Advanced dermatology jeopardy orientation for family medicine residents (with gameshow in other slides) Identify the most common lesions seen in primary care practice Identify the 4S’s: Serious Skin Signs in Sick Patients Apply metacognitive principles to dermatologic diagnosis System I pattern recognition System II hypothetical-deductive reasoning

1. Choose a category.
You will be given the answer.
You must give the correct
question. Click to begin.

2. Click here for
Final Jeopardy

3. Do Not Miss
I Read You
(Like Braille)
Potent
Potables
10 Point
20 Points
30 Points
40 Points
50 Points
Seeing Red
10 Point 10 Point 10 Point 10 Point
20 Points 20 Points 20 Points 20 Points
30 Points
40 Points
50 Points
30 Points 30 Points 30 Points
40 Points 40 Points 40 Points
50 Points 50 Points 50 Points
Cancer?
I Can, Sir!

4. Most common acquired new growths in
Caucasians (adults averaging about 20)

5. What are common moles
(nevomelanocytic nevi)?
Board
• Very common, small (1 cm), circumscribed, acquired
pigmented macules, papules, or nodules
• Composed of groups of melanocytic nevus cells
located in the epidermis, dermis, and, rarely,
subcutaneous tissue
• benign, acquired tumors arising as nevus cell clusters
at:
• the dermal-epidermal junction (junctional NMN)
• invading the papillary dermis (compound NMN)
• and ending their life cycle as dermal NMN with
nevus cells located exclusively in the dermis
where, with progressive age, there will be
fibrosis.

6. These two lesions can be mistaken for each
other, one is cancerous, the other is benign.

7. Board
What is a key distinguishing
factor between:
Keratoacanthoma Dermatofibroma
• formerly considered a
pseudocancer, it is now regarded as
a variant of SCC
• Relatively common, rapidly
growing epithelial tumor w/
potential for destruction and
metastasis; however, in most cases
spontaneous regression
• A dome-shaped nodule with central
keratotic plug
• Treatment is by excision
• very common, button-like dermal
nodule
• usually on the extremities as a
result of an insect bite
• possibly a histiocytic reaction
• Significant only because of its
cosmetic appearance or its being
mistaken for other lesions, such as
malignant melanoma when it is
pigmented
• (+) “Dimple sign”

8. These are three underlying lesions seen
after biopsy of a cutaneous horn.

9. What lesion should be biopsied
due to potential risk of invasive
SCC/BCC?
Board
• >50% of lesions have a benign base, but…
• Hypertrophic (solar) actinic keratosis
• SCCIS (Bowen's)
• invasive SCC
• BCC
• SCC
• SK
• Wart
• many others have been reported

10. This lesion was initially misdiagnosed as
eczema, psoriasis, and dermatophytosis
(on the Checklist)
Patches/plaques stage:
randomly distributed, well-and/
or ill defined patches
and plaques; may be scaly
and appear in various shades
of red.
Plaque and early
nodular stage: reddish-brownish
scaly, and
crusted plaques and flat
nodules.
Tumor stage:
Scaly and crusted
eczema-like plaques turn
nodular or ulcerate.

11. What the heck is Mycosis fungoides?
Board
• Most common cutaneous lymphoma (T cell)
• Arises in mid-late adulthood with 2:1 male
predominance
• Related features are pruritus, may be
intractable; alopecia, palmoplantar
hyperkeratosis, and bacterial infections
• Categorized as patch, plaque, or tumor stage
• Extensive infiltration can
cause leonine facies
• Confluence may lead to
erythroderma

12. These two LR statistics describe
the likelihood of the following
lesions being cancerous:

13. What do lesions at risk for melanoma look like if the
A) ABCDE = 0 (LR+ 0.07) (NPV 0.9%)
B) ABCDE = 5 (LR+ 98 to 107) (PPV 92.2%)
Board
Simel, David; Drummond Rennie (2008-08-25). THE
RATIONAL CLINICAL EXAMINATION : EVIDENCE-BASED
CLINICAL DIAGNOSIS (Jama & Archives Journals)
(p. 482). McGraw-Hill. Kindle Edition.
ABCDE
(JAMA)
Multivariate
Findings for
Melanoma [LR(+)]
5 positive 98
>/= 4 8.3
>3 3.3
>2 2.6
>1 1.5
0 0.07
ABCDE
(EE+)
Multivariate
Findings for
Melanoma [LR(+)]
5 positive 107
>/= 4 8.3
>3 3.3
>2 2.6
>1 1.5
EE+: Pigmented Lesion -> Melanoma
https://www.essentialevidenceplus.com/conte
nt/hpcalc/testsum.cfm?sx=106&testtype=H

14. This procedure is helpful in diagnosing
many conditions, particularly in the
distinction of benign and malignant
growth patterns in pigmented lesions.
.

15. What is the purpose of
Dermoscopy/Dermatoscopy?
(epiluminescence microscopy)
Board

16. The 4 “Ps” of Lichen Planus

17. What is characterized by purple,
polygonal, pruritic papules?
Board
polygonal
• In the mouth milky-white
reticulated
papules; may
become erosive and
even ulcerate.
• Main symptom:
pruritus; in the
mouth, pain.
• Therapy: sx, not
curative. Acitretin
(C), glucocorticoid
use (I).

18. The presenting complaints for this
patient with palpable purpura

19. What is Henoch-Schonlein purpura?
bowel angina, bowel ischemia with
bloody diarrhea, hematuria and red
cell casts, and arthritis.
Board

20. This is the test used to diagnose
the following multisytem disease
Seen in patients who are neglected children, alcoholic, homeless,
etc., with bleeding gums and loose teeth.

21. When would I check a
Vitamin C level?
Board
• Scurvy is an acute or chronic disease of infancy and of middle/old age
• Humans are unable to synthesize ascorbic acid and require it as an
essential dietary vitamin. Deficiency of vitamin C leads to reduction in
collagen formation with associated capillary fragility
• Precipitating factors: Pregnancy, lactation, and thyrotoxicosis when there
are increased requirements of ascorbic acid; most common in alcoholism.
• With no vitamin C intake, symptoms of scurvy occur after 1–3 months.
• Lassitude, weakness, arthralgia, and myalgia.

22. Three items in the workup for
this patient
CRASH and Burn:
Conjunctivitis
Rash
Arthritis
Strawberry tongue
Hands (skin peeling)
and Burn: fever >5 days

23. What is the mnemonic for Kawasaki’s disease?
1. Chem: LFTs
2. Heme: WBC>18K, Plt
high, ESR elevated
3. UA: Pyuria
4. EKG: PR & QT
prolongation, ST and T
wave changes
5. Echo: Coronary aneurysm
(20% of cases)
MANAGEMENT
• Hospitalize and monitor for cardiac and
Board
vascular complications
• IVIG 2 g/kg over 10 h
• Aspirin 100 mg/kg per day until fever
resolves or until day 14 of illness,
followed by 5 to 10 mg/kg per day until
ESR and platelet count have returned to
normal
• Glucocorticoids Contraindicated
Associated with a higher rate of
coronary aneurysms.

24. The description, stage and treatment
of Acne vulgaris shown below.

25. What does stage II acne
(inflammatory acne,
papules and pustules) look like?
Board
Comedones Only
For this treatment, topical retinoids are the
mainstay of treatment. Choices include
tretinoin, adapalene, and tazarotene
Moderate to Severe Inflammatory Acne
Oral antibiotics including the tetracyclines
(minocycline, doxycycline, tetracycline) are
the first-line choices
Inflammatory Acne (Papules and Pustules),
Mild to Moderate Severity
Topical antibiotics are the treatment of choice for these
patients. Choices include benzoyl peroxide, azelaic acid,
clindamycin, erythromycin, and dual agents combining
benzoyl peroxide with either erythromycin or
clindamycin
Severe Papulonodular Acne
Oral isotretinoin is indicated for severe papulonodular
acne

26. The rash below with “tear-drops of silver
scale” which can follow strep infections.

27. What is Guttate Psoriasis?
Board
Multiple small scaly plaques with adherent silver
scale that tend to affect most of the body. Usually
the trunk, upper arms and thighs
The diagnosis of guttate psoriasis is made by the
combination of history, clinical appearance of the
rash, and evidence for preceding infection.
The rash comes on very quickly, usually within a
couple of days, and may follow a streptococcal
infection of the throat. It tends to
affect children and young adults and has a good
chance of spontaneously clearing completely
‘Gutta’ is Latin for
tear drop; guttate
psoriasis looks like
a shower of red,
scaly tear drops that
have fallen down on
the body

28. When erythema and warmth are
present, this is the key factor that
helps distinguish this condition
from cellulitis.

29. What is the importance of
marking the border of stasis
Board
dermatitis?
Ddx
cellulitis: redness,
swelling, pain, fever,
a red streak up the
leg and swollen
nodes in the groin
Treatment: Topical glucocorticoids
(short term). Topical antibiotic
treatments (e.g., mupirocin) when
secondarily infected. Culture for
methicillin-resistant
Staphylococcus aureus (MRSA).

30. Four potential complications of a
patient with the following progression
of lesions.

31. Board
What does the following
mnemonic help us recall?
Bell’s Palsy
Arthritis
Kardiac arrhythmia
Encephalopathy
a key Lyme Pie

32. 3 Key Features that
Differentiate
Irritant Contact Dermatitis (80%)
from
Allergic Contact Dermatitis (20%)

33. Board

34. This condition is often
seen in the summertime.

35. What is miliaria?
Board
• Miliaria crystallina
• caused by obstruction of the sweat ducts close to the
surface of the skin
• appears as tiny superficial clear blisters that break easily.
• Miliaria rubra (prickly heat)
• occurs deeper in the epidermis
• results in very itchy red papules
• Miliaria profunda
• results from sweat leaking into the dermis
• Miliaria pustulosa
• pustules due to inflammation and bacterial infectio

36. Two severe
complications to
monitor for if there is
an outbreak of this
condition in the
trigeminal nerve

37. What is herpes zoster
ophthalmicus and Ramsay
Hunt Syndrome?
Board

38. The treatment for these coin
shaped lesions, common in the
wintertime

39. When do you use emollients and moderate-high potency
corticosteroids?
Board
Nummular eczema
chronic, pruritic, inflammatory
dermatitis occurring in the form
of coin-shaped plaques
(nummularis in latin: “like a
coin”) composed of grouped
small papules and vesicles on
an erythematous base.
1. Emollients
2. Moderate-to-high
potency corticosteroids
1. Clobetasol
propionate 0.05% (I;
$12-14/15g)
2. Fluocinonide 0.05%
(II; $18/15g)
3. Triamcinolone 0.5%
DDx: Atopic dermatitis, contact (III; $13/15g)
dermatitis, psoriasis, tinea corporis.

40. This lesion gradually goes
away over this time period.

41. What is a hemangioma of
infancy?
Board
• Proliferative phase: 3 to 9 months, enlarging
rapidly during the first year
• Involution phase: the HI regresses, gradually
over 2 to 6 years and is usually complete by
the age of 10
• Involution varies greatly between
individuals and is not correlated with size,
location, or appearance of the lesion.
• 80% of the time, there is no skin change.

42. Under Wood’s Lamp
light, this lesion
appears coral red.

43. Board
What device can diagnose these conditions?
Dark
Freckles and melasma (Circumscribed hypermelanosis)
are more evident (darker)
Benign Blue Spot (Mongolian sacral spot, dermal melanin)
does not become accentuated
Light
Vitiligo has exaggerated areas of whiteness
Tuberous sclerosis and tinea versicolor are hypomelanotic
(and duller areas of whiteness)
Colors
Dermatophytosis with Microsporum canis in the
hair shaft (green to yellow)
Pityriasis versicolor (Yellow fluorescence)
Pseudomonas abscesses (pale blue)
Intertrigo erythrasma with Corynebacterium
minutissiumum (coral pink-red)
Other
Porphyria (pinkish-red urine; addition of dilute HCl intensifies
the fluorescence)
Corneal abrasions & dendrites with application of fluorescein
(although cobalt blue light and slit lamp are ideal)
http://www.pcds.org.uk/p/skin-disease-examination
Wolff, Klaus (2009-02-19). Fitzpatrick's Color Atlas and Synopsis of Clinical
Dermatology : Sixth Edition (Fitzpatrick's Color Atlas & Synopsis of Clinical
Dermatology) (Kindle Locations 845-874). McGraw-Hill. Kindle Edition.

44. This combination
antifungal/corticosteroid
is expensive, uses a
high-potency steroid and
should never be ordered.

45. Why does Lotrisone
(Betamethasone/Clotrimazole)
have a bad reputation?
Board
Betamethasone costs $23 for 15g
Clotrimazole costs $18 for 15 g
Lotrisone costs $53 for 15g

46. Daily Double!
First Line Treatment for this condition

47. When would I treat with topical
CS and a vitamin D analogue or a
retinoid?
Board
Clobetasol 0.05% $12-14/15g (NNT = 2)
Fluticasone propionate ointment 0.005% safe on face/groin $17/15g
Calcipotriene (vitamin D agent) 0.005% ~$340/60? (NNT vs placebo = 2)
Tazarotene (retinoid) ?$? (NNT vs placebo = 6)

48. This patient used this alternative to
nitrogen freezing to avoid
hypopigmentation.

49. When are second-line agents like
imiquimod or topical 5-FU (Carac)
appropriate for actinic keratoses?
Board
• Cryotherapy with liquid nitrogen is effective and cheap).
• Imiquimod [B] (usually causes strong local irritation)
• 3% diclofenac gel [B] needs prolonged use >3 months before
more permanent treatment results can be expected.
• 5-FU is most effective therapy for actinic keratosis, but less well
tolerated and more costly {LOE1a}
AK stats
Risk of progression:
0% to 0.5% per
lesion
Rate of regression
15% to 63% per
lesion
Rate of recurrence:
15% to 53%.
12 packets of imiquimod (Aldara) cost $170
compared with $730 for a 30 g tube of 5-FU cream

50. These different patterns of toe
infections require different
approaches for treatment

51. What is the difference between:
Distal and Lateral Subungual Onychomycosis
Superficial White Onychomycosis
Proximal Subungual Onychomycosis
• Debridement: weekly, in DLSO, nailbed should be removed; in SWO, it can be
Board
debrided with a curette
• Topical lacquer: Ciclopirox (Penlac, $42) typically only effective for SWO
• Systemic agents:
• Terbinafine (250mg/d x6 wk for fingers, 12-16 wk for toes), $6.50/
• Itraconazole 200mg/day x6wk for fingers (for dermatophytes/candida only),
$16.50/

52. What are the Top Ten offending
agents that can cause these conditions?

53. Medications most commonly implicated in Stevens-
Johnson syndrome or toxic epidermal necrolysis.
Medications Odds Ratio
Sulfonamide antibiotics (Bactrim) 172
Carbamazepine (Tegretol) 90
Corticosteroids 54
Phenytoin (Dilantin) 53
Allopurinol 52
Phenobarbital 45
Valproic acid (Depakene) 25
Cephalosporins 14
Piroxicam (Feldene) 12
Quinolones 10
Aminopenicillins 6.7
Board
Antibiotics
Allopurinol
Anti-convulsants
Corticosteroids
NSAID (oxicam)

54. Make your wager

55. These are the
lesions that can be
readily identified
through
dermoscopy

56. Board
Benign melanocytic lesions:
Congenital melanocytic naevi,
Lentigines - lentigo simplex; solar lentigo; ink-spot lentigo
Benign melanocytic naevi (common moles)
Blue naevi; Spitz naevi; Atypical melanocytic naevi