WIS - 1

December 2018
Question - 1
• A 4-year-old child presents to
the clinic with a 3-month
history of an asymptomatic
uniformly pink papule ( Figure
361-2E ) on her right cheek. It
grew rapidly over the first 4
weeks and has since stabilized.
Which of the following is the
most likely diagnosis?
a) Dysplastic melanocytic nevus
b) Pyogenic granuloma
c) Cherry angioma
d) Spitz nevus
e) Acne vulgaris
 Answers- 1
• D

• Spitz nevi are benign, usually acquired, proliferations of

melanocytes with histopathologic features that sometimes
overlap with those of melanoma. Most Spitz nevi appear
during childhood, often with a rapid initial growth phase.
The face and lower extremities are the most common
locations. Lesions classically appear as uniformly pink, tan,
red, or red-brown, solitary, dome-shaped papules. They are
usually symmetric, well circumscribed, and less than 1 cm
in diameter. The surface may be smooth or verrucous;
darkly pigmented lesions are occasionally observed.
Question - 2
Parents of a 2-year-old boy present to
your office with concern regarding
this lesion on their child’s leg. They
recently had a family friend pass
away from melanoma. The lesion has
been present since birth and has been
increasing in size in proportion to the
child’s growth.
• What is the best description of the
lesion?
a) Large congenital melanocytic
nevus (CMN)
b) Medium CMN
c) Melanoma
d) Nevus of Ota
e) Becker nevus
 Answers- 2
• B

– CMN are classically defined as melanocytic nevi present at birth or within the first few months of life. The lesions are
categorized on the basis of final size into 3 major groups: small (20 cm; in a neonate, >9 cm on the head and >6 cm on
the body). CMN enlarge in proportion to the child’s growth. The color of CMN ranges from tan to black, and the
borders are often geographic and irregular. Many CMN have an increased density of dark, coarse hairs. Many of these
features are represented above and the size of the lesion is 6 cm, making it a medium CMN. The risk for the
development of cutaneous melanoma within small- and medium-sized CMN is controversial and is thought to be 1%
or less over a lifetime. Becker nevi are a cutaneous hamartoma, often located on the shoulder or upper trunk, as a large
tan or brown patch that breaks up into smaller islands at the periphery. Nevus of Ota presents as speckled grayish
brown to blue-black patches involving the skin, conjunctiva, sclera, tympanic membrane, and/or oral and nasal mucosa
in areas innervated by the first and second divisions of the trigeminal nerve.
Question - 3
A 19-year-old boy presents to your
clinic with a 4-month history of
lightening of the skin on his leg as
shown in Figure 361-4C . What is
the etiology of this disorder?
a) Autoimmune destruction of
melanocytes in the epidermis and
hair follicles
b) Primary adrenal insufficiency
c) Clone of cells with reduced
melanogenic potential that arises
during embryonic development
d) Protein deficiency
e) Copper deficiency
 Answers- 3
– a
• The above photograph depicts vitiligo. Vitiligo is a benign disorder
characterized by complete loss of pigmentation (depigmentation)
within well-demarcated areas of skin. It is an autoimmune process with
destruction of melanocytes in the epidermis and less often hair
follicles. It is a common acquired disorder affecting approximately 1%
of the population. In 50% of the cases onset is prior to 20 years of age.
Although it is a benign disorder, the disfigurement of childhood
vitiligo may lead to considerable psychologic distress, decreased
selfesteem, and social isolation. Primary adrenal insufficiency, Addison
disease, causes hyperpigmentation. Protein and copper deficiency
cause pigmentary dilution, but not depigmentation or complete loss of
melanocytes. A nevus depigmentosus is a clone of cells with reduced
melanogenic potential that arises during embryonic development.
Despite its name, a nevus depigmentosus is a hypopigmented patch,
not depigmented.
Question - 4
• A 5-year-old boy presents to the emergency room
with a rash on his arms and legs that abruptly started
3 days ago. Other symptoms include the development
of oral ulcers. On examination, you note an
uncomfortable child with symmetrically distributed
target lesions consisting of a dusky center surrounded
by pale edema and a darker violaceous rim. The rash
is located on the face and extremities with
involvement of the palms and soles, and the rash
spares the trunk. You also note blistering and
hemorrhagic crusting of the lips and oral mucosa. The
conjunctiva and genitalia are normal on examination.

• What is the most common underlying etiology

attributed for this rash?
a) Mycoplasma pneumoniae
b) Amoxicillin
c) Trimethoprim and sulfamethoxazole
d) HSV
e) Cefaclor
 Answers- 4
• d
– The clinical vignette is a description of erythema multiforme ( Figure 362-1 ). Erythema
multiforme is an acute, self-limited hypersensitivity reaction. The most common cause of
erythema multiforme is a recent HSV infection. As highlighted by the description, a cardinal
feature of erythema multiforme is the development of target lesions. The rash usually starts as
an erythematous, edematous papule that then rapidly progresses to a target lesion that can range
from 1 to 3 cm in size. A target lesion is defined by 3 zones: dusky, vesicular, or purpuric
center; a pale, edematous surrounding ring; and an erythematous or violaceous outer ring.
Features that help distinguish erythema multiforme from Stevens-Johnson syndrome (SJS)
include distribution (erythema multiforme is often distributed acrally where SJS is more often
on the trunk), lesion morphology (skin lesions in SJS are often atypical targets with only 2
rings), and mucosal involvement (by definition SJS involves more than 1 mucosal surface). As
mentioned, HSV is the most common cause of erythema multiforme. Multiple medications, and
bacterial and viral infections have been implicated in cases of erythema multiforme, yet, by far,
the most common underlying cause is HSV. M. pneumonia e and trimethoprim and
sulfamethoxazole are 2 of the most common causes of SJS. Cefaclor is classically associated
with serum-like sickness.
Question - 5
• Which disorder can be associated with
persistent extensive dermal melanocytosis
(Mongolian spots) that affects the ventral and
dorsal trunk, and can progress over time?
a) Tuberous sclerosis
b) Hurler syndrome
c) Menkes kinky hair syndrome
d) Neurofibromatosis type 1
e) Neonatal lupus erythematosus
 Answers- 5
•b
– Congenital dermal melanocytosis are ill-defined, homogeneous, gray-blue
patches, most often in the sacral and buttocks areas, that are present at birth (
Figure 361-3E ). The bluish discoloration is a result of active melanocytes in
the middle to lower dermis. These patches are quite common, present in nearly
85% to 100% of Asian neonates, more than 60% of African American neonates,
and almost 10% of Caucasian neonates. They can also be seen in extrasacral
sites such as the upper back, shoulders, arms, and legs, though less commonly.
Usually by 6 to 10 years of age the bluish discoloration will disappear, but in
approximately 5% of individuals they can have persistence into adulthood,
especially with patches located on the distal extremities. Extensive persistent
dermal melanocytosis that affects the ventral and dorsal trunk, and enlarges
over time can be a sign of a lysosomal storage disease (eg, Hurler syndrome or
GM1 gangliosidosis). Tuberous sclerosis, Menkes kinky hair syndrome,
neurofibromatosis type 1, and neonatal lupus erythematous are not associated
with persistent and progressive dermal melanocytosis.
Question - 6
This 4-week-old infant presents
to urgent care with a 2-day
history of an asymptomatic rash (
Figure 362-2 ). What is the most
likely pathogenic factor in this
child’s disease?
a) Delayed hypersensitivity to
baby shampoo
b) Hypersensitivity to
Malassezia furfur
c) Inherited dry and sensitive
skin
d) Inherited tendency toward
psoriasis (HLA-CW6)
e) Transplacental transfer of
anti-Ro antibodies
 Answers- 6
• E
This child has a rash characteristic of neonatal lupus erythematosus
(NLE) with annular, erythematous patches or plaques over the head
and neck. NLE may also present with diffuse facial erythema,
particularly in a periorbital distribution referred to as “raccoon eyes,”
or telangiectatic lesions. Extracutaneous manifestations of NLE
include permanent congenital heart block, thrombocytopenia,
leukopenia, hemolytic anemia, hepatitis, pulmonary disease, and
central nervous system involvement. NLE is caused by transplacental
passage of maternal anti-Ro (SSA), or less commonly anti-La (SSB),
or anti-U1RNP antibodies from mother to fetus. Atopic dermatitis
(inherited dry and sensitive skin) and contact dermatitis (delayed
hypersensitivity to baby shampoo) are usually not annular, polycyclic,
or well demarcated. Psoriasis rarely presents with facial lesions in
early infancy. Neonatal cephalopustulosis (hypersensitivity to M.
furfur ) is more papular and not so brightly erythematous.
Question - 7
What is the most common type of skin disease
in children with HIV?
a) Atopic dermatitis
b) Seborrheic dermatitis
c) Mucocutaneous candidiasis
d) Molluscum contagiosum
e) Verruca vulgaris
 Answers- 7
•c
Mucocutaneous infection is the most common type of skin
disease associated with HIV. Persistent oral candidiasis
and/ or candidal diaper dermatitis occur in more than 65%
of children with HIV infection. Other fungal infections
include unusual and severe patterns of tinea corporis,
tinea capitis, and onychomycosis. Cutaneous viral
infections such as molluscum and verruca vulgaris can be
particularly severe in children with HIV, but are less
common. Cutaneous inflammatory disorders such as
seborrheic dermatitis, eczema, and psoriasis are
exacerbated by HIV infection.
 Question - 8
• A 1-year-old boy is brought to urgent
care for evaluation of abrupt-onset
blisters on his face, abdomen, arms,
and legs over the past 2 days. He is
itchy and a little more fussy than
usual. He is afebrile and eating and
drinking normally. On examination,
you note multiple clustered tense
vesicles and bullae in a rosette
pattern on his face, trunk, and
extremities. He has no eye, mouth, or
genitourinary lesions. He is generally
well appearing with normal vital
signs.
• What is the most likely diagnosis?
a) Bullous impetigo
b) Bullous pemphigoid
c) Erythema multiforme (EM)
d) Linear IgA bullous dermatosis (LABD)
e) Stevens-Johnson syndrome
 Answers- 8
•D
• This is a description of LABD, also known as chronic bullous dermatosis of
childhood. LABD usually has its onset during the first decade of life after 1 year
of age. Typically, there is a sudden eruption of tense bullae and vesicles with
clustering into annular or rosetted arrays. The scalp, face, perineum, abdomen,
buttocks, and thighs are the most commonly affected sites, but the distal
extremities may also be involved. Some patients have mucous membrane
involvement. Scarring does not occur, but postinflammatory pigmentary
changes may be pronounced. Pruritus is a variable symptom LABD is often
initially misdiagnosed as bullous impetigo or bullous EM. Bullous impetigo
usually has a less generalized distribution and the vesicles and bullae are
flaccid or ruptured. Bullous EM should still have target lesions with a bullous
center, edematous ring, and peripheral erythema. Patients with Stevens-
Johnson syndrome must have involvement of at least 2 mucous membranes.
Bullous pemphigoid is less common than LABD in childhood and does not have
the classic rosettes of bullae, but biopsy is necessary to distinguish these 2
entities.
Question - 9
• A 2-month-old infant presents
with a solitary 0.5 cm firm, dome-
shaped, yellow-red papule on the
left temple. The parents state
that they did not notice the lesion
at birth. The subset of patients
with the above finding and which
other condition have an
increased incidence of
myelogenous leukemia?
a) Down syndrome
b) Noonan syndrome
c) Neurofibromatosis type 1
d) Tuberous sclerosis
e) Ataxia telangiectasia
Answers- 9
•C
– The infant described in the above vignette is
presenting with a juvenile xanthogranuloma (JXG),
which is characterized by an infiltration of histiocytes
into the skin. They commonly present within the first
year of life, and are on the head and neck most often.
Infants who present with JXG should be evaluated for
neurofibromatosis type 1 with a thorough clinical
examination, as this subset is at increased risk for
developing myelogenous leukemia. Patients with JXG
and Down syndrome, Noonan, ataxia telangiectasia,
or tuberous sclerosis are not at any increased risk for
myelogenous leukemia.
Question - 10
• You are evaluating a 3-year-old boy who presents to
the urgent care clinic with few scattered red-brown
papules on his torso. His mother is concerned, because
these lesions will occasionally be pruritic. When he
scratches these spots or when he takes a warm bath,
they will often flare up and become hive-like. What is
the most likely diagnosis?
a) Urticaria pigmentosa
b) Dermatofibroma
c) Langerhans cell histiocytosis
d) Dermatitis herpetiformis
e) Erythema multiforme
 Answers- 10
•A
• The boy in the vignette is exhibiting signs of urticaria pigmentosa, the
most common form of cutaneous mastocystosis in children. It presents
with varying numbers of red to brown macules, papules, or plaques on
any part of the body. They often produce a cobblestone-like appearance
to the skin. These lesions can cause a wheal and flare reaction, known as
Darier sign, when stroked (see Figure 19-5 ). Some medications, such as
aspirin, alcohol, morphine, codeine, thiamine, scopolamine, and
polymyxin B, can cause mast cell degranulation and thereby cause a
reaction. Also physical stimuli such as hot or cold baths or swimming
pools can induce acute mast cell granulation. Most children with urticarial
pigmentosa follow a benign, self-limited course with improvement or
spontaneous resolution within the first decade of life. Dermatofibroma is
usually a solitary, firm, light brown papule. Langerhans cell histiocytosis
can present with varying morphologies, but most commonly flat-topped,
scaly papules in the scalp. Dermatitis herpetiformis presents with very
itchy vesicles and papules. Erythema multiforme presents with target
lesions.
Question - 11
• A 2-month-old boy presents for a well-child visit. The infant
is growing and developing well. On examination, you notice
a total of 10 hemangiomas distributed on his scalp, back,
and thighs. They are well circumscribed, not ulcerated, and
on average 1.5 × 1.5 cm in size. The mother believes that
these have been increasing in size for the past month. The
infant is at risk of developing which of the following
conditions?
a) Kasabach-Merritt phenomenon (KMP)
b) Dandy-Walker malformation
c) Subglottic hemangioma
d) Hepatic hemangiomas
e) Congenital cardiac malformation
Answers- 11
•D
– Infants with 5 or more infantile hemangiomas are at increased risk of
extracutaneous hemangiomas. The most common extracutaneous hemangiomas
noted in these patients are hepatic hemangiomas. Therefore, infants with more
than 5 hemangiomas should undergo at minimum an abdominal ultrasound to
rule out visceral hemangiomas. Infants with hepatic hemangiomas are at risk of
developing high-output cardiac failure and hypothyroidism. Both Dandy-
Walker malformation and congenital cardiac malformations are features of
PHACE disorder. PHACE is classically associated with a large, segmental
facial hemangioma and not multiple localized hemangiomas. Subglottic
hemangiomas are most often associated with hemangiomas involving the
mandibular area, that is, “beard” hemangiomas; therefore, patients with
hemangiomas in this distribution should be referred to otolaryngology to rule
out airway hemangiomas. KMP is associated with kaposiform
hemangioendothelioma or tufted angiomas and is characterized by a
consumptive coagulopathy. KMP is not associated with infantile hemangiomas.
Question - 12
• A 10-month-old infant presents to the emergency room in
critical condition. The infant is lethargic and you notice a
large, indurated purple mass on the thigh with an
ecchymotic border. The mother states that the patient had a
“birthmark” in this area that has rapidly increased in size in
the last week. Labs reveal thrombocytopenia,
hypofibrigonemia, and elevated D-dimer. Which of the
following vascular anomalies is associated with this
condition?
a) Infantile hemangioma
b) Arteriovenous malformation
c) Rapidly involuting congenital hemangioma (RICH)
d) Tufted angioma
e) Angiokeratoma
 Answers- 12
•d
– The clinical vignette describes an infant with KassabachMerritt phenomenon
(KMP). KMP is characterized by thrombocytopenia from platelet trapping and
coagulopathy from consumption of coagulation factors in the vascular tumor.
– Kaposiform hemangioendothelioma and tufted angioma are the vascular tumors
associated with KMP—infantile hemangiomas are not associated with KMP.
Tufted angiomas can be present at birth or develop shortly after and can present
as either violaceous plaque or firm cutaneous nodule ( Figure 364-1D ).
Hypertrichosis is commonly found overlying tufted angiomas. RICH is present
at birth and is GLUT-1 negative ( Figure 364-1C ). Unlike infantile
hemangiomas, RICH have no growth phase and demonstrate accelerated
spontaneous involution often leaving skin atrophy. RICH is not associated with
KMP. Arteriovenous malformations are high-flow vascular malformations that
can lead to serious sequelae such as high-output cardiac failure, bony erosion,
or catastrophic bleeding but are not associated with thrombocytopenia and
coagulopathy. Angiokeratomas are benign vascular malformation of capillaries
with overlying hyperkeratosis
Question - 13
• A 2.5-month-old male infant presents with a rapidly
expanding vascular mass on the right upper eyelid. The
mother states she noticed a deeply red vascular papule a
couple weeks after he was born but this area has been
increasing in size recently. On examination, the infant is
well appearing but has a large, deeply red vascular tumor of
the upper eyelid occluding approximately 75% of the visual
field. Which of the following is the most appropriate
treatment?
a) Triamcinolone 0.1% ointment twice per day
b) Intralesional triamcinolone
c) Oral propranolol
d) Conservative watching
e) Referral for surgical debulking
Answers- 13
•C
– The majority of infantile hemangiomas do not require medical therapy as the natural time line
of hemangiomas involves spontaneous involution. The typical growth phase of infantile
hemangiomas is 4 to 6 months (deep or segmental hemangiomas can continue to grow up to 1
year of age) and then they start to slowly involute. However, certain hemangiomas are life or
disease threatening and require early aggressive medical therapy. Periorbital hemangiomas
place infants at risk of astigmatism and as they grow, they can obstruct the visual axis causing
amblyopia. The first-line treatment for disease threatening hemangiomas would be either oral
corticosteroid or oral propranolol. Since 2008, the efficacy of oral propranolol has been shown
in multiple case reports and case series and it is currently being used instead of oral
corticosteroids as a first-line agent in many institutions. The mechanism by which propranolol
acts to rapidly arrest the growth phase of hemangiomas and promote involution is unknown but
could be related to vasoconstriction or suppression angiogenesis factors such as basic fibroblast
growth factor (bFGF) and vascular endothelial growth factor (VEGF). Topical or intraregional
corticosteroids have inferior efficacy compared with oral corticosteroids or oral propranolol
when the desired effect is to quickly arrest hemangioma growth and promote involution. Given
the response of infantile hemangiomas to medical therapy or pulsed dye laser therapy, surgical
debulking is rarely used as first-line therapy. Other types of hemangiomas that would
necessitate referral and expedited treatment include life-threatening hemangiomas (high-output
cardiac failure or airway occlusion), nasal tip hemangiomas (risk of splaying ala cartilage),
extensive ear involvement (risk of permanent disfigurement), hepatic hemangiomas, airway
hemangioma, and hemangiomas complicated by large ulcerations
Question - 14
• The mother of a 4-year-old boy who you follow in your primary
clinic has several questions as to whether her son requires further
evaluation for a “birthmark” that he had as an infant. The mother
states that her son had a faint pink patch on his midforehead that has
faded over time. Pictures of the child as an infant reveal a pink patch
affecting the midline forehead and glabella. On today’s examination,
no vascular stain is appreciated and he otherwise has a normal
examination. What is the most appropriate next step in the
management of this patient?
a) Refer to neurology for developmental testing.
b) Refer to ophthalmology.
c) Reassurance that no further workup is needed.
d) CT head without contrast.
e) MRI of brain with and without contrast.
 Answers- 14
• C
– The clinical vignette describes an infant with a nevus simplex, commonly referred to as a
salmon patch. A nevus simplex is a common type of capillary malformation that affects the
glabella, eyelids, perinasal area, upper lip, and nape. It commonly fades by age 2; however,
lesions on the nape can persist much longer. Nevus simplex is not associated with underlying
pathology and does not require further referrals or testing. It can be quite difficult to
distinguish nevus simplex from a port wine stain particularly in the young infant. Nevus
simplex that involves the forehead tends to have a V-shaped distribution in the middle of the
forehead as opposed to following a trigeminal distribution. Furthermore, port wine stains
persist throughout the patient’s life. Port wine stains grow proportionally with child’s overall
growth and tend to darken overtime from a pink-red to a deep purple hue. Sturge-Weber
syndrome is a neurocutaneous syndrome characterized by a port wine stain in a V1
distribution, ipsilateral cerebral vascular malformations (cerebral atrophy, cortical
calcifications, and leptomeningeal vascular malformations), and ophthalmic abnormalities
(glaucoma, increased retinal vascularity). Patients with an isolated V2 or V3 distributed port
wine stain are not at increased risk for Sturge-Weber syndrome
Question - 15
• An infant is born with a large mass affecting the
left neck. On examination, you note a large skin-
colored mass that transilluminates and is
compressible with palpation. A karyotype reveals
an XO abnormality. Which is the most likely
diagnosis?
a) Infantile hemangioma
b) Thryoglossal duct cyst
c) Cystic hygroma
d) Venous malformation
e) Teratoma
Answers- 15
•C
– Macrocystic lymphatic malformations, also known as a cystic hygroma,
are caused by aberrant lymphatic channels and are often present at
birth. They commonly affect the head, neck, chest, and axilla. A
characteristic feature is that these lesions will enhance with
transillumination and this helps distinguish this lesion from other
vascular anomalies and tumors. Furthermore, cystic hygromas are
associated with karyotype abnormalities, most often Turner syndrome
but also Down syndrome, Noonan syndrome, and trisomy 18 and 13.
Cystic hygromas can be so large that they can be detected by in utero
ultrasound and can lead to life-threatening airway pathology requiring
tracheostomy. Diagnosis can be confirmed through imaging such as
MRI. The most common treatment is sclerotherapy. Infantile
hemangioma, venous malformation, and teratoma would not
transilluminate. A thyroglossal duct cyst is midline, rather than lateral
neck.
Question - 16
• Which of the following is involved in the
pathogenesis of acne vulgaris?
a) Abnormal desquamation of follicular keratinocytes
b) Exaggerated host response to Staphylococcus aureus
c) Excessive intake of chocolate products
d) Exaggerated host response to Pityrosporum
e) Repeated trauma to the skin
Answers- 16
•A
– Acne is a multifactorial disease, involving excessive or
increased sebum production, abnormal epithelial cell
proliferation and desquamation, microbial
proliferation, and inflammation. The primary
pathogenic step is believed to be abnormal
desquamation of follicular keratinocytes that results in
comedone or microcomedone formation. The primary
bacterium involved is P. acnes. Pityrosporum and S.
aureus are not involved in the pathogenesis of acne,
although both can cause pustules. Repeated trauma to
the skin (picking) is a sequela of acne and can lead to
scarring. Eating chocolate does not cause acne.
Question - 17
• A mother is concerned for her 2-year-old son because
he looks pale and is constantly found eating sand from
the sand box in the park. He is very picky eater and is
only taking a limited number of solids. You perform a
CBC with differential and discover the child has iron
deficiency anemia. What nail abnormality is most likely
associated with iron deficiency anemia?
a) Koilonychia
b) Onycholysis
c) Melanonychia striata
d) Nail pitting
e) Subungual debris
Answers- 17
•A
– Koilonychia can be seen in a variety of conditions including iron
deficiency anemia, hypothyroidism, hemochromatosis, and
lichen planus, or can be an autosomal dominant trait It can
present in infancy and if it is an isolated finding in infancy, it
resolves spontaneously over time. Onycholysis is the separation
of nail plate from nail bed and can be caused by trauma,
psoriasis, fungal or yeast infections, or certain medications.
Melanonychia striata are longitudinal brown or black bands that
can be present in melanocytic nevi or a lentigo in the nail
matrix. Nail pitting can be a normal variant or can be seen in
psoriasis, alopecia areata, or eczema. Subungual debris can be
seen in onychomycosis, but is not seen with iron deficiency
anemia.
Question - 18
• A 1-year-old child comes in for his well-child
check. On physical examination, you see 1- to
2-mm, transverse, white bands on the
fingernails. What should you screen for?
a) Asthma
b) Seasonal allergies
c) Lead poisoning
d) Milk protein intolerance
e) Child abuse
Answers- 18
•C
– The child in the vignette is presenting with Mees
lines, 1 to 2 mm transverse white bands on the
nails. These can often be seen with lead, arsenic, or
thallium poisoning. Seasonal allergies, asthma,
milk protein intolerance, and child abuse are not
associated with Mees lines
Question - 19
• A 6-month-old female infant is brought to
urgent care for a blistering diaper rash. The
mother reports a 4-day history of blisters that
easily rupture. The rash is limited to the
diaper area. On examination, the child is
afebrile and well appearing. In the diaper
area, there are scattered flaccid bullae and
moist superficial erosions, some with a
collarette of scale. The remainder of the skin
examination is normal.
• Which of the following is the most likely
diagnosis?
a) Epidermolysis bullosa
b) Friction blisters
c) Bullous impetigo
d) HSV
e) Staphylococcal scalded skin syndrome
Answers- 19
• C
– Bullous impetigo is caused by toxin-producing S. aureus strains that
cause blister formation in the epidermis just below the stratum
corneum, producing superficial flaccid bullae. Infants are most
commonly affected. There is a predilection for involvement of
intertriginous areas such as the diaper area, axillae, and neck folds. This
is in contrast to the more common nonbullous or crusted impetigo,
which is caused by S. aureus or less frequently group A β-hemolytic
streptococci (GABHS). Nonbullous impetigo presents in older children
and typically affects exposed areas such as the face, arms, and legs.
Treatment of bullous impetigo is with either topical or oral
antistaphylococcal antibiotics, depending on severity of infection.
Epidermolysis bullosa usually presents at birth in areas of trauma and
friction. Friction blisters would be quite unusual in this location and in
this age group. HSV presents with clusters of small monomorphous,
round vesicles or erosions. Staphylococcal scalded skin syndrome
presents with more generalized erythema and painful skin
Question - 20
• A 10-year-old girl is brought to urgent care by her mother
for a new skin rash that started 3 weeks ago. The rash is
intensely itchy. Topical over-the-counter hydrocortisone has
not improved the rash. On examination, she is well
appearing with an eruption consisting of many excoriations,
erythematous papules, a few vesicles, and 2 fine linear
plaques between her fingers. Which of the following is the
most likely diagnosis?
a) Papular urticaria
b) Atopic dermatitis
c) Scabies infestation
d) Viral exanthem
e) Tinea corporis
Answers- 20
• C
– This child’s clinical description is most consistent with the presentation
of scabies. The multiple different morphologies (papules, excoriation,
and burrows) are characteristic of scabies. Older children have the
classic distribution that can be generalized with accentuation in the
folds, umbilicus, and genitalia, and between the fingers. In older
children, the head and neck should be spared. Diagnosis is confirmed
by demonstration of a mite, egg, or scybala (feces) microscopically
from skin scrapings. First-line treatment is with permethrin 5% cream
that is approved in infants 2 months and older. Treatment should be
repeated about 1 week later. All household contact should be treated.
Mite control precautions should be taken. Papular urticaria, atopic
dermatitis, tinea, and viral exanthems can all be itchy, but do not have
the same polymorphous appearance, nor do they have burrows (fine
linear plaques).
THANKS