NMS Q&A Family Medicine

Dermatology 31114. The answer is D. Dark-skinned people, be they ofAfrican, Southeast Asian, or other ethnic origin, manifest,as a result of the subacute phase of an inflammatory process,a muddy-looking hyperpigmentation locally. Inflammationthat lasts much longer causes the opposite, that is,a loss of pigmentation. Both conditions will reverse aftersubsidence of the inflammatory process. Hyperpigmentationwill reverse itself sooner than hypopigmentation.15. The answer is E. Acanthosis nigricans. This patientprobably has PCOS and thus stands a strong chance ofbeing insulin resistant, hence prediabetic type 2 or clinicallydiabetic. Acanthosis nigricans accompanies suchconditions in a minority but significant proportion ofcases. The pigmentation of Addison disease tends toinvolve the creases of the palms, soles, axillae (as opposedto the concavities), extensor joint surfaces, tongue, nails,and belt or bra lines. Seborrheic keratoses may be pigmented,but they occur as “stuck on” 1-cm 2 lesions on theopen areas of the skin. Nummular eczema is pruritic andpigmented only in dark-skinned people. Epidermoid cystsare not noted for dark coloration except at the punctum,where the sebaceous comedone is found.16. The answer is A. PCOS is associated with irregularmenses, obesity, hirsutism, and insulin resistance. Acanthosisnigricans is connected with the insulin resistance oftype 2 diabetes, both type A (PCO) and type B (autoimmune).Addison disease does not fit the pattern of pigmentation(see discussion of Question 12). Thyroiddiseases have no particular association with pigmentabnormalities in humans. Pregnancy often manifests the“mask of pregnancy,” involving the face. In the age groupof the 40s and 50s, acanthosis nigricans is associated alsowith the following cancers: non-small cell lung, breast,gastrointestinal, prostate, and myeloproliferative diseaseas well as carcinoid.17. The answer is B. Dermatomyositis in its classic presentationinvolves the purple discoloration of the eyelidsand periorbital edema (“heliotrope eyes”) and proximalmuscle weakness. In 10% of patients, the rash precedesmyositis by up to 2 years. Lupus erythematosus causes aclassic facial rash (seldom seen in primary care practice);polymyositis is generally assumed to be dermatomyositiswithout dermatitis. Charcot–Marie–Tooth disease is ademyelinating disease of the central nervous systeminvolving the distal extremities, leading to the stork-legdeformity. Contact dermatitis seldom occurs on the faceexcept in reaction to cosmetics and virtually always ispruritic.18. The answer is D. Herpes zoster (HZ, “shingles”) ischaracterized by a searing superficial type pain associatedwith a varicelliform vesicular rash. The vesicles occur onan erythematous background. The rash occurs simultaneouslyor within 2 to 3 days after the onset of the pain andlast about 10 days through phases of subsequent crusting,dark colored eschar, and resolution, sometimes with scarformation. Shingles is seldom confused with HS becausethe vesicles of HS are distributed within an area of only afew centimeters, whereas HZ usually covers the majorityof a complete dermatome or as this case, a cranial nerve,that is, the ophthalmic branch of cranial n. V. Dermatitisherpetiformis, contact dermatitis, and eczema are all pruriticwhile HZ is not, unless late in the healing phase.There is a close correlation, when the ophthalmic branchof the trigeminal nerve is involved in herpes zoster,between involvement of the tip of the nose and involvementof the cornea.ReferencesFitzgerald PA . Endocrinology . In: Tierney LM , McPhee SJ ,Papadakis MA , eds. Current Medical Diagnosis and Treatment. 43rd ed . New York : McGraw-Hill/Appleton & Lange ;2004 : 1062 – 1145 .Fitzpatrick TB , Eisen AZ , Wolff L , Freedberg IM , Austen KF , eds.Dermatology in General Medicine . 3rd ed . New York/St. Louis/San Francisco: McGraw-Hill; 1971 .Habif TP. Clinical Dermatology . St. Louis : Mosby ; 2004 .Jemal A , Tiwari RC , Murray T , et al. Cancer statistics 2004 . CACancer J Clin. 2004 ; 54 : 8 – 29 .McPhee SJ , Papadakis MA . Current Medical Diagnosis and Treatment. 49th ed . New York/Chicago : Lange, McGraw-Hill ;2010 .Schwayder T . Common skin problems in children . Patient Care.2004 ; July:32 –36.U.S. Preventive Services Task Force . Recommendations andrationale . Am Fam Physician. 1996 ; 69 : 903 – 904 .