Tumors of the Dermis: Questions

1. A 30-year-old woman presented with firm, tan papules on her leg that is less than 1 cm in size. With
time, the papule has flattened. The following are true of her condition, except:
a. dermal neoplasm called benign fibrous histiocytoma
b. may be caused by an abnormal response to injury and inflammation
c. common tumors appear to be partially composed of factor VII-positive dermal dendritic cells
d. most common form of this lesion is called dermatofibroma
e. biologic behavior of this lesion is indolent

2. Which of the following microscopic findings can most likely be seen from the woman in question # 1?
a. circumscribed dermal proliferation of spindle-shaped cells
b. epidermal hyperplasia characterized by upward elongation of hyperpigmented rete ridges
c. generalized thinning of the overlying epidermis
d. swirling alignment of spindled cells
e. metaplastic cells surrounding collagen bundles

3. The following are indicative of dermatofibrosarcoma protuberans:

a. honeycomb pattern produced from deep extension from the dermis into subcutaneous fat
b. closely packed fibroblasts arranged in a storiform pattern
c. subcutis infiltration, resembling “Swiss cheese” in appearance
d. all of the above
e. none of the above

4. In dermatofibrosarcoma protuberans, which gene mutation is involved in the overexpression &

increased secretion of PDGFβ that drives tumor cell growth?
a. translocation of fibroblast growth factor-1
b. translocation of collagen 1A1
c. translocation of epidermal growth factor
d. translocation of tumor growth factor β
e. none of the above

5. The following are true regarding dermatofibrosarcoma protuberans, except:

a. Well-differentiated, primary fibrosarcoma of the skin
b. Mitosis occurs rarely
c. They are slow-growing
d. Since they are malignant, they usually metastasize
e. none of the above

TUMORS OF CELLULAR IMMIGRANTS TO THE SKIN

1. A 3 year-old female presents with multiple red-brown macules and papules, pruritus (itching),
and flushing. Physical examination reveals that skin lesions can be produced by firm rubbing. A
biopsy of one of these skin lesions reveals perivascular collections of mononuclear cells that
stain positively with Toluidine blue or Giemsa stain. What is the correct diagnosis?
A. Mycosis fungoides
B. Merkel cell carcinoma
C. Weber-Christian disease
D. Letterer-Siwe disease
E. Urticaria pigmentosa

2. A 65-year-old man presents with multiple eczema-like lesions scattered over his body. These
lesions do not respond to topical steroid therapy. A biopsy of one of the lesions reveals a dermal
 infiltrate of atypical appearing mononuclear cells, some of which occupy spaces within the
epidermis. The peripheral smear exhibits atypical lymphocytes with markedly convoluted nuclei.
These malignant cells originated from
A. CD4-positive T cells
B. CD5-positive B cells
C. CD8-positive T cells
D. CD16-positive natural killer cells
E. CD21-positive B cell

3. What granules is demonstrated ultrastructurally by electron microscopy and

immunohistochemical staining with CD1 on the infiltrating cells confirm derivation from
Langerhans cells?

A. Fordyce granules
B. Birbeck granules
C. Keratohyalin granules
D. Sulfur granules
E. None of the above

4. This is a malignant CD4+ (T-helper) cell with a hyperconvoluted or cerebriform nucleus and a
histologic landmark of mycosis fungoides .
A. Langerhans cells
B. Signet ring cells
C. Sézary-Lutzner cell
D. Mast cell
E. None of the above
5. Identify the structure with purple cytoplasmic granules stained by Giemsa.

A. Langerhans cells
B. Signet ring cells
C. Sézary-Lutzner cell
D. Mast cell
E. None of the above
Disorders of Epidermal Maturation

1) What layer of the skin is thickened in this micrograph?

a. Stratum basale
b. Stratum lucidum
c. Stratum spinosum
d. Stratum corneum

2) An infant of 8 months shows signs of Xerosis, White fine scales; usually most prominent on the
extensor surface of the extremities with flexural sparing; although it is frequently associated with AD
which shows changes in flexural areas. Scales are coarser on the lower extremities, and hypo linear
palmo-plantar thickening. Which type of ichthyosis is the most probable cause?
a. Ichthyosis vulgaris
b. Congenital ichthyosiform erythroderma
c. Lamellar ichthyosis
d. X-linked ichthyosis

3) Which type/s of ichthyosis is autosomal recessive?

a. Ichthyosis vulgaris
b. Congenital ichthyosiform erythroderma
c. Lamellar ichthyosis
d. X-linked ichthyosis
e. B and C

4)Which type of ichthyosis seen in the picture?

a. Ichthyosis vulgaris
b. Congenital ichthyosiform erythroderma
c. Lamellar ichthyosis
d. X-linked ichthyosis
5) The statements are all true except?
a. All forms of ichthyosis exhibit a buildup of compacted stratum corneum that is associated with loss of
normal basketweave pattern
b. There is generally marked inflammation
c. Variations in the thickness of the epidermis and the stratum granulosum and the gross appearance and
distribution of lesions are used to subclassify these disorders
d. The primary abnormality in some forms of ichthyosis is defective desquamation, leading to retention of
abnormally formed scale

Acute Inflammatory Dermatoses

1. Which of the following choices is correct concerning urticaria

a. A common disorder of the skin characterized by localized mast cell degranulation and
resultant dermal microvascular hyperpermeability
b. Most often occurs before the age of 20
c. Individual lesions develop within minutes and do not fade until a few days
d. NOTA
e. AOTA
2. Choose the best answer
a. Mast cell-dependent, IgE-dependent urticaria: is an example of a TYPE IV reaction triggered
by the binding of IgE antibodies
b. Mast cell-dependent, IgE-independent urticaria: results from substances that directly incite
the degranulation process mast cells
c. Mast cell-independent, IgE-independent: triggered by local factors that increase vascular
permeability
d. A & B
e. B &C
3. A patient presents to the clinic with a red papulovesicular, oozing crusted rash with characteristic
raised scaling plaques. Patient claims to work as a gardener in a botanical garden for poisonous
plants and forgot to wear gardening gloves on his way to trim a a shrub. What is the possible
pathogenesis of his skin condition?
a. Reactive chemicals introduced at the epidermal surface modify self proteins, acting as
haptens, and these proteins become neoantigens an dupon re exposure, memory T
cells release cytokines and chemokines
b. Exposure to UV light alters the antigen causing the hypersensitivity reaction
c. Increased sebum production due to a response in androgen concentration
d. AOTA
e. NOTA
4. Which of the following is the correct staging of eczema development
 a. 1. Initial dermal edema and perivascular infiltration 2. Epidermal spongiosis and microvesicle
formation 3. Hyperkeratosis 4. Abnormal scaling along with progressive acanthosis
b. 1. Initial dermal edema and perivascular infiltration 2. Epidermal spongiosis and
microvesicle formation 3. Abnormal scaling along with progressive acanthosis 4.
Hyperkeratosis
c. 1. Epidermal spongiosis and microvesicle formation 2. Initial dermal edema and perivascular
infiltration 3. Abnormal scaling along with progressive acanthosis 4. Hyperkeratosis
d. 1. Epidermal spongiosis and microvesicle formation 2. Initial dermal edema with no
perivascular infiltration 3. Abnormal scaling along with progressive acanthosis 4.
Hyperkeratosis
e. NOTA

5. 24 yo patient presents to a clinic with a red, macular rash with a targetoid appearance. Upon
taking patient history, the patient was just recently prescribed with a beta-lactam antibiotic for her
tonsillitis and the lesion appeared a few hours after taking the said antibiotic. Which of the
following is/are true about the presented skin lesion?
a. Characterized by keratinocyte injury mediated by skin-homing CD8+ cytotoxic T lymphocytes
b. CD8+ cytotoxic T cells are more prominent in the central portion of the lesions
c. CD4+ helper T cells and langerhans cells are more prevalent in the peripheral zones
d. It is an uncommon self-limited hypersensitivity reaction to certain infections and drugs
e. AOTA

Chronic Inflammatory Dermatoses

1. A 30 year old man have well-demarcated, pink to salmon-colored plaques covered by loosely
adherent silver-white scale as shown above. Which of the following is least likely regarding its
pathogenesis?
A. Increased sebum production often in response to androgens
B. HLA-Cw*0602 allele
C. Lymphocytes produce growth factors for keratinocytes that contribute to epidermal thickening
D. Koebner phenomenon
E. NOTA

2. Which of the following is least likely regarding the disorder in the photo above?
A. Self-limited, resolving spontaneously 1 to 2 years after onset
B. Wickham striae appear as white dots or lines highlighted in the papules
C. Squamous cell carcinoma may occur in chronic mucosal and paramucosal lesions
D. Colonization of the skin by fungi Malassezia
E. NOTA

3. A 30 year old man is complaining of joint pain and lesions in his elbows, knees, scalp,
lumbosacral areas, and glans penis. Histology shows epidermal hyperplasia, parakeratotic scale,
and accumulation of neutrophils within the superficial epidermis. Which is most likely a
morphologic feature?
A. Individual lesions are macules and papules on an erythematous-yellow, often greasy base
B. Mounds of parakeratosis containing neutrophils and serum at the ostia of hair follicles
C. Early lesions may be dominated by inflammation, marked by the presence of small
pustules and erythema
D. Lesions consist of itchy, violaceous, flat-topped papules that may coalesce focally to form plaques
E. NOTA
 4. A 28 year old man came in with flat-topped pink-purple, polygonal papule has a white lacelike
pattern of lines in his wrists and elbows. Also seen are oral lesions that appear as white and
reticulated involving the mucosa. The picture above shows the histological exam, which of the
following is a least likely finding?
A. Dense, continuous infiltrate of lymphocytes along the dermoepidermal junction
B. Stratum granulosum is thinned or absent, and extensive overlying parakeratotic
scale
C. Dermoepidermal interface takes on an angulated zigzag contour (sawtoothing)

D. Presence of Civatte bodies anucleate, necrotic basal cells incorporated into the inflamed
papillary dermis
E. NOTA
5. Koebner phenomenon may be seen in:
A. Seborrheic dermatitis
B. Psoriasis
C. Lichen Planus
D. Both A and B
E. Both B and C

Blistering Diseases: Inflammatory Blistering Disorders

1. Several skin disorders give rise to vesicles or bullae (blisters) in the skin. The location of the bulla often
aids in the diagnosis. What disorder is most likely to produce the type of blister that is schematically
illustrated in the figure above?
A. Urticaria
B. Impetigo
C. Bullous pemphigoid
D. Pemphigus vulgaris
E. Acute eczematous dermatitis
ANS: C. Bullous pemphigoid

2. All of the following are true regarding pemphigus except:

A. The majority of individuals who develop pemphigus are in the fourth to sixth decades of life.
B. Men and women are equally affected by pemphigus.
C. It is a blistering disorder caused by autoantibodies that result in the dissolution of intercellular
attachments within the epidermis and mucosal epithelium.
D. AOTA
E. NOTA
ANS: E. NOTA

3. Ms. L.C. is a 36-year-old woman who has developed vesicular skin lesions over the past week. On
physical examination, she has multiple, 0.2- to 1-cm vesicles and bullae on the skin of her scalp, axillae,
groin, and knees. Many lesions appear to have ruptured, and a shallow erosion with a dried crust of
serum remains. A biopsy specimen of an axillary lesion examined microscopically shows epidermal
acantholysis and formation of an intraepidermal blister. The basal cell layer is intact. Which of the
following additional tests is most likely to explain the pathogenesis of the Ms. L.C.’s disease?
A. Immunostaining with antidesmoglein
B. Darkfield microscopy of vesicular fluid
C. HLA genotyping
D. Viral culture of vesicular fluid
E. Quantitation of serum IgE level
ANS: A. Immunostaining with antidesmoglein

4. Mr. K.C. is a 65-year-old man who has developed pruritus followed by blistering skin lesions over the
trunk, legs, and arms over the past month. On physical examination, there are 1- to 4 cm tense bullae,
particularly over flexural surfaces of skin. A biopsy of one lesion is examined microscopically by direct
immunofluorescence staining and shows a subepidermal bulla, with both IgG and C3 deposited linearly
along the dermal-epidermal junction. He is treated with topical corticosteroids, and a month later the
lesions are healed without scarring. Which of the following components of the skin has most likely been
targeted by an autoantibody in this man?
A. Reticulin
B. Hemidesmosome
C. Lamina densa
D. Keratinocyte cell membrane
E. Nucleus
ANS: B. Hemidesmosome

5. Mr. PSJ is a 32-year-old man who has had an outbreak of pruritic lesions over the extensor surfaces of
the elbows and knees during the past month. He has a history of malabsorption that requires him to eat a
special diet, but he has had no previous skin problems. On physical examination, the lesions are 0.4- to
0.7-cm vesicles. A 3-mm punch biopsy of one of the lesions over the elbow is performed and on
microscopic examination shows accumulation of neutrophils at the tips of dermal papillae and formation of
small blisters caused by separation at the dermoepidermal junction. Immunofluorescence studies show
granular deposits of IgA localized to tips of dermal papillae. Laboratory studies show serum antigliadin
antibodies. What is the most likely diagnosis?
A. Pemphigus vulgaris
B. Bullous pemphigoid
C. Erythema multiforme
D. Dermatitis herpetiformis
E. Contact dermatitis
ANS: D. Dermatitis herpetiformis

Noninflammatory blistering diseases

1. True about porphyria EXCEPT
A. Group of uncommon inborn or acquired disturbances of porphyrin metabolism
B. Cutaneous manifestations include urticaria and vesicles with scarring
C. Produces subepidermal blisters associated with IgA autoantibodies to fibrils that bind
epidermal BM to the dermis
D. Defects to specific pigments present in hemoglobin, myoglobin, and cytochromes
E. Blister at the dermoepidermal junction

2. False about porphyria EXCEPT

A. Affected subepidermal region contains ground glass appearance similar to a specific viral
infection
B. Fibrin and neutrophils accumulate selectively at the tips of the dermal papillae
C. Degranulation of eosinophils typically detected beneath the the epidermal basal cell layer
D. Shows dissolution or lysis of the intercellular bridges that connect squamous epithelial cells
E. Adjacent dermis contains vessels with walls that are thickened by glassy deposits of
serum proteins, including immunoglobulins

3. What type of Epidermolysis Bullosa are caused by mutations in BPAG2, the same protein that is
targeted by autoantibodies in bullous pemphigoid
A. Simplex type
B. Junctional type
C. Dystrophic type
D. Mixed type
E. AOTA

4. This type of Epidermolysis Bullosa shows an autosomal dominant mode of inheritance with defects at
the basal cell layer caused by mutations in keratin 14 and keratin 5
A. Mixed type
B. Dystrophic type
C. Juntional type
D. Simplex type
E. Simplex-dystrophic type

5. Most likely true of Epidermolysis Bullosa

A. The common feature is the proclivity to from blisters at sites of pressure, rubbing, or
trauma at or soon after birth
B. Presents with vesicles associated scarring that are exacerbated by exposure to sunlight
C. May present with urticarial plaques associated with severe pruritus
D. Blisters formed at early adulthood
E. Both A and B