Journal of the Dermatology Nurses' Association:
doi: 10.1097/JDN.0000000000000028
DEPARTMENTS: Skin Test

Skin Test

Linton, Christina P.

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1. Which of the following clinical presentations should raise the suspicion of PHACES syndrome?

a. Large, segmental facial hemangioma

b. Three or more hemangiomas in any location

c. Any hemangioma that doubles in size during the first 6 weeks of life

d. Hemangioma in the lumbosacral region

2. What does PUPPP stand for?

a. Purpuric urticarial plaques and pruritus of pregnancy

b. Persistent and unexplained pruritic papules of pregnancy

c. Pruritic urticarial papules and plaques of pregnancy

d. Polymorphic urticarial and papular prurigo of pregnancy

3. For which of the following lesions is Mohs micrographic surgery generally not considered an acceptable treatment option?

a. Primary squamous cell carcinoma in situ on the cheek

b. Recurrent superficial basal cell carcinoma on the forearm

c. Primary keratoacanthoma-type squamous cell carcinoma on the scalp

d. Recurrent nodular basal cell carcinoma on the back

4. A 42-year-old woman presents complaining of asymptomatic discoloration that has been slowly worsening over the last year. Examination reveals reticulate hyperpigmentation with telangiectasia on her lower anterior neck, lateral neck, and mid-upper chest. What is the most likely cause of her condition?

a. Repeated exposure to cold, windy weather

b. Daily use of nickel-containing jewelry

c. Chronic sun exposure without sunscreen

d. Habitual perfume use before sun exposure

5. When evaluating a skin scraping for scabies, what does the term scybala refer to?

a. Fecal matter

b. Mite fragments

c. Unhatched eggs

d. Immature mites

6. When providing education for an individual with idiopathic onycholysis of the fingernails, which of the following instructions should be included?

a. Soak the affected nails in warm water for 20 minutes twice daily.

b. Apply clear nail polish twice weekly to help protect the nails.

c. Wear vinyl gloves during waking hours and cotton gloves at night.

d. Keep the affected nails short.

7. What is the recommended daily allowance (RDA) for Vitamin D in adults less than 70 years old?

a. 200 international units (IUs)

b. 600 IUs

c. 1000 IUs

d. 1400 IUs

8. Which of the following conditions is least likely to be associated with an underlying malignancy?

a. Acanthosis nigricans

b. Dermatomyositis

c. Bazex syndrome

d. Bullous pemphigoid

9. A 2-year-old boy presents with his mother who reports that he has had a fever of 102°F–103°F for the last 3 days. He did not seem to have any other symptoms so she did not seek medical care. This morning, his fever was gone, but he now has a rash. Examination reveals 1- to 5-mm pink macules and papules scattered on his trunk and neck. What is the most likely diagnosis?

a. Measles

b. Roseola infantum

c. Scarlet fever

d. Rubella

10. What temperature is liquid nitrogen?

a. −40.8°C or −41.4°F

b. −79.0°C or −110.2°F

c. −89.5°C or −129.1° F

d. −195.8°C or −320.4°F

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1. a. Large, segmental facial hemangioma. PHACES syndrome is a constellation of clinical findings associated with extensive, segmental, craniofacial hemangiomas that usually affect female infants. The features of this syndrome include posterior fossa brain malformations, hemangioma, arterial abnormalities, cardiac abnormalities, eye abnormalities, and sternal defects. Because only one extracutaneous anomaly is required for diagnosis, the clinical spectrum varies considerably. Although not typically associated with PHACES syndrome, lumbosacral hemangiomas are significant because they may signal underlying occult spinal dysraphism or spinal cord defects.

Paller, A. S., & Mancini, A. J. (2011). Hurwitz clinical pediatric dermatology (4th ed.). New York, NY: Elsevier Saunders.

Wolff, K., Goldsmith, L. A., Katz, S. I., Gilchrest, B. A., Paller, A. S., & Leffell, D. J. (2008). Fitzpatrick’s dermatology in general medicine (7th ed.). New York, NY: McGraw-Hill Medical.

2. c. Pruritic urticarial papules and plaques of pregnancy. The term PUPPP was first used by Lawley et al. in 1979. The eruption is characterized by erythematous papules and plaques that begin as 1- to 2-mm lesions within the abdominal striae. They then spread over the course of a few days to involve the abdomen, buttocks, thighs, and in some cases, the arms and legs. The lesions coalesce to form urticarial plaques, and intense pruritis is a characteristic. Most cases occur in primagravidas and rarely recur with subsequent pregnancies. Onset is generally late in the third trimester and delivery results in resolution. Fetal and maternal outcomes are not affected.

James, W. D., Berger, T. G., & Elston, D. M. (2011). Andrews’ diseases of the skin: Clinical dermatology (11th ed.). Philadelphia, PA: Saunders/Elsevier.

3. b. Recurrent superficial basal cell carcinoma on the forearm. The American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery have recently published appropriate use criteria for Mohs micrographic surgery. According to these guidelines, Mohs is generally not considered acceptable for the treatment of primary or recurrent actinic keratosis with focal squamous cell carcinoma in situ in any anatomic location. Mohs is also generally not considered acceptable for the treatment of recurrent superficial basal cell carcinoma, primary superficial basal cell carcinoma, or primary nodular basal cell carcinoma of <1 cm on the trunk or extremities (excluding the pretibial surface, hands, feet, nail units, and ankles) of immunocompetent patients. In addition to these situations, there are several tumors for which the appropriateness of Mohs is uncertain. These guidelines do not address whether Mohs is preferred over another modality for specific tumors, and clinical judgment should be used to weigh all contributing factors when making treatment decisions for individual patients.

Ad Hoc Task Force, Connolly, S. M., Baker, D. R., Coldiron, B. M., Fazio, M. J., Storrs, P. A., … Wisco, O. J. (2012). AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: A report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery. Journal of the American Academy of Dermatology, 67(4), 531–550.

4. c. Chronic sun exposure without sunscreen. Poikiloderma of Civatte is the result of chronic sun damage and typically affects the lateral neck, lower anterior neck, and V of the chest while sparing the submental area, which is shaded by the chin. This condition generally manifests itself in fair-skinned men and women in their mid-to-late 30s or early 40s.

James, W. D., Berger, T. G., & Elston, D. M. (2011). Andrews’ diseases of the skin: Clinical dermatology (11th ed.). Philadelphia, PA: Saunders/Elsevier.

5. a. Fecal matter. Because scabies mites are too small to be seen with the naked eye (0.35 mm × 0.3 mm), a mineral oil skin scraping can be helpful to confirm the diagnosis. When visualized through a microscope, scabies mites have an oval body with wrinkle-like corrugations and eight short legs. Immature scabies mites (larvae) look like adults but have three pairs of legs instead of four. The presence of oval-shaped eggs and/or dark-colored fecal pellets (scybala) can also confirm the diagnosis of scabies.

Bolognia, J. L., Jorizzo, J. L., & Rapini, R. P. (2007). Dermatology (2nd ed.). St. Louis, MO: Elsevier/Mosby.

6. d. Keep the affected nails short. Onycholysis is separation of the nail plate from the underlying nail bed because of disruption of the onychocorneal band. Idiopathic onycholysis usually affects the fingernails of women and is often a consequence of mechanical or chemical damage. It is important to promote reattachment; otherwise, the nail bed becomes cornified, and the nail plate can no longer adhere to the nail bed. Education should include instructions about minimizing trauma and avoiding chemical irritants. The nails should be kept short because a long nail acts as a lever and, when the distal nail is hit, a greater force is transmitted proximally. The exposed nail bed should be dried carefully after each hand washing, and if the hands will be involved in wet work, it is recommended that light cotton gloves be worn under vinyl gloves. Affected individuals should be counseled to not wear artificial nails, wear poorly fitting shoes, use their fingernails as tools, or use nail hardeners, especially those with formaldehyde. Education should also include the need to avoid chemical irritants including nail cosmetics, strong soaps, and certain foods such as citruses. Application of a topical antiseptic solution, such as thymol 4% in chloroform, on the exposed nail bed may also be useful.

Daniel, C. R., Iorizzo, M., Piraccini, B. M., & Tosti, A. (2011). Simple onycholysis. Cutis, 87, 226–228.

7. b. 600 IUs. According to the National Academy of Sciences Institute of Medicine (IOM), the RDA of vitamin D for children, teenagers, and adults aged 1–70 years is 600 IUs. For infants and children aged 0–1 year, the RDA is 400 IUs, and for adults over 70 years old, the RDA is 800 IUs. These recommendations are based on the assumption of minimal sun exposure. The IOM asserts that 600 IUs of vitamin D per day meets the needs of almost every individual in the United States and Canada. The IOM also concluded that, although a strong body of rigorous evidence links a person’s vitamin D level to their bone health, the current evidence linking vitamin D with other health benefits is inconsistent, inconclusive, and insufficient.

Institute of Medicine. (2011). Dietary reference intakes for calcium and vitamin D. Retrieved from http://www.iom.edu/~/media/Files/Report%20Files/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D/Vitamin%20D%20and%20Calcium%202010%20Report%20Brief.pdf

8. d. Bullous pemphigoid. Bullous pemphigoid is characterized by large, tense subepidermal bullae with a predilection for the groin, axillae, trunk, thighs, and flexor surfaces of the forearms. Bullous pemphigoid has been reported to be precipitated by medications and associated with diabetes mellitus, rheumatoid arthritis, pemphigus foliaceus, dermatomyositis, ulcerative colitis, myasthenia gravis, and thymoma. Acanthosis nigricans presents as hyperpigmented and hyperkeratotic velvety, slightly elevated plaques that are frequently associated with acrochordons. The benign variant is associated with obesity and diabetes mellitus and is normally limited to certain areas, such as the neck and axillae. In contrast, malignant acanthosis nigricans arises spontaneously, progresses rapidly, and often presents with severe and extensive cutaneous involvement. Bazex syndrome (acrokeratosis paraneoplastica) is a rare, acral psoriasiform dermatosis that is associated with internal malignancy. Bazex syndrome precedes the cancer diagnosis in 65%–70% of patients and shows improvement in 90%–95% of patients with successful treatment of the underlying noeplasm. Classical dermatological findings include well-defined erythematous to violaceous plaques covered by fine-to-thick adherent psoriasiform-like scale symmetrically distributed on acral areas, ear helices, and nasal and malar surfaces. Among adults older than 40 years who have dermatomyositis, 15%–50% also have an underlying malignancy. Cutaneous manifestations include a heliotrophic rash with periorbital edema, gottron papules in the finger joints, and violaceous poikiloderma overlying the chest, upper back, elbows, and knees.

James, W. D., Berger, T. G., & Elston, D. M. (2011). Andrews’ diseases of the skin: Clinical dermatology (11th ed.). Philadelphia, PA: Saunders/Elsevier.

Shah, K. R., Boland, C. R., Patel, M., Thrash, B., & Menter, A. (2013). Cutaneous manifestations of gastrointestinal disease, Part I. Journal of the American Academy of Dermatology, 68(2), 189.e1–e21.

9. b. Roseola infantum. Roseola infantum is a common cause of sudden, unexplained high fever in children 6–36 months old and is associated with human herpesvirus-6 and human herpesvirus-7. The fever ranges from 38.9°C (102° F) to 40.6°C (105°F) and can be associated with convulsions and lymphadenopathy, although the infant is usually remarkably well despite the high fever. The fever remains consistently high, with morning remission, until the fourth day, when it falls precipitously to normal, coincident with the appearance of a morbilliform eruption consisting of small blanchable pink macules and papules, 1–5 mm in diameter on the trunk and neck, that may remain discrete or become confluent. The buttocks, face, and extremities may be affected, and often, there is a blanched halo around the lesions. The course is self-limited, and resolution occurs within 1–2 days with only symptomatic management. Measles begins with a prodrome that consists of fever, malaise, conjunctivitis, and prominent upper respiratory symptoms. Pathognomonic 1-mm white papules on an erythematous base appear on or after the second day of illness on the buccal mucosa opposite the premolar teeth (Koplik spots). After 1–7 days, erythematous flat papules appear on the face and neck where they become confluent, spreading to the trunk and arms in 2–3 days where they remain discrete. The exanthema and fever subsides after 6–7 days. Scarlet fever classically presents with a finely punctate erythema that occurs first on the upper trunk. The initial punctate lesions become confluently erythematous and may be accentuated in the skin folds. The exanthem fades in 4–5 days and is followed by desquamation on the body and sheet-like exfoliation on the palms/fingers and soles/toes. In some mild infections, only the exfoliation is noted. The eruption is caused by group A streptococcus infection (often pharyngitis) and is treated with antibiotics. The eruption caused by rubella (also known as German measles or 3-day measles) begins on the forehead and spreads inferiorly to the face, trunk, and extremities during the first day. The facial exanthema fades by the second day, and the remaining lesions fade by the third day.

James, W. D., Berger, T. G., & Elston, D. M. (2011). Andrews’ diseases of the skin: Clinical dermatology (11th ed.). Philadelphia, PA: Saunders/Elsevier.

Wolff, K., Fitzpatrick, T., & Johnson, R. (2009). Fitzpatrick’s color atlas and synopsis of clinical dermatology (6th ed.). New York, NY: McGraw-Hill.

10. d. −195.8°C or −320.4°F. Liquid nitrogen is the cryogen of choice in dermatology because it is easy to store and use, environmentally friendly, nonflammable, and inexpensive and has the lowest temperature of all the common cyrogens. This lower temperature correlates with rapid freezing. Rapid freezing causes intracellular ice crystal formation with the disruption of electrolytes and pH changes, whereas slow freezing causes extracellular ice formation and less cell damage. Other available cryogens include Freon (−40.8°C or −41.4°F), solid carbon dioxide (−79.0°C or −110.2°F), and nitrous oxide (−89.5°C or −129.1° F).

Wolff, K., Goldsmith, L. A., Katz, S. I., Gilchrest, B. A., Paller, A. S., & Leffell, D. J. (2008). Fitzpatrick’s dermatology in general medicine (7th ed.). New York, NY: McGraw-Hill Medical.

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