Adult Gerontology - Dermatology - Q & A

A linear arrangement along a nerve distribution is a description of which type of skin lesion? A. Annular B. Zosteriform C. Keratotic D. Linear

Answer: B A zosteriform lesion is a linear arrangement along a nerve distribution and typifies herpes zoster. An annular lesion is ring shaped. Linear simply implies that the lesion appears in lines. A keratotic lesion has horny thickenings.

A Wood's light is especially useful in diagnosing which of the following? A. Tinea versicolor B. Herpes zoster C. A decubitus ulcer D. A melanoma

Answer: A A Wood's light is especially useful in diagnosing tinea versicolor or other fungal infections. A Wood's light produces a "black light" through longwave ultraviolet rays. It accentuates minor losses of melanin, which makes it useful in diagnosing tinea versicolor and vitiligo, in which there is hypopigmentation

A basal cell carcinoma is A. an epithelial tumor that originates from either the basal layer of the epidermis or cells in the surrounding dermal structures. B. a malignant tumor of the squamous epithelium of the skin or mucous membranes. C. an overgrowth and thickening of the cornified epithelium. D. lined with epithelium and contains fluid or a semisolid material.

Answer: A A basal cell carcinoma is an epithelial tumor that originates from either the basal layer of the epidermis or cells in the surrounding dermal structures. A squamous cell carcinoma is malignant and originates in the squamous epithelium. An overgrowth and thickening of the cornifi ed epithelium is a keratosis. A cyst is a benign closed sac in or under the skin surface that is lined with epithelium and contains fluid or a semisolid material.

Your 24-year-old client whose varicella rash just erupted yesterday asks you when she can go back to work. What do you tell her? A. "Once all the vesicles are crusted over." B. "When the rash is entirely gone." C. "Once you have been on medication for at least 48 hours." D. "Now, as long as you stay away from children and pregnant women."

Answer: A A client who has a varicella rash can return to work once all the vesicles are crusted. Varicella is contagious from 48 hours before the onset of the vesicular rash, during the rash formation (usually 4-5 days), and during the several days while the vesicles dry up. The characteristic rash appears 2 to 3 weeks after exposure. Treatment is effective only if started within the first few days, and then only to shorten the course of the disease. Clients should avoid contact with pregnant women and children who have not been exposed to varicella.

A darkfield examination is used to cutaneously diagnose which disease? A. Syphilis B. Viral blisters C. Scabies D. Candidiasis

Answer: A A darkfield examination is used to diagnose syphilis cutaneously. Viral blisters can be diagnosed cutaneously by the Tzanck smear, a scraping can be done to look for scabies, and a potassium hydroxide preparation and culture are used to diagnose candidiasis.

What is an excessive amount of collagen that develops during scar formation called? A. A keloid B. A skin tag C. An angioma D. A keratosis

Answer: A A keloid is an elevated, irregularly shaped, and progressively enlarging scar that arises from excessive amounts of collagen during scar formation. A skin tag is a soft papule on a pedicle. An angioma is a benign vascular tumor. A keratosis is any skin condition in which there is a benign overgrowth and thickening of the cornifi ed epithelium.

Silas, age 82, comes to your office with a fairly new colostomy. Around the stoma, he has a papular rash with satellite lesions. What does this indicate? A. A fungal infection, usually Candida albicans B. An allergic reaction to the appliance C. A normal reaction to fecal drainage D. Contact dermatitis

Answer: A A papular rash with satellite lesions around a stoma indicates a fungal infection. It may be a consequence of persistent skin moisture or an adverse effect of antibiotic therapy. If Silas were having an allergic reaction to the appliance, he would have an erythematous vesicular rash limited to the site of the faceplate of the appliance. If the appliance fi ts properly, fecal drainage should not come in contact with the skin. Contact dermatitis may result from fecal drainage on the skin or from the faceplate of the appliance and often presents as erythema with burning that generally occurs within the area of exposure to the offending agent.

A 70-year-old client with herpes zoster has a vesicle on the tip of the nose. This may indicate A. ophthalmic zoster. B. herpes simplex. C. Kaposi's sarcoma. D. orf and milker's nodules.

Answer: A Ophthalmic zoster (herpes zoster ophthalmica) involves the ciliary body and may appear clinically as vesicles on the tip of the nose. The client with a herpetic lesion on the nose indicating ophthalmic zoster needs to be referred to an ophthalmologist to preserve the eyesight. Herpes simplex primarily occurs on the perioral, labial, and genital areas of the body. Kaposi's sarcoma in the older adult usually occurs in the lower extremities. Orf and milker's nodules almost always appear on the hands.

What is a safe and effective treatment for mild psoriasis? A. Coal tar preparations B. Systemic steroids C. Topical antibiotics D. Systemic antihistamines

Answer: A A safe and effective treatment for mild psoriasis is the use of coal tar preparations. The concentration is increased every few days from 0.5% to a maximum of 10%. A contact period of several hours is required, and the odor is unpleasant. Topical corticosteroids are widely used because they are relatively easy to apply. Topical steroids are appropriate in cases involving 10% or less of body surface. Topical antibiotics are indicated for acne rosacea, and systemic antihistamines are indicated for pityriasis rosea. Some of the chemicals in coal tar may cause cancer but only in very high concentrations as in coal tar used for industrial paving. Any client using coal tar regularly should be aware of the signs and symptoms and have a skin cancer checkup annually. Ongoing treatment for psoriasis may include topical creams and ointments, such as vitamin D compounds like calcipotriene, corticosteroids, retinoids such as tazarotene, and anthralin. These may be used in combination with sunlight (phototherapy). For severe psoriasis, systemic therapy may be required; this includes the use of such medications as retinoids, methotrexate, and cyclosporine, usually in addition to continued topical treatments and exposure to ultraviolet light

Louis, age 52, presents with pruritus with no rash present. He has hypertension, diabetes, and end-stage renal disease (ESRD). One of the differential diagnoses would be A. uremia from chronic renal disease. B. contact dermatitis. C. lichen planus. D. psoriasis.

Answer: A All of the conditions listed result in pruritus. Only uremia from chronic renal disease, however, results in pruritus with no rash present. The other conditions—contact dermatitis, lichen planus, and psoriasis—all have a rash present.

Which agent is ineffective against psoriasis? A. Topical antifungals B. Systemic medications C. Phototherapy D. Topical corticosteroids

Answer: A Antifungal agents are ineffective against psoriasis. The most common form of treatment is corticosteroids applied topically. Systemic treatments are used in more severe cases, and phototherapy, from either natural or artificial light, may also be helpful

Candidiasis may occur in many parts of the body. James, age 29, has it in the glans of his penis. What is your diagnosis? A. Balanitis B. Thrush C. Candidal paronychia D. Subungual Candida

Answer: A Candidiasis of the glans of the penis is balanitis. Thrush is oral candidiasis, candidal paronychia involves the tissue surrounding the nail, and subungual Candida is candidiasis under the nail

Dry, itchy skin in older adults results from A. the reduction of sweat and oil glands. B. loss of subcutaneous tissue. C. dermal thinning. D. decreased elasticity

Answer: A Dry, itchy skin in older adults results from the reduction of sweat and oil glands. Loss of subcutaneous tissue, dermal thinning, and decreased elasticity are normal changes associated with aging, and they may cause wrinkles and sagging of the skin.

Which disease usually starts on the cheeks and spreads to the arms and trunk? A. Erythema infectiosum (fifth disease) B. Rocky Mountain spotted fever C. Rubeola D. Rubella

Answer: A Erythema infectiosum (fifth disease) usually starts on the cheeks and spreads to the arms and trunk. Rocky Mountain spotted fever, which is associated with a history of tick bites, starts as a maculopapular rash with erythematous borders appearing first on the wrists, ankles, palms, soles, and forearms. Rubeola (measles) starts as a brownish-pink maculopapular rash around the ears, face, and neck and then progresses over the trunk and limbs. Rubella (German measles) starts as a fine, pinkish, macular rash that becomes confluent and pinpoint after 24 hours.

Janice, age 35, states that her son is allergic to eggs, and she heard that he should not receive the flu vaccine. How do you respond? A. "Although measles, mumps, rubella, and influenza vaccines contain a minute amount of egg, most egg-allergic individuals can tolerate these vaccines without any problems." B. "Most of the allergic reactions are caused by the actual vaccinations; therefore, a skin test should be done first." C. "You're right. We should not give this vaccination to your son." D. "He should not have a skin test done if he has this allergy because a serious cellulitis may occur at the testing site."

Answer: A If a client is allergic to eggs and does not think that he or she should receive the flu vaccine, advise the client that, although measles, mumps, rubella, and influenza vaccines contain a minute amount of egg, most individuals who are allergic to eggs can tolerate these vaccines without any problems; that some of the allergic reactions are caused by the gelatins in the vaccinations and not the actual vaccinations; and that if the client can eat a whole egg with no reaction, he or she should have no problem with the vaccination. If the history of the allergy is questionable, it is safest to perform a skin test using the vaccine in dilute amounts and then administer the vaccine under strict observation, allowing a 2-hour wait to observe for any reaction.

Mr. Swanson, age 67, presents to the clinic for his annual health exam. He asks you if there is anything he can do to prevent the painful blistering sores on his lip that develop in the summertime when he plays golf. You explain to Mr. Swanson that the way to prevent the development of these lesions is to A. protect the lips from sun exposure with a blocking agent such as zinc oxide or a lip balm that contains a broad-spectrum sunscreen. B. apply acyclovir 5% cream 5 times a day for 4 days. C. take acyclovir 500 mg tablet 5 times a day for 5 days. D. wear a visor.

Answer: A Mr. Swanson has recurrent HSV-1 orolabial herpes. Factors that trigger reactivation include local skin trauma, sunlight exposure, and other systemic changes such as menses, fatigue, or fever. In this question, the clinician is teaching prevention. Protecting the lips from sun exposure is a preventive measure. Application of topical antivirals or administration of oral antivirals are for the treatment of infection and are given to reduce the time to healing of primary and recurrent infection. Wearing a wide-brim hat minimizes exposure to sunlight but may not provide adequate coverage of the lower face and lips.

The ABCDEs of melanoma identification include which of the following? A. Asymmetry: One half does not match the other half. B. Border: The borders are regular; they are not ragged, notched, or blurred. C. Color: Pigmentation is uniform. D. Diameter: The diameter is 5 mm.

Answer: A One of the warning signs of cancer is a lesion that does not heal or one that changes in appearance. The ABCDEs of melanoma identification should be taught to all clients. A is for a symmetry: One half does not match the other half. B is for b order irregularity: The edges of a melanoma are ragged, notched, or blurred. C is for color: Pigmentation is not uniform; there may be shades of tan, brown, and black, as well as red, white, and blue. D is for diameter: greater than 6 mm. E is for an evolving lesion, as well as for elevation.

An eczematous skin reaction may result from A. penicillin. B. allopurinol (Zyloprim). C. an oral contraceptive. D. phenytoin (Dilantin).

Answer: A Penicillin, neomycin, phenothiazines, and local anesthetics may cause an eczematous type of skin reaction. Allopurinol (Zyloprim) and sulfonamides may cause exfoliative dermatitis, oral contraceptives may cause erythema nodosum, and phenytoin (Dilantin) and procainamide (Pronestyl) may cause drug-related systemic lupus erythematosus

Permethrin (Elimite) applied over the body overnight from the neck down is the preferred treatment for A. scabies. B. eczema. C. herpes simplex. D. psoriasis.

Answer: A Permethrin (Elimite) applied over the body overnight from the neck down is the preferred treatment for scabies. Lindane (Kwell) is also often effective. Topical corticosteroids or systemic antihistamines are indicated for eczema. Acyclovir (Zovirax) is the treatment for herpes simplex, and coal tar preparations are used to treat psoriasis.

Which of the following is a predisposing condition for furunculosis? A. Diabetes mellitus B. Hypertension C. Peripheral vascular disease D. Chronic fatigue syndrome

Answer: A Predisposing conditions for furunculosis or carbuncles include diabetes mellitus, HIV disease, and injection drug use. Furunculosis (boils) and carbuncles are very painful inflammatory swellings of a hair follicle that result in an abscess, caused by coagulase-positive Staphylococcus aureus .

Which of the following is a secondary skin lesion? A. Acne nodule B. Neoplasm C. Seborrheic dermatitis D. Herpes simplex

Answer: A Primary skin lesions are original lesions arising from previously normal skin. Secondary lesions can originate from primary lesions. Seborrheic dermatitis is a scale, and the only secondary lesion listed. The others—acne nodule, tumor (neoplasm), and a vesicle—are primary lesions.

Which of the following should be used with all acne medications? A. Sunscreen B. Oily makeup C. Plain soap D. A light alcohol wipe once a week.

Answer: A Sunscreen should be used with all acne medications. Oily makeup or oily hair conditioners or scalp products should be avoided. The face should be washed gently at least twice per day with an antibacterial soap.

The "herald patch" is present in almost all cases of A. pityriasis rosea. B. psoriasis. C. impetigo. D. rubella.

Answer: A The "herald patch" is present in almost all cases of pityriasis rosea . Pityriasis rosea is a common, acute, viral, self-limited condition. The eruption usually begins with a solitary oval, pink, scaly plaque, 3 to 5 cm in diameter, on the trunk or proximal extremities. It is called the herald patch because it heralds, or precedes, the widespread eruption by 7 to 14 days.

Bob, age 59, has a nevus on his shoulder that has recently changed from brown to bluish black. You advise him to A. have an excisional biopsy. B. monitor the nevus for a change at the end of 1 month. C. apply benzoyl peroxide solution. D. apply hydrocortisone 1% cream.

Answer: A The ABCDEs (asymmetry, border irregularity, color changes, diameter, evolving/elevation) of melanomas should be taught to all clients. A change in color may indicate a melanoma, and an excisional biopsy should be done. Monitoring for a month may enable a melanoma to extend extensively, resulting in death. Benzoyl peroxide and hydrocortisone may be used with folliculitis.

Which structure of the skin is responsible for storing melanin? A. Epidermis B. Dermis C. Sebaceous glands D. Eccrine sweat glands

Answer: A The epidermis stores melanin, which protects tissues from the harmful effects of ultraviolet radiation in sunlight. The dermis is the second layer of the skin. Its fibrous connective tissue gives the skin its strength and elasticity. The sebaceous glands are sebum-producing glands that assist in retarding evaporation and water loss from the epidermal cells. The eccrine sweat glands open directly onto the skin's surface and are widely distributed throughout the body in the subcutaneous tissue.

Maryann, age 28, presents to the clinic because of a rapid onset of patchy hair loss. The skin within these oval patches of hair loss is very smooth. Tapered hairs that resemble exclamation points are seen at the margin of a patch of hair loss. Based on these findings, you suspect Maryann has A. alopecia areata. B. trichotillomania. C. tinea capitus. D. androgenic alopecia.

Answer: A The findings are consistent with alopecia areata: nonscarring hair loss, rapid onset, and most commonly the pattern is sharply defined round or oval patches. The cause of trichotillomania is mechanical, and the patch typically has an irregular, angulated border. Androgenic alopecia is premature loss of hair in an androgen-sensitive area of the scalp and is commonly termed "male pattern baldness." Tinea capitus is caused by a fungal infection of the skin and hair shaft. Most commonly there is diffuse or patchy adherent scale on the scalp.

The majority of malignant melanomas are A. superficially spreading. B. lentigo maligna . C. acral-lentiginous. D. nodular.

Answer: A The majority (70%) of malignant melanomas are superficially spreading. These have a good prognosis because they tend to spread superficially before invading the tissues. The next most common type (10%) presents as a black nodule; 5% of melanomas present as lentigo maligna , which arise from precursor lesions, and another 5% are acral lentiginous. These arise on the hands or feet and are the most common type seen in Asians and African Americans.

The viral exanthem of Koplik's spots is present in A. rubeola. B. rubella. C. fifth disease. D. varicella.

Answer: A The viral exanthem of Koplik's spots is present in rubeola (measles). Koplik's spots are observed on the buccal mucosa before the rash appears. In rubella (German measles), there are variable erythematous macules on the soft palate, and in fi fth disease (erythema infectiosum), there is no exanthem. In varicella (chickenpox), there may be sparse lesions on the mucosal surfaces, especially the hard palate.

Shelby, age 14, has a blister filled with clear fluid on her arm. It is the result of contact with a hot iron. How do you document this? A. Bulla B. Wheal C. Cyst D. Pustule

Answer: B A bulla is a primary skin lesion filled with fluid that is larger than 1 cm in diameter. It is also known as a vesicle. A wheal is also a primary skin lesion larger than 1 cm in diameter that is transient, elevated, and hive-like, with local edema and inflammation. A cyst is filled with fluid and may occur in a variety of sizes. A pustule is a superficial, elevated lesion filled with purulent fluid.

Which form of acne is more common in the middle-aged to older adult and causes changes in skin color, enlarged pores, and thickening of the soft tissues of the nose? A. Acne vulgaris B. Acne rosacea C. Acne conglobata D. Nodulocystic acne

Answer: B Acne rosacea is a chronic type of facial acne that occurs in middle-aged to older adults. Over time, the skin changes in color to dark red, pores become enlarged, and the soft tissue of the nose may exhibit rhinophyma, an irregular bullous thickening. Acne vulgaris is the form of acne common in adolescents and young to middle-aged adults. Acne conglobata begins in middle adulthood and causes serious skin lesions such as comedones, papules, pustules, nodules, cysts, and scars, primarily on the back, buttocks, and chest. Severe (nodulocystic) acne consists mostly of nodules and cysts and always results in scar formation.

The skin cancer that arises from skin cells, that characteristically occurs on body areas exposed to the sun, that most commonly presents as a pearly nodule with fine telangiectasias over the surface with a border that appears rolled, and that is the most common skin cancer is a(an) A. actinic keratosis. B. basal cell carcinoma C. squamous cell carcinoma. D. malignant melanoma.

Answer: B Basal cell carcinomas arise from skin cells and are the most common type of nonmelanoma skin cancer (greater than 80%). Squamous cell carcinomas are less common and account for 20% of skin cancers. Actinic keratosis often precedes squamous cell carcinoma. Melanoma begins in the melanocytes.

Justin, an obese 42-year-old, cut his right leg 3 days ago while climbing a ladder. Today his right lower leg is warm, reddened, and painful without a sharply demarcated border. What do you suspect? A. Diabetic neuropathy B. Cellulitis C. Peripheral vascular disease D. A beginning stasis ulcer

Answer: B Cellulitis is a spreading infection of the epidermis and subcutaneous tissue that usually begins after a break in the skin. The skin is warm, red, and painful. Although Justin may have diabetic neuropathy, peripheral vascular disease, or a stasis ulcer, the information is not complete enough for you to suspect those conditions. The information and assessment data given fully support a diagnosis of cellulitis.

Helen, age 39, comes to your clinic for generalized joint pain especially in the knees and hands. She tells you that the pain is moderate, spreading, and symmetrical. She reports having had a sore throat and low-grade fever for a few days and then developing a rash described as warm erythema of the cheeks, which lasted about 4 days before disappearing. You ask her if the rash on the cheeks included the nasolabial folds or circumoral skin, and she tells that the rash did not cover these areas. Two days later, she developed a nonspecific macular eruption that preceded the joint pain. Her rash faded within 2 weeks, but she tells you that it comes and goes if she's bathed in hot water or spends time in the sunlight. Your patient's symptoms are most consistent with a diagnosis of A. rubella. B. erythema infectiosum. C. rheumatoid arthritis. D. scarlet fever.

Answer: B Erythema infectiosum (fifth disease) is distinguished by its erythematous, warm rash, which gives the appearance of "slapped cheeks," and it does not involve the nasolabial folds or the circumoral region. Women are more likely to have joint pain as a symptom of erythema infectiosum. While joint pain is a symptom of rheumatoid arthritis, the onset is not preceded by an erythematous rash of the cheeks. Rubella presents with a diffuse maculopapular rash and fever. Although the face appears flushed, the typical presentation of scarlet fever includes a sandpaper-like rash with fine, pinhead size eruptions on an erythematous base that is more generalized and not found on the face.

Dan, age 57, has just been given a diagnosis of herpes zoster. He asks you about exposure to others. You tell him that A. once he has been on the medication for a full 24 hours, he is no longer contagious. B. he should stay away from children and pregnant women who have not had chickenpox. C. he should wait until the rash is completely gone before going out in crowds. D. he should be isolated from all persons except his wife.

Answer: B If a client has just been given a diagnosis of herpes zoster, advise the client to stay away from children and pregnant women who have not had chickenpox until crusts have formed over the blistered areas. He does not have to wait until the rash is completely gone. Herpes zoster is contagious to people who have not had chickenpox, including his wife.

Sandra, age 69, is complaining of dry skin. What do you advise her to do? A. When bathing, vigorously use a washcloth to exfoliate and remove upper layers of the stratum corneum. B. Bathe or shower with lukewarm water and use a mild soap or skin cleanser. C. Use a dehumidifier. D. Decrease the oral intake of fluids.

Answer: B If a client is complaining of dry skin, the client should use tepid water and a mild cleansing cream or soap, use a humidifier to humidify the air, and increase the oral intake of fluids to assist in replacing some of the fluids lost from the skin. Advise the client that it is not necessary to take a bath or shower every day because soaps and hot water are drying.

Danny, age 18, presents with a pruritic rash on his upper trunk and shoulders. You observe flat to slightly elevated brown papules and plaques that scale when they are rubbed. You also note areas of hypopigmentation. What is your initial diagnosis? A. Lentigo syndrome B. Tinea versicolor C. Localized brown macules D. Ochronosis

Answer: B If a client presents with a pruritic rash on his upper trunk and shoulders and you observe areas of hypopigmentation and fl at to slightly elevated brown papules and plaques that scale when they are rubbed, suspect tinea versicolor. Lentigines are macular tan to black lesions, ranging from 1 mm to 1 cm in size. They do not increase in color with exposure to the sun. One or more lentigines are seen in normal individuals. Multiple ones need to be further assessed. Localized brown macules are freckles. Ochronosis is a condition with poorly circumscribed, blueblack macules.

All of the following medications may cause alopecia except A. warfarin (Coumadin). B. minoxidil (Rogaine). C. levonorgestrel (Norplant). D. acetylsalicylic acid (aspirin).

Answer: B Minoxidil (Rogaine) is a vasodilator and may stimulate vertex hair growth. Anticoagulants (e.g., warfarin as well as some Factor Xa inhibitors), oral/hormonal contraceptives, and salicylates (aspirin) may cause alopecia. Other drugs that may cause alopecia include antithyroid drugs, allopurinol, propranolol, amphetamines, and levodopa.

Clubbing is defined as A. elongation of the toes. B. broadening of each thumb. C. a birth deformity of the feet. D. a thickening and broadening of the ends of the fingers.

Answer: D Clubbing is defined as a thickening and broadening of the ends of the fingers. Clubbing is a bulbous appearance and swelling of the terminal phalanges, increasing the normal 160° angle between the nailbed and the digit to 180°. In adults, it is usually caused by pulmonary disease and the resultant hypoxia.

Which of the following types of cellulitis is referred to as "flesh-eating bacteria"? A. Erysipelas B. Necrotizing fasciitis C. Periorbital cellulitis D. Peripheral vascular cellulitis

Answer: B Necrotizing fasciitis is a cellulitis that is often referred to as "flesh-eating bacteria." The hallmarks of necrotizing fasciitis are its rapid progression of infection, the severity of the symptoms, and tissue necrosis. The infection spreads rapidly along the facial planes. Treatment is early and complete surgical debridement of necrotic tissue along with high-dose antibiotics. Loss of life or limb is a potential complication. Erysipelas is a bacterial skin infection involving the upper dermis that characteristically extends into the superficial cutaneous lymphatics. Periorbital cellulitis, also called preseptal cellulitis, is a common infection of the eyelid and periorbital soft tissues that is characterized by acute eyelid erythema and edema. Peripheral vascular cellulitis is infection under the subcutaneous tissue of an extremity.

The NP tells Samantha, age 52, that she has an acrochordon on her neck. What is the NP referring to? A. A nevus B. A skin tag C. A lipoma D. A wart

Answer: B Skin tags (acrochordons) are benign overgrowths of skin, commonly seen after middle age and usually found on the neck, axilla, groin, upper trunk, and eyelid. A nevus is a mole, and a lipoma is a benign subcutaneous tumor that consists of adipose tissue. A wart is a circumscribed elevation due to hypertrophy of the papillae and epidermis.

Which is the drug of choice for tinea capitis? A. A topical corticosteroid B. An oral antifungal C. A topical antifungal D. An antibiotic

Answer: B The drug of choice for tinea capitis is oral antifungal griseofulvin (Grisactin) taken for 6 to 8 weeks. It should be administered with fat-containing foods because fat is required for optimal absorption. Although topical antifungal agents are effective, they take an extremely long time to work. Topical corticosteroids and antibiotics are not effective for fungal lesions.

You are examining Barbara, age 27, who presents with multiple lesions that are dry, dusky red, well-localized, plaques, 5 to 20 mm in diameter, with a "stuck on" appearance, located on her face, scalp, and external ears. You note there is atrophy, telangiectasia, depigmentation, and follicular plugging present. On examination of the scalp, there are areas of total hair loss. There is depigmented scarring of the concha of the ear. Your most likely diagnosis is A. seborrheic dermatitis. B. discoid lupus erythematosus. C. psoriasis. D. tinea capitus.

Answer: B The lesions of discoid lupus erythematosus are dry and have a stuck-on appearance, which differentiates them from seborrheic dermatitis and psoriasis. Old lesions that have caused scarring further distinguish these lesions from seborrheic dermatitis, psoriasis, and tinea capitus. Depigmented scarring of the concha of the ear is a classic fi nding.

Elizabeth, age 83, presents with a 3-day history of pain and burning in the left forehead. This morning she noticed a rash with erythematous papules in that site. What do you suspect? A. Varicella B. Herpes zoster C. Syphilis D. Rubella

Answer: B The rash of herpes zoster is characteristic in that it appears on only one side of the body. Herpes zoster begins in a dermatomal distribution, most commonly in the thoracic, cervical, and lumbosacral areas, although it also occurs on the face. Although herpes zoster is caused by the reactivation of latent varicella virus in the distribution of the affected nerve, varicella (chickenpox) presents with a scattered rash on both sides of the body. A client with syphilis would present with sharply circumscribed, ham-colored papules with a slight scale and lesions over the entire body, especially on the palms and soles. Rubella (German measles) occurs in childhood. It begins on the face and rapidly (in hours) spreads down to the trunk.

Tom, age 50, is complaining of an itchy rash that occurred about a half hour after putting on his leather jacket. He recalls having a slightly similar rash last year when he wore his jacket. The annular lesions are on his neck and both arms. They are erythematous, sharply circumscribed, and both flat and elevated. His voice seems a little raspy, although he states that his breathing is normal. What is your first action? A. Order a short course of systemic corticosteroids. B. Determine the need for 0.5 mL 1:1,000 epinephrine subcutaneously. C. Start daily antihistamines. D. Tell Tom to get rid of his leather jacket.

Answer: B Tom has hives. Although all the actions are appropriate, the first step is to determine the need for 0.5 mL 1:1,000 epinephrine subcutaneously (SQ). With Tom's neck involvement, it is most important to determine if respiratory distress is imminent, in which case the epinephrine must be administered

What is the name of the acquired disorder characterized by complete loss of pigment of the involved skin? A. Tinea versicolor B. Vitiligo C. Tuberous sclerosis D. Pityriasis alba

Answer: B Vitiligo, which usually appears in childhood, is an acquired disorder characterized by complete loss of pigment of the involved skin. Although tinea versicolor does have areas of hypopigmentation, they are scattered and do not have complete loss of pigment. In tuberous sclerosis, ash-leaf spots, which are hypopigmented macules, 2 to 3 cm in size, are present at birth. Pityriasis alba is also an acquired disorder of hypopigmentation characterized by poorly demarcated, slightly scaly, oval hypopigmented macules that vary from 1.5 to 2 cm in size.

Zinc oxide, magnesium silicate, ferric chloride, and kaolin are examples of A. chemical sunscreens. B. physical sunscreens. C. agents used in tanning booths. D. emollients.

Answer: B Zinc oxide, magnesium silicate, ferric chloride, and kaolin are examples of physical sunscreens that refl ect and scatter ultraviolet light. Chemical sunscreens such as PABA, benzophenones, and salicylates absorb ultraviolet light and act as a radiation fi lter. Tanning booths should be avoided because ultraviolet (UVA) radiation emitted by tanning booths damages the deep skin layers.

A darkfield microscopic examination is used to diagnose A. scabies. B. leprosy. C. syphilis. D. infections.

Answer: C A darkfield microscopic examination is used to diagnose syphilis. A darkfield examination, with its special condenser, causes an oblique beam of light to refract off objects too small to be seen by conventional microscopes, such as the narrow organism Treponema pallidum that causes syphilis. Application of a special tetracycline solution followed by shining a Wood's light on the skin may accentuate the burrow of scabietic mites, thus helping to diagnose scabies. A direct acid-fast stain is used to diagnose leprosy, and a potassium hydroxide (KOH) stain helps diagnose Candida infections.

Which skin lesions are directly related to chronic sun exposure and photodamage? A. Skin tags B. Seborrheic keratoses C. Actinic keratoses D. Angiomas

Answer: C Actinic keratoses, also called senile or solar keratoses, are epidermal skin lesions that are directly related to chronic sun exposure and photodamage. Skin tags occur in middle-aged adults of both genders and may be associated with acromegaly or acanthosis nigricans. Seborrheic keratoses are lesions most often seen in older adults and do not appear to be related to damage from sun exposure. Angiomas are common, small, red to purple papules unrelated to sun exposure.

The morphology of which lesion begins as an inflammatory papule that develops within several days into a painless, hemorrhagic, and necrotic abscess, eventually with a dense, black, necrotic eschar forming over the initial lesion? A. Furuncle-carbuncle B. Hidradenitis suppurativa C. Anthrax D. Cellulitis

Answer: C Although cellulitis, furuncle-carbuncles, and hidradenitis suppurativa are all distinctive abscesses, only anthrax has the morphology described. It results in a dense, black, necrotic eschar gradually forming over the initial lesion. A furuncle-carbuncle is a pustular lesion surrounding one or several hair follicles, and a hidradenitis suppurativa lesion results in scarring and fibrotic bands. Cellulitis begins as a tender, warm, erythematous area of the skin and then takes on multiple presentations but not with a dense, black, necrotic eschar as described here.

Sandy asks what she can do for Dolores, her 90-year-old mother, who has extremely dry skin. You respond, A. "After bathing every day, use a generous supply of moisturizers." B. "Use a special moisturizing soap every day." C. "Your mother does not need a bath every day." D. "Increase your mother's intake of fluids."

Answer: C Although increasing fluids and applying a moisturizing cream will help the general problem, Dolores does not need a bath every day because that will exacerbate the dryness of her skin. Plain water should be used rather than special soap.

Balanitis is associated with A. diabetes. B. macular degeneration. C. Candida infection of the penis. D. measles.

Answer: C Balanitis is associated with Candida infection of the penis. Candidiasis (moniliasis) may affect the mouth (thrush), penis (balanitis), or vagina (vaginitis).

Client teaching is an integral part of successfully treating pediculosis. Which of the following statements would you incorporate in your teaching plan? A. "It's okay to resume sharing combs, headsets, and so on, after being lice free for 1 month." B. "Soak your combs and brushes in rubbing alcohol for 8 hours." C. "Itching may continue after successful treatment for up to a week." D. "Spraying of pesticides in the immediate environment is essential to prevent recurrence."

Answer: C Client education is essential when treating pediculosis. Clients should be informed that itching may continue after successful treatment for up to a week because of the slow resolution of the inflammatory reaction caused by the lice infestation. Clients and parents should be instructed not to share hats, combs, scarves, headsets, towels, and bedding. Combs and brushes can be soaked in rubbing alcohol for 1 hour. Excessive decontamination of the environment is not necessary. Environmental spraying of pesticides is not effective and, therefore, is not recommended. Bedclothes and clothing should be washed in hot, soapy water.

Which of the following warts appears cauliflower-like and is usually found in the anogenital region? A. Plantar warts B. Filiform and digitate warts C. Condyloma acuminata D. Verruca plana

Answer: C Condyloma acuminata is a cauliflower-like wart usually found in the anogenital region and is usually sexually transmitted. Plantar warts appear at points of maximum pressure such as the heads of metatarsal bones or heels; filiform or digitate warts are fingerlike, fl esh-colored projections emanating from a narrow or broad base, usually in the facial region; and verruca plana are fl at warts that are pink, light brown, or yellow with slightly elevated papules that may undergo spontaneous remission.

Which type of wart has finger-like, flesh-colored projections emanating from a narrow or broad base? A. Common warts B. Flat warts (verruca plana) C. Filiform warts D. Plantar warts

Answer: C Filiform/digitate warts are finger-like, flesh-colored projections emanating from a narrow or broad base. Common warts are small, hardened growths of keratinized tissue. Flat warts are pink, light brown, or yellow and slightly elevated papules. Plantar warts appear at maximum points of pressure such as the heads of the metatarsal bones or heels or anywhere on the plantar surface

Sandra, age 32, comes into the clinic. She has painful joints and a distinctive rash in a butterfly distribution on her face. The rash has red papules and plaques with a fine scale. What do you suspect? A. Lymphocytoma cutis B. Relapsing polychondritis C. Systemic lupus erythematosus D. An allergic reaction

Answer: C If a client comes into the clinic complaining of painful joints and has a distinctive rash in a butterfly distribution on the face that has red papules and plaques with a fine scale, suspect systemic lupus erythematosus. Acute lupus erythematosus occurs most often in young adult women. In the acute phase, the client is febrile and ill. The presence of these skin lesions in a client with neurological disease, arthritis, renal disease, or neuropsychiatric disturbances also supports the diagnosis. Lymphocytoma cutis is also most common on the face and neck. It occurs in both sexes and has smooth, red to yellow-brown papules up to 5 cm in diameter. Relapsing polychondritis occurs in adults with a history of arthritis. It appears as a macular erythema, tenderness, and swelling over the cartilaginous portions of the ear.

Jim, age 59, presents with recurrent, sharply circumscribed red papules and plaques with a powdery white scale on the extensor aspect of his elbows and knees. What do you suspect? A. Actinic keratosis B. Eczema C. Psoriasis D. Seborrheic dermatitis

Answer: C If a client presents with recurrent, sharply circumscribed red papules and plaques with a powdery white scale on the extensor aspect of his elbows and knees, suspect psoriasis. This is a classic presentation of psoriasis. Besides the extensor aspect of the elbows and knees, it occurs frequently in the presacral area and scalp, although lesions may occur anywhere. Actinic keratosis is distributed on sun-exposed areas such as the face, head, neck, and dorsum of the hand and appears as poorly circumscribed, pink to red, slightly scaly lesions. Eczema presents as a group of pinpoint pruritic vesicles and papules on a coin-shaped erythematous base that usually worsens in winter. Seborrheic dermatitis has a symmetric appearance of raised, scaly, red, greasy papules and plaques that may be sharply or poorly circumscribed.

Thomas, age 35, uses a high-potency corticosteroid cream for his dermatoses. You tell him the following: A. "You must use this for an extended period of time for it to be effective." B. "It will work better if you occlude the lesion." C. "It may exacerbate your concurrent condition of tinea corporis." D. "Be sure to use it daily."

Answer: C If a client uses a high-potency corticosteroid cream for a dermatosis, tell the client that it may exacerbate concurrent conditions such as tinea corporis and acne. Topical corticosteroids should not be used indiscriminately on all cutaneous eruptions. They should not be used for an extended period of time, and the lesion should not be occluded. Intermittent therapy with high potency agents, such as every other day, or 3 to 4 consecutive days per week, may be more effective and cause fewer adverse effects than continuous regimens. This is also true of lower-potency corticosteroids

Which of the following secondary skin lesions usually result from chronic scratching or rubbing? A. Crusts B. Scales C. Lichenification D. Atrophy

Answer: C Lichenification is a thickening of the skin that usually results from chronic scratching or rubbing. Crusts represent dried serum, blood, pus, or exudate. Scales are yellow, white, or brownish flakes on the surface of the skin that represent desquamation of stratum corneum. Atrophy represents loss of substance of the skin.

Psoriasis may occur after months of using A. vitamins. B. hormone replacement therapy. C. NSAIDs. D. antihistamine nasal sprays.

Answer: C Psoriasis may occur after extended therapy with many medications, including beta blockers, lithium, NSAIDs, gold, antimalarials, and angiotensinconverting enzyme (ACE) inhibitors, and after heavy alcohol intake.

Which lesion results in scales or shedding flakes of greasy, keratinized skin tissue? A. Eczema B. Impetigo C. Psoriasis D. Herpes

Answer: C Psoriasis results in scales or shedding fl akes of greasy, keratinized skin tissue. The color may be white, gray, or silver, and the texture may vary from fine to thick. The other lesions—eczema, impetigo, and herpes—result in crusts that are dried blood, serum, or pus left on the skin surface when vesicles or pustules burst. They can be red-brown, orange, or yellow.

Buddy, age 13, presents with annular lesions with a scaly border and central clearing on his trunk. What do you suspect? A. Psoriasis B. Erythema multiforme C. Tinea corporis D. Syphilis

Answer: C Psoriasis, erythema multiforme, tinea corporis, and syphilis all have lesions with annular configurations. Tinea corporis (ringworm) has ring-shaped lesions with a scaly border and central clearing or scaly patches with a distinct border on exposed skin surfaces or on the trunk. Psoriasis has annular lesions on the elbows, knees, scalp, and nails. Erythema multiforme has annular lesions that are mostly acral in distribution and are often associated with a recent herpes simplex infection. Secondary syphilis lesions are usually on the palmar, plantar, and mucous membrane surfaces.

Tanisha, a 24-year-old African American mother of four young children, presents in the clinic today with varicella. She states that three of her children also have it and that her eruption started less than 24 hours ago. Which action may shorten the course of the disease in Tanisha? A. Calamine lotion B. Cool baths C. Acyclovir (Zovirax) D. Corticosteroids

Answer: C Tanisha should take acyclovir (Zovirax). If started within the first 24 to 48 hours after the rash appears, it may shorten the course of varicella (chickenpox). Acyclovir is not, however, recommended for children under 2 years of age. (IV dosing may be used for children under 1 year of age for chickenpox.) In children, treatment of varicella consists of cool baths with Aveeno for pruritus and calamine lotion to dry the lesions.

The five Ps—purple, polygonal, planar, pruritic papules—are present in A. ichthyosis. B. lichen planus. C. atopic dermatitis. D. seborrheic dermatitis

Answer: C The five Ps—purple, polygonal, planar, pruritic papules—are present in lichen planus. Lichen planus occurs in clients of all ages but is more common in adults. It has a primary skin lesion with the five Ps that looks like a shiny, violaceous, flat-topped papule that is very pruritic. Ichthyosis vulgaris lesions are fine, small, flaky white scales with minimal underlying erythema that can be found anywhere but are more prominent on the extensor aspects of the extremities. Atopic dermatitis (eczema) presents differently at different ages and in persons of different races, but it usually starts as red, weepy, shiny patches. Seborrheic dermatitis presents as dry scales with underlying erythema.

Steve, age 29, has a carbuncle on his neck. After an incision and drainage (I&D), an antibiotic is ordered. What is the most common organism involved? A. Streptococcus B. Moraxella catarrhalis C. Staphylococcus aureus D. Klebsiella

Answer: C The most common offending organism in furuncle/carbuncle lesions is Staphylococcus aureus . Other organisms that may cause these lesions are Escherichia coli, Pseudomonas aeruginosa, Streptococcus faecalis, as well as the anaerobes Peptostreptococcus, Peptococcus, and Lactobacillus species. Systemic antibiotic treatment is indicated for most cases and an antistaphylococcal antibiotic is prescribed. A culture and sensitivity is appropriate for large or atypical lesions

What is the most effective treatment for urticaria? A. An oral antihistamine B. Dietary management C. Avoidance of the offending agent D. Corticosteroids

Answer: C The most effective treatment for urticaria (hives) is avoidance of the offending agent. Usually the offending antigen is identifiable and exposure is self-limited. Treatment with oral antihistamines is usually effective for symptomatic relief of itching, swelling, and nasal symptoms. Dietary management may sometimes be helpful if the cause of the problem is a known food, such as shellfish, nuts, fish, eggs, chocolate, or cheese. Corticosteroids have a minimal role in treating urticaria; a brief trial may be indicated for temporary relief in a difficult case.

Andrea, age 63, tells you that over several years she has noticed the development of lightly pigmented tan macules with irregular borders on her face, hands, arms and upper body. She is concerned about her appearance and that the lesions are increasing in size and number as she ages. You explain to her that A. she must have a biopsy right away. B. using sunscreen with at least SPF30 will cause them to fade. C. hydroquinone solutions can reduce hyperpigmentation when used as directed. D. liquid nitrogen should not be used to treat these lesions.

Answer: C The patient has solar lentigines. An increase in the number and size of lesions with advancing age reflects cumulative solar damage to the skin. Hydroquinone 4% (a bleaching cream) is effective at reducing hyperpigmentation when applied to the affected area twice a day for a maximum of 2 months. Liquid nitrogen is also usually effective but requires clinician training and experience for correct application. Stable solar lentigines do not require treatment. Sunscreens are used for prevention of solar skin damage.

Which treatment would you order for anogenital pruritus? A. Suppositories for pain B. Antifungal cream for itching C. A high-fiber diet for constipation D. Zinc oxide ointment

Answer: C Treating constipation, preferably with a high-fiber diet, may help anogenital pruritus. Most cases of anogenital pruritus have no obvious cause and chiefly cause nocturnal itching without pain. Although the condition is benign, it may be persistent and recurrent. Hydrocortisone-pramoxine (Pramosone) 1% or 2.5% cream, lotion, or ointment applied externally after bowel movement up to three or four times a day helps with pruritus. Suppositories are not necessary. Anogenital hygiene needs to be stressed. Potent fluorinated topical corticosteroids and antifungals may lead to atrophy and striae after several days and should be avoided.

Why is ultraviolet light therapy used to treat psoriasis? A. To dry the lesions B. To kill the bacteria C. To decrease the growth rate of epidermal cells D. To kill the fungi

Answer: C Ultraviolet (UV) light therapy is used to treat psoriasis to decrease the growth rate of epidermal cells. This assists in decreasing the hyperkeratosis. Treatments are given daily and last only for seconds. While light therapy may dry the lesions (although they are already dry), it doesn't kill bacteria or fungi. The main reason UV light therapy is given is to decrease the hyperkeratosis.

Which of the following therapeutic modalities is useful for severe uncontrollable atopic dermatitis? A. Emollients B. Compresses C. Ultraviolet light D. Tars

Answer: C Ultraviolet light is useful for severe, uncontrollable atopic dermatitis. Therapeutic modalities useful for the management of acute atopic dermatitis include emollients, compresses, and ultraviolet light. Although tars are useful for chronic, dry, lichenified lesions, they are not helpful for acute dermatitis. Emollients are best applied and most helpful if used immediately after bathing or showering. Compresses are indicated for acute weeping lesions to help cool and dry the skin, which reduces inflammation.

You are teaching Harvey, age 55, about the warts on his hands. What is included in your teaching? A. Treatment is usually effective, and most warts will not recur afterward. B. Because warts have roots, it is difficult to remove them surgically. C. Warts are caused by the human papillomavirus. D. Shaving the wart may prevent its recurrence.

Answer: C Warts are caused by the human papillomavirus. One in four people is infected with this virus and, despite treatment, most warts recur. Broken or abraded skin can spread the transport of the virus as well as vigorous rubbing, shaving, nail biting, and sexual intercourse. Warts do not have roots, contrary to popular opinion. The underside of a wart is smooth and round.

You suspect a platelet abnormality in the 40-year-old woman who presents to your clinic with A. red to blue macular plaques. B. multiple freckle-like macular lesions in sun-exposed areas. C. numerous small, brown, nonscaly macules that become more prominent with sun exposure. D. red, flat, nonblanchable petechiae.

Answer: D A client with a platelet abnormality may present with red, flat, nonblanchable petechiae. Red to blue macular plaques are ecchymoses; multiple freckle-like macular lesions in sun-exposed areas indicate xeroderma pigmentosum; and numerous small, brown, nonscaly macules that become more prominent with sun exposure are freckles.

During a camping trip, Jim, age 35, abruptly developed fever, headache, and joint pain. A few days after the onset of the fever, a blanchable macular rash began on his wrists and ankles and quickly spread to the palms and soles before becoming generalized. The rash is now petechial. You suspect that Jim has A. Rocky Mountain spotted fever. B. flea bites. C. Kawasaki syndrome. D. Lyme disease.

Answer: D A petechial rash of the wrists and ankles that is followed by spread to the palms and soles is a characteristic finding of Rocky Mountain spotted fever. In Stage I of Lyme disease, there is an expanding bull's eye lesion (erythema migrans) and flu-like symptoms. The skin changes associated with flea bites are red to purpuric pruritic papules that generally are more concentrated on the legs. Adult cases of Kawasaki disease are rare. The rash of Kawasaki disease is a polymorphous exanthem with vesicles or crusts.

Which skin lesion is morphologically classified as pustular? A. A wart B. Impetigo C. Herpes simplex D. Acne rosacea

Answer: D Acne rosacea, acne vulgaris, folliculitis, candidiasis, and miliaria are classified as pustular lesions. Papular lesions include warts, corns, Kaposi's sarcoma, basal cell carcinoma, and scabies. Vesicular lesions include herpes simplex, varicella, and herpes zoster. Erosive lesions include impetigo, lichen planus, and erythema multiforme.

Adverse effects from prolonged or high-potency topical corticosteroid use on an open lesion may include A. epidermal proliferation. B. striae. C. vitiligo. D. easy bruisability

Answer: D Adverse effects from prolonged or high-potency topical corticosteroid use may include cutaneous atrophy, telangiectases, and easy bruisability, as well as systemic absorption, which may include growth retardation, electrolyte abnormalities, hyperglycemia, hypertension, and increased susceptibility to infection. Vitiligo is caused by loss of melanin. Striae may occur after use of oral corticosteroids or occlusive topical corticosteroid therapy.

The total loss of hair on all parts of the body is referred to as A. female pattern alopecia. B. alopecia areata. C. alopecia totalis. D. alopecia universalis

Answer: D Alopecia universalis is the loss of hair on all parts of the body. Female pattern alopecia is progressive thinning and loss of hair over the central part of the scalp. Male pattern baldness is a pattern of receding hairline and hair thinning on the crown. Alopecia areata appears as round or oval bald patches on the scalp and other hairy parts of the body. Alopecia totalis is the loss of all hair on the scalp.

A thinning of skin that appears white or translucent is defined as A. a scale. B. a cyst. C. a fissure. D. atrophy.

Answer: D Atrophy is a thinning of the skin (epidermis and dermis) and may appear white or translucent. A scale is where epithelial cells are shed in variable sizes. A cyst is an elevated encapsulated lesion that is deeper than a pustule, with distinct borders. A fissure is a linear crack extending from the epidermis to the dermis.

What is the most common rosacea trigger? A. Alcohol B. Cold weather C. Skin care products D. Sun exposure

Answer: D Clients with rosacea usually have a long history of flushing in response to sun exposure. Alcohol, cold weather, and skin care products may also be triggers, but not nearly as often. Other triggers may include emotional stress, spicy foods, exercise, wind, hot baths, and hot drinks.

What is a noninvasive method of treating skin cancer (other than melanoma) that uses liquid nitrogen? A. Mohs' micrographic surgery B. Curettage and electrodesiccation C. Radiation therapy D. Cryosurgery

Answer: D Cryosurgery is a noninvasive method of treating skin cancer other than melanoma in which liquid nitrogen is used to freeze and destroy the tumor tissue. Mohs' micrographic surgery involves shaving thin layers of the tumor tissue horizontally, then taking a frozen section to determine tumor margins. Curettage and electrodesiccation are used to treat basal cell cancers less than 2 cm in diameter and primary squamous cell cancers less than 1 cm in diameter. Radiation therapy is used for lesions that are inoperable because of their location.

You're teaching Mitch, age 18, about his tinea pedis. You know he doesn't understand your directions when he tells you which of the following? A. "I should dry between my toes every day." B. "I should wash my socks with bleach." C. "I should use an antifungal powder twice a day." D. "I should wear rubber shoes in the shower to prevent transmission to others."

Answer: D If a client has tinea pedis, tell the client to dry between the toes every day, wash socks with bleach, and use an antifungal powder twice per day. Rubber or plastic-soled shoes can harbor the fungus and therefore should not be worn. The shower should be washed with bleach to kill the fungi. Antifungal powder or sprays are preferred over creams, as fungi thrive in warm, moist environments.

Large, flaccid bullae with honey-colored crusts around the mouth and nose are characteristic of A. a burn. B. Rocky Mountain spotted fever. C. measles. D. impetigo.

Answer: D Large, flaccid bullae with honey-colored crusts around the mouth and nose are characteristic of impetigo. These weeping erosions can appear anywhere but usually appear on the face and nose and around the mouth. Hemorrhagic blisters may be present with a burn. Rocky Mountain spotted fever presents with petechiae beginning at the wrist and ankles and going to the palms and soles, then centrally to the face. Measles begins with red macules on the back of the neck, then spreads over the face and upper trunk. The lesions then become papular and may be confl uent over the face.

Mildred, age 72, presents to the clinic with a blistering rash that is generalized but located mostly in skin folds and on flexural areas. She describes the course of the rash as beginning with pruritic urticarial papules that coalesced into plaques that turned dark red in about 2 weeks, followed by the development of vesicles and bullae. She tells you that the lesions are moderate to severely pruritic. During your exam, you determine the bullae are very tense and do not rupture when pressure is applied. Her daily medications include an ACEI, a loop diuretic, and an NSAID. What is your diagnosis? A. Dermatitis herpetiformis B. Pemphigus vulgaris C. Bullous drug eruption D. Bullous pemphigoid

Answer: D Most cases of bullous pemphigoid occur after 60 years of age. The bullae are very tense; firm pressure on the blister will not result in extension into the normal skin, which occurs with pemphigus. The bullae of pemphigus are fragile. Dermatitis herpetiformis presents with smaller vesicles and is more often found on elbows, knees, buttocks, and the posterior scalp. Bullous drug eruptions occur in areas similar to those favored by bullous pemphigoid, and a thorough review of the client's medications should be done. Some loop diuretics, ACEI, and NSAIDs have been implicated in triggering bullous pemphigoid.

Michael, a 25-year-old military reservist, presents to your clinic for a rash that began on his chest and has since developed into smaller lesions more concentrated on the lower abdomen and pubic area. In obtaining a history of the present illness, he reports that he had an upper respiratory infection one month before the rash developed. He tells you it started with one large lesion on his left chest that was oval shaped, and 1 to 2 weeks later he developed numerous smaller lesions on the lower abdomen and groin. It has been 2 weeks since the smaller lesions developed, and he tells you he is concerned that the rash isn't improving. As you examine the patient you note that the lesions are salmon colored and have a thin collarette of scale within the lesion. The original lesion is still present. You suspect Michael has A. guttate psoriasis. B. tinea versicolor. C. secondary syphilis. D. pityriasis rosea.

Answer: D Pityriasis rosea is a common, self-limiting, usually asymptomatic eruption with a distinct first appearing lesion. This "herald patch," which appears suddenly and without symptoms, usually is on the chest or back. Secondary lesions appear 1 to 2 weeks later while the "herald patch" remains. The "scaling collarette" is another classic symptom of pityriasis rosea. The lesions usually resolve spontaneously in 4 to 12 weeks without scarring. Outbreaks have been known to occur in close quarters like military barracks and dormitories. Tinea versicolor may be excluded by potassium mydroxide examination early in the course. Secondary syphilis is excluded by RPR or FTA. Guttate psoriasis often follows a streptococcal infection. The lesions of guttate psoriasis have a different morphology and distribution.

Which of the following statements about malignant melanomas is true? A. They usually occur in older adult males. B. The client has no family history of melanoma. C. They are common in populations with dark skin. D. The prognosis is directly related to the thickness of the lesions.

Answer: D The prognosis for a patient with a malignant melanoma is directly related to the thickness of the lesion. Malignant melanomas usually occur in middle-aged adults of both sexes. The client usually has a family history of melanoma. Melanomas occur rarely in blacks; when they do, the lesions usually develop on the palms of the hands and soles of the feet and under the nails.

Tinea unguium is also known as A. tinea capitis. B. pityriasis versicolor. C. tinea manuum. D. onychomycosis.

Answer: D Tinea unguium is tinea of the nails, also known as onychomycosis. Tinea capitis is tinea of the scalp; pityriasis versicolor is tinea versicolor; and tinea manuum is tinea of the hands.

Jill, age 29, has numerous transient lesions that come and go, and she is diagnosed with urticaria. What do you order? A. Aspirin B. Ibuprofen C. Opioids D. Antihistamines

Answer: D Transient urticaria requires antihistamines on a regular basis. Aspirin, ibuprofen, and opioids are to be avoided.