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Board Review Corner Skin Disorders: The Skin Also Rises Atopic and Contact Dermatitis, Urticaria and Angioedema, by Mark Boguniewicz, M.D. 1. A 62-year-old male is sent to you for consultation of an eczematous rash on his chest. He reports that the rash has been present for approximately eight years. It is quite pruritic leading to incessant scratching that has resulted in secondary infections a number of times. He has been treated with topical corticosteroids as well as oral antibiotics with only partial improvement. His past history is negative for childhood eczema, asthma or allergies. He is otherwise in good health. On physical examination, he has a large indurated plaque on the lateral aspect of his trunk with excoriations, but no pustules or vesicles. No other cutaneous lesions except for a few pigmented nevi. His toenails are dystrophic, but otherwise, his nails show no pitting. He has no lymphadenopathy. The remainder of the exam is unremarkable. The most appropriate step in the management of this patient would be: A. Patch test the patient. B. Start the patient on prednisone 60 mg for 10 days, followed by a gradual taper. C. Biopsy the skin lesion. D. Prescribe a sedating antihistamine. E. Obtain a scraping for fungal culture. 2. A 23-month-old male presents with an eczematous rash that has been present since approximately six months of age. Despite treatment with a topical steroid, he continues to have red, indurated lesions on his face and all four extremities. He is constantly scratching, often waking up with bloody sheets. He was breast fed for almost six months and currently is on a non-restricted age-appropriate diet. His mother suspects strawberries and chocolate as triggers and brings him to you for evaluation of food allergies. Appropriate advice regarding this child’s atopic dermatitis and food allergies would be: A. Food allergy has no relationship to this child’s eczema. B. Serum RAST to foods including strawberry and chocolate would be the most sensitive test to evaluate for allergies. C. Selected prick tests to several common food allergens could be done. D. The child should be put on a restricted diet of rice, turkey, sweet potato and applesauce. 3. A 28-year-old female presents for evaluation of severe atopic dermatitis. She has had an eczematous rash since infancy that got better during early adolescence, but recurred during her college years. On exam, she has lichenified lesions on her eyelids, neck, as well as the flexural aspects of her extremities. Which of the following statements would be true with respect to this patient? A. The predominant T cell-derived cytokine from an acute lesion would be IFN-~ B. A positive prick skin test to egg protein would be definitive for food allergy-induced atopic dermatitis. C. A skin culture from an uninvolved area of skin would grow toxin-secreting S. aureus. D. Serum eosinophil cationic protein and major basic protein levels would be low. 4. A 38-year-old female presents for evaluation of chronic hives. She has had recurrent hives along with occasional periocular angioedema for the past 3 months that are extremely itchy, often cause her to have swelling of hands or feet and tend to last for several hours. Extensive review does not suggest any specific physical, allergen, medication or other trigger. Review of systems is unremarkable. Examination reveals several raised, blanching erythematous lesions on the trunk and legs. The true statement regarding this patient is: A. Patient’s serum complement 4 level will be low. B. Patient’s lesions are likely associated with a hidden allergen in her diet. C. Patient may have histamine-releasing IgG antibodies directed against the alpha chain of the high affinity IgE receptor on mast cells and basophils. D. Patient has an autosomal dominant disease. 5. A 43-year-old female presents with an 18-month history of chronic periocular dermatitis. She describes her rash as extremely itchy with red, scaling lesions and occasional oozing that is worse in the winter months, but is present all year. She has been using an over-the-counter topical steroid. She has a history of seasonal allergic rhinitis. On examination, she has eczematous lesions with induration of the upper and lower eyelids and injected conjunctivae. The most appropriate recommendation would be: A. Prescribe steroid eye drops. B. Prescribe a more potent topical steroid for 14 days, then resume the low potency steroid. C. Have the patient try an antifungal cream in the a.m. and a topical nonsteroidal cream in the p.m. D. Patch testing. Answers: 1. C 2. C 3. C 4. C 5. D |
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