Education

SELF-ASSESSMENT MiNI-PROGRAM LAMAR S. OSMENT, M.D.

A 57-year-old belligerent city dwelling Caucasian woman consulted the Dermatology Clinic complaining that "None of t h e doctors I've seen have helped me a b i t , and I've seen quite a few over t h e past 5 years." As the interview proceeded it was learned the initial lesion h a d appeared as a single erythematous pruritic papule on the left cheek. The lesion had spread slowly over the next f e w weeks and becatne a 5 cm erythematous slightly elevated plaque covering t h e nose and cheeks. A diagnosis of phototoxic dermatitis was considered, w h e n it became apparent from her reco r d that she took a thiazide diuretic daily. The solitary lesion improved slightly after being treated for 10 days with 1 % hydrocortisone cream, but intralesional injections of triamcinolone acetonide suspension, 10 mg per 1 cc, failed to add to the modest improvement already obtained. At this point the patient became discouraged and consulted a second physician, who suggested a biopsy. The histologic sections were those of subacute nonspecific dermatitis. Systemic oral corticosteroids were then administered. Two weeks later the lesion had improved about 50%. At this time the steroids were discontinued and the eruption underwent a marked exacerbation w i t h i n a week. The face was eventually affected by the process in its entire midportion. At this point she was seen in the Dermatology Clinc. 1 . Which one of the following conditions that one might consider in the

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from the Department of Dermatology, University of Alabama Medical College, Birmingham, Alabama

differential diagnosis of this patient's condition would most likely present a specific diagnostic histologic picture rather than one of nonspecific dermatitis? A. B. C. D.

Atopic dermatitis Discoid lupus erythematosus Dermatophytosis Seborrheic dermatitis

2. After examining the photograph accompanying this case history, which of the following tests which previously had not been done do you believe would likely be most helpful in establishing a diagnosis? A. B. C. D.

Examination with Wood's light Diascopy of the lesion Examination for NIkolsky sign Direct microscopic exam of scales

Examination with Wood's light, diascopy of the lesion, and the test for Nikolsky sign were all negative. Direct microscopic visualization of the scales showed fungal hyphae and arthrospores. A diagnosis of Tinea faciei was made and a culture of the organism was made on Sabouraud's medium. 3. Which of the following organisms would you most likely expect to grow on the media? A. Malassezia furiur 15. Trichophyton mentagrophyies, granular lorm. C. Trichophylon verrucosum D. Trichophyton rubrum

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INTERNATIONAL JOURNAL OF DERMATOLOGY

4. After 2 weeks, a colony grew containing the characteristics of Trichophyton rubrum. Which of the following modalities would now be inappropriate therapy? A. B. C. D.

Topical haloprogin Topical tolnaftate Topical sodium sulfacetamide Oral griseofulvin

Answers and Explanations 1. Correct answer is B, discoid lupus erythematosus. Dermatophytosis may be suspected if organisms were present in the stratum corneum. Atopic dermatitis, seborrheic dermatitis and dermatophytosis all have similar histologic findings in the subacute forms: spongiosis, intracellular edema, moderate acanthosis, and varying degrees of parakeratosis. A moderately severe mixed inflammatory infiltrate with lymphocytes predominating is usually present. 2. Correct answer is D. Only examination of the scales under the microscope is likely to give specific information. Either a positive or negative examination would be helpful. The other examinations, while interesting, would seldom be diagnostic. 3. Answer is D, Trichophyton rubrum. M. Furfur, the cause of tinea versicolor, is cultured with great difficulty. T. mentagrophytes (granular) and T. verrucosum

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5. In testing for delayed and immediate hypersensitivity to intradermal trichophyton experimentally, the highest correlation (for chronic dermatophyte infection) was found to be between susceptibility and: A. Lack of immediate sensitivity B. Presence of delayed sensitivity C. Lack of delayed sensitivity

are generally associated with infections acquired in a rural setting. 4. Answer is C, topical sodium sulfacetamide. This preparation is effective in treatment of Tinea versicolor but not superficial dermatophytes. 5. Answer is C. Delayed hypersensitivity (T-cell function) is a correlate of fungal immunity. Lack of delayed hypersensitivity or coexistent immediate hypersensitivity to trichophyton intradermal testing is associated with susceptibility to chronic tinea infections. References 1. Lever, W. F., Histopathology of the Skin. 3rd edition. Philadelphia, J. B. Lippincott, 1961. 2. Ceorge, L. K., Hand, E. A., and Merges, R. A., Observation on rural and urban ringworm. J. Invest. Dermatol. 27:335, 1956. 3. Jones, H. E., Reinhardt, ). H., and Rinaldi, M. C, A Clinical, Mycological, and Immunological Survey for Dermatophytosis. Arch. Dermatol. 106:61, 1973. Triamcinolone acetonide suspension: Kenalog—10 injectible