CME Examination Dermatology

To claim CME credit, complete this case-based posttest online at http://www.aad.org/olc.
Note: CME
quizzes are available after the first of the month in which the article is published. A minimum score of
70% must be achieved to claim CME credit. If you have any questions, please contact the Member
Resource Center of the American Academy of Dermatology toll-free at (866) 503-SKIN (7546), (847)
240-1280 (for international members), or by e-mailing mrc@aad.org.
CME examination
Identification No. JA0419
April 2019 issue of the Journal of the American Academy of Dermatology.
Lipner SR, Scher RK. J Am Acad Dermatol 2019;80:835-51.
Directions for questions 1 and 2: Choose the single best A 35-year-old woman with a history of diabetes mellitus
response. and psoriasis presents with onycholysis and subungual
hyperkeratosis of her right great toenail for 1 year. Her
A 59-year-old woman presents with longitudinal melano-
fingernails have pitting and onycholysis. She has been
nychia of her left great toenail that has been present for
using a topical antifungal on her right great toenail for the
2 years. There is accompanying subungual hyperkeratosis.
past 6 months with no improvement in her nail.
Using dermoscopy, there is black, white, and yellow
discoloration of subungual debris. 2. What is the appropriate next step in managing this
patient?
1. What is the next appropriate step in managing this
a. Continue the topical antifungal medication
patient?
b. Stop the topical antifungal medication and start a
a. Photography and ask the patient to return for a
systemic antifungal medication
follow-up visit in 6 months
c. Perform a potassium hydroxide preparation with
b. Schedule an appointment to obtain a biopsy
direct microscopy and send the scrapings for
specimen of the nail
fungal culture or polymerase chain reaction studies
c. Perform a potassium hydroxide preparation with
d. Stop the topical antifungal medication and ask the
direct microscopy and send the scrapings for
patient to return in 4-8 months to sample the nail
fungal culture or polymerase chain reaction studies
e. Stop the topical antifungal medication and start a
d. Start a topical antifungal medication
topical steroid for her nails
e. Start a systemic antifungal medication
852
To claim CME credit, complete this case-based posttest online at http://www.aad.org/olc. Note: CME
CME examination
October 2018 issue of the Journal of the American Academy of Dermatology.
Antia C, Baquerizo K, Korman A, Bernstein JA, Alikhan A. J Am Acad Dermatol 2018;79:599-614.
Directions for questions 1-4: Choose the single best A 43-year-old woman presents with a 4-day history of a
response. generalized pruritic rash. Each lesion last 6 to 10 hours and
then goes away. She denies any history of urticaria.
A 40-year-old woman presents with a 10-week history of
generalized, pruritic, pink papules. Individual lesions last 3. Which of these medications may be contributing to
for a few hours and are present $5 days each week. The her condition?
patient feels well and denies malaise and arthralgias. She is a. Fish oil
occasionally using diphenhydramine with temporal b. Ibuprofen
improvement of pruritus. c. Vitamin D
d. Penicillin
1. Which of the following is the most useful first step to
e. Lamotrigine
diagnosis?
a. Detailed history, review of systems, and clinical
examination You diagnose a 22-year-old woman with chronic inducible
b. Complete blood cell count with differential, eryth- urticaria. To further characterize the specific subtype, you
rocyte sedimentation rate, and C-reactive protein decide to challenge the patient with a test. You subject the
c. Obtain a skin biopsy specimen patient to a round of intense exercise, during which she
d. Skin prick testing breaks a sweat. After the test, the number and size of the
e. Immunologic panel hives is greatly increased.
A 60-year-old African American man with hypertension 4. Which of the following diagnoses is correct?
presents to the emergency department with new onset a. Cholinergic urticaria
facial swelling and abdominal pain. He denies new med- b. Heat urticaria
ications, insect stings, or new foods in the last 3 months. He c. Aquagenic urticaria
has taken lisinopril for [2 years. He denies a personal or d. Delayed pressure urticaria
family history of urticaria. e. Contact urticaria
2. Which of the following is the next best step?

a. Continue lisinopril because blood pressure control
takes precedence
b. Start intravenous corticosteroids
c. Monitor for respiratory distress
d. Admit him to the intensive care unit for constant
monitoring
e. Prescribe him diphenhydramine and discharge him
home
615
CME examination
Identification No. JB1018
October 2018 issue of the Journal of the American Academy of Dermatology.
Antia C, Baquerizo K, Korman A, Alikhan A, Bernstein JA. J Am Acad Dermatol 2018;79:617-33.
Directions for questions 1-4: Choose the single best She is started on an appropriate regimen and seen at a
response. follow-up appointment a few weeks later. She notes
minimal improvement, so you add hydroxyzine to her
A 24-year-old woman with chronic urticaria that is mostly
regimen and schedule a return visit. One week later, she
controlled with cetirizine 10 mg/day calls your office and
calls noting excessive sedation and an inability to stay
leaves a message. She mentions that she recently found out
awake at work. Her disease control has remained the same.
that she has become pregnant and immediately stopped all
medications; however, she is having an urticaria flare. 3. Following the treatment algorithm proposed by the
US Task Force, what would be your next step?
1. Which of the following is the most appropriate
a. Increase the dose of hydroxyzine
response?
b. Start the patient on cyclosporine
a. Advise her to discontinue cetirizine and start
c. Start the patient on omalizumab
hydroxyzine
d. Increase the dose of cetirizine
b. Advise her to try to live with it because no urticarial
e. Stop all medications and give the patient a ‘‘pre-
medication is safe during pregnancy
scription holiday’’
c. Advise her to resume taking cetirizine at her cur-
rent dose
d. Advise her to discontinue the cetirizine and start You are seeing a patient with chronic urticaria for a second
chloroquine opinion. He brings you the results of a skin biopsy
e. Advise her to terminate the pregnancy specimen performed at another office. The biopsy results
show a heavy neutrophilic infiltrate.
A 46-year-old woman presents to your office for manage- 4. What is your treatment of choice?
ment of chronic urticaria. She was diagnosed with chronic a. Cyclosporine
urticaria 1 month ago by her primary care physician and b. Omalizumab
started taking cetirizine 5 mg/day. Since then, she has c. Prednisone
noted little improvement and complains of increased d. Dapsone
pruritus and hives. e. Hydroxychloroquine
2. You offer her multiple additional treatment options,
which include any of the following except:
a. Increase the dose of cetirizine to 10 mg/day
b. Add fexofenadine 180 mg/day
c. Add famotidine 20 mg twice a day
d. Add hydrocortisone 1% cream as needed
e. Add diphenhydramine 50 mg at bedtime
634
Resource Center of the American Academy of Dermatology at toll-free (866) 503-SKIN (7546), (847)
CME examination
November 2018 issue of the Journal of the American Academy of Dermatology
Tziotzios C, Lee JYW, Brier T, Saito R, Hsu C-K, Bhargava K, Stefanato CM, Fenton DA, McGrath JA.
J Am Acad Dermatol 2018;79:789-804.
Directions for questions 1 and 2: Choose the single best In the process of establishing the clinical history and
response. examining the above individual, you note erythematous
involvement of the glans and inner foreskin, and it
A 66-year-old biomedical scientist and retired anatomy
transpires that the patient had not sought clinical input
demonstrator is referred to you for a generalized, intensely
for this issue, mostly because of embarrassment. The
pruritic, erythematous skin eruption. His medical history is
patient recalls that fruste forme hypospadias and wide
unremarkable for any cutaneous disorders and is only
urethral meatus were previously noted by a primary care
notable for hypertension, for which his primary care
physician with a special interest in urology, although the
physician started him on treatment with an angiotensin-
redness only became evident 6 months ago and is mostly
converting enzyme inhibitor several months before the
asymptomatic.
onset of the skin complaint. The physical examination
shows lesions that are widely and symmetrically distrib- 2. Which of the following statements is true?
uted over his trunk and extremities, and their morphology a. There is no association between urine microincon-
is somewhat psoriasiform. They have no Wickham striae tinence and lichen sclerosus
on dermoscopy. b. Fruste forme hypospadias and pooling of urine
because of a wide urethral meatus are not associ-
1. Which of the following statements is correct?
ated with a higher incidence of lichen sclerosus
a. The lesions have psoriasiform morphology and
c. Men circumcised at birth do not tend to develop
this is not a feature seen in lichenoid drug erup-
lichen sclerosus
tions (LDEs)
d. Obtaining a skin biopsy specimen in patients with
b. LDEs tend to affect younger individuals and show a
lichen sclerosus is not helpful
gender predilection toward males
e. There is no association between lichen sclerosus
c. The absence of Wickham striae is atypical of LDEs
and autoimmunity
and their absence excludes it as a differential
d. Angiotensin-converting enzyme inhibitors are not
commonly associated with LDEs
e. Patch testing is not highly specific and is therefore
not routinely used in patients experiencing LDEs
805
CME examination
December 2018 issue of the Journal of the American Academy of Dermatology.
Nelson CA, Stephen S, Ashchyan HJ, James WD, Micheletti RG, Rosenbach M. J Am Acad Dermatol 2018;987-1006.
Directions for questions 1-4: Choose the single best A 58-year-old man with AML presents with multiple tender
response. erythematous papules on his trunk 10 days after beginning
a course of cytarabine. A diagnosis of neutrophilic eccrine
A 54-year-old woman with acute myeloid leukemia (AML)
hidradenitis is suspected.
is admitted to the hospital with fever and the acute onset of
tender erythematous plaques on her face, trunk, and upper 3. Which of the following skin biopsy specimen findings
extremities. She is pancytopenic. A skin biopsy specimen is would be sufficient to establish the diagnosis?
obtained and reveals papillary dermal edema and a pre- a. Acid-fast, Gram, and Gomori methenamine silver
dominantly neutrophilic infiltrate in the dermis. Tissue stains highlighting filamentous organisms in ec-
culture is negative. crine epithelial cells
b. Neutrophils surrounding and infiltrating acrosyringia
1. Which of the following is the most appropriate initial
c. Neutrophils at the dermoepidermal junction with
therapy?
papillary dermal edema
a. Dapsone
d. Keratinous obstruction of eccrine ducts at the level
b. Systemic corticosteroids
of the mid-epidermis with vasodilation and a
c. Pegylated granulocyte-colony stimulating factor
perivascular lymphocytic infiltrate
d. Canakinumab
e. Eccrine glands with degenerative vacuolar changes
e. Pentoxifylline
A 34-year-old woman complains of recurrent oral and

The patient’s AML harbors a mutation in the fms-like genital ulcers. On previous skin pathergy testing, she
tyrosine kinase-3 gene. She reports that she initiated developed a pustule on her flexor forearm 36 hours after
treatment with quizartinib 2 weeks earlier. insertion of a sterile needle.
2. Which of the following is the most likely primary 4. Which of the following statements is accurate
explanation for her cutaneous eruption? regarding this patient’s condition?
a. Overstimulation of neutrophil production in the a. Human leukocyte antigen B51 association is most
bone marrow by granulocyte-colony stimulating common in Northern Europe
factor b. Corticosteroids are ineffective in the treatment of
b. Immune complex deposition within postcapillary this condition
venules c. Gastrointestinal vasculitis may lead to bowel
c. Degranulation of mast cells perforation
d. Differentiation of leukemic clones into mature d. Retinal vasculitis is the most frequent ocular
neutrophils manifestation
e. De novo development of antibodies to quizartinib e. Oral ulcers occur most often on the hard palate
1007
CME examination
May 2019 issue of the Journal of the American Academy of Dermatology.
Freites-Martinez A, Shapiro J, Goldfarb S, Nangia J, Jimenez JJ, Paus R, Lacouture ME. J Am Acad Dermatol 2019;80:1179-96.
Directions for questions 1-4: Choose the single best A 68-year-old man was diagnosed with metastatic
response. colorectal adenocarcinoma. The patient had been
receiving cetuximab for 3 months and presented to the
A 38-year-old woman was diagnosed with stage III breast
clinic with a painful rash on his scalp and face. His
cancer and will receive taxane-based chemotherapy.
dermatologic examination revealed thick yellow odorous
The patient is concerned about chemotherapy-induced
plaque and crusting on his scalp and beard areas. The
alopecia and consulted for any possible strategy to prevent
patient did not have any other dermatologic or systemic
her hair loss.
symptoms.
1. What is the optimal strategy to prevent cytotoxic
3. Which treatment option is the most appropriate in this
chemotherapy-induced alopecia in this patients with
patient?
breast cancer?
a. Topical antibiotic
a. Minoxidil foam 5%
b. Topical low-potency corticosteroids
b. Platelet-rich plasma
c. Culture/sensitivity-driven oral antibiotics and
c. A scalp cooling device
topical corticosteroids
d. Finasteride 2.5 mg
d. Minoxidil 5%
e. Spironolactone 50 mg
e. Anticancer therapy hold
2. Which of the following options is one of the primary
4. Which other hair disorder do you NOT expect to see
contraindications for the strategy chosen above?
in patients who are taking cetuximab?
a. Breast cancer
a. Eyelash trichomegaly
b. Hormone-sensitive tumors
b. Hirsutism
c. Hematologic malignancies
c. Pigmentary hair changes
d. Childbearing age
d. Eyebrow trichomegaly
e. Hyperkalemia
e. Pattern alopecia (similar to androgenetic type)
1197
CME examination
May 2019 issue of the Journal of the American Academy of Dermatology.
Freites-Martinez A, Shapiro J, van den Hurk C, Goldfarb S, Jimenez JJ, Rossi AM, Paus R, Lacouture ME. J Am Acad Dermatol
2019;80:1199-213.
Directions for questions 1-4: Choose the single best A 47-year-old female breast cancer survivor has been
response. noticing hair thinning over the past 2 months. The patient
was treated with lumpectomy, breast radiotherapy, and
A 62-year-old woman was diagnosed with stage III hor-
initiated adjuvant therapy with tamoxifen. Her scalp ex-
mone receptorenegative breast cancer and was treated
amination revealed features of androgenetic alopecia, with
with surgery, radiation, and chemotherapy (doxorubicin
receding of the frontoparietal hairline and miniaturized
hydrochloride and cyclophosphamide, followed by pacli-
hairs in the crown area.
taxel). At her 1-year follow-up, the patient reported
incomplete hair regrowth after completion of chemo- 3. Which of the following may be the most likely culprit
therapy. An examination of the scalp revealed features of of the hair changes seen in this breast cancer survivor?
diffuse nonscarring alopecia with hair dystrophy, and the a. Cytotoxic chemotherapy
hair pull test was negative. Trichoscopy revealed minia- b. Radiation
turized hairs and few yellow dots. The patient had no other c. Tamoxifen
skin or nail findings. d. Local immune hair dysregulation
e. Cancer surgery
1. What is the most probable diagnosis?
a. Telogen effluvium 4. Which treatment option is the most appropriate in this
b. Endocrine therapyeinduced alopecia patient?
c. Persistent radiotherapy-induced alopecia a. Topical minoxidil
d. Androgenetic alopecia b. Topical steroids
e. Persistent chemotherapy-induced alopecia c. Topical spironolactone
d. Reassure the patient; she does not need to be
2. Which of the following is the most probable cause of
treated
alopecia in this cancer survivor?
e. Oral finasteride 1 mg/day
a. Taxane chemotherapy
b. Radiation therapy
c. Aromatase inhibition
d. Surgery-related telogen effluvium
e. Increased androgen sensitivity of hair follicles
1214
CME examination
January 2019 issue of the Journal of the American Academy of Dermatology.
Gardner LJ, Strunck JL, Wu YP, Grossman D. J Am Acad Dermatol 2019;80:1-12.
Directions for questions 1-3: Choose the single best response. A 37-year-old woman had a biopsy specimen obtained
from a lesion on her arm that showed invasive melanoma
1. Which of the following is NOT a potential contrib-
to a depth of 0.5 mm. The pathology report also noted the
uting factor to recent trends in increased melanoma
absence of ulceration and mitotic figures, but histologic
incidence?
features of regression in the lower 25% of the tumor.
a. Increased exposure to ultraviolet radiation
b. Variation in case ascertainment and reporting 3. What is the most appropriate course of management?
c. Increased vitamin D consumption a. Wide local excision with 1-cm margins, but
d. Increased screening and biopsy specimens sentinel lymph node biopsy is not indicated
e. Overdiagnosis of melanoma b. Tell her that because regression indicates an
immune antitumor response, her risk of recurrence
2. Which of the following is the most clearly demonstrated
is low
benefit to melanoma screening?
c. Regression may preclude an accurate assessment
a. Detection of other skin abnormalities
of tumor depth, and therefore excision with 2-cm
b. Less reliance on skin self-examination
margins is indicated
c. Increased use of skin self-examination
d. According to American Joint Committee on Cancer
d. Detection of earlier stage (ie, thinner) melanoma
guidelines, regression in thin melanoma is an
e. Reduction in the number of skin biopsy specimens
indication for sentinel lymph node biopsy
obtained
e. The metastatic risk of melanoma with regression is
unpredictable, so additional molecular testing is
indicated
13
CME examination
Klapperich ME, Bowen GM, Grossman D. J Am Acad Dermatol 2019;80:15-25.
Directions for questions 1-3: Choose the single best A 54-year-old man was recently diagnosed with minimally
response. invasive (0.71-mm) nonulcerated stage I melanoma. He
requested to have the 31-gene expression profile (GEP)
A 46-year-old woman presents to the clinic with a concern
prognostic test performed, and the results came back as
about a changing mole. A biopsy specimen was obtained
GEP class 2.
from the lesion using the shave biopsy technique, and the
pathology results are consistent with melanoma, depth at 2. Based on this result, what should the patient be told?
least 0.7 mm, without ulceration. The pathologist confirms a. He should have wide local excision with 2-cm
that the maximum depth cannot be absolutely determined margins because his melanoma is higher risk
because the deep margin is positive, but that the deep b. Wide local excision with conventional (1-cm)
margin is only focally involved. margins and a sentinel lymph node biopsy is
needed
1. What is the most appropriate next step in
c. His risk of future distant metastasis is higher than
management?
would be predicted by his pathology results
a. No further treatment is necessary
d. He has a higher 5-year overall survival than GEP
b. Assume the depth from the biopsy specimen is
class 1 patients with the same melanoma depth
accurate and treat with wide local excision with
e. Additional molecular testing is needed to decide
1-cm margins
whether a sentinel lymph node biopsy is indicated
c. Perform another biopsy procedure to remove any
residual disease
d. Wide local excision with 1-cm margins and sentinel
lymph node biopsy
A 49-year-old woman presents to the clinic for follow-up.
e. Wide local excision with 2-cm margins and sentinel
She was diagnosed with stage IIB melanoma on the upper
lymph node biopsy
thigh 1 year earlier.
3. What is the most appropriate screening plan going
forward?
a. Skin examination and a computed tomography
(CT) scan every 3-6 months for the next 4 years
b. Skin examination and a CT scan every 3-6 months,
and a magnetic resonance imaging scan of the
brain every year for the next 4 years
c. Skin examination every 3 months, but no imaging
for the next 4 years
d. Skin examination and regional ultrasound imaging
every 6-12 months for the next 9 years
e. Skin examination every 3-6 months and regional
ultrasound imaging every 6-12 months for the next
2-4 years
26
CME examination
February 2019 issue of the Journal of the American Academy of Dermatology
Cameron MC, Lee E, Hibler B, Giordano CN, Barker CA, Mori S, Cordova M, Nehal KS, Rossi AM.
Directions for questions 1-4: Choose the single best A Mohs surgeon is reviewing the National Comprehensive
response. Cancer Network Guidelines for management of BCC with
his fellow.
A 68-year-old man presents with a 25-year history of a
longstanding 10-cm pink pearly ulcerated plaque with 3. Which of the following BCCs would NOT qualify as
rolled borders on his scalp that is concerning for a locally ‘‘high-risk?’’
advanced basal cell carcinoma (BCC). A biopsy specimen a. A 7-mm superficial BCC on the right temple
is obtained and a BCC is confirmed. On subsequent b. A 1.8-cm nodular BCC on the upper arm
imaging, he is found to have lymphadenopathy and a c. A 9-mm micronodular BCC on the back
lung nodule that is concerning for metastatic BCC. He is d. A 2.1-cm nodular BCC on the chest
referred to medical oncology for consideration of systemic e. A 7-mm morpheaform BCC on the neck
targeted therapy. His oncologist recommends vismodegib,
but the patient is concerned about the side effects of this
A 63-year-old female physicist presents to the dermatology
drug.
clinic for a total body skin examination. She has been
1. Which of the following is NOT recognized as a diagnosed with numerous BCCs in the past and is wary of
common side effect of vismodegib? undergoing more skin biopsy procedures. She wants to
a. Muscle spasms know if there are any noninvasive modalities that are being
b. Loss of appetite studied for the diagnosis of BCC. The patient recently read
c. Migraines in a physics journal about an imaging technology that relies
d. Alopecia on infrared light projected onto the skin to produce an
e. Nausea image based on the sum of light refractions of various skin
structures to produce a noninvasive, real-time diagnostic
A dermoscopy expert is giving a Grand Rounds lecture to assessment of skin. Unfortunately, she cannot recall the
residents about dermoscopy for skin neoplasms. He re- name of this imaging modality.
views the dermoscopic features for various subtypes of
4. To which modality is she referring?
BCC.
a. Reflectance confocal microscopy
2. Which of the following features is NOT consistent b. Multiphoton tomography
with a diagnosis of superficial BCC? c. Optical coherence tomography
a. Shiny white-red structureless areas d. Raman spectroscopy
b. Maple leafelike areas e. Terahertz pulse imaging
c. Blue-grey ovoid nests
d. Superficial fine telangiectasias
e. Multiple small erosions
340
CME examination
Cameron MC, Lee E, Hibler B, Barker CA, Mori S, Cordova M, Nehal KS, Rossi AM. J Am Acad Dermatol 2019;80:303-317.
Directions for questions 1-4: Choose the single best A 72-year-old woman who is a molecular biologist has a
response. history of several basal cell carcinomas (BCCs) and is
diagnosed with a new nodular BCC on the cheek. She is
A 65-year-old man presents with a lesion on his back that
curious about the carcinogenesis of her BCC.
had been present for several years. The clinical examina-
tion reveals a skin-colored pedunculated papulonodule. A 2. In answering her questions, which of the following
shave biopsy specimen is obtained, and a seasoned statements would be FALSE about BCC carcinogenesis?
dermatopathologist notes that the results show a fibroepi- a. Constitutive activation of Hedgehog signaling
thelioma of Pinkus. pathway plays a large role in BCC carcinogenesis
b. Ultraviolet B lightedriven mutagenesis plays a
1. What was most likely seen on histopathology?
predominant role in transforming keratinocyte
a. Large dermal nodules of malignant basaloid kera-
progenitor cells into BCCs
tinocytes, peripheral palisading, and mucoid
c. Activating mutations of PTCH1 and SUFU
stroma with plump spindle cells
contribute to BCC carcinogenesis
b. Multiple collections of delicate strands of
d. Activating mutations of SMO contribute to BCC
epidermal basaloid keratinocytes arranged in a
carcinogenesis
reticular pattern within a spindle cell stroma
e. Sporadic BCCs arise from long-term resident ker-
c. A well-circumscribed tumor of anastomosing
atinocyte progenitor cells of the interfollicular
strands of basaloid cells and scattered small
epidermis and upper infundibulum that undergo
infundibulum-like cystic structures
mutagenesis
d. Multiple lobular foci of basaloid palisading kerati-
nocyte tumors attached superficially to epidermis
with a myxoid stroma and band-like lichenoid
infiltrate
e. Thin cords with angulated ends of few basaloid
keratinocytes imbedded in a sclerotic collagenous
stroma
318
J AM ACAD DERMATOL CME examination 319
VOLUME 80, NUMBER 2
A 26-year-old woman presents to the clinic with a chief A 72-year-old man who is a smoker and who has a history
complaint of longstanding decreased hair growth of her of rheumatoid arthritis presents for surgical treatment for a
scalp. The clinical examination reveals hypotrichosis of the BCC of the neck. He has a history of ionizing radiation to
scalp and eyebrows as well as lesions on her cheek and the neck for a laryngeal squamous cell carcinoma. He also
back that are concerning for BCC. Numerous facial milia has been on chronic immunosuppressive therapy for a
and bilateral acral erythema are also noted. On further previous renal transplant. Given that this is his third
interview, the patient reports a longstanding history of diagnosis of BCC, he is curious as to what previous
decreased sweating and easy ‘‘overheating outside.’’ She is exposures or medical conditions may have increased his
accompanied by her 6-year-old who also has similar facial risk for BCC development.
milia, acral erythema, and hypotrichosis.
4. Based on previous epidemiologic studies, which of
3. What is the most likely diagnosis? his previous exposures or medical conditions has
a. Nevoid basal cell carcinoma syndrome NOT been shown to increase risk for BCC
b. RothmundeThomson syndrome development?
c. Bazex-Dupre-Christol syndrome a. Ionizing radiation
d. Sch€
opf-Schulz-Passarge syndrome b. Smoking
e. Rombo syndrome c. Immunosuppressive therapy for an organ
transplant
d. Rheumatoid arthritis
e. Arsenic-contaminated food and water
CME examination
Lipner SR, Scher RK. J Am Acad Dermatol 2019;80:853-67.
Directions for questions 1 and 2: Choose the single best A 65-year-old woman presents with onycholysis and
response. subungual hyperkeratosis of her right great toenail for
1 year. The thickness of her nail is 1 mm, with 10% surface
A 43-year-old man presents with onycholysis and subun-
area of the nail plate involved, and without involvement of
gual hyperkeratosis of all of his toenails and scale on his
the nail matrix. No other nails are affected. A previous nail
plantar feet that has been present for many years. His right
clipping with histopathology revealed hyphae infiltrating
great toenail measures 3 mm in thickness and he complains
the nail plate. She prefers topical treatment for her ony-
of pain when walking. He brings a recent report showing a
chomycosis. Her medications include cisapride and
toenail culture positive for Trichophyton rubrum. His
cyclosporine.
medical history is significant for hypercholesterolemia,
for which he is taking simvastatin. 2. What is the most appropriate treatment for this
patient?
1. What is the most appropriate treatment for this
a. Recommend treatment with ciclopirox 8% nail
patient?
lacquer, efinaconazole 10% solution, or tavaborole
a. Recommend treatment with efinaconazole 10%
5% for her nail for 48 weeks and treat concurrently
solution for 48 weeks
for tinea pedis
b. Recommend treatment with oral itraconazole for
b. Recommend treatment with oral itraconazole daily
3 months
for 3 months
c. Recommend treatment with oral terbinafine for
c. Recommend treatment with oral terbinafine daily
3 months
for 3 months
d. Recommend treatment with a neodymium-doped
d. Recommend treatment with oral fluconazole
yttrium aluminium garnet laser weekly for 1 month
weekly until the nail grows out
e. Recommend that the patient not be treated
e. Recommend treatment with a neodymium-doped
yttrium aluminium garnet laser laser weekly for
1 month
868
CME examination
Identification No. JD0119
Kaushik SB, Lebwohl MG. J Am Acad Dermatol 2019;80:43-53.
Directions for questions 1 and 2: Choose the single best A 29-year-old woman who is 16 weeks pregnant presents
response. to your clinic with psoriasis affecting [12% of her body
surface area. She wants to discuss the available treatment
A 42-year-old man is diagnosed with plaque psoriasis
options for her as she feels miserable and states that
affecting [15% of his body surface area. He is a corporate
psoriasis is adversely affecting her quality of life.
consultant and frequently travels internationally for work.
You plan to start him on ustekinumab because of its 2. Which of the following drugs is the preferred agent to
convenient dosing schedule. You conduct all screening treat moderate to severe psoriasis during pregnancy?
investigations and he has a positive QuantiFERON test but a. Infliximab
a normal chest radiograph. b. Acitretin
c. Methotrexate
1. What is the next best step for management?
d. Certolizumab
a. Multidrug therapy for his tuberculosis for
e. Topical steroids
$12 months before starting any systemic drug
b. Nine months of isoniazid prophylaxis, but he can
be started on the systemic drug after 1 to 2 months
of prophylaxis
c. Because the chest radiograph is negative, he can
be started on systemic psoriasis drugs without any
need for prophylaxis
d. He is not a good candidate for systemic therapy
and should be managed with topical drugs only
e. He should be switched to some other systemic
agent
54
CME examination
Identification No. JC0119
Directions for questions 1-3: Choose the single best Her neurologist diagnoses her with multiple sclerosis.
response.
2. Which of the following drugs should be avoided in
A 50-year old woman with plaque psoriasis affecting[10% this patient?
of her body surface area presents for a follow-up visit to a. Tumor necrosis factorealpha inhibitors
your clinic. Her medical history is significant for well- b. Apremilast
controlled hypertension and diabetes mellitus for 10 years. c. Interleukin-17 inhibitors
You started her on an injectable medicine a few months d. Cyclosporine
earlier, which resulted in significant improvement. e. Acitretin
However, on this visit she states that she has been
experiencing numbness and tingling of her arms and legs
A 60-year-old man presents to your office for evaluation of
since her last visit.
his 1-year history of extensive plaque psoriasis affecting
1. What should be the next steps in her management? [10% of his body surface area. He states that he has tried
a. Obtain chest radiograph multiple creams and ointments without much improve-
b. Refer to neurology ment and would like to discuss other treatment options. He
c. Observation and reassurance mentions that he has been treated for multiple precancer-
d. Send her for computed tomography scan ous lesions and has had 2 squamous cell skin cancers.
e. Discontinue the injectable drug
3. Which of the following drugs has a preventative effect
on non-melanoma skin cancers?
a. Cyclosporine
b. Tumor necrosis factorealpha inhibitors
c. Acitretin
d. Ustekinumab
e. Apremilast
41
CME examination
response.
a. Cyclosporine
c. Acitretin
d. Ustekinumab
e. Apremilast
41
CME examination
response.
a. Cyclosporine
c. Acitretin
d. Ustekinumab
e. Apremilast
41
Resource Center of the American Academy of Dermatology at toll-free (866) 503-SKIN (7546), (847)
CME examination
Yelamos O, Braun RP, Liopyris K, Wolner ZJ, Kerl K, Gerami P, Marghoob AA. J Am Acad Dermatol 2019;80:365-77.
Directions for questions 1-4: Choose the single best The same 87-year-old man mentioned above also has a
response. 3-mm pink papule on his temple. On dermoscopy, the
lesion shows shiny white blotches and strands, a blue
A 47-year-old white woman with atypical mole syndrome
ovoid nest, and an arborizing vessel.
presents for a skin cancer surveillance examination. The
physical examination reveals that a brown 5-mm macule 3. What is the most likely diagnosis and best treatment
appears to have changed. On dermoscopy, the macule option for this lesion?
reveals a pigment network and a focal area with a negative a. Superficial basal cell carcinoma treated with
network in the center. imiquimod
b. Superficial basal cell carcinoma treated with photo-
1. What is the most likely diagnosis?
dynamic therapy
a. Spitz nevus
c. Superficial basal cell carcinoma treated with
b. Dysplastic nevus
surgery
c. Nodular melanoma
d. Nodular basal cell carcinoma treated with surgery
d. Melanoma arising in a nevus
e. Morpheaform basal cell carcinoma treated with
e. Traumatized nevus
surgery
A 52-year-old white man presents with a bleeding pig-

An 87-year-old man with Fitzpatrick skin phototype II mented lesion on his lower back. Dermoscopically, the
presents with multiple keratotic papules on his forehead. lesion shows a blue-white veil over a raised area, shiny
On clinical examination, one of these lesions reveals a few white streaks, an area with scar-like depigmentation and
white circles on dermoscopy. peppering, a milky red area, and polymorphous vessels.
2. What is the most likely histologic diagnosis? 4. Which dermoscopic feature does not correlate with
a. Morpheaform basal cell carcinoma dermal invasion in melanoma?
b. Grade I actinic keratosis a. Blue-white veil
c. Nevus with balloon cell changes b. Shiny white streaks
d. Lentigo maligna c. Scar-like depigmentation and peppering
e. Well-differentiated squamous cell carcinoma d. Milky red area
e. Polymorphous vessels
378
CME examination
Berger AP, Ford BA, Brown-Joel Z, Shields BE, Rosenbach M, Wanat KA. J Am Acad Dermatol 2019;80:883-98.
Directions for questions 1-3: Choose the single best 1. What fungal infection is most likely in this patient?
response. a. Aspergillosis
b. Candidiasis
A 58-year-old man with a recent kidney and pancreas
c. Fusariosis
transplant who is currently taking tacrolimus and predni-
d. Mucormycosis
sone was admitted with shortness of breath and scattered
e. Scedosporiosis
purpuric plaques involving the face and trunk. A punch
biopsy specimen was obtained, and the histopathologic 2. In addition to the punch biopsy specimen obtained
[F1-4/C] results appear in Fig 1. for histopathologic review, what other tests should be
performed?
a. Blood cultures
b. A computed tomography scan of the chest
c. A complete metabolic panel
d. Tissue culture
e. All of the above
3. What treatment should be initiated in this patient?
a. Echinocandin
b. Fluconazole
c. Liposomal amphotericin
d. Terbinafine
e. Voriconazole
Fig 1. Histopathology of specimen demon-

strating hyphae. (Hematoxylin-eosin stain;
original magnification: 360.)
899
CME examination
April 2019 issue of the Journal of the American Academy of Dermatology
Shields BE, Rosenbach M, Brown-Joel Z, Berger AP, Ford BA, Wanat KA. J Am Acad Dermatol 2019;80:869-80.
Directions for questions 1 and 2: Choose the single best 1. What angioinvasive fungal infections should be
response. considered in this patient?
a. Aspergillosis
A 62-year-old man recently underwent treatment with
b. Fusariosis
rituximab before allogeneic hematopoietic stem cell trans-
c. Mucormycosis
plantation. Several weeks later he presented to the hospital
d. Scedosporiosis
with multiple, deep, subcutaneous nodules, some with
e. All of the abaove
central eschar (Fig 1).
There are many shared risk factors for angioinvasive fungal

infections, including immunosuppression, malignancy,
transplantation, trauma, and chronic disease, such as
HIV/AIDS.
2. What risk factor is more specific for the development
of a Mucormycetes infection?
a. Autoimmune disease
b. Corticosteroid use
c. Diabetes mellitus
d. Hypercortisolism
e. Iron overload
[F1-4/C]
Fig 1. Red to violaceous subcutaneous nodule

on the arm.
881
To claim CME credit, successfully complete this case-based posttest online at http://www.aad.org/olc.
Note: CME quizzes are available after the first of the month in which the article is published. If you
have any questions, please contact the Member Resource Center of the American Academy of
Dermatology toll-free at (866) 503-SKIN (7546), (847) 240-1280 (for international members), or by
e-mailing mrc@aad.org.
CME examination
June 2019 issue of the Journal of the American Academy of Dermatology.
Azarchi S, Bienenfeld A, Lo Sicco K, Marchbein S, Shapiro J, Nagler AR. J Am Acad Dermatol 2019;80:1509-21.
Directions for questions 1-4: Choose the single best A 29-year-old nonsmoking woman presents with acne and
response. terminal hairs along her chin and abdomen. She reports
regular menses and serum androgen studies are within
A 21-year-old overweight woman has multiple breakouts
normal limits. She reports a history of migraines with auras
on her chin and jaw line every month. She has a noticeable
and admits to excessive alcohol consumption on the
amount of coarse hairs on her chin and above her lip. She is
weekends. She is not sexually active.
sexually active with 1 male partner and she is taking a
combined oral contraceptive (COC) pill. After 1 month of 3. What is the ideal therapy for this patient to treat both
taking the COC, the patient states that she has not seen her acne and hirsutism?
much improvement in her acne or hirsutism. a. A COC
b. Spironolactone 50 mg daily
1. How would you best counsel or treat the patient?
c. Finasteride 5 mg daily
a. Switch to a COC with less androgenic activity
d. Flutamide 250 mg daily
b. Continue her current COC
e. Dutasteride 2.5 mg daily
c. Switch to spironolactone 100 mg daily
d. Add flutamide 250 mg daily
e. Start finasteride 5 mg daily A 50-year-old woman presents with worsening hair loss on
the vertex of her scalp. Both her mom and older sister have
A 27-year-old healthy woman with no medical problems similar patterned hair loss. She has tried minoxidil without
would like to start an oral medication for acne. She has any significant improvement. She has a history of low
been taking a COC for [4 years and continues to have blood pressure and frequent syncopal episodes. She is
inflammatory and comedonal acne. After discussion with interested in starting an oral therapy.
her dermatologist, she is started on spironolactone. 4. Which of the following is the best treatment option?
2. What testing is necessary at her 6-week follow-up a. A COC
appointment? b. Spironolactone 50 mg twice daily
a. Serum potassium c. Finasteride 5 mg daily
b. Complete blood cell count d. Flutamide 250 mg daily
c. Free testosterone and dehydroepiandrosterone- e. Biotin supplementation
sulfate
d. No additional testing is needed
e. Basic metabolic panel
1522
CME examination
July 2019 issue of the Journal of the American Academy of Dermatology.
Haley CT, Mui UN, Vangipuram R, Rady PL, Tyring SK. J Am Acad Dermatol 2019;81:1-21.
Directions for questions 1-4: Choose the single best An 80-year-old white man who is a retired farmer presents
response. to the office for his yearly skin examination. He has a 4-cm
violaceous nodule on the posterior aspect of his neck. He
A 35-year-old man with epidermodysplasia verruciformis
states that it began as a tiny bump 7 weeks earlier and has
returns to the clinic for follow-up of an excised cutaneous
‘‘grown quickly but does not hurt.’’ The remainder of the
squamous cell carcinoma (cSCC). This patient has been
physical examination is normal, and the subject has no
treated for numerous cSCCs and cutaneous warts in the
lymphadenopathy. An incisional biopsy specimen of the
past.
lesion is obtained, and the histologic examination reveals
1. Which treatment modality should be avoided when Merkel cell carcinoma.
treating this patient for cSCC?
3. Immunohistochemistry staining for which protein
a. Topical retinoids
would reveal a paranuclear pattern?
b. Mohs micrographic surgery
a. CK20
c. Photodynamic therapy
b. CK7
d. Radiation therapy
c. CD45
e. Cidofovir
d. Thyroid transcription factor-1
2. Which 2 human papillomavirus types are associated e. Vimentin
with the majority of cSCCs in patients with epider-
4. Which of the following is an appropriate initial man-
modysplasia verruciformis?
agement strategy for this patient?
a. 16 and 18
a. Initiate avelumab therapy
b. 5 and 8
b. Mohs micrographic surgery and adjuvant
c. 6 and 11
chemotherapy
d. 13 and 32
c. Cervical lymph node dissection
e. 31 and 33
d. Sentinel lymph node biopsy, wide local excision,
and radiation therapy
e. Enroll in a clinical trial
22
CME examination
Mui UN, Haley CT, Vangipuram R, Tyring SK. J Am Acad Dermatol 2019;81:23-41.
Directions for questions 1-4: Choose the single best A 69-year-old Japanese man presents to the emergency
response. room complaining of nausea, abdominal pain, and a 5-day
history of generalized weakness. The family reports that
A 35-year-old woman presents to the clinic for the evalu-
the patient had become irritable with abnormal behavior
ation of a rash on her legs and white patches in her mouth.
over the last 2 days. On examination, the patient has severe
The physical examination reveals purple, flat-topped,
anorexia, generalized lymphadenopathy, hepatospleno-
polygon-shaped plaques that are intensely pruritic and
megaly, hyperpigmented patches on the chest, and ulcer-
white, lace-like patches on the buccal mucosa. The lesions
ated nodules on the arms and abdomen. He was
had been present for a few months without any significant
tachypneic, tachycardic, and hypertensive. He was found
changes. A punch biopsy specimen was obtained that
to have a serum calcium level of 15 mg/dL and low
revealed a ‘‘saw-tooth’’ pattern of epidermal hyperplasia
parathyroid hormone levels. A malignancy-associated hy-
with acanthosis and parakeratosis.
percalcemia is suspected and workup for malignancy was
1. What could be the next step after confirming the skin initiated. His peripheral smear showed T lymphocytes with
diagnosis? multilobulated nuclei exhibiting a ‘‘flower’’ appearance.
a. Order human T-lymphotrophic virus 1 DNA by
3. Which viral agent is associated with this malignancy?
polymerase chain reaction
a. Human T-lymphotrophic virus 1
b. Order a viral hepatitis panel
b. EpsteineBarr virus
c. Perform direct immunofluorescence
c. Hepatitis B virus
d. Obtain HIV antibody testing
d. Hepatitis C virus
e. Order immunohistochemical analysis for
e. Human herpesvirus-8
EpsteineBarr virus
4. What is the best next step in the treatment of this
2. What is the recommended first-line treatment for this
condition?
condition?
a. Interferon
a. Intralesional corticosteroids
b. Zidovudine
b. Systemic corticosteroids
c. Radiotherapy
c. High-potency topical corticosteroids
d. Allogeneic stem cell transplant
d. Topical calcineurin inhibitors
e. Systemic chemotherapy
e. Observation until spontaneous resolution
42
CME examination
Maymone MBC, Greer RO, Burdine LK, Cheng A-D, Venkatesh S, Sahitya PC, Maymone AC, Kesecker J, Vashi NA. J Am Acad
Dermatol 2019;81:43-56.
Directions for questions 1 and 2: Choose the single best 2. What is the primary treatment option for this patient?
response. a. Sclerosing agent
b. Laser therapy
A 47-year-old woman presented with a purple-red lesion
c. Corticosteroids
located between her incisor and canine of lower gingival
d. Surgical excision
mucosa. A biopsy specimen was obtained, and the histo-
e. Cryotherapy
logic examination revealed giant cells and ovoid mesen-
chymal cells.
1. What is the most likely diagnosis?
a. Pyogenic granuloma
b. Peripheral ossifying fibroma
c. Peripheral giant cell granuloma
d. Irritation fibroma
e. Oral hemangioma
57
CME examination
August 2019 issue of the Journal of the American Academy of Dermatology.
Wambier CG, Lee KC, Soon SL, Sterling JB, Rullan PP, Landau M, Brody HJ, International Peeling Society.
Directions for questions 1 and 2: Choose the single best 2. What are the ingredients in a phenol-croton oil peel?
response. a. Castor oil, phenol, water, and soap
b. Croton oil, phenol, water, and Septisol
A 60-year-old woman presents for treatment of her deep
c. Croton oil, phenol, olive oil, and water
perioral rhytides (Glogau classification of photoaging IV).
d. Croton oil, phenol, acetone, and water
She does not take any medications and does not have any
e. Croton oil, phenol, oleic acid, and Septisol
cardiac history. You decide to perform a deep chemical
peel on the perioral rhytides.
1. What is the active ingredient of deep chemical peels?
a. Phenol
b. Septisol
c. Croton oil
d. Oleic acid
e. Acetone
337

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To claim CME credit, complete this case-based posttest online at http://www.aad.org/olc.

April 2019 issue of the Journal of the American Academy of Dermatology.

Lipner SR, Scher RK. J Am Acad Dermatol 2019;80:835-51.

October 2018 issue of the Journal of the American Academy of Dermatology.

Antia C, Baquerizo K, Korman A, Bernstein JA, Alikhan A. J Am Acad Dermatol 2018;79:599-614.

2. Which of the following is the next best step?

October 2018 issue of the Journal of the American Academy of Dermatology.

Antia C, Baquerizo K, Korman A, Alikhan A, Bernstein JA. J Am Acad Dermatol 2018;79:617-33.

November 2018 issue of the Journal of the American Academy of Dermatology

December 2018 issue of the Journal of the American Academy of Dermatology.

A 34-year-old woman complains of recurrent oral and

May 2019 issue of the Journal of the American Academy of Dermatology.

May 2019 issue of the Journal of the American Academy of Dermatology.

January 2019 issue of the Journal of the American Academy of Dermatology.

Gardner LJ, Strunck JL, Wu YP, Grossman D. J Am Acad Dermatol 2019;80:1-12.

January 2019 issue of the Journal of the American Academy of Dermatology.

Klapperich ME, Bowen GM, Grossman D. J Am Acad Dermatol 2019;80:15-25.

February 2019 issue of the Journal of the American Academy of Dermatology

February 2019 issue of the Journal of the American Academy of Dermatology

April 2019 issue of the Journal of the American Academy of Dermatology.

Lipner SR, Scher RK. J Am Acad Dermatol 2019;80:853-67.

January 2019 issue of the Journal of the American Academy of Dermatology.

Kaushik SB, Lebwohl MG. J Am Acad Dermatol 2019;80:43-53.

January 2019 issue of the Journal of the American Academy of Dermatology.

Kaushik SB, Lebwohl MG. J Am Acad Dermatol 2019;80:27-40.

January 2019 issue of the Journal of the American Academy of Dermatology.

Kaushik SB, Lebwohl MG. J Am Acad Dermatol 2019;80:27-40.

January 2019 issue of the Journal of the American Academy of Dermatology.

Kaushik SB, Lebwohl MG. J Am Acad Dermatol 2019;80:27-40.

February 2019 issue of the Journal of the American Academy of Dermatology

A 52-year-old white man presents with a bleeding pig-

April 2019 issue of the Journal of the American Academy of Dermatology.

Fig 1. Histopathology of specimen demon-

April 2019 issue of the Journal of the American Academy of Dermatology

There are many shared risk factors for angioinvasive fungal

Fig 1. Red to violaceous subcutaneous nodule

June 2019 issue of the Journal of the American Academy of Dermatology.

July 2019 issue of the Journal of the American Academy of Dermatology.

July 2019 issue of the Journal of the American Academy of Dermatology.

July 2019 issue of the Journal of the American Academy of Dermatology.

August 2019 issue of the Journal of the American Academy of Dermatology.

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