Derm

Front 1

This could show what infections?

Back 1

Herpes zoster/Varicella
Herpes simplex

Front 2

60-yo man c/o pruritic popular eruption involving chest and back. Best dx is?

Back 2

Grover's disease (focal acantholytic disease)
Often associated w/ heat, sweating, sunlight exposure.

Front 3

Skin bx showing papillary dermal edema and dense interstitial infiltrate of neutrophils involving the upper half of the reticular dermis. Best dx?
Often associated w/ what malignancy?

Back 3

Sweet's syndrome
Abrupt onset of tender or painful erythematous plaques and nodules on the face and extremities and less commonly on the trunk, in association with fever (usually), malaise and a neutrophil leukocytosis.
AML Acute myeloid leukemia

Front 4

Bx specimen showing discontinuity of parakeratosis sparing adnexal structures, dense dermal elastosis.

Back 4

Actinic keratosis/Solar keratosis

Front 5

Basal cell carcinoma. What is this subtype?

Back 5

Fibroepithelioma of Pinkus type

Front 6

2 cm white "scar-like" plaque on left side of nose extending onto the cheek. No hx of prior injury or previous surgical procedure at site. Best interpretration?

Back 6

Sclerosing or morpheaform BCC

Front 7

45-yo woman c/o painful subcutaneous nodules on both legs of 4 wks duration. Lesions are not ulcerated. Image shows inflammation within septae between fat lobules. Dx?

Back 7

erythema nodosum
May be associated with streptococcus infexn, TB, sarcoidosis, coccidioidomycosis, UC, Behcet’s disease, drug rxns or idiopathic; also Hodgkin lymphoma, RCC and carcinomas of colon, pancreas and uterine cervix

Front 8

83-yo man c/o generalized rash characterized by oval erythematous asxmatic patches over entire torso. Eruption had waxed and waned over 10 yrs. Best dx?

Back 8

Cutaneous T-cell lymphoma (mycosis fungoides)
Most common primary cutaneous T cell lymphoma.
By definition, are negative for HIV1, HIV2, HTLV.
Aytpical lymphocytes w/ cerebriform nuclei, Pautrier's microabscesses

Front 9

46-yo diabetic developed multiple papulonodules of the arms and legs that clinically were thought to be molluscum contagiosum. Bx demonstrated invagination of epidermal lined by epithelium w/ strands of eosinophilic material w/in epithelium. Dx?

Back 9

Reactive perforating collagenosis
Occurs in setting of diabetes and chronic renal disease especially in patients on dialysis.

Front 10

6-yo boy presented w/ 0.8 cm red nodule of forearm that had appeared 4 months ago. Dx?

Back 10

Spitz nevus
Symmetric well-circumscribed melanocytic proliferation arising in the epidermis and extending into dermis. Maturation present.

Front 11

What is this called?

Back 11

Lentigo maligna (in situ melanoma w/ solar elastosis)

Front 12

What is this?
What is it seen in?

Back 12

Spongiosis
Seen in eczematous dermatoses: contact dermatitis, nummular dermatitis, photoallergic dermatitis, atopic dermatitis

Front 13

15-yo boy p/w asxmatic papulonodules on the dorsum of the hands, histologically characterized by foci of mucin deposition surrounded by a palisading arrangement of histiocytes. dx?

Back 13

Granuloma annulare
Associated with morphea, chronic HCV infection, autoimmune thyroiditis, 2ndary hyperparathyroidism, Plummer’s dx, MDS metastatic carcinoma.

Front 14

25-yo male p/w generalized eruption clinically resembling a drug eruption of 1 week's duration. It was asxmatic. Bx shows lymphocytes and plasma cells. dx?

Back 14

2ndary syphilis
Characterized by plasma cells in the inflammatory infiltrate.

Front 15

Rough, slightly tender lesion of the forehead present for months. dx?

Back 15

Seborrheic keratosis
Epidermal proliferation, horn pseudocysts (called "pseudo" b/c they connect to surface and represent papillomatosis), sharp demarcation "string sign" of base of epidermal proliferation.

Front 16

57 year old Japanese man with facial plaque slowly enlarging for at least 5 years. Dx?

Back 16

Microcystic adnexal carcinoma
Hyalinized stroma, basaloid strands.
Perineural invasion common.

Front 17

72-yo woman w/ enlarging brown macule on left first toe. Dx?

Back 17

Acral lentiginous melanoma

Front 18

60-yo man noted sudden appearance of a 1-cm nodule on the back of the neck that was friable and bled easily. Dx?

Back 18

Pyogenic granuloma

Front 19

35-yo HIV+ man p/w 1 cm non-tender asxmatic brown intracutaneous nodule on the calf. What is the dx?

Back 19

Dermatofibroma
Limited infiltration into subcutaneous tissues.
Collagen trapping, Grenz zone in superficial dermis.
F13A+
CD163+
CD68+ (early lesions)
CD34- (differentiates it from DFSP F13A-, CD34+)
CD34 may be + in cellular type

Front 20

30-yo woman had a "mole removed from her chest. Surgical site healed with a flat white mark in the center of which was a blue-black macule. The site was re-excised and the specimen shown. Dx?

Back 20

Recurrent (persistent) nevus

Front 21

45-yo man w/ slowly enlarging nodule of skin of the right thigh. Lesion was raised above surface and measured 3 cm in diameter. What immunostain is most likely +?

Back 21

CD34+ for Dermatofibrosarcoma Protuberans DSFP
Residual fat cells are in linear arrangement resembling a string of pearls,
which is characteristic of DFSP but not benign fibrous histiocytoma.
Storiform pattern

Front 22

30-yo man developed a raised firm to rubbery nodule of the perianal-buttock area. Lesion measured 1.5 cm in diameter. Dx?

Back 22

Granular cell tumor

Front 23

45-yo man with painful ulcerated lesion of the pinna of right ear. Dx?

Back 23

Chondrodermatitis nodularis chronica helicis
Hyperplasia of epidermis often w/ focal ulceration. Granulation tissue, fibrosis, solar elastosis, and mixed inflammatory infiltrate (lymphs, neuts, plasma cells) between ulcer and underlying cartilage.
Degeneration of cartilage.

Front 24

45-yo man w/ multiple nodules of forehead and scalp that appeared at puberty and have been asxmatic. Dx?
Syndrome?
Genetics?

Back 24

Cylindroma
Hyalinized cylinders surrounding lobules of cells. Hyalinized droplets w/in the tumor.
turban tumor syndrome, Brooke-Spiegler syndrome
AD, mutations in CYLD gene at chromosome 16q12-13

Front 25

2-yo boy p/w well-circumscribed yellow nodule of the scalp which was itchy but otherwise asxmatic. Dx?

Back 25

Juvenile xanthogranuloma
monotonous CD68+ histiocytic cells

Front 26

6-yo boy w/ nodular lesion of the left cheek. Bx was described as showing aggregates of basaloid cells in association w/ granulomatous inflammation. Dx?

Back 26

Pilomatricoma
● Solid nests of basaloid cells undergoing abrupt trichilemmal-type keratinization
● Ghost cells, often foreign body reaction, calcification or ossification with extramedullary hematopoiesis

Front 27

40-yo woman presented w/ 5 mm flesh-colored papule of the right nasolabial fold.

Back 27

Trichoepithelioma
No artifactual retraction between tumor and stroma as in BCC. Can look similar to trichilemmoma as well. Trichilemmoma is characterized by downward proliferation of pale-staining (glycogen-containing) keratinocytes.
Papillary mesenchymal bodies seen in this lesion.

Front 28

The dx of erythema chronicum migrans (cutaneous manifestation of Lyme dz is made by ?

Back 28

Clinical features, serologic studies, and a cutaneous bx excluding other conditions.

Front 29

Name the 2 most important prognostic histologic findings in a bx specimen of melanoma.

Back 29

Tumor thickness (Breslow measurement)
Presence or absence of ulceration

Front 30

In what conditions can you see necrotic keratinocytes?

Back 30

Erythema multiforme (picture on other side)
Fixed drug reaction
Phototoxic reaction
Graft vs. host disease (pictured above)

Front 31

Subepidermal blister with neutrophils. What is on the differential?

Back 31

Bullous lupus erythematosus
Dermatitis herpetiformis
Bullous pemphigoid
IgA bullous dermatosis

Front 32

Patient w/ photodermatitis on hands and face.

Back 32

Porphyria cutanea tarda
most common type of porphyria: uroporphyrin decarboxylase deficieny

Front 33

Describe 3 histologic features of the lesion shown.

Back 33

Psoriasis vulgaris
Confluent parakeratosis
Neutrophils in parakeratotic layer (Munro's microabscesses)
Loss of granular layer

Front 34

What histologic features are associated w/ lichen planus?

Back 34

Compact orthokeratosis (usually no parakeratosis)
Hypergranulosis
Liquefaction degeneration
Civatte bodies: Necrotic keratinocytes in the basal layer
Saw-tooth rete ridges
Lichenoid lymphocytic infiltrate

Front 35

1. Affected target antigen in this lesion is?
2. What malignancies can be associated w/ these lesions?

Back 35

1. Desmoglein 3 - Pemphigus vulgaris
IgG autoantibody
DIF: chicken-wire pattern of IgG and C3 in intercellular spaces
2. Paraneoplastic pemphigus: lymphoma, thymoma, SCC, carcinoma of bronchus, pancreas and breast

Front 36

What is this disease?
What does DIF show?

Back 36

Hailey-Hailey disease (Benign familial pemphigus)
AD, deficiency of desmoplakin and plakoglobin
"dilapidated brick wall"
DIF is negative

Front 37

Leukocytoclastic vasculitis presents clinically as?

Back 37

Painful, palpable purpura
Vasculitis w/ neutrophils, eos, lymphocytes, or histiocytes.
Nuclear dust
Extravasated RBCs
Thrombi sometimes

Front 38

The following neoplasm is positive for P63 & CD10 and negative for wide spectrum cytokeratin, CK 5/6, SMA and S100.

Back 38

Spindle cell carcinoma
Also called metaplastic carcinoma
● Tumor is contiguous with basal layer of epidermis
● Usually at least focal SCC
Tend to lose epithelial markers; thus, include at least two epithelial markers (P63 and CK 5/6). Also, these tumors as any other cutaneous malignant spindle tumors may express CD10.

Front 39

The pictured neoplasm can present in eruptive fashion in which genetic condition?

Back 39

Down Syndrome
Syringoma
Proliferation of eccrine ductal structures in the dermis. "Tadpole-shaped" when sectioned at angle.

Front 40

What immunostain has distinctive staining?

Back 40

CK20 perinuclear dot-like staining
Merkel cell tumor
EMA+
NSE+
CD56+

Front 41

A 65-year-old woman presents with a large multinodular lesion on her scalp.

Back 41

Proliferating trichilemmal cyst
Lobular intradermal proliferation of squamous cells, which may simulate a SCC, but has individual lobules with a characteristically sharply defined and regular non-infiltrative border.

Front 42

The pictured neoplasm was biopsied out of clinical suspicion for non-melanoma skin cancer. Dx?

Back 42

Clear cell acanthoma
Zone of irregular psoriasiform epidermal hyperplasia, composed of cells with pale cytoplasm, with a very sharp demarcation from the normal epidermis

Front 43

A 56-year-old man presents with a lesion on his forehead.

Back 43

Desmoplastic trichilemmoma
Rare variant of trichilemmoma arising from the outer root sheath or infundibular epithelium. Shows typical areas of conventional trichilemmoma, especially at the periphery of the lesion. In the center of the lesion, there are narrow irregular cords of smaller epithelial cells admixed with a dense hyalinized hypocellular stroma.

Front 44

This 36-year-old man has pruritic papules and vesicles of the elbows and shoulders. Punch biopsy is performed (see image) and direct immunofluorescence (DIF) reveals granular deposition of IgA in the papillary dermal tips. The other finding most likely to be present in this patient is

Back 44

gluten sensitivity
Dermatitis herpetiformis
HLA-B8
HLA-DR3
HLA-DQw2

Front 45

Common diagnostic feature of ?

Back 45

Cryoglobulinemia types 2 and 3
Leukocytoclastic vasculitis associated w/ drugs, infections or rheumatologic d/o

Front 46

What is this tumor? What syndrome can it be associated w/?

Back 46

sclerotic fibroma (storiform collagenoma, plywood fibroma)
Can present in Cowden's syndrome.
Tumor is well-circumscribed & unencapsulated hypocellular dermal nodule. Composed of thickened & hyalinized collagen bundles arranged in a laminated fashion with intervening clefts (focal storiform pattern may be present).

Front 47

What is pseudoxanthoma elasticum?

Back 47

Pseudoxanthoma elasticum is an inherited elastic tissue disorder due gene defect on chrom 16 w/ grouped, pseudoxanthomatous yellowish papules in flexural areas.
Calcification of elastic fibers occurs, leading to laxity of the skin and vessel wall changes that lead to HTN, cerebrovascular accidents, and GI hemorrhage.

Front 48

A 22-year-old man presents with a subcutaneous nodule on the dorsal aspect of the distal arm. A punch biopsy is performed, which shows a deep lesion composed of EMA positive spindled to epithelioid cells arranged in palisaded configuration around central zones of necrotic material. What stain would be most diagnostically specific?

Back 48

Loss of INI1 indicating epithelioid sarcoma
Differential includes epithelioid sarcoma, infectious granuloma, granuloma annulare, or rheumatoid nodule.

Front 49

A 59-year-old woman presents to the dermatology clinic complaining of extensive tender purpuric lesions on thighs and buttocks. What is this? What is it associated w/?

Back 49

Calciphylaxis
Rare dermatosis associated w/ calcification of small- & medium-sized vessels resulting in ischemic necrosis of the skin. Characterized by exquisitely tender purpuric lesions, most often on medial thighs or buttocks. Calciphylaxis most often affects pts w/ end-stage renal disease (ESRD) undergoing hemodialysis or peritoneal dialysis & patients with kidney transplantation. Histologically, there is calcification of small vessels in deep dermis and subcutaneous tissue.

Front 50

A 17-year-old man presents with an isolated pustular lesion on his arm. The biopsy shows a subepidermal blister with many eosinophils. What is the most likely dx?

Back 50

Bullous arthropod bite reaction

Front 51

A 35-year-old woman presents to the clinic with multiple ulcerated papules on the trunk and limbs, some of which have regressed per the patient. A biopsy was taken and shows a wedge-shaped mixed cellular dermal infiltrate which includes a variable number of large atypical lymphocytes admixed with eosinophils, histiocytes and rare plasma cells. What marker is + in the atypical lymphocytes?

Back 51

CD30
Lymphomatoid papulomatosis
Indolent clinical course, although 10% are associated with or evolve to anaplastic large cell lymphoma

Front 52

A localized tumor of the skin is biopsied. The tumor depicted in the image is positive for CD20, BCL-2, BCL-6, MUM-1 and negative for CD3 and CD5 and BCl-1. What is the classic clinical setting of the neoplasm represented in this question?

Back 52

Older women on the leg
Primary cutaneous diffuse large B-cell lymphoma, leg-type (PCDLBCL-LT).
PCDLBCL-LT is characterized by a predilection for the leg (72%), for women, an advanced age at onset (mean age 76 years), frequent relapses and extracutaneous dissemination.
Any PCDLBL-LT with bcl-2+ and MUM-1+ is designated as such regardless of anatomic location

Front 53

How should mitoses in melanoma be reported?

Back 53

Dermal mitoses/square mm

Front 54

In a patient with multiple cutaneous lesions, similar to that depicted in the image, and confirmed deletion mutations in DNA mismatch repair protein MSH2, what is the most important clinical follow-up in addition to a complete clinical dermatology exam?

Back 54

GI endoscopy
Muir-Torre syndrome
Clinical variant of Lynch syndrome
● Rare AD d/o with < 100 adenomas, usually in proximal colon
● Multiple colorectal tumors associated w/ multiple sebaceous tumors (mostly cystic tumors, including carcinomas), keratoacanthomas and BCC
● Rare case reports of HCC in non-cirrhotic background
● 15% of women develop endometrial cancer

Front 55

Bx was taken from the lip of a 46-year-old man. In which syndrome can you see similar lesions?

Back 55

Verruciform Xanthoma.
Can be seen in CHILD (congenital hemidysplasia with ichthyosiform erythroderma and limb defects) syndrome.

Front 56

The following lesion is found in a patient with tuberous sclerosis.

Back 56

Angiofibroma/adenoma sebaceum

Front 57

Associated w/ vacuolar to lichenoid interface pattern

Back 57

Lupus erythematosus
Dermatomyositis
Acute GVHD
Erythema multiforme

Front 58

Paraneoplastic pemphigus does not exhibit this histologic reaction pattern.

Back 58

Psoriasis-like

Front 59

Desmoplastic melanoma is most commonly associated w/?
What is the most reliable immunstain for desmoplastic melanoma?

Back 59

lentigo maligna
S100

Front 60

Kamino bodies are seen most commonly in what lesions?

Back 60

Spindle and epithelioid cell nevus

Front 61

Patient w/ large tense blisters on flexor surfaces, trunk, intertriginous regions and mucosa. DIF staining with IgG (and C3) as above. dx?
Target for antibodies?

Back 61

Bullous pemphigoid
Chronic autoimmune blistering disease.
BP-Ag1: 230 kD protein, Desmoplakin I/II
BP-Ag2: 180 kD polypeptide transmembranous glycoprotein, type XVII collagen

Front 62

Differentiate between EIC and trichilemmal cyst (pilar cyst)

Back 62

Epidermal inclusion cyst has a granular layer and
"dry" keratin.
Trichilemmal cyst has no granular layer and "wet" or compact keratin.

Front 63

Patient w/ clinically indurated skin

Back 63

Scleroderma (morphea)

Dermal collagen markedly thickened and tightly packed, epithelial adnexa obliterated, mucin absent, superficial and deep lymphoplasmacytic perivascular infiltrate

Front 64

This condition results from?

Back 64

Chronic trauma. Lichen simplex chronicus

Thickened epidermis and papillary dermis, pruritus frequently present. Irregular acanthosis, hyperkeratosis w/ focal parakeratosis and hypergranulosis, vertically oriented collagen bundles, superficial lymphocytic infiltrate

Front 65

The age of this patient is most likely?

Back 65

Under 10

Bullous urticarial pigmentosa (mastocytosis)

rare subepidermal vesiculobullous dz

Front 66

What is this?

Back 66

Promontory sign of Kaposi's sarcoma: adnexal structures and preexisting vessels protruding into newly-formed vessels

flat monomorphous cells lining vascular spaces, hyaline globules

Front 67

Patient who developed verrucous nodule on foot after wading through an irrigation canal. Dx?

Back 67

Atypical Mycobacterium marinum

swimming pool granuloma

Front 68

Back 68

Coccidioidomycosis

Front 69

Back 69

Erythema multiforme

vacuolar alteration, keratinocyte necrosis, sparse lymphocytic infiltrate

Front 70

Back 70

eruptive xanthoma

associated w/ hypertriglyceridemia

Front 71

HIV patient w/ widespread subcorneal pustules. Cx identified?

Back 71

Staphylococci or streptococci

Bullous impetigo

Front 72

Back 72

Keratoacanthoma: may be multiple, characterized by striking nuclear atypia, usually regress w/ fibrosis and rarely metastasize.

Front 73

Back 73

Congenital melanocytic nevus

Hamartoma involving other tissue types