Dermatology 2

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  1. What  is the Pathophysiology of pemphigus Vulgaris?
    • Autoantibodies against intercellular material [PGI 00,AI 03] of the epidermal cells  - the cells seperate from each other and epidermis becomes 'unglued', phenomena called acantholysis.
    • Because of thin walled lesion, the bulla cannot hold for long and breaks. It acts like a burn.
    • There is loss of a lot of fluid leading to dehydration, infection and sepsis.
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  2. What is the pathophysiology of pemphigus foliaceus?
    The pathophysiology is similar to pemphigus vulgaris [PGI 99] except that it is more localized in hair follicles.
  3. Pruritus is not seen in [JIPMER 95,AI 04,91] 
    A) Contact dermatitis 
    B) Pemphigus 
    C) Lichen simplex chronicus
    D) Psoriasis 
    B) Pemphigus
    (this multiple choice question has been scrambled)
  4. What are the various types of Pemphigus?
    • Pemphigus vulgaris 
    • - Most common type 
    • - IgG antibodies against adherin adhesion molecule

    • Pemphigus foliaceous 
    • - Associated with drugs (captopril, penicillamine) and other autoimmune disorders 
    • - IgG antibody against desmoglein proteins 

    • Pemphigus vegitans 
    • - least common [UP 92]
  5. What is Tzanck test?
    • A microscopic examination of cellular material from skin lesions to help diagnose certain vesicular diseases.
    • The tissue is scraped from the base of a vesicle, placed on a slide, and stained with Wright's or Giemsa's stain. Multinucleated  giant cells are diagnostic of
    • herpes virus [MANIPAL 01] or
    • - varicella.
    • - pemphigus [KARNATAKA 01]

    • Tzanck cells are degenerated epithelial cells from the keratin layer [SGPGI 03] of the skin (acantholytic cells), rounded and devoid of intercellular attachments. The periphery of these cells is basophilic and the nucleus is spheric and enlarged with prominent nucleoli.
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  6. How do you diagnose pemphigus lesions?
    • Demonstration of acantholytic cells in Tzanck smear from lesions. [AI 96]
    • Acantholytic cells have hyperchromatic nuclei and perinuclear halo. [PGI 96]
  7. What is herpes gestationis?
    • Pemphigoid gestationis is also called as herpes gestationis. It is a rare non-viral, sub-epidermal blistering disease of pregnancy and puerperium. 
    • Most common site of herpes gestationis is Umbilicus.
  8. How do you diagnose pemphigoid lesion? [AIIMS 04]
    Direct immunofluorescence microscopy of normal appearing perilesional skin shows linear deposits of IgG and/or C3 in epidermal basement membrane.

    [@ PemphiGus and PemphiGoid lesions - IgG, Dermatitis herpetiformis - IgA]
  9. What is the difference between Pemphigus vulgaris and Bullous Pemphegoid?
    Pemphigus vulgaris // Bullous Pemphegoid 

    Blister is intraepidermal, [AI 91,99]  and separation of epidermal cells is known as acantholysis. [AI 95,03,AIIMS 03] // Blister is always subepidermal. 

    Thin walled skin lesion, so more chance of rupture – leads to dehydration and sepsis // Thick walled tense bullous  lesion which may be hemorrhagic  – less chance to rupture – less chance of  dehydration and sepsis 

    Most common site of primary involvement is mucous membrane // Most common sites are legs, arms, head and trunk

    Mucosal involvement  // Early and common [AI 97,UP 96]  // Late and rare. [AI 00,]

    Nikolsky sign // Positive // Negative 

    [@ Pemphigus vulgaris is more vulgar, it occurs in oral mucosa, Bullows pemphigoid are Bullow (below) the epidermis] 
  10. What is Dermatitis herpetiformis?
    • Duhring's disease (k/a Dermatitis herpetiformis)  is a autoimmune, chronic blistering skin condition, characterised by blisters filled with a watery fluid.  
    • Despite its name, DH is neither related to nor caused by herpes virus. The name means that it is a skin inflammation having an appearance similar to herpes.
    • It is always associated with underlying Celiac disease.
    • It is an intensely pruritic chronic papulovesicular skin condition, symmetrically distributed over extensor surfaces. (knee, elbow, buttocks, back). [AIIMS 02] 
    • It is associated with HLA-B8.  
    • Eruption is usually polymorphic and occurs in crops. 
    • General health of patient is unaffected. 
    • Direct immunofluorescence examination demonstrates the presence of IgA in the papillary tips [AI 12, 04] in skin around the lesion is all patients. 
    • Dapsone is the drug of choice in dermatitis herpetiformis. [AI 91,UP 97,AIIMS 05] .
    • Gluten free diet is beneficial in Dermatitis herpetiformis. [KARNATAKA 96] 
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    • [Note:
    • Antibodies are formed against wheat gluten (esp Gliadin).
    • The cause of diarrhea in these cases is the antibody.]
  11. What is epidermolysis bullosa?
    • Epidermolysis bullosa are a heterogenous group of hereditary blistering disorders. All of them are characterized by induction of blisters by trauma and exacerbation of blistering in warm weather. 
    • Disorders can be catagorized in 3 main headings:
    • i. Epidermolysis bullosa simplex
    • ii. Junctional epidermolysis bullosa
    • iii. Dystrophic epidermolysis bullosa

    Junctional epidermolysis bullosa is an autosomal recessive condition which is life-threatening. Affected infant is usually blistered  at birth or develops lesion during the neonatal period. [AIIMS 01]
  12. A newborn baby of non-consanguinous marriage developed erosions and blisters in areas where mother handles the child, for feeding and other purposes. Perioral areas are involved and extensive denudation is noted. There is associated history of death of one sibling from a similar presentation.. Which of the following is the most likely diagnosis: [AI 12]
    A. Epidermolysis bullosa
    B. Langerhan's cell histiocytosis
    C. Neonatal pemphigus
    D. Congenital syphilis
    A. Epidermolysis bullosa
    (this multiple choice question has been scrambled)
  13. What is Nikolsky sign?
    It is a  peculiar vulnerability of the skin where  the apparently normal epidermis can be separated at the basal layer and rubbed off when pressed with a sliding motion.

    • It is positive in [AIIMS 00]
    • Pemphigus vulgaris,
    • Steven Johnson's syndrome,
    • Toxic Epidermal Necrolysis,
    • Staphylococcal scalded skin syndrome,
    • Porphyria.
  14. What are the important  drugs causing Drug eruption? [AI 94]
    • Penicillamine 
    • Penicillin 
    • Phenobarbitol
    • Quinolones
    • Rifampin
    • Sulfadrugs

    • Allopurinol
    • Lamotrigine

    [@PQRS All Lamo]

    Note that these are the same drugs that cause  allergic interstitial nephritis resulting in eosinophinuria and  hemolysis.
  15. What are the clinical features of drug eruption?
    • The eruption usually appears within hours of administration of the offending agent.
    • Common locations include the genitalia (most commonly involved site), extremities and perioral region.
    • The eruption appears as circular area of erythema that can become bullous and resolve by hyperpigmentation. [AI 05]
  16. What are the grades of severity of allergic drug eruptions?
    • Urticaria: localized rashes
    • Morbiliform  hypersensitivity: diffuse, erythrematos maculopapular rash 

    Fixed drug reaction: eruption only on one area 

    Erythrema multiforme: When morbiliform (measles like) rashes become more severe and  have red rings

    Stevens Johnson syndrome: when mucous membranes start to be involved. Oral cavity, eyes, respiratory epithelium sloughs leading to pulmonary lesions – die of respiratory failure. 

    Toxic Epidermal Necrolysis: when lesion becomes even more worse leading to sloughing of the skin even on minor  pressure (Nikolsky sign)
  17. What are the clinical features of erythrema multiforme? [AI 00]
    • It represents the hypersensitivity reaction to drugs or infection. 
    • It is generally idiopathic but the most common cause is infection of herpes simplex virus.
    • The lesions may be urticaria-like and some have obvious ‘bull’s-eye’ or ‘target’ lesions. [AI 98] 
    • Blisters may be seen in the centre or around the edges of the lesions.
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    Stevens–Johnson syndrome is severe bullous erythema multiforme with marked mucosal involvement [SGPGI 99] including the mouth, eyes and genitals, and constitutional disturbance.
  18. What are the conditions which are associated with Erythema Multiforme?
    • Malignancy
    • Collagen vascular disease - SLE, dermatomyositis, PAN
    • Infections - Herpes, Mycoplasma, Leprosy 
    • Drugs - sulfonamides, penicillamine, salicylates
  19. How do you differentiate between Staph scalded skin syndrome,Toxin Epidermal necrolysis and toxic shock syndrome?
    • All of them acts like burn and are kept in burn unit, have staph infections, hypovolemia, Nikolsky positive
    • In TEN, there is h/o of drugs intake, not in SSSS.
    • In toxic shock syndrome, there is hypotension, tachycardia and shock. This leads to increased Cr and urea.
  20. Steven Johnson syndrome is characterized by [IOM 12]
    A) Tense bulla
    B) Both mucosal lesion with target lesion and purpura
    C) Mucosal ulceration with target lesion
    D) Purpura with target lesion
    B) Both mucosal lesion with target lesion and purpura
    (this multiple choice question has been scrambled)
  21. What is the difference between the lesion of lyme disease and erythrema multiforme?
    • Both have  red rings, but
    • Lyme disease rash is larger - >5cm,
    • Erythrema multiforme – small rings
  22. In which drugs do you find Lichenoid drug eruption?
    • Gold 
    • Antimalarials
  23. What is the difference between  condylomata lata and condylomata accuminata?
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    • Condylomata  lata – flat – secondary syphilis 
    • Condylomata accuminata – cauliflower like lesions on vulva, labia, perineum, vagina [AIIMS 98]  -  HPV infection
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  24. What are the strains of HPV causing condyloma acuminatum?
  25. How do you manage a case of condyloma acuminate?
    • Topical application of podophyllin. [MAHE 99,AIIMS 03] 
    • Laser therapy 
    • Surgery 
    • Recombinant interferon -2a.
  26. What is Seborrheic keratosis?
    Seborrheic  keratosis is the benign hyperpigmented lesions of skin with no malignant potential.
  27. what is the most common cancer in earth ?
    Basal cell carcinoma. It includes 70% of all the malignancies of skin.
  28. What are the features of rodent ulcer?
    • Rodent ulcer or basal cell carcinoma (BCC) [BHU 02,UP 95]  is a low grade malignancy seen in white skinned people. 
    • 90% of the lesions are found on the face, [AI 95,IOM 11]  generally above the line joining the lobe of ear to corner of mouth. The most common site is around the inner canthus of eye.
    • Shiny like a pearl.
    • Palisading growth pattern into the dermis. 
    • Although called a rodent ulcer, most of the lesions are non-ulcerated [KARNATAKA 01] and have a nodular appearence. 
    • Dissemination by lymphatics or the blood stream does not occur.  [AI 94] 
    • Surgical excision is the treatment of choice [AIIMS 91] with cure rates between 85-95%. BCC is very radiosensitive and raditherapy is reserved  elderly patients not suitable for surgery.

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  29. From which cells does the basal cell carcinoma originate ?
    Basal cell carcinoma arise from the basal cells of hair follicles and not the basal cell of all the skin layer . So , basal cell carcinoma is absent in the parts where the hair follicles are absent like in palm and soles and lips.
  30. What are the risk factors for squamous cell carcinoma?
    • Chronic sun exposure
    • Fair complexion
    • Chronic skin ulcers and sinus tracts

    First two risk factors are risk factors for basal cell carcinoma also.
  31. What is Actinic keratosis?
    It is a sun induced dysplasia of the keratinocytes. It is the precursor lesion of squamous cell carcinoma. [AIIMS 02] 

    (Acitinic means sun, these lesions are present in sun exposed areas)
  32. Which is most premalignant? [IOM 09]
    A) Actinic keratosis
    B) Giant cell tumor 
    C) Osteoma
    D) Fibroadenoma
    A) Actinic keratosis
    (this multiple choice question has been scrambled)
  33. What is keratoacanthoma?
    • Keratoacanthoma is a low grade squamous cell carcinoma that manifests  as an exophytic nodule with central keratinous debris. 
    • Keratoacanthoma appears as a dome shaped papule with a central keratotic crater, expands rapidly and commonly regresses without therapy.
  34. What is Bowen disease?
    Squamous cell carcinoma in situ

    • [@ ABC - For squamous cell carcinoma
    • Actinic keratosis - Premalignant lesion  
    • Bowen disease - Carcinoma in Situ
    • Carcinoma -  Squamous  cell carcinoma]
  35. Epithelial pearls are seen in [IOM 97]
    A) Choriocarcinoma
    B) Squamous cell carcinoma
    C) Basal cell carcinoma
    D) Adenocarcinoma
    B) Squamous cell carcinoma
    (this multiple choice question has been scrambled)
  36. What are the important premalignant conditions of skin? [KERELA 94]
    • Bowen's disease 
    • Leukoplakia
    • Radiodermatitis
    • Paget's disease of nipple
    • Senile (solar or actinic ) keratosis
    • Chronic scars
  37. What is naevi? What are its types?
    Melanocytes are derived from the neural crest and are seen as clear cell in the basal layer of epidermis in normal skin. Their number may be increased in the layers of the skin leading to formation of benign pigmented naevi. (Nevi means birth mark)

    • Various types are 
    • a) Lentigo -  within the basal layer of epidermis
    • b) Junctional nevus - localized aggregations projecting into the dermis. It is immature, unstable and premalignant. [AIIMS 96] 
    • c) Dermal nevus - entirely within dermis. 
    • d) Compound nevus - junctional + dermis.
  38. What are the signs and symptoms of melanoma?
    • Asymmetrical skin lesion.
    • Border of the lesion is irregular.
    • Color: melanomas usually have multiple colors.
    • Diameter: moles greater > 6 mm are more likely to be melanomas than smaller moles.
    • Enlarging: Enlarging or evolving

    [@ ABCDE]
  39. What are the clinical types of malignant melanoma? [AI 97]
    1. Superficial spreading: Most common

    2. Nodular melanoma: worst after amelanotic type.  [KERELA 94] 

    3. Lentigo maligna melanoma:  Less common, least malignant. Occurs in old age and common in face (Hutchinson’s melanotic freckle). 

    4. Acral lentiginous melanoma:  It has got a poor prognosis. It is least common.  It mimics fungal infection/pyogenic granuloma.

    5. Amelanotic melanoma:This is the worst type.

    6. Desmoplastic melanoma.
  40. Prognosis/biological behaviour of melanoma is indicated by [IOM 09]
    A) Vertical growth 
    B) Size
    C) Rapid growth 
    D) Histological type 
    A) Vertical growth
    (this multiple choice question has been scrambled)
  41. Soft tissue sarcoma is ideally treated with [AIIMS 91]
    A) Radiotherapy 
    B) Therapeutic embolization
    C) Chemotherapy 
    D) Wide excision
    D) Wide excision

    Radical excision
    with a negative margin is the standard surgical procedure for local soft tissue sarcoma. The adjuvant use of radiotherapy and/or chemotherapy improves the local control rate and permits the use fo limb-sparing surgery. 
    Prognosis is related to the stage, [AIIMS 96, AI 98] with 5-year survival rates averaging 75% for  Cancer stage I, 55% for stage II, and 29% for stage III.
    (this multiple choice question has been scrambled)
  42. One of the following arises from dermis? [IOM 98]
    A) Squamous cell carcinoma
    B) Basal cell carcinoma
    C) Melanoma
    D) Dermatofibrosarcoma
    D) Dermatofibrosarcoma
    (this multiple choice question has been scrambled)
  43. What are the various causes of alopecia?
    • Non scarring alopecia
    • - Alopecia areata 
    • - Tinea capitis 
    • - Traumatic alopecia 
    • - SLE 

    • Scarring alopecia / Cicatricial alopecia 
    • - Cutaneous lupus 
    • - Lichen planus 
    • - Linear scleroderma 
    • - DLE  [AI 99, UP 00]

    [Pelade: Fr. to remove hair = alopecia areata]
  44. What is Pseudopelade?
    Cicatrical alopecia [PGI 90] is also called as pseudopelade.  It is a  scarring type of alopecia; usually occurs in scattered, irregular patches; of uncertain cause.
  45. What is alopecia areata?
    • Alopecia areata is characterised by a sudden loss of hair over circumscribed patches  due to autoimmune destruction of the hair follicles.
    • The patches are completely bald, and the skin surface is smooth, A few exclamation mark stumps [SGPGI 99] may be seen at the  edges of patches. 
    • Secondary syphilis is associated with alopecia areata.
    • Management - Inject steroids and do VDRL. Topical minoxidil  [JIPMER 92]  can also be used. Alopecia areata totalis gives excellant response to topical diphencyprone.
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  46. What is Telogen Effluvium?
    • It is the disorder in which hair follicles fall away.
    • (Telogen means Hair follicle, Ef - away, fluvim – flow away.)
  47. What is acne vulgaris?
    • Acne vulgaris is caused by overproduction of sebum and sebaceous duct blockage. [JIPMER 91,AIIMS 01]
    • Acne begins typically at puberty, when there is increased secretion of androgen in both sexes. 
    • The most pathognomic lesion of acne vulgaris is the comedone, which may be closed (whitehead) or open (blackhead). 
    • Comedones, erythematous papulopustular lesions, and in some patients, cyst develop due to increased production of oil in adolescence.
    • The lesions are situated chiefly on cheeks, forehead, chin, nose, and temporal region.

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    • Closed/white comedone

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  48. What are the features of acne conglobata?
    • Acne conglobata is an atypical and severe form of acne. It is characterised by numerous inflamed cystic lesions, sinuses and extensive  scarring over the face and upper trunk.
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  49. What are the steps in management of Acne?
    • Topical cleaners, Benzoyl peroxide
    • If doesnot work, topical vitamin A (retinoic acid)
    • If doesnot work, add a topical antibiotic like erythromycin or Clindamycin
    • If doesnot work, Switch to oral antibiotic, Minocycline
    • If even doesnot work, Switch to Oral Vitamin A derivative (Retinoic acid derivative). It is highly teratogenic causing microotia and 8th nerve damage.
  50. A 24 years old unmarried woman has multiple nodular, cystic, pustular and comadonic lesions on face, upper back and shoulder for 2 years. The drug of choice for her treatment would be [AI 06]
    A) Isotretinoin 
    B) Acitretin 
    C) Azithormycin
    D) Doxycycline 
    A) Isotretinoin

    For severe nodulocystic acne in unmarried woman, oral tretinoin is the drug of choice. [IOM 09]
    (this multiple choice question has been scrambled)
  51. A 17yr old girl with acne has been taking a drug for the last tow years. She now presents with blue black pigmentation of nails. The likely medication causing the above pigmentation is: [AI 10]
    A. Tetracycline
    B. Doxycycline
    C. Minocycline
    D. Azithromycin
    C. Minocycline
    (this multiple choice question has been scrambled)
  52. What is acne rosacea? [AI 05]
    • It is an inflammatory disorder mainly affecting central face
    • It is seen almost exclusively in adults, only rarely affecting the patients less that 30 years of age. 
    • Rosacea is more often seen in women
    • It is characterised by presence of erythema, telangectases, and superficial pustules but is not associated with presence of comedones.

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  53. What are the important systemic diseases causing pigmentation? [SGPGI 03]
    • Addison's disease
    • Nelson's syndrome
    • Ectopic ACTH syndrome
    • Porphyria cutanea tarda
    • Hemochromatosis
    • Pellagra
    • Biliary cirrhosis
    • Scleroderma
    • POEMS syndrome
    • Vitamin B12, folate deficiency
  54. What is Vitiligo?
    • Vitiligo is an acquired condition in which circumscribed depigmented patches develop. There is complete loss of melanocytes from a circumscribed patch of skin.
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  55. What are the important features of chloasma? [AIIMS 99,00, AI 00]
    • It is characterized by asymptomatic, very superficial looking macular areas of brownish pigmentation
    • Lesions are usually located over bridge of nose, both cheeks, upper lip and forehead. 
    • It  occurs in pregnancy and in some women taking oral contraceptives. 
    • Augmented by exposure to the sun.

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  56. Light brown macules over cheeks of a woman for the past 5 years, never been erythematous. Most likely diagnosis is [AIIMS 00]
    A) Malingering
    B) Chloasma 
    C) SLE 
    D) Photodermatitis 
    B) Chloasma
    (this multiple choice question has been scrambled)
  57. What are the skin markers in internal malignant diseases? [KERELA 99,AI 96]
    • Acanthosis nigricans [SGPGI 03] 
    • Bullous pemphigoid
    • Acquired iCthyosis
    • Dermatomyositis 
    • Erythema gyratum repens 

  58. What do Acanthosis nigricans indicate? [SGPGI 96]
    • It may be the sign of occult malignancy,most importantly of the gastrointestinal tract. 
    • It may be the reflection of an endocrinopathy such as acromegaly, PCOS, cushing syndrome or insulin resistant diabetes mellitus.
  59. What is erythema nodosum?
    Erythema nodosum is due to a vasculitis in the deep dermis and subcutaneous fat. Painful, palpable, dusky blue-red nodules are most commonly seen on the lower legs.

    • Common provoking factors of  erythema nodosum are [AI 99,IOM 05] 
    • 1. Infections e.g.  streptococci, mycobacteria, [UP 99]  Brucella, Mycoplasma, Rickettsia, Chlamydia
    • 2. Drugs e.g. Sulphonamides, [MANIPAL 02]  oral contraceptives 
    • 3. Systemic disease e.g. Sarcoidosis, ulcerative colitis and Crohn’s disease, SLE
    • 4. Pregnancy

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  60. Erythema nodosum is seen in all of the folllowing except: [AI 11]
    A. Tuberculosis
    B. Pregnancy
    C. SLE
    D. Chronic pancreatitis
    D. Chronic pancreatitis

    Erythema nodosum has NOT been mentioned with chronic pancreatitis.
    (this multiple choice question has been scrambled)
  61. What is Sweet's syndrome?
    Sweet's syndrome (SS), or acute febrile neutrophilic dermatosis is a skin disease characterized by the sudden onset of fever, leukocytosis, and tender,  erythematous, well-demarcated papules and plaques that show dense  infiltrates by neutrophil granulocytes on histologic examination.

    Systemic corticosteroids (prednisone) produce rapid improvement and are the “gold standard” for treatment.
  62. A child with fever presents with multiple tender erythematous skin lesions. On microscopic examination, the skin lesions are seen to have neutrophilic infiltration in the dermis. What is the diagnosis? [AI 11]
    A. Sweet's syndrome
    B. Erythema nodosum leprosum
    C. Erythema nodosum
    D. Behcet's syndrome
    A. Sweet's syndrome
    (this multiple choice question has been scrambled)
  63. A young female presents with a history of fever and nodular lesion over the shin. Histopathology reveals foamy histiocytes with neutrophilic infiltration. There is no evidence of vasculitis. Most probable diagnosis is: [AI 11]
    A. Behcet's syndrome
    B. Erythema nodosum leprosum
    C. Sweet's syndrome
    D. Erythema nodosum
    D. Erythema nodosum

    Erythema nodosum > Sweet's syndrome

    Fever and nodular lesions with neutrophilic infiltration and absence of vasculitis may be seen in both Sweet's syndrome and Erythema nodosum.
    Presence of histiocytic infiltration is more typical of erythema nodosum, and uncommon/rare in sweet syndrome.
    (this multiple choice question has been scrambled)
  64. What is Necrobiosis lipoidica diabeticorum?
    • This  condition  is  associated  with  diabetes  mellitus.  Typically, the lesions appear as shiny, atrophic and slightly yellow plaques on the shins (anterior surface of legs).
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  65. What is icthyosis?
    • Ichthyosis   is characterized by  dry, thickened, scaly or flaky skin.  In many types there is cracked skin,  which is said to resemble the scales on a fish; the word ichthyosis comes from the Ancient Greek  ichthys, meaning "fish. 
    •  Many different metaphors such as alligator, collodion, crocodile, (Sauroderma), [AIIMS]   fish, and porcupine skin have been used to describe the various types and stages of ichthyosis.  

    • Most common type is icthyosis vulgaris which is inherited as autosomal dominant. [AI 93] 
    • The most common disease to be associated with acquired icthyosis is Hodgkin's disease. [TN 96]
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  66. What is Pyoderma gangrenosum?
    • Pyoderma gangrenosum is an idiopathic necrotizing skin disease and the primary lesion is a pustule with a deeply violaceous rim. The central area becomes necrotic forming a deep ulcer, with a broad violaceous rim and an overhanging edge. The lesion is very tender and expands peripherally. 
    • Pyoderma gangrenosum is seen in patients with [AI 92] 
    • Ulcerative colitis, [TN 97] 
    • Crohn's disease,
    • Collagen vascular disease,  and
    • Sweet's syndrome. 
  67. What is Burow's solution?
    Burow's solution is a solution of aluminium acetate and is used in dermatology in drying agent for weeping skin lesions.
  68. 'Liver' spots are signs of 
    A) Senility
    B) Hepatoma 
    C) Echinococcus 
    D) Cirrhosis 
    A) Senility

    In Lentigo senilis; flat, brown spots appear on the exposed skin of aged white people. Although these spots are commonly known as 'liver' spots, they are not  related to liver disease. Also k/a sun-spots, age-spots.
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    (this multiple choice question has been scrambled)
  69. Name important sexually transmitted pathogens. [JIPMER 00, AIIMS 00, AI 93,UP 94]
    Bacteria - Neisseria gonorrhoeae, Treponema pallidum , Hemophilus ducreyi, Mycoplasma hominis, Calymmatobacterium granulomatis, Chlamydia trochomatis, Group B Streptococcus, 

    Viruses - HIV, Hepatitis B, Cytomegalovirus, HSV 2, Human papilloma virus, Molluscum contagiosum virus,  Herpes simplex

    Protozoan -  Trichomonas vaginallis, Giardia lamblia, Entamoeba histolytica, 

    Fungal - Candida albicans 

    Ectoparasites - Phthirus pubis, Sarcoptes scabei
  70. What are the various causes of STD with painful and painless ulcers?
    • Painful - 
    • Chancroid [CUPGME 03]
    • Herpes Genitalis

    • Painless 
    • Granuloma Inguinale (also k/a Donovanosis) 
    • Syphilis
    • Eruption secondary to drugs
    • Lymphogranuloma venereum

    [@ CHISEL

    STDs with ulcer are cofactor for HIV because, it increases the chance for HIV transmission.
  71. What  is the cause  STD without ulcer?
    • Chlamydia,
    • HPV
    • Gonorrhea 
    • HBV, 
    • HIV
    • Trichomoniasis
  72. How do you characteristics of various ulcers in STD?
    • Chancroid: Ragged soft edge (irregular edge), painful
    • Chancre:smooth round rolled hard edge, painless
    • Herpes: smooth edge, painful
    • Granuloma inguinale: beefy red color because of  presence of capillaries in granulation tissues. 
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  73. What is bubo and pseudobubo?
    • A bubo is the swelling of the lymph nodes. It is found in infections such as bubonic plague, gonorrhea, tuberculosis, LGV,  chancroid or syphilis.  
    • PseuDObubo  is found in DOnovanosis. [AI 96]   There is diffuse intradermal and subcutaneous swelling or suppuration and  involvement of underlying lymph nodes in minimal.
  74. Lymphadenphathy is not seen in [UP 94, AI 95]
    A) Primary syphillis
    B) LGV
    C) Donovanosis
    D) Chancroid 
    C) Donovanosis
    (this multiple choice question has been scrambled)
  75. What  is the causative organism for Chancroid/soft chancre/simple chancre?
    • Hemophilus ducrey.  [AI 99,BHU 02,UP 01,95]
    • [@ In du-crey-i, you do cry, because it is painful]

    There is considerable evidence to suggest that all chancroid ulcers are not caused by H. ducreyi. Other organisms isolated from the ulcer include Herpes virus Hominis, [AI 99] Corynebacterium species, Staph epidermidis etc.
  76. How do you diagnose chancroid?
    Culture of H. ducreyi from the lesion.
  77. How do you manage a case of chancroid?
    • The CDC recommendation for chancroid is a single oral dose (1 gram) of Azithromycin, or a single IM dose of Ceftriaxone.
    • Trimethoprim-sulfamethoxazole, one double strength tablet twice daily for 7 days is used where resistant strains are not prevelant.
  78. What are the important features of Lymphogranuloma venerum?
    • Caused by Chlamydia trochomatis L1-3. [AIIMS 99, UP 94] 
    • The most characteristic feature of the disease is inguinal lymphadenopathy, starting 2-6 weeks after presumed exposure. These enlarged glands are called as bubos
    • This is most commonly unilateral and more in males. 
    • The nodes get attached to overlying skin and to deeper tissue. Suppuration occurs in the nodes with formation of multiple abscess which may rupture producing multiple discharging sinuses. [AI 94] 
    • Extensive involvement of chains of lymph nodes, above and below the inguinal ligament - sign of groove. [AIIMS 99] 

    • Late complications of LGV include
    • - Genital elephantiasis [AI 02] due to lymphatic involvement,
    • - Esthiomene - Vaginal and rectal stricture

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  79. How do you diagnose and manage LGV?
    • Diagnosis is made by Frei intradermal test, [AI 96,93] by complement fixation test or by recovery of chlamydiae from the blood, feces or buboes. 
    • Treatment - Doxycycline [KERELA 90]  for one weeks for uncomplicated genital infection, two weeks for complicated genital infections, and three weeks course for lymphogranuloma venerum.

    [@ ABCDEFG - Asymptomatic lesion, Bubo, Chlamydia trochamatis is causative agent, Doxycycline is DOC, Estheiomine, Frei's test, Groove's sign]
  80. What is the causative organism of Donovanosis/Granuloma inguinale? [AI 97,AIIMS 04, RAJASTHAN 01]
    Calymmatobacterium granulomatis - now called as Klebsiella granulomatis.

    • The organism is pleomorphic, intracellular , gram-negative bacillus surrounded by a well-defined  capsule . The capsule stains as a sense acidophilic zone surrounding the bacterium which resembles a closed 'safety pin' [AI 92]   due to bipolar condensation of chromatin.
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  81. Where do you find the DONOVAN bodies? [JIPMER 00, KERELA 99]
    • In  Granuloma inguinale. The Donovan bodies are present within the lymphocytes. 
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  82. How do you treat a case of granuloma inguinale?
    Drugs effective in treatment of donovanosis are trimethoprim-sulfamethoxazole, tetracycline, erythromycin, newer quinolones and chloramphenicol.

    Streptomycin once commonly used for this condition, is not widely used now a days. 
  83. What are the typical lesions in Primary and secondary syphilis?
    • Primary – Chancre (localized) 
    • Secondary - Condyloma lata [AIIMS  99,UP 00] [systemic]
  84. What is the course of Syphillis? What is the fate if the primary syphilis is not treated?
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  85. What is the characteristic of lesion of primary syphillis? [AIIMS 01]
    • The lesion of primary syphillis is called as Chancre. 
    • Chancre begins as single painless papule that rapidly becomes eroded and usually becomes indurated, with a characteristic cartilaginous consistency on palpation of edge and base of ulcer. 
    • Location -In males, the ulcer is located in  penis in heterosexuals, anal canal, rectum, mouth in homosexuals. In females, located in cervix and labia. 
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    Regional lymphadenopathy within a week of onset of lesion, the nodes being firm, nonsuppurative, and painless. Inguinal lymphadenopathy is bilateral.
  86. What are the characteristic of skin manifestation of secondary syphillis?
    • The skin rash consists of macular, papular, papulosquamous and occasionally pustular syphillides, often more than 1 form is present at the same time. 
    • The rash is usually asymptomatic [AI 91,UP 96] - about 25% of patients with a discernible rash of secondary syphillis may be unaware that they have dermatologic manifestations. 
    • Initial lesions are bilaterally symmetrical, pale red or pink, non-pruritic, round macules.
    • Motheaten alopecia is seen. [KARNATAKA 99] 
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    • Note that, vesicular lesion is the feature of congenital syphillis. [PGI 99, JIPMER 01, AI 94]
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  87. A young man presents to the emergency department with a maculopapular rash 2 weeks after healing of a painless genital ulcer. The most likely etiological agent is: [AI 11]
    A. Chlamydia trachomatis
    B. Calymmatobacter granulomatis
    C. Treponema pallidum
    D. Treponema pertunae
    C. Treponema pallidum

    Development of a maculopapular rash two weeks after having a painless genital ulcer suggests a diagnosis of secondary syphilis (T. pallidum).
    (this multiple choice question has been scrambled)
  88. What are the manifestations of Tertiary syphilis?
    • Cardiovascular syphilis –  Aortic aneurysm. 
    • Neurosyphillis – Meningovascular, general paralysis of insane,   Tabes dorsalis,  Argyll Robertson pupil.  

    General paresis of insane and tabes dorsalis usually appear 5-15 years after primary syphillis.
  89. What are the features of cardiovascular syphilis?
    • Uncomplicated aortitis
    • Coronary ostial stenosis
    • Aortic regurgitation 
    • Calcification of ascending aorta
    • Saccular aneurysm
    • Tree bark appearence of aorta
  90. Which part of the aorta do the syphilis affect?
    • Ascending aorta [JIPMER 95] and sometimes the  root of aorta to cause aortic regurgitation.
    • Extreme aortic regurgitaion of the aorta causes the heart to enlarge leading to cor bovinum (large heart like a cow).
  91. The chance of isolating viable spirochetes are least in [JIPMER 02]
    A) Condyloma 
    B) Chancre
    C) Rash 
    D) Gumma
    D) Gumma

    Diagnosis by microscopy is applicable in primary and secondary stages of syphillis and in cases of congenital syphillis in superficial lesions. Tertiary lesions contain few spirochetes and may represent manifestations of delayed hypersensitivity.
    (this multiple choice question has been scrambled)
  92. What are the various tests for diagnosing syphilis? [AIIMS 98, UP 00]
    • Non-treponemal (reagin) tests
    • - VDRL test 
    • - RPR test

    • Treponemal tests
    • - FTA-ABS test,
    • - TPHA test,
    • - MHA-TP test.
    • T. pallidum immobilization (TPI)  test - most specific treponemal test. [CUPGME 03,IOM 09,10]
  93. Primary syphillis is best diagnosed by [IOM 12]
    A) Wet mount 
    B) TPPA
    C) VDRL 
    D) TPHA
    B) TPPA

    The microhemagglutination assay for T. pallidum (MHA-TP) has been replaced by Treponema Pallidum Particle Aggglutination test (TP-PA test), which is more sensitive for primary syphillis.
    (this multiple choice question has been scrambled)
  94. What is the difference in lab parameters in primary and secondary syphilis?
    • Features:                 Primary     /   Secondary
    • VDRL:                     -ve         /      +ve
    • Darkfield microscopy:+ve      /      +ve
    • FTA-ABS:               +ve        /      +ve
  95. What is Wasserman reaction?
    Classical example of complement fixation test [UP 93] is Wasserman reaction, used for serodiagnosis of syphillis.
  96. Which lab parameters are used to monitor efficacy of treatment in syphillis?
    VDRL [AI 91] and RPR test are used to assess the clinical activity of syphillis or to monitor the response of therapy.
  97. Maximum specificity in VDRL test is seen in case of
    A) Tertiary syphillis 
    B) Primary syphillis 
    C) GPI
    D) Secondary syphillis 
    D) Secondary syphillis
    (this multiple choice question has been scrambled)
  98. Which of the following is false regarding syphillis [AIIMS 91]
    A) IgM test is specific for congenital syphillis. 
    B) VDRL is nonspecific 
    C) VDRL is negative in secondary syphillis.
    D) TPI is most specific 
    C) VDRL is negative in secondary syphillis
    (this multiple choice question has been scrambled)
  99. What are the conditions associated with false positive VDRL test?  [KERELA 94]
    • Leprosy [AI 00] 
    • Malaria 
    • SLE 
    • Rheumatoid arthritis 
    • Menstruation 
    • Pregnancy 
    • Repeated  blood loss
  100. What  is the treatment for syphilis?
    Primary and secondary  syphilis – Intramuscular benzathine penicillin [AI 93,IOM 01] 2.4million units/week. Primary receives 1 week, and secondary 3 weeks of IM therapy.

    • Tertiary syphilis  – IV  Penicillin 10-20 million units/day for 10 days.
  101. What is the treatment  for syphilis in penicillin allergic patients?
    • Primary and secondary syphilis - Doxycycline. 
    • Tertiary syphilis, pregnant patients – Must be desensitized and penicillin is given after desensitization.
  102. Which drug is used in syphilis in pregnancy? [AI 12]
    • Benzathine penicillin.
    • Serology titres should decrease 4 folds after 3-6 months. Even if the patient is allergic, we give penicillin G after oral desensitization.
  103. Name the diseases caused by nonveneral treponemes? [KARNATAKA 00]
    • Endemic syphilis or Bejel - caused by Treponema pallidum spp. endemicum. 
    • Yaws - caused by Treponema pallidum spp. pertenue
    • Pinta - caused by Treponema pallidum spp. carateum. [JIPMER 01]
  104. What are the important features of Yaws? [AI 08,11]
    • Yaws are endemic, non veneral, treponemal disease caused by Treponema pertenue
    • Yaws is not transmitted by sexual or transplacental route. It is transmitted by direct contact with an infectious lesion. 
    • Secondary Yaws can involve bone. Periostitis may result in nocturnal bone pain and polydactylitis. 
    • Late stages of it is characterized by destruction of gummas of skin, bone and cartilage. There is no heart or nerve involvement. 
    • Yaws may show cross immunity with syphillis.
    • Yaws cannot be serologically differentiated from syphillis (Treponema pallidum).
  105. Which organism is mostly responsible for creating adhesions?
    • Chlamydia –  
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  106. What  is the DOC for Chlamydia?
    Doxycycline. [MANIPAL 02] One week course for uncomplicated genital infections, and two weeks course for complicated Chlamydial infections. 

    Single dose of  Azithromycin  1 gm is preferred these days.
  107. What is the DOC for Chlamydia in pregnancy?
    • First choice - Azithromycin [AI 10] or amoxycillin 
    • Alternatice choice - Erythromycin
  108. The drug of choice to treat Chlamydia infection in pregnancy is [AI 10]
    A) Tetracycline
    B) Penicillin
    C) Erythromycin 
    D) Doxycycline
    C) Erythromycin

    The currently recommended regimen during pregnancy is Azithromycin or Amoxycillin, with erythromycin a third choice. Since, azithromycin and amoxycillin are not provided, the best choice is erythromycin.
    (this multiple choice question has been scrambled)
  109. What was the  most common disease prior to invention of antibiotics?
    Gonorrhea  -  in 1900 in NYC, 80% of male adults had Gonococcus and 20% had syphilis.
  110. What are the various  organs of  the body where Gonococcus can act?
    • Lower reproductive tract -  Bartholin abscess 
    • Upper reproductive tract – PID 
    • Disseminineted disease – joint to cause septic arthritis, 
    • Ophthalmic gonorrhea
  111. Gonococcus is not involved in [AI 98]
    A) Ovary
    B) Cervix 
    C) testis 
    D) fallopian tube
    C) testis
    (this multiple choice question has been scrambled)
  112. What is the most important feature of Gonorrhea?
    Purulent discharge per urethra.
  113. What is the most common site of Postgonorrheal stricture?
    The most common site of postgonorrheal stricture is the bulbar urethra. [UP 97]  The next two common sites are penoscrotal junction and distal part of spongy urethra in that order. The membranous urethra and prostatic parts of urethra are exempt from this condition.
  114. 7 year old girl has vulvovaginits. Gram stain of the discharge shows intracellular gram negative diplococcic. What further investigation should be initiated?
    Sexual abuse
  115. How do you treat gonorrhea?
    A single dose of any  of the 4 most effective drugs for gonorrhea i.e ceftriaxone, cefixime, ciprofloxacin, or ofloxacin  + 7-day course of doxycycline (for potential coinfection with chlamydiae ).
  116. What are the important features of molluscum contagiosum?
    • - Caused by Pox virus. 
    • - Characterized by pearly, flesh colored, umbilicated skin lesions. [AIIMS 99] 
    • - Transmitted by close contact including sexual intercourse
    • - The condition is usually self limiting.

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Card Set:
Dermatology 2
2015-07-22 15:41:20
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