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DERMATOLOGY
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PGI Supplement November 2017
1. Which of the following play (s) a role in pathogenesis of
Rosacea:
a. Demodex folliculorum
b. Propionobacterium acne
c. H.pylori
d. Malassezia furfur
Rosacea Neena Khanna 5th/131
•• A pathogenic role for the follicular mite Demdex folliculorum
and the microaerophilic gram-negative bacterium Heliobacter
pylori is suspected
•• It is chronic skin disorder characterized by- erythema and
telangiectasia and punctuated by acute episodes of papules,
pustules and swelling
Rosacea: Causes www.medicalnewstoday.com
Experts are not sure what causes rosacea. The following related
factors are thought to contribute:
•• Abnormalities in facial blood vessels
•• Light skin color
•• Demodex folliculorum (microscopic mite): Demodex
folliculorum lives on human skin and usually causes no
problems. However, patients with rosacea have much higher
numbers of these mites than others do. It is unclear whether
the mites cause the rosacea, or whether the rosacea causes the
overpopulation of the mites.
•• H. pylori bacteria: H. pylori, a bacteria found in the gut,
stimulates the production of bradykinin, a small polypeptide
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known to cause blood vessels to dilate. Experts suggest that this
bacterium may play a role in the development of rosacea.
Family history (inheritance, genes)
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••
“A bug that causes infections in the intestines may play a role.
This bug, H pylori, is common in people who have rosacea. Scientists
cannot prove that H pylori can cause rosacea. Many people who do
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not have rosacea have an H pylori infection”- www.aad.org
“A mite that lives on everyone’s skin, demodex, may play a
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role. This mite likes to live on the nose and cheeks, and this is where
rosacea often appears. Many studies found that people with rosacea
have large numbers of this mite on their skin. The problem is some
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people who do not have rosacea also have large numbers of this mite
on their skin”- www.aad.org
Acne Rosacea Harrison 19th/352
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•• Acne rosacea, commonly referred to simply as rosacea, is an
inflammatory disorder predominantly affecting the central face.
•• It is characterized by the presence of erythema, telangiectases,
and superficial pustules but is not associated with the presence
of comedones.
•• Rosacea of very long standing may lead to connective tissue
overgrowth, particularly of the nose (rhinophyma) . Rosacea
may also be complicated by various inflammatory disorders
of the eye, including keratitis, blepharitis, iritis, and recurrent
chalazion. These ocular problems are potentially sight-
threatening and warrant ophthalmologic evaluation.
Answer
1. a. Demodex folliculorum; c. H.pylori
2. b. 50–70%Tricholoroacetic acid; c. 10-25% Podophyllin resin; e. Imiquimod (5% cream) 
 [Ref: Neena Khanna 5th/339,291; Roxburg 17th/55; Harrison 19th/1201]
•• “Acne vulgaris: Microbial colonization (Organism implicated)
includes- Propionibacterium spp. Especially P.acnes, malasse-
zia furfur and staph. epidermidis”- Neena Khanna 5th/121
2. Treatment for genital warts include (s):
a. 10–30% Tricholoroacetic acid
b. 50–70%Tricholoroacetic acid
c. 10-25% Podophyllin resin
d. Clindamycin
e. Imiquimod (5% cream)
Anogenital warts: Treatment Neena Khanna 5th/339
•• Topical podophyllin (25%)
•• Tricholoroacetic acid (50-100%)
•• Cryotherapy with liquid nitrogen
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•• Topical podophyllotoxin (0.5%)
•• Imiquimod (5% cream)
Table 1. (Harrison 18th): Treatment of External, Exophytic Anogenital
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Warts
I. Administered by provider
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A. Cryotherapy with liquid nitrogen or cryoprobe weekly
B. Podophyllin resin, 10–25% weekly for up to 4 weeks
tN C. Trichloroacetic acid or bichloroacetic acid, 80–90% weekly
D. Surgical excision
E. Other regimens
 1. Intralesionally administered interferon
 2. Laser surgery
II. Administered by patient
A. Podofilox, 0.5% solution or gel twice daily for 3 days, followed by
4 days without therapy. This cycle may be repeated four times.
B. Imiquimod, 5% cream 3 times per week for up to 16 weeks
Therapeutic Options  Harrison 19th/1201
Podophyllotoxin: Podophyllotoxin (0.05% solution or gel and
••
0.15% cream) induces necrosis of genital wart tissue that heals
within a few days.
•• Sinecatechins: Sinecatechins (15% ointment) is used to treat
genital warts but should not be used to treat vaginal, cervical,
or anal lesions.
•• Imiquimod (5% or 3.75% cream) is a patient-applied topical
immunomodulatory agent thought to activate immune cells
by binding to a Toll-like receptor—an event that leads to an
inflammatory response.
•• Cryotherapy (liquid nitrogen) for HPV-associated lesions
causes cellular death. Genital warts usually disappear after two
or three weekly sessions but often recur.
[Ref: Neena Khanna 5th/131; Roxburg 17th/166; Harrison 19th/352; Robbins 9th/1174]
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 Dermatology

Table 2. (Harrison 19th/1201): Recommended Treatments That Must Differential Diagnosis of Sporotrichoid Spread
Be Administered by a Clinician for Genital Warts and Other Human dermtuts.tripod.com
Papilloma virus–Associated Lesions •• Atypical Mycobacteria: Mycobacterium avium complex (including
Mycobacterium intracellulare and M avium), Mycobacterium
Variable Cryotherapy Surgical Laser Interferon marinum infection (fish tank granuloma), M kansasii,
Removal
•• lepromatous leprosy
Effectiveness Good Excellent Excellent Good •• lupus vulgaris
Recurrence Frequent Frequent Frequent Frequent •• sarcoidosis
•• Leishmania
Adverse Mild, well Mild, well Mild to Frequent,
effects tolerated tolerated moderate, moderately
•• Blastomycosis
well severe •• histoplasmosis
tolerated •• Pasteurella tularensis
•• Nocardia brasiliensis
Availability Good Good Fair Fair
•• Paecilomyces infection

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Cost Inexpensive Moderately Very Very
4. Agent (s) associated with allergic contact dermatitis:
expensive expensive expensive
a. Poison ivy
3. Sporotrichoid pattern is/are seen in: b. Nickel

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a. Sporotrichosis c. Gold
b. Lichen nitidus d. Paraphenylene diamine
c. Lichen planus e. Rubber

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d. Fish tank granuloma
Agents causing allergic contract dermatitis: Nickel, poison ivy,
e. Lupus vulgaris
rubber (mercaptobenzthiazole, thiouram), ethylene diamine,
tNneomycin, lanolin etc”- Roxburg 17th/123
“There are several infectious diseases that present as erythematous
“Vesicle: A small, fluid-filled lesion, <0.5 cm in diameter, raised
papules or nodules in a lymphocutaneous or sporotrichoid pattern,
above the plane of surrounding skin. Fluid is often visible, and the
i.e., in a linear arrangement along the lymphatic channels. The two
lesions are translucent (e.g., vesicles in allergic contact dermatitis
most common etiologies are Sporothrix schenckii (sporotrichosis)
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caused by Toxicodendron [poison ivy]) ”-Harrison 19th/339
and the atypical mycobacterium Mycobacterium marinum.
Additional causes include Nocardia, Leishmania, and other atypical Table 3: Harrison 19th/341
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mycobacteria and dimorphic fungi; culture of lesional tissue will aid

in the diagnosis”-Harrison 19th/366 Allergic Anywhere Localized erythema, vesicles, scale, and
Sporotrichoid lymphocutaneous infection is an uncommon contact pruritus (e.g., fingers, earlobes-nickel;
dermatitis dorsal aspect of foot- shoe; exposed
syndrome that is often misdiagnosed and improperly treated. Of
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surfaces – poison ivy)

the several hundred cases seen each year in the United States, the
majority are caused by Sporothrix schenckii, Nocardia brasiliensis, Table 4 (Neena Khanna 5th/113): Agents causing allergic contract
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Mycobacterium marinum or Leishmania brasiliensis. The dermatitis

“sporotrichoid” disease begins at a site of distal inoculation and
leads to the development of nodular lymphangitis”- www.aafp.org Agent Source
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Sporotrichosis: Sporotrichoid pattern- Neena Khanna 5th/317 Plants Parthenium Airborne exposure (so called
DDx for Sporotrichoid spread (www.coursehero.com): airborne contact dermatitis, ABCD)
•• Cat Scratch
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•• Anthrax Metals Nickel Costume jewelery and clips

•• TB/Tularemia Chromates Chromium plating and cement
•• Nocardia Leather in footwear
•• Sporotrichosis – mc Cosmetics Paraphenylene Hair dyes
•• Phaeohyphomycosis/Pyogenic bacteria diamine
•• Leishmania Fragrances Cosmetics, perfumes and
•• Atypical mycobacteria – mc shampoos
•• Tularemia
Formaldehyde Preservatives in cosmetics
•• Also, burkholderia mallei, cowpox, acanthomoeba spp, P. boydii)
Parabens Preservatives in cosmetics
Medicines Neomycin Topical antibiotics
Benzocaine Local anesthetics
Answer
3. a. Sporotrichosis; d. Fish tank granuloma; e. Lupus vulgaris  [Ref: Neena Khanna 5th/317,67; Roxburg 17th/; Harrison 19th/366]
4. a. Poison ivy; b. Nickel; d. Paraphenylene diamine; e. Rubber [Ref: Neena Khanna 5th/113; Roxburg 17th/123; Harrison 19th/339; Nelson 20th/3152]

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PGI Supplement November 2017

Agent Source “Pyogenic Granuloma (Lobular Capillary Hemangioma): A

pyogenic granuloma is a small red, glistening, sessile, or pedunculated
Rubber Mercapto mix Shoe soles and uppers papule that often has a discernible epithelial collarette”- Nelson
(additives)
20th/3127
Thiuram mix Rubber gloves Vascular malformations (angioma)/Capillary naevi
(additives)
Roxburg 17th/194-97
Contact Dermatitis Harrison 19th/345 •• Stork mark
•• Contact dermatitis is an inflammatory skin process caused by •• Port-wine stains
an exogenous agent or agents that directly or indirectly injure •• Capillary angioma
the skin. •• Cavernous haemangioma
•• In irritant contact dermatitis (ICD), this injury is caused by •• Lymphangioma circumscriptum
an inherent characteristic of a compound—for example, a •• Angiokeratoma
concentrated acid or base. •• Senile angioma (Campbell de Morgan spots, cherry angioma)
•• Agents that cause ACD induce an antigen-specific immune •• Capillary aneurysm

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response (e.g., poison ivy dermatitis) . The clinical lesions of •• Glomus cell tumour
contact dermatitis may be acute (wet and edematous) or chronic •• Pyogenic granuloma
(dry, thickened, and scaly), depending on the persistence of the Keratoacanthoma: Skin coloured nodule which develops a

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insult central horny plug —Neena Khanna 5th/386
•• The most common irritants encountered are chronic wet work,
Other Capillary Vascular Malformations www.dermnetnz.org
soaps, and detergents. Treatment should be directed toward
•• Angiokeratoma circumscriptum is a raised warty dark red-
the avoidance of irritants and the use of protective gloves or

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purple lesion that is most commonly found on the lower leg
clothing.
or foot. It is often covered with rough scaly patches of skin. In
•• The most common cause of ACD is exposure to plants, especially
tN many cases, they are present at birth but may also develop in
to members of the family Anacardiaceae, including the genus
childhood or adulthood.
Toxicodendron. Poison ivy, poison oak, and poison sumac are
•• Angiokeratomas are harmless lesions that usually require
members of this genus and cause an allergic reaction marked
no treatment. For cosmetic reasons or concerns of possible
by erythema, vesiculation, and severe pruritus. The eruption
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melanoma, surgical removal or laser therapy may be performed.
is often linear or angular, corresponding to areas where plants
have touched the skin. The sensitizing antigen common to these Table 5 (Nelson 20th/3122): Vascular Malformations
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plants is urushiol, an oleoresin containing the active ingredient

pentadecylcatechol. The oleoresin may adhere to skin, clothing, Type Examples
tools, and pets, and contaminated articles may cause dermatitis Capillary Port-wine stain
even after prolonged storage. Venous Venous malformation
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5. Which of the following is/are vascular malformation: Angiokeratoma circumscriptum (hyperkeratotic venule)
a. Campbell de Morgan spots
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Cutis marmorata telangiectasia congenital (congenital

b. Hutchinson freckle
phlebectasia)
c. Angiokeratoma
d. Keratoacanthoma Arterial Arteriovenous malformation
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e. Pyogenic granuloma Lymphatic Small vessel lymphatic malformation (lymphangioma

circumscriptum)
Campbell de Morgan spots: These are arteriovenous fistulas at the
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Large vessel lymphatic malformation (cystic hygroma)

dermal capillary level in sun exposed skin of older patients”- L and
B 26th/599 Keratoacanthoma (KA) is a relatively common low-grade
“Hutchinson freckle, also known as lentigo maligna, is a non- tumor that originates in the pilosebaceous glands and closely
familial precursor to lentigo maligna melanoma, which accounts for resembles squamous cell carcinoma (SCC). In fact, strong arguments
5-15% of cases of malignant melanoma. It is most frequent in the support classifying keratoacanthoma as a variant of invasive SCC.
head and neck”- radiopaedia.org/articles/hutchinson-freckle; Neena In most pathology/biopsy reports, dermatopathologists refer to
Khanna 5th/394 the lesion as “squamous cell carcinoma, keratoacanthoma-type.”
“Pyogenic granuloma: These share many histological emedicine.medscape.com
characteristics of haemangiomas and are probably a subtype Dermatofibroma (Histiocytoma, sclerosing haemangioma):
thereof ”- L and B 26th/600 contain large number of small blood vessels-Roxburg 17th/197
Dermatofibroma: Benign tumor of fibrous tissue”- Neena Khanna
5th/404
Answer
5. a . Campbell de Morgan spots; c. Angiokeratoma; e. Pyogenic granuloma
 [Ref: Nelson 20th/3122-28; L and B 26th/599-600; Schwartz 10th/411-13; 1666-69; Roxburg 17th/194-97]

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