Upload
others
View
2
Download
0
Embed Size (px)
Citation preview
be used to describe the rash appro-priately, both in the chart and incorrespondence to other physi-cians. When looking at the shapeof the lesions, it is helpful to deter-mine if they were self-induced bythe patient (excoriation by a finger-nail) or naturally caused (a plantarheel fissure). One should documentif the lesions are plantar foot, dor-sal foot, or proximal on the lowerleg. Nail involvement should benoted. Finally, the fingernails anddorsum and palmar aspects of thehands should be examined as manyskin dermatoses mirror the pedalinvolvement there.
Continued on page 176
Welcome to Podiatry Management’s CME Instructional program. Our journal has been approved as a sponsor of Contin-uing Medical Education by the Council on Podiatric Medical Education.
You may enroll: 1) on a per issue basis (at $20.00 per topic) or 2) per year, for the special introductory rate of $139 (yousave $61). You may submit the answer sheet, along with the other information requested, via mail, fax, or phone. In the nearfuture, you may be able to submit via the Internet.
If you correctly answer seventy (70%) of the questions correctly, you will receive a certificate attesting to your earned credits. You willalso receive a record of any incorrectly answered questions. If you score less than 70%, you can retake the test at no additional cost. A listof states currently honoring CPME approved credits is listed on pg. 182. Other than those entities currently accepting CPME-approvedcredit, Podiatry Management cannot guarantee that these CME credits will be acceptable by any state licensing agency, hospital, man-aged care organization or other entity. PMwill, however, use its best efforts to ensure the widest acceptance of this program possible.
This instructional CME program is designed to supplement, NOT replace, existing CME seminars. Thegoal of this program is to advance the knowledge of practicing podiatrists. We will endeavor to publish high quality manuscripts bynoted authors and researchers. If you have any questions or comments about this program, you can write or call us at: PodiatryManagement, P.O. Box 490, East Islip, NY 11730, (631) 563-1604 or e-mail us at [email protected].
Following this article, an answer sheet and full set of instructions are provided (p. 182).—Editor
APRIL/MAY 2010 • PODIATRY MANAGEMENTwww.podiatrym.com 175
tice the color, shape, and size in ad-dition to laterality of the lesions on
the lower extremity. Primary andsecondary lesions (Table 1) should
By Tracey C. Vlahovic, DPM, FAPWCAand Michelle Oliver, BA
Apatient first presenting witha red, scaly, itchy foot or legcan prove to be a challenge
to diagnose and manage. Whenfaced with a patient with an in-flammatory skin condition in theoffice, the podiatric physicianshould have a systematic approachto arrive at a baseline differentialdiagnosis: observe, ask, and applyan algorithm.
ObserveUpon entering the treatment
room, the practitioner should no-
Objectives
1) To provide asystematic approachto examining andtreating inflamma-tory skin conditions
2) To discuss themost common skinconditions seen inthe podiatric practi-tioner’s office
3) To discuss thefirst line treatmentfor inflammatoryskin disorders
Continuing
Medical Education
Plaque psoriasis
presents as
an erythematous
plaque with a
silvery scale.
The authors present a systematic approach toexamining and treating inflammatory skinconditions.
DifferentiatingDermatologicalDiagnosis andTreatment
C O N T I N U I N G M E D I C A L E D U C AT I O NC O N T I N U I N G M E D I C A L E D U C AT I O N
the dermis from a pathology per-spective.
Other questions to consider ask-ing patients are the color of socksthey wear (azo dyes in blue sockscan be a potential allergen), occu-pation, and any associated dailyhazards. Also, oneshould ask aboutboth over-the-counter andhomeopathic ornatural treatmentoptions they havetried. In order toplan for a possi-ble in-office biop-sy during thatvisit, it is impor-tant to ask whatthe natural pro-gression of the le-sions has beenand where thenewest crops oflesions are.
Now thatbasic observationand questioninghave occurred,it’s important todelve more deeply into the chiefcomplaint and examine the skinfully. Common skin signs of in-flammation are calor (heat), rubor(redness), tumor (swelling) and pru-ritis (itching), which ultimatelypoint to skin barrier dysfunction.The skin barrier, which is stratumcorneum with the lipid-enrichedextracellular matrix surroundingthe corneocytes, is the body’s pro-tective wall and regulates home-
ostasis, trans-epidermal water loss,and prevents entry of foreign parti-cles and pathogens into the body.Trans-epidermal water loss is thenewest target in the dermatologicalpharmaceutical armamentarium inorder to reduce skin flares and com-
fort the patientwith an inflam-matory skin der-matosis.
Apply anAlgorithm
To begin for-mulating a differ-ential diagnosis,there is a basic al-gorithm to followfor treating themost commonskin disorders en-countered in theoffice: is it aplaque, scale, orzebra? (Table 2) Awell-defined andgeometric shapedplaque is oftenpsoriasis, buteczema and
lichen planus also must be consid-ered. Circular, serpiginous scales aremost often tinea but xerosis shouldbe ruled out. Remember that tineapedis is KOH positive and may in-volve both the interspaces and theplantar foot. Any papules, vesiclesor other skin markings are consid-ered “zebras” for this algorithm’spurpose.
Following the above algorithm,the most common inflammatory
skin conditions thepodiatric practition-er will encounter areas follows:
PlaquePlaque psoria-
sis presents as anerythematous plaquewith a silvery scale.These lesions are ge-ographic, bilateral,and symmetrical,and typically occuron the extensor sur-faces. The plaquescan also be pruriticand affect joints aswell as the nails dur-
Continued on page 177
176 www.podiatrym.comPODIATRY MANAGEMENT • APRIL/MAY 2010
Differentiating...
AskQuestions that will help form
differential diagnoses should beasked while completing the physi-
cal exam of the skin. Often, the pa-tient will answer a question thatwill help direct the diagnosis. Be-yond asking the history of presentillness, past medical history andfamily history, the podiatric physi-cian should consider asking if thereis a personal or family history of al-lergic rhinitis, sensitive skin, asth-ma or skin cancer. The patientshould be asked if he has ever seena dermatologist before and if he hasany skin lesions or “rashes” any-where else on the body that may ormay not be similar to what is seenon the feet.
Unfortunately, most patients donot correlate what is happening onthe rest of the body to what is man-ifesting on the plantar aspect of thefeet. It is the physician’s responsi-bility to ask the questions in orderto make that connection. It is help-ful to ask if the skin has ever beenbiopsied (for example, “did youhave a piece of skin removed andthen have stitches?”). A skin scrap-ing for KOH that was completed byanother physician does not countas a proper biopsy to base the diag-nosis on, as a biopsy of inflamma-tory skin disorders should include
Continuing
MedicalEducation
TABLE 1
Primary Skin Lesions:MaculePatchPlaqueNoduleVesicleBullaeWhealTelangiectasia
Secondary Skin Lesions:UlcerAtrophyScaleCrustErosionExcoriationScarLichenification
TABLE 2Algorithm
Plaque—� Consider psoriasis, lichen planus,eczema
Scale—� Consider xerosis, tinea pedis,ichythosis, non-inflamed to mildly inflamedpsoriasis and eczema
Zebra—� Blisters? Bullous diabeticorum,pemphigus, drug reaction
Target lesions? Erythema multiformeminor, drug reaction
Trans-epidermal water
loss is the newest
target in the
dermatological
pharmaceutical
armamentarium in
order to reduce skin
flares and comfort the
patient with an
inflammatory skin
dermatosis.
Wickham’s stri-ae, which is the finewhite lacy overlay onthe plaques, may also beseen. This skin condition canbe so pruritic that activities ofdaily living may be compromised.It may also affect the toenails, ap-pearing anywhere from a proximalsubungual onychomycosis-like pre-sentation to a thinning of the nailwith a ‘wing’ of skin or pteryigiumpointing distally (Figure 4).1 Nailinvolvement should be treated im-
mediately as it can irreversibly scarthe nail unit. Lichen planus canalso form lesions in the mouth.2
Case Example #2A young male presented with
numerous small plaques andpapules that wereextremely pruritic(Figure 5). He hadbeen diagnosedwith tinea pedis,and had triedover-the-counterantifungals withno improvement.During his officevisit, the extent ofinvolvement ofthe nails and oralcavity were notedand a diagnosis oflichen planus wasmade.
In addition topsoriasis and
lichen planus, a scaly erythematousrash with fissures could also be aneczematous reaction pattern. De-fined plaques may or may not bepresent, but eczema should be a dif-ferential diagnosis when consider-ing psoriasis. An eczematous reac-tion that is often seen is atopic der-matitis. This is usually inherited, as
APRIL/MAY 2010 • PODIATRY MANAGEMENTwww.podiatrym.com 177
arthritic component of psoriasiswhich may manifest in dactylitis ofthe digits (sausage toes), enthesitisof the Achilles tendon, and distalinterphalangeal joint involvement.
Case Example #1A young male patient presented
to the clinic with a pruritic andscaly plantar rash (Figures 2-3) thatwas mis-diagnosed as tinea pedis atthe emergency department. He hadpresented there for painful fissureson his feet that prevented himfrom walking properly. He wasgiven oral ketoconazole at the EDand then presented to the office. Apunch biopsy was taken confirmingthe clinical suspicion of psoriasis,and topical corticosteroid therapywas implemented. The patienthealed unevent-fully from theacute flare andpresents periodi-cally for mainte-nance treatment.
If the patientpresents with cir-cular papules orplaques with little
or nos c a l et h a textendproxi-ma l l yf r o mt h ef o o t ,the differential diagno-sis of psoriasis thatshould be considered islichen planus. Lichenplanus is characteristicof the “P’s”: plentiful,pruritic, purple, pol-ished, popular and pla-nar lesions that are bi-lateral and symmetrical.
ing the progression of the disease.Psoriasis can develop either inchildhood or as an adult. Besidesplaque psoriasis, pustular psoriasisappears as sterile pustules on theplantar foot.
P l a n t a rplaque andpustular pso-riasis are fre-quently mis-diagnosed aseither vesicu-lar or moc-casin tineapedis. Due tothe fissuring
that often accompanies psoriaticplaques, it has also been misdiag-nosed as xerosis. If the patient’scurrent treatment consists of eitheran oral or topical antifungal, andisn’t improving the skin conditionwithin the appropriate time frame,a biopsy of the skin, in order to de-termine if a topical steroid shouldbe used, is warranted. Upon exami-nation of one patient, the handswere also involved. A skin biopsy ofthe plantar foot lesion revealed pso-riasis, and the patient was started
on first-line therapy:topical corticosteroids.
Also, if the patientonly presents with ony-chomycosis-like nail in-volvement and has notresponded to oral anti-fungals, a diagnosis ofpsoriatic nail diseaseshould be considered.Another clue to aid inthe diagnosis of psoriat-ic nails includes exam-ining for the presence oferythema peri-ungually,onycholysis, and pitting(Figure 1).1 Patients mayalso present with the
Differentiating...
Continued on page 178
Continuing
Medical Education
Figure 2: Psoriasis upon first presenta-tion
Figure 3: Psoriasis uponone month of using topi-cal steroid therapy
Figure 1: Nail diseasein psoriasis
Figure 4: Nail involvement in lichenplanus
Figure 5: Pedal lichen planus
Lichen planus
is characteristic of
the “P’s”: plentiful,
pruritic, purple,
polished, popular and
planar lesions that
are bilateral
and symmetrical.
plantar feet and doesn’t have to bebilateral and symmetrical.
Patch TestThe patch test
done in an aller-gist’s or dermatol-ogist’s office willassist in pin-point-ing the allergencausing the reac-tion. When pa-tients have a his-tory of chronic ve-nous insufficiencywith skin that be-comes indurated,inflamed, andpruritic, venous stasis dermatitis isthe standard diagnosis. Since stasisdermatitis is the most commoncause of an id reaction on thepalmar aspect of the hand, it isimportant for the physician toexamine the hands to aid inthe diagnosis. L a s t l y ,dyshidrotic eczema is a specificcondition that should not bean overall term applied to anyinflamed skin condition. Con-trary to its name, it is not
linked tosweat glanddysfunction.D y s h i d r o t i ceczema (pom-pholyx) character-istically has prurit-ic tapioca pud-ding-like blisterson the palmar as-pect of the handswith minimal footinvolvement.4 Thiscan be a self-limit-ing condition;however, most pa-tients have debili-tating pain and fis-suring that can bedifficult to treat.
Case Example #3A female patient presented with
denuded and inflamed skin on theanterior tibia (Figure 6). She report-ed that this began after the use oftriple antibiotic ointment. Uponfurther history and examination ofthe patient, a working diagnosis ofallergic contact dermatitis to thepreservatives in triple antibioticointment was made. The drug was
removed from the patient’s regi-men, and topical steroids weregiven. The patient’s inflamed skin
resolved in fourweeks.
ScaleXerotic, or
dry skin, shouldhave scales pre-sent within theskin lines on theplantar foot. Moc-casin tinea pedis,on the otherhand, usually pre-sents with smallserpiginous scales
plantarly. The most common formof dry skin that is KOH negative en-countered on the lower extremity is
termed asteatotic or xerotic eczema.It can also be termed erythemacraquele. This is commonly knownas “winter itch” due to its increasedseverity especially during the win-ter months in the northern part ofthe United States.
Asteatotic eczema commonlypresents on the anterior aspect of the
leg as pruritic, annular, scalingpatches. This condition is frequentlymisdiagnosed as tinea corporis, but is
Continued on page 179
178 www.podiatrym.comPODIATRY MANAGEMENT • APRIL/MAY 2010
Differentiating...
patients will present with apersonal or family history of
asthma, hay fever, and skin rashappropriate for their age. It is oftendescribed as an “itch that gets arash” and can’t be described as hav-ing a primary lesion as is the casewith psoriasis and lichen planus.3
Atopic dermatitis, like the otherforms of eczema, can be describedas having an acute, sub-acute, andchronic stage of the disease. Duringthe acute phase, patients experi-ence intense pruritus with an ery-thematous scaling and oozing skinrash. Clinically, this can also ap-pear as dry skin eczema, contactdermatitis, stasis dermatitis or evena dermatophyte infection. Sub-acute forms of atopic dermatitispresent with less pruritus, erythe-ma, scaling, and fissured skin rash.
Chronic eczema presents withpruritus, hyper- and hypopigmentedplaques of previous inflamed skin,scaly and lichenified skin. Due to thesevere skin barrier disruption in allforms of atopic dermatitis, these pa-tients are susceptible to secondarybacterial infec-tions and thisshould be consid-ered in the treat-ment plan. Over-all, differential di-agnosis for atopicdermatitis include:tinea pedis, con-tact dermatitis,lichen simplexchronicus (chron-ic form of atopic)and dyshidrosi-form eczema.
If the patientdoesn’t fit intohaving the“triad” of atopicdermatitis, othertypes of eczemashould be considered. Allergic con-tact dermatitis can occur when apatient has developed sensitivity toa product (detergent, soap, glue,dye) after using it for a length oftime. Allergic contact dermatitis is aresult of an antigen-antibody reac-tion that presents eight to twenty-eight days after initial introductionto the allergen. Contrary to belief, acontact dermatitis can occur on the
Continuing
MedicalEducation
Since stasis dermatitis
is the most common
cause of an id reaction
on the palmar aspect
of the hand, it is
important for the
physician to examine
the hands to aid in
the diagnosis.
Figure 6: Allergic contact dermatitis
Figure 7: keratoderma climacterum
Asteatotic eczema
is also seen in
patients with
dementia who
bathe frequently.
APRIL/MAY 2010 • PODIATRY MANAGEMENTwww.podiatrym.com 179
arch with no underlying erythema(Figure 8). A biopsy helped to diag-nose her with psoriasis and the ap-propriate therapy commenced.
ZebraIf vesicles, bulla, or other skin le-
sions are present,the podiatricphysician shouldconsider severalother diagnoses. Adiabetic patientwho presents withtense blisters thatseem to appearovernight, mostlikely has bullosisd i abe t i co rum. 5
Bullosis diabetico-rum may have lit-tle inflammationpresent and mayheal uneventfullyif the patient does-n’t pop or scratch
them. Bullous pemphigoid, com-monly seen in older adults in nurs-ing homes, will present with subepi-dermal blistersthat originallywere urticarialplaques thatturned into tensebullae. These le-sions are locatedw i d e s p r e a dthroughout thebody on flexuralsurfaces.
N i k o l s k y ’ ssign, or exfolia-tion of the upperlayers of epider-mis upon rubbingof the skin, isnegative andthese lesions cancrust, pigment,but not scar un-less excoriatedinto an ulcer.Pemphigus vul-garis is a chronicdisease affectingadults which canbe life-threaten-ing due to its le-sions beginningin the mouth and affecting the oro-pharyngeal area. Flacid bullae thenprogress to the face, neck, chest,groin and intertriginous areas.
KOH negative. Asteatotic eczema isalso seen in patients with dementiawho bathe frequently. Patients canalso develop dry, cracked heels plan-tarly which is known as keratodermaclimacterum (Fig-ure 7).
In addition tothese environ-mental causes ofdry skin, themost common in-herited form isichthyosis vul-garis. These pa-tients presentwith fish scale-like dryness thatmay improvewith age.Ichthyosis vul-garis can also beacquired and maybe associatedwith diabetes, renal disease, andvarious types of cancer.
Circular scales with serpiginous
borders are often diagnosed as tineapedis, but other skin conditionsthat present as small circular, scalyrimmed lesions are pityriasis roseaand secondary syphilis. There havealso been instances of plantar psori-asis presenting as scaly skin with noerythema.
Case Example #4A female patient presented to
the clinic for a second opinion. Shehad been previously diagnosed ashaving xerosis, but continued tohave extreme pruritus that was notcontrolled by any topical medica-tion. Her plantar feet had a local-ized plaque with scale in the medial
Differentiating... These are tender lesionsand are usually Nikolsky’ssign positive.
If patients have target lesionswith three zones of color (center le-sion surrounded by a clear zone,and followed by a red border) asso-ciated with circular papules and/orplaques with mild scaling; onemust consider erythema multi-forme minor. This is associatedafter a manifestation of herpes sim-plex (recent cold sore or genital le-sion) and the target lesions maypresent on the feet.6 Drug reactionsmay also present as target-like le-sions with less defined target zonesof color on the lower extremity.
First-Line Treatment OptionsWhen treating a condition that
is fungal, bacterial, or inflammato-ry in nature, the podiatric practi-tioner should use the appropriatedrug, but if one is unsure of thecause, a biopsy of the skin lesionshould be completed. Inflammato-ry skin conditions often warranttopical corticosteroid therapy as a
first line methodin treatment.
It is useful toavoid combina-tion steroid-anti-fungal drugs orm e t h y l p r e d -nisolone dosepacks as thesemay create aquick fix, but ulti-mately can causefrustration for thedermatologica lpatient. The re-bound effect fromthe dose pack canbe potentially de-bilitating by caus-ing a dermatitisthat is worse thanthe original reac-tion, and the dosepack itself isn’tthe same as pre-scribing a trueprednisone taper.
When indoubt, the first linetherapy for an in-
flammatory skin dermatosis should be atopical steroid and a skin moisturizer orkeratolytic (such as urea or lactic acid).
Continued on page 180
Continuing
Medical Education
Dyshidrotic eczema
(pompholyx) charac-
teristically has pruritic
tapioca pudding-like
blisters on the palmar
aspect of the hands
with minimal foot
involvement.
Figure 8: Psoriatic Scale plantarly
A diabetic patient who
presents with tense
blisters that seem to
appear overnight,
most likely has
bullosis diabeticorum.
Pemphigus vulgaris is
a chronic disease
affecting adults which
can be life-threatening
due to its lesions
beginning in the
mouth and affecting
the oro-pharyngeal
area.
should be added to decrease trans-epidermal water loss and decreaseflares.7 If the patient is in the sub-
acute or chronic stage and a topicalsteroid is warranted for the level ofirritation and pruritus present, thepractitioner should prescribe theappropriate steroid class (Table 3).
The goal in treating inflamma-tory conditions is to ultimatelyhave the patient use little to notopical steroid, and use the previ-ously mentioned skin moisturizersas maintenance, if possible. If thepatient does not respond to the
topical steroid aspredicted, furtherconsideration ofother diagnosesshould be givenand a biopsyshould beplanned. If this isnot within thecomfort zone ofthe practitioner,he should thenrefer the patientfor a dermatologyconsult.
Overall, in-flammatory skindermatoses can bechallenging andfrustrating forboth the practi-
tioner and patient. By doing a thor-ough history and skin exam, the as-tute practitioner can create a work-ing list of differential diagnosesthat can be further changed byboth reaction to treatment and, ofcourse, a biopsy result. �
References1 Zaiac MN and Daniel CR: “Nails in
Systemic Disease,” Dermatol Ther, vol15, 2002, pg 99-106.
2 Bolognia JL, Jorizzo JL, Rapini RP.Dermatology. Volumes 1 and 2, 1st edi-tion, 2003.
3 Brenninkmeijer EE, Schram ME,Leeflang MM, Bos JD, Spuls PI. Diagnos-tic criteria for atopic dermatitis: a sys-tematic review. Br J Dermatol. Apr2008;158(4):754-65.
4 Lofgren SM, Warshaw EM.Dyshidrosis: epidemiology, clinicalcharacteristics, and therapy. Dermatitis.Dec 2006;17(4):165-81
5 Cantwell AR Jr, Martz W. Idiopathicbullae in diabetics. Bullosis diabeticorum.Arch Dermatol. Jul 1967;96(1):42-4.
6 Huff JC. Erythema multiforme andlatent herpes simplex infection. SeminDermatol. Sep 1992;11(3):207-10.
7 Cork MJ, Danby S. Skin barrierbreakdown: a renaissance in emollienttherapy. Br J Nurs. Jul 23-Aug 122009;18(14):872, 874, 876-7.
180 www.podiatrym.comPODIATRY MANAGEMENT • APRIL/MAY 2010
Differentiating...
The stage (acute, sub-acute,a n d
ch ron -ic) ofthe skindisorderand thel e n g t hof timethe con-d i t i o npresentswill aidin thelevel oftop i c a ls t e ro idw h i c hs h ou l dbe used.
F o rthe severe, acute inflammatory skinconcerns, Class 1 drugs should beused for two weeks consecutively.Some examples of Class 1 steroidsinclude: clobetasol (Clobex, Olux,Temovate), betamethasone (Dipro-lene), diflorasone (Psorcon), halobe-tasol (Ultravate), fluocinonide(Vanos).
In the author’s experience, norefills are given due to the side-ef-fects of using a Class I steroid forlonger than four-teen days. Side-effects includeskin thinning oratrophy whichcan lead tostretch marks,telangiectasias,and hypopig-mentation, toname a few. It ishelpful to titratedown from aClass 1 steroid toa mid-potencypreparation afterthat initial twoweek period.
For example,one could havethe patient use aClass 1 steroid on Monday,Wednesday, and Friday with themid-potency topical steroid for thedays in between.
The fairly new skin barrier pro-tection emollient moisturizers (Im-pruv lotion, Mimyx, Atopiclair)
Continuing
MedicalEducation
Dr. Vlahovic is an Associate Profes-sor at Temple University School of Podi-atric Medicine.
Ms. Oliver is a fourth year student atTemple University School of PodiatricMedicine, Philadelphia, PA.
TABLE 3Topical Steroid Classes
Class I: Ultra potentClass II: PotentClass III: Upper mid-strengthClass IV: Mid-strengthClass V: Lower-mid strengthClass VI: MildClass VII: Least potent (hydrocortisone)
Adapted from the National Psoriasis Foundation Topical Steroids PotencyChart
Side-effects of using a
Class I steroid for
longer than fourteen
days include skin
thinning or atrophy
which can lead to
stretch marks,
telangiectasias, and
hypopigmentation.
When in doubt,
the first line therapy
for an inflammatory
skin dermatosis
should be a topical
steroid and a skin
moisturizer or
keratolytic
(such as urea
or lactic acid).
APRIL/MAY 2010 • PODIATRY MANAGEMENTwww.podiatrym.com 181
an ID reaction is:
A) Atopic dermatitis
(eczema)
B) Irritant contact dermatitis
C) Stasis dermatitis
D) Lichen simplex chronicus
7) Which of the following
doesn’t the patient need to have
to diagnose of atopic dermatitis
(eczema)?
A) paronychia of great toe
B) personal history of
asthma, runny nose, skin rash
C) pruritis
D) chronic relapsing course
8) Asteatotic Eczema (Eczema
craquele) is associated with:
A) children
B) high humidity
C) frequent bathing
D) hyperhidrosis
9) Bullosa diabeticorum
(diabetic bullae) usually appear
as ____ blisters on the lower
extremity.
A) tense
B) flaccid
C) pus-filled
D) hemorrhagic
10) Pemphigus vulgaris lesions
most commonly begin in this
location:
A) Pretibial
B) Soles
C) Thighs
D) Mouth
1) All of the following are
primary lesions EXCEPT:
A) macule
B) bulla
C) tumor
D) scale
2) In plaque psoriasis, which of
the following best describes the
lesion?:
A) plaque with silver scale
B) plaque with yellow scale
C) plaque with pustules
D) plaque with peeling inside
edge
3) The pustules in palmar/
plantar psoriasis are filled
with:
A) sterile fluid
B) staph aureus
C) pseudomonas
D) strep
4) Lichen planus can be
described by all of the following
EXCEPT:
A) Peachy
B) Pruritic
C) Purple
D) Papular
5) The best differential diagnosis
for plantar psoriasis is:
A) atopic dermatitis
B) herpes simplex
C) erythema multiforme
D) neurotic excoriations
6) The most common cause of
11) Which of the following is a
Class 1 steroid?:
A) Psorcon (diflorasone)
B) Cortaid (hydrocortisone)
C) Aclovate (aclometasone)
D) Kenalog (triamcinolone)
12) Contact dermatitis:
A) is bilateral and
symmetrical
B) intensity varies on each
limb
C) only involves vesicles
D) never itches
13) Dyshidrosic eczema
(pompholyx):
A) is linked to sweat
glands
B) occurs mostly on the
hands
C) first appears as pustules
D) is a drug reaction
14) One of the side-effects of
using a Class 1 topical steroid
consecutively over the initial
two-week period is:
A) lichenification
B) scar formation
C) atrophy
D) hyperkeratosis
15) Which of the following is a
secondary skin lesion?
A) telangiectasia
B) scale
C) papule
D) patch
Continuing
Medical Education
E X A M I N A T I O N
See answer sheet on page 183.
Continued on page 182
182 PODIATRY MANAGEMENT
16) The new skin barrier moisturizers help to
reduce flare by:
A) decreasing trans-epidermal water loss
B) increasing trans-epidermal water loss
C) decreasing T-cell lymphocyte
involvement
D) increasing T-cell lymphocyte
involvement
17) The target lesion in erythema multiforme
minor has __ zone(s) of color:
A) 1
B) 2
C) 3
D) 4
18) A differential diagnosis for tinea pedis
would be:
A) pityriasis rosea
B) erythema multiforme minor
C) nevi
D) stretch mark
19) Dyshidrotic eczema has vesicles that can
be described as:
A) grapefruit-like
B) tapioca-like
C) peau d’orange-like
D) raspberry-like
20) The latest treatment for inflammatory skin
dermatoses involves prescribing:
A) a topical steroid and a moisturizer
B) a topical steroid and an NSAID
C) a topical steroid and sunscreen
D) a topical steroid and diphenhydramine
E X A M I N A T I O N
(cont’d)
See answer sheet on page 183.
Continuing
MedicalEducation
PM’sCPME Program
Welcome to the innovative Continuing EducationProgram brought to you by Podiatry ManagementMagazine. Our journal has been approved as asponsor of Continuing Medical Education by theCouncil on Podiatric Medical Education.
Now it’s even easier and more convenientto enroll in PM’s CE program!
You can now enroll at any time during the yearand submit eligible exams at any time during yourenrollment period.
PM enrollees are entitled to submit ten examspublished during their consecutive, twelve–monthenrollment period. Your enrollment period beginswith the month payment is received. For example,if your payment is received on September 1, 2006,your enrollment is valid through August 31, 2007.
If you’re not enrolled, you may also submit anyexam(s) published in PM magazine within the pasttwelve months. CME articles and examinationquestions from past issues of Podiatry Man-agement can be found on the Internet athttp://www.podiatrym.com/cme. Each lessonis approved for 1.5 hours continuing education con-tact hours. Please read the testing, grading and pay-ment instructions to decide which method of partici-pation is best for you.
Please call (631) 563-1604 if you have any ques-tions. A personal operator will be happy to assist you.
Each of the 10 lessons will count as 1.5 credits;thus a maximum of 15 CME credits may beearned during any 12-month period. You may se-lect any 10 in a 24-month period.
The Podiatry Management Magazine CMEprogram is approved by the Council on PodiatricEducation in all states where credits in instruction-al media are accepted. This article is approved for1.5 Continuing Education Contact Hours (or 0.15CEU’s) for each examination successfully completed.
www.podiatrym.com
Home Study CME credits nowaccepted in Pennsylvania
Over, please
Please print clearly...Certificate will be issued from information below.
Name _______________________________________________________________________Soc. Sec. #______________________________Please Print: FIRST MI LAST
Address_____________________________________________________________________________________________________________
City__________________________________________________State_______________________Zip________________________________
Charge to: _____Visa _____ MasterCard _____ American Express
Card #________________________________________________Exp. Date____________________
Note: Credit card is the only method of payment. Checks are no longer accepted.
Signature__________________________________Soc. Sec.#______________________Daytime Phone_____________________________
State License(s)___________________________Is this a new address? Yes________ No________
Check one: ______ I am currently enrolled. (If faxing or phoning in your answer form please note that $2.50 will be chargedto your credit card.)
______ I am not enrolled. Enclosed is my credit card information. Please charge my credit card $20.00 for each examsubmitted. (plus $2.50 for each exam if submitting by fax or phone).
______ I am not enrolled and I wish to enroll for 10 courses at $139.00 (thus saving me $61 over the cost of 10 individualexam fees). I understand there will be an additional fee of $2.50 for any exam I wish to submit via fax or phone.
Note: If you are mailing your answer sheet, you must completeall info. on the front and back of this page and mail with yourcredit card information to: Podiatry Management, P.O. Box490, East Islip, NY 11730.
TESTING, GRADING AND PAYMENT INSTRUCTIONS(1) Each participant achieving a passing grade of 70% or
higher on any examination will receive an official computer formstating the number of CE credits earned. This form should be safe-guarded andmay be used as documentation of credits earned.
(2) Participants receiving a failing grade on any exam will benotified and permitted to take one re-examination at no extra cost.
(3) All answers should be recorded on the answer formbelow. For each question, decide which choice is the best an-swer, and circle the letter representing your choice.
(4) Complete all other information on the front and back ofthis page.
(5) Choose one out of the 3 options for testgrading: mail-in,fax, or phone. To select the type of service that best suits yourneeds, please read the following section, “Test Grading Options”.
TEST GRADING OPTIONSMail-In GradingTo receive your CME certificate, complete all information
and mail with your credit card information to:Podiatry Management
P.O. Box 490, East Islip, NY 11730There is no charge for the mail-in service if you have already
enrolled in the annual exam CPME program, and we receive this
ENROL LMENT FORM & ANSWER SH E E T
�
183
Continuing
Medical Education
exam during your current enrollment period. If you are not en-rolled, please send $20.00 per exam, or $139 to cover all 10 exams(thus saving $61* over the cost of 10 individual exam fees).
Facsimile GradingTo receive your CPME certificate, complete all information and
fax 24 hours a day to 1-631-563-1907. Your CPME certificate willbe dated and mailed within 48 hours. This service is available for$2.50 per exam if you are currently enrolled in the annual 10-examCPME program (and this exam falls within your enrollment period),and can be charged to your Visa, MasterCard, or American Express.
If you are not enrolled in the annual 10-exam CPME pro-gram, the fee is $20 per exam.
Phone-In GradingYou may also complete your exam by using the toll-free ser-
vice. Call 1-800-232-4422 from 10 a.m. to 5 p.m. EST, Mondaythrough Friday. Your CPME certificate will be dated the same dayyou call and mailed within 48 hours. There is a $2.50 charge forthis service if you are currently enrolled in the annual 10-examCPME program (and this exam falls within your enrollment peri-od), and this fee can be charged to your Visa, Mastercard, Ameri-can Express, or Discover. If you are not currently enrolled, the feeis $20 per exam. When you call, please have ready:
1. Program number (Month and Year)2. The answers to the test3. Your social security number4. Credit card information
In the event you require additional CPME information,please contact PMS, Inc., at 1-631-563-1604.
Enrollment/Testing Informationand Answer Sheet
�
184 www.podiatrym.comPODIATRY MANAGEMENT • APRIL/MAY 2010
ENROL LMENT FORM & ANSWER SH E E T (cont’d)Continuing
MedicalEducation
LESSON EVALUATION
Please indicate the date you completed this exam
_____________________________
How much time did it take you to complete the lesson?
______ hours ______minutes
How well did this lesson achieve its educationalobjectives?
_______Very well _________Well
________Somewhat __________Not at all
What overall grade would you assign this lesson?
A B C D
Degree____________________________
Additional comments and suggestions for future exams:
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
1. A B C D
2. A B C D
3. A B C D
4. A B C D
5. A B C D
6. A B C D
7. A B C D
8. A B C D
9. A B C D
10. A B C D
11. A B C D
12. A B C D
13. A B C D
14. A B C D
15. A B C D
16. A B C D
17. A B C D
18. A B C D
19. A B C D
20. A B C D
Circle:
EXAM #4/10Differentiating Dermatological Diagnosis
and Treatment(Vlahovic and Oliver)