules that he accidently discovered while he was urinating. He stated that he engaged in multiple, but safe, sexual activities lately. On examination, 2 rows of small, smooth, filiform papules with light skin color and texture lie around the corona circumference. What is the appropriate management for this case?

Reassure the patient that no treatment is needed

You have a visit with this diabetic patient in your office, for the first time. He is a 60-year-old male, with a history of known diabetes for 15 years. He is on Insulin and his diabetes has been under control most of the time. You take his history and physical, which includes inspection of his feet. You realize that there is a non-infected blister on his left plantar surface. You teach the patient how to take care of his feet. You also advise him to have an appropriate nutritional low fat diet, keep his blood sugar under control, and have prescriptive footwear. Your patient comes back after one month. This time there is a 3 cm x 3 cm wound instead of a blister. You evaluate the wound for soft tissue infection, osteomyelitis, and vascular efficiency. Studies show inadequate blood circulation in his left foot. Which one of the following is the first intervention?

Revascularization

50-year-old woman has had a facial rash and a 10-year history of reddening of her face that comes and goes. On physical exam, you note erythema, telangiectasia, red papules, and tiny pustules on both cheeks. What is the most likely diagnosis?

Rosacea

55-year-old man states that he recently noticed that he has started to flush easily and his nose appears unusually large. Additionally, during an appointment with his eye specialist the month before, he was prescribed medication for blepharitis and keratitis. What is the most likely diagnosis?

Rosacea

26-year-old African American man presents with a rash on his back. He first noticed the rash 3 weeks ago. He describes small whitish upper back lesions that are not painful and do not itch. He has no significant past medical history; he has no known drug or food allergies; he is not taking any medications. On physical examination, there are several small hypopigmented macules that coalesce on the upper third of his back. Fine scaling is produced on scratching. The remainder of the physical examination is unremarkable. How should you proceed in the management of this patient?

Scrape lesions and KOH stain.

20-year-old Caucasian woman presents to the hospital with a 2-month history of itchiness of her scalp. On examination you note greasy yellowish scales on her scalp and eyebrows. What is the most likely diagnosis?

Seborrheic dermatitis

65-year-old man suffers from Parkinson's Disease. He is in the habit of wearing a cap. On his visit to the doctor's office, he complains of itching of the scalp since his last visit. On examination, the scalp has dry scales; there is underlying erythema. He also complains of itching and dryness below his underbelly. What is the most likely diagnosis?

Seborrheic dermatitis

47-year-old Caucasian man presents because he is worried that he has cancer on his back. He had his shirt off at a company picnic and someone suggested that he should get a spot on his back checked. On physical exam, there is a single lesion about 3 mm in size on his posterior (back); it is brown/black in color and has a "stuck-on" appearance. It is sent to pathology. What is your initial diagnosis?

Seborrheic keratosis

An obese man presents with redness and itching in his groin area. He stated that he was on vacation and had participated in sports and swimming activities. He was diagnosed with tinea cruris, which was confirmed with a KOH swab. Based on the above diagnosis, what is the most important sign?

Sharply demarcated erythematous lesions with central clearing and scaly, actively spreading peripheries

64-year-old man presents with a painful wound on his lower leg; the wound has been increasing in size over past 3 months. At first, the pain was localized, but it now radiates to his thighs and groin. The wound has foul-smelling drainage. He states that he suffered an injury in a traffic accident about 10 years ago. There was no fracture; however, over the following years, the wound did not heal despite daily care in terms of dressing changes. Infection has developed around the wound and evolved into an ulcer. The patient then developed chronic osteomyelitis. He was treated several times with intravenous antibiotics; the last treatment was finished a week ago, and it lasted 6 weeks. His suffers from diabetes, hypertension, and hepatitis B and C. On examination, you find afebrile well-nourished man. Above his left ankle he has 8x9cm exophytic mass with irregular edges, and foul smelling seropurulent drainage. There is also regional lymphadenopathy. Vascular exam is within normal limits. The compete blood count is normal, and the erythrocyte sedimentation rate is 90. In this case, what is the most accurate diagnostic method?

Soft tissue biopsy

69-year-old Caucasian woman presents with a painful lesion on her lip that has been rapidly increasing in size and bleeding for the past month. She gives a long history of sun exposure and several blistering sunburns in her adolescence. On examination, there is a tender, pink papule 2 cm in diameter on her lower lip. What is the most likely diagnosis?

Squamous cell carcinoma

70-year-old man presents for a routine physical examination. He has been in a good state of health, but he is concerned about a growth on his right leg. He states that it has been present for about 1 year; it disappears once in a while, but then it returns, sometimes covered with white scales that then dropped off. On further questioning, he gives a history of spending countless hours at the beach body surfing as a youth; he rarely used sunscreen. On examination of the skin, you note a round pinkish spot measuring about 0.5 cm in diameter on the posterolateral aspect right leg. The lesion is raised; it feels dry and rough to touch. You suspect skin cancer, and you refer the patient to a dermatologist who decides to cauterize the lesion with liquid nitrogen. Within 3 weeks, the area becomes crusted, shrinks, and falls off. 2 weeks thereafter, the spot returned, and after a month, it develops into an open sore that will not heal. What is the most likely diagnosis?

Squamous cell carcinoma (SCC)

62-year-old diabetic man presents with darkened skin in the groin area for 2 months. Clinical examination reveals a raised dark reddish discoloration of skin with fine brownish scales and a sharp border. Under the Wood lamp, the lesion had coral red fluorescence. What layer of the skin is responsible for this change in skin color?

Stratum corneum

17-year-old girl presents with a painful, swollen, red left forearm. Symptoms began about 2 days prior to presentation; they followed a bug bite and initially presented as a small red area. She does not recall any other injuries to the arm. She denies fever, chill, nausea, and vomiting, but she states that she has had increased pain and swelling over the last day or so. She has no significant past medical history, and she had been well until this recent illness. Physical examination reveals a well-developed, well-nourished patient in mild distress. Her exam is significant for an erythematous, warm, shiny plaque area measuring approximately 5 cm in diameter with a well-defined border on her left forearm. Vital signs are as follows: blood pressure 110/72 mm Hg, pulse 78 beats per minute, temperature 99.6°F, and respiratory rate 14 breaths/min. What is the most common cause of this condition in the United States?

Streptococcus pyogenes

46-year-old Caucasian woman presents for her regular physical check-up. She is slightly overweight, but in general good health with no significant medical history. Her vitals are normal. She is active and likes to spend time outdoors, but sometimes gets skin irritation from sand while running at the beach. She has felt an itching sensation around a mole she has had on her leg since birth. Upon visual examination, you suggest dermatoscopy testing which excludes seborrheic keratosis. What is the most appropriate next step in the management of this patient?

Surgical treatment

A 23-year-old woman presents with a rash and swollen joints. She had been healthy previously, and the only medication she takes is acetaminophen. A review of systems includes recent fevers and a 5 lb weight loss in the past month; she is also experiencing photosensitivity and hematuria. She denies oral ulcers, nasal congestion/discharge, ear pain, pleuritic symptoms, chest pain, neural symptoms, bruising, and bleeding. On physical exam, her temperature is 101°F; her blood pressure is 130/85 mm Hg. She has a malar rash as well as diffusely swollen, warm, and tender joints. Her cardiopulmonary exam is normal. She has no costovertebral angle tenderness. Trace bipedal edema is noted. Diagnostic studies reveal: Erythrocyte sedimentation rate 50 mm/hour Hemoglobin 11 g/dL Anti-double-stranded DNA antibodies Positive Anti-nuclear antibody Positive Anti-histone antibody Positive Platelet count 200,000 cells/mL White blood cell count 12,000 cells/mm3 Chest X-ray Normal Urinalysis No bacterial growth. Numerous dysmorphic red blood cells. 10 white blood cells/high power field. Red blood cell casts. 510 mg albumin/g creatinine. Complement 3, 4 Both reduced Anti-neutrophil cytoplasmic antibody Negative What is the most likely diagnosis?

Systemic lupus erythematosus

24-year-old woman presents with a mildly pruritic rash on her arms, neck, and trunk. On physical examination, there are multiple scattered lesions with marked vesicles, pustules, and sharply marginated plaques with a central clearing and crusting at the margins that produce annular configurations. What detail of the patient's history, if elicited, may denote the etiologic cause of this disorder?

The patient works with animals

13-year-old boy presents for the treatment of acne vulgaris that did not respond to antibiotic therapy. On physical examination, the patient's torso and shoulders showed several ill-defined annular lesions, with fine scale and decreased pigmentation. Samples of the skin were obtained, and a potassium hydroxide preparation was positive for hyphae. A diagnosis of tinea versicolor is considered. What is true regarding the patient's condition?

There is a high recurrence rate.

10-year-old boy presents with a 1-week history of a rash on his scalp. His mother states that the boy has been scratching his head often, and she notes that there are areas where his hair appears to have fallen out. She attempted to treat it with over-the-counter preparations, but his condition has not improved. The boy is active and otherwise healthy. The rash appears as erythematous, circular, scaly patches. There are areas where the hairs have become brittle and broken off. A scraping of one of the patches is placed in potassium hydroxide solution and shows hyphae. What is the most likely diagnosis?

Tinea capitis

A 32-year-old migrant worker presents because some of his toenails have changed color and have become brittle. You ask him to remove his shoes and socks; you note a yellow-brown discoloration of the first and fifth toenails. On closer exam, the toenails have become thickened and friable; there is debris under the nail distally. What is the most likely diagnosis?

Tinea unguium

13-year-old boy is very self-conscious and refuses to participate in gym class during summer school because he has areas of blotchy paleness on his upper trunk. The areas affected are scaly and vary in color from white to light tan. A skin scraping is done and evaluated by KOH preparation, revealing what looks like "spaghetti and meatballs." What is the most likely diagnosis?

Tinea versicolor

15-year-old boy is at his dermatologist after returning from a 2-week trip to Mexico during spring break. He presents with some concerns over discoloration on his skin. Physical exam reveals macules with a hypopigmented light brown appearance that fluoresce yellow-green under Wood lamp. KOH prep displays hyphae and spores that appear with "spaghetti and meatball" appearance. What is the most likely diagnosis?

Tinea versicolor

18-year-old man presents with a rash. He states that the rash began a few weeks ago and it has worsened over the past 2 weeks. He denies fever, chills, nausea, vomiting, or weight loss. He also denies recent travel or illness. He has no significant past medical history and is otherwise healthy. Physical exam reveals a well-developed well-nourished man in no acute distress. He has areas of hyperpigmentation on his back and chest. A scraping taken from the back area shows orange fluorescence under UV light. What is the most likely cause of this patient's symptoms?

Tinea versicolor

20-year-old college student presents with brown spots on the upper trunk. On examination, brown velvety hyperpigmented macules with scales and scrapping are found on the central upper trunk, sparing the other areas. On microscopic examination, scales, yeast, and short hyphae are observed. What is the most likely diagnosis?

Tinea versicolor

23-year-old woman has scheduled an appointment with you today. She complains of itchy, scaly patches on both her knees and lower legs. The patch was initially penny-sized but has recently increased in size and is mildly itchy now. There is no history of infection, drug intake, or insect bites. However, she says that she has been under extreme stress over the last month due to family issues. On examination, you note whitish, irregular, slightly raised plaques on the knees and legs. Auspitz sign and Koebner phenomenon are positive. You note similar lesions in the right axilla. Overall, about 10% of the skin surface is involved. Scalp, mucous membrane, and nails are normal. What is the best treatment option at this stage?

Topical clobetasol + topical calcipotriene

24-year-old woman presents with a mildly pruritic rash on her arms, neck, and trunk. On physical examination, there are multiple scattered lesions with marked vesicles, pustules, and sharply marginated plaques with a central clearing and crusting at the margins that produce annular configurations. What is the most appropriate treatment for this patient?

Topical clotrimazole applied BID

35-year-old woman presents with intensely pruritic red papules over the anterior wrists. On close examination, the papules are shiny; they have a flat surface and there is occasional central umbilication. A red plaque is seen along the scratch line at the anterior forearm. What is the best initial therapy for the patient?

Topical corticosteroid

45-year-old man with stage 4 chronic kidney disease due to type 1 diabetes presents with a rash. His temperature is 98.6°F. His oropharyngeal, nasal, cardiac, and pulmonary examinations are normal. He has trace bipedal edema and several dry scratched areas on his limbs and back. No petechiae or purpura are noted. His most recent serum intact parathyroid hormone level was acceptable; so were his hemoglobin, phosphorus, and iron saturation levels. What should your initial step be?

Topical emollients

28-year-old man presents with a 1-week history of an itchy scaly rash on his elbows. When he scratches it hard, scales come off and the rash bleeds. Examination reveals the elbows are affected bilaterally. The lesions appear as 3-4 cm annular whitish scales on an erythematous base that is irregular and well-demarcated. The antecubital fossae are unaffected. What is an appropriate treatment?

Topical fluorinated glucocorticoids

A patient presents with a rash that involves the hands and wrists. On examination of the rash, you note flat-topped, sharply defined purple papules measuring 1 to 10 mm in size. You apply mineral oil and examine the lesions with a hand lens and note white lines within the lesions. You also notice that he has nail dystrophy and a white lacy pattern on his buccal mucosa. What would be an appropriate treatment?

Topical glucocorticoids with intralesional triamcinolone

49-year-old woman is evaluated by dermatology for a lesion below her left eye; the image can be seen in the image. Its presence has been notable for 1 year, and it has been slowly enlarging. A diagnosis of basal cell carcinoma (BCC) is made, and her treatment options are explained to her. She absolutely refuses surgery, saying surgery was responsible for killing her father. What is a reasonable treatment option in this case?

Topical imiquimod

61-year-old woman presents with a 3-week history of breakouts on her face. She presented with a similar issue 6 months earlier, but she did not receive treatment. Physical examination reveals erythema and dilated vessels on the cheeks. What is an appropriate treatment?

Topical metronidazole cream

A 16-year-old Caucasian girl presents with a 6-month history of blackheads and whiteheads on her face. On examination, there are a few papules and pustules on her cheeks; there are no nodules. Her mother reports having similar spots on her face at this age. What is an appropriate first-line medication for this patient?

Tretinoin

28-year-old woman presents with dark spots on her nose. She states that she was diagnosed with acne vulgaris, but the treatment was not successful. On examination, small black papules less than 1 mm are found on her nose, but they are not surrounded by inflammation. On removal with forceps, the patient does not feel any discomfort. Examination of the lesion with hand lens shows vellus hairs in the keratinous plug. What is the most likely diagnosis?

Trichostasis spinulosa

35-year-old man presents with hair loss on the side of his head. He states that during long office working hours he has a habit of pulling his hair at a certain area; this behavior increases with stress. He also states that he has been subjected to a severe workload lately. He does not take any medications. On examination, a 1 cm x 1 cm area of normal skin with no hair over the right temporal area is seen. No exclamation mark hairs are found. What is the most likely diagnosis?

Trichotillomania

A 42-year-old man presents for an annual well-adult physical exam. He has been in a good general state of health since his last visit, but his wife is concerned with a spot on his back; she has noticed it increasing in size over the past 6-8 months. He has always had numerous freckles and moles, but he has no personal or family history of skin cancer. He admits to frequenting tanning parlors in college; he still tans before social events on occasion. Physical examination shows the lesion depicted (refer to the image). He also has approximately 20 other small round nevi on his arms and back that appear normal. What feature is most predictive of poor outcome in this case?

Tumor thickness

70-year-old man on vacation in the US presents for what appears to be suspicious skin lesion on his cheek. He has had a longstanding discolored patch; it has recently enlarged in size, and there is crusting. A biopsy confirms your suspected diagnosis. After undergoing treatment, he wants to take measures to prevent a recurrence. What is the most appropriate advice for prevention of recurrence?

Wear protective clothing and avoid midday sun.

45-year-old Caucasian woman presents because she is worried she may have skin cancer. While interviewing the patient, you note the patient has an extremely fair complexion. When you examine the lesions that the patient is concerned about, you note the following description in your documentation: "5 papules that vary in diameter from 0.3-0.6 centimeters dispersed on the skin around the sternal angle. Lesions vary in color from flesh-toned to slightly hyperpigmented, and when palpated have a sandpaper texture." Based on the most likely diagnosis, what would be the most appropriate pharmaceutical regimen at this time?

5-fluorouracil cream

A 22-year-old woman is evaluated for a chronic pruritic lesion. She reveals that it began on her posterior scalp, but it has now spread to her elbows, knees, and gluteal cleft. The lesions appear to wax and wane, but as of late, they have been spreading further. A picture of her lesions is shown. She is extremely distressed by her condition; she is particularly worried because her mother succumbed to squamous cell carcinoma. A biopsy of the lesion is likely to demonstrate what histological finding?

Acanthosis with intracorneal pustule formation and lymphocytic infiltration

25-year-old woman with no significant medical history goes to her primary care physician's office presenting with inflammation and lesions on her forehead, chin, and upper back. She recently moved from the northeast and her symptoms began shortly thereafter. They began about 6 months ago and have steadily worsened. She denies any recent illness and states that she has been eating a lot of junk food since her move due to stress and lack of time to prepare regular meals. Physical examination reveals a well-developed female in no acute distress. Her exam is normal with the exception of areas of erythema and numerous eruptions on her face and upper back. The eruptions consist of comedones and pustules and surround areas of excoriation. The rest of the skin exam is normal. The most likely diagnosis is

Acne vulgaris

33-year-old woman presents with red pimples and mild itching on her face. Upon examination, the patient has swollen open and closed comedones, papules, and pustules. She states that she never experienced these symptoms before, even when she was a teenager. What is your diagnosis?

Acne vulgaris

A woman presents with her 17-year-old son due to concerns about his face. She states that he seems to break out in a rash on his face and it has been getting worse over the last 3 years. On physical examination, you note multiple closed comedones and papulopustules covering his cheeks, forehead, and chin. What is the most likely diagnosis?

Acne vulgaris

65-year-old man is being treated at the dermatologist for a lesion on his face for the past 5 weeks that will not go away. Additionally, the patient has a history of staying out in the sun, as he lives in Florida. Upon physical exam, a 0.6 cm macule that appears flesh-colored and slightly hyperpigmented is present on his right cheek. Upon palpation, the macule feels like sandpaper and is tender to the patient. All labs are within normal limits. What is the most likely diagnosis?

Actinic keratoses

55-year-old man presents with lesions on the top of his head. He noticed them about 6 months ago and did not think much about them until more of them appeared. Physical examination of the scalp shows that he is slightly balding and has scattered multiple lesions that appear to be <1 cm in size. The lesions are yellow-brown, dry, and scaly. Upon palpation, the lesions have a rough coarse texture and are tender. What is the most likely diagnosis?

Actinic keratosis