2. T e treatment o a hydro uoric acid skin burn is A. Application o calcium carbonate gel
B. Irrigation with sodium bicarbonate C. Injection o sodium bicarbonate D. Local wound care only
Answer: A
Injuries that have speci ic additional treatments include hydro luoride burns. Hydro luoride is ound in air con-ditioning cleaners and petroleum re ineries. reatment o hydro luoride burns should include topical or locally injected calcium gluconate to bind luorine ions. Intra-arterial calcium gluconate can provide pain relie and preserves arteries rom necrosis, whereas intravenous (IV) calcium repletes resorbed calcium stores. opical calcium carbonate gel and quaternary ammonium compounds detoxi y luoride ions. his mitigates the leaching o calcium and magnesium ions by the luoric acid rom the a ected tissues and prevents potentially severe hypocalcemia and hypomagnesemia that predispose to cardiac arrhythmias. (See Schwartz 10th ed., pp. 479–480.) 1. Following caustic injury to the skin with an alkaline agent
the e ected area should initially be
A. reated with running water or saline or 30 minutes B. reated with running water or saline or 2 hours C. reated with a neutralizing agent
D. reated with topical emollients and oral analgesics
Answer: B
he treatment or both types o injuries is based on neutraliza-tion o the inciting soluneutraliza-tion and starts with running distilled water or saline over the a ected skin or at least 30 minutes or acidic solutions and 2 hours or alkaline injuries. It should be noted that neutralizing agents do not o er a signi icant advantage over dilution with water, may delay treatment, and may worsen the injury due to the exothermic reaction that may occur. he clinician observes and treats based on the degree o presentation. Many cases are success ully managed conservatively with topical emollients and oral analgesics, and most cases result in edema, erythema, and induration. I signs o deep second-degree burns develop, local wound care may include debridement, Silvadene, and protective petro-leum gauze. In severe cases, injury to the underlying vessels, bones, muscle, and tendon may occur, and these cases may be managed within 24 hours by liposuction through a small cath-eter and then saline injection. Surgery is indicated or tissue necrosis, uncontrolled pain, or deep-tissue damage. Antibi-otics should not be administered unless signs o in ection are present. (See Schwartz 10th ed., p. 479.)
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Actinomycosis should be considered in the di erential diag-nosis o any acute, subacute, or chronic cutaneous swelling o the head and neck. he cervico acial orm o Actinomycetes in ection is the most common presentation, typically as an acute pyogenic in ection in the submandibular or paraman-dibular area, but in ection could be elsewhere in the mandib-ular and maxillary regions. he primary skin in ection may spread to adjacent structures such as the scalp, orbit, ears, and other areas. Oral in ection may spread to the hypopharynx, larynx, trachea, salivary glands, and sinuses. Actinomycosis can spread beyond boundaries o tissue planes and may also mimic chronic osteomyelitis. reatment consists o a combi-nation o penicillin therapy and surgical debridement. Deb-ulking and debriding in ected tissue arising rom sinus tracts and abscess cavities inhibit actinomycosis growth in most cases. (See Schwartz 10th ed., p. 484.)
4. issue ischemia resulting in wounds that are characterized as a partial-thickness injury with a blister is considered
A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4
Answer: B
issue pressures that exceed the pressure o the microcircula-tion (30 mm Hg) result in tissue ischemia. Frequent or pro-longed ischemic insults will ultimately result in tissue damage.
Areas o bony prominence are particularly prone to isch-emia, the most common areas being ischial tuberosity (28%), trochanter (19%), sacrum (17%), and heel (9%). issue pres-sures can measure up to 300 mm Hg in the ischial region dur-ing sittdur-ing and 150 mm Hg over the sacrum while lydur-ing supine.
Muscle is more susceptible than skin to ischemic insult due to its relatively high metabolic demand. Wounds are staged as ollows: stage 1, nonblanching erythema over intact skin;
stage 2, partial-thickness injury (epidermis or dermis)—
blister or crater; stage 3, ull-thickness injury extending down to, but not including, ascia and without undermining o adjacent tissue; and stage 4, ull-thickness skin injury with destruction or necrosis o muscle, bone, tendon, or joint capsule. (See Schwartz 10th ed., p. 482.)
3. T e area most amenable to salvage by resuscitative and wound management techniques ollowing thermal injury is called the
Exposure o the skin to thermal extremes disrupts its primary unction as a barrier to heat loss, evaporation, and microbial invasion. he depth and extent o injury are dependent on the duration and temperature o the exposure. he pathophysi-ology and management are discussed elsewhere in this book.
Brie ly, the epicenter o the injury undergoes a varying extent o necrosis (depending on the exposure), otherwise re erred to as the zone of coagulation, which is surrounded by the zone o stasis, which has marginal per usion and question-able viability. his is the area o tissue that is most amenquestion-able to salvage by appropriate resuscitative and wound manage-ment techniques, which would theoretically limit the extent o injury. he outermost area o skin shows characteristics simi-lar to other in lamed tissues and has been designated the zone o hyperemia. he degree o burn corresponds to histologic layers o the a ected dermis and correlates with management and prognosis pertaining to timeline o healing and magni-tude o scarring. (See Schwartz 10th ed., p. 480.)
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8. richilemmal cysts
A. Are the most common type o cutaneous cysts B. Are ound between the orehead to nose tip C. Are typically ound on the scalp o emales
D. Occasionally develop bone, tooth, or nerve tissue
Answer: C
here are three types o cutaneous cysts: epidermal, dermoid, and trichilemmal. All o these benign entities comprise epi-dermis that grows toward the center o the cyst, resulting in central accumulation o keratin to orm a cyst. All clinically appear as a white, creamy substance-containing subcutane-ous, thin-walled nodule. Epidermal cysts are the most com-mon cutaneous cyst and histologically characterized by mature epidermis complete with granular layer. richilemmal cysts are the second most common lesion; they tend to orm on the scalp o emales, have a distinct odor a ter rupture, histologically lack a granular layer, and have an outer layer resembling the root sheath o a hair ollicle. Dermoid cysts are congenital, ound between the orehead to nose tip, and con-tain squamous epithelium, eccrine glands, and pilosebaceous units, occasionally developing bone, tooth, or nerve tissue.
he eyebrow is the most requent site o presentation. hese cysts are commonly asymptomatic but can become in lamed and in ected, thus necessitating incision and drainage. A ter the acute phase subsides, the entire cyst should be removed to prevent recurrence. (See Schwartz 10th ed., p. 486.)
7. A 3-mm basal cell carcinoma (BCC) o the skin should be treated with
A. Biopsy and gross total excision B. Dermatologic laser vaporization
C. Excision with 2- to 4-mm normal margin D. Electrodesiccation
Answer: C
Basal cell carcinoma (BCC) arises rom the basal layer o non-keratinocytes and represents the most common tumor diag-nosed in the United States. Annually it accounts or 25% o all diagnosed cancers and 75% o skin cancers. he primary risk actor or disease development is sun exposure (ultraviolet [UV] B rays more than UVA rays) particularly during adoles-cence; however, other actors include immune suppression (ie, organ transplant recipients, human immunode iciency virus [HIV]), chemical exposure, and ionizing radiation exposure.
BCC can also be a eature o inherited conditions such as xero-derma pigmentosa, unilateral basal cell nevus syndrome, and nevoid BCC syndrome. he natural behavior o BCC is one o local invasion rather than distant metastasis. Untreated BCC can result in signi icant morbidity. hirty percent o cases are ound on the nose, and bleeding, ulceration, and itching are o ten part o the clinical presentation. (See Schwartz 10th ed., p. 486.)
6. Initial treatment o nonpurulent, complicated cellulitis is A. Vancomycin with a β-lactam, with methicillin-resistant Staphylococcus aureus (MRSA) coverage added i no response is observed.
Empiric MRSA coverage is warranted in all other compli-cated skin and subcutaneous in ections. Vancomycin is the mainstay o therapy, although it is in erior to β-lactams or methicillin-sensitive S. aureus (MSSA) and has a relatively slow onset o e icacy in vitro. Linezolid, daptomycin, tigecy-cline, and telavancin are other FDA-approved alternatives or MRSA treatment. Clindamycin is also approved or S. aureus;
however, resistance may develop, and diarrhea can occur in up to 20% (Clostridium difficile related). (See Schwartz 10th ed., p. 483.)
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Answer: C
Melanoma growth most commonly starts as a localized, radial growth phase ollowed by a vertical growth phase that deter-mines metastatic risk. he subtypes o melanoma include lentigo maligna, super icial spreading, acral lentiginous, mucosal, nodular, polypoid, desmoplastic, amelanotic, and so t tissue. he most common subtype is super icial spread-ing, accounting or 70% o cases. (See Schwartz 10th ed.,
he most common sites o distant metastasis are the lungs and liver ollowed by the brain, gastrointestinal tract, distant skin, and subcutaneous tissue. A limited subset o patients with small-volume, limited distant metastases to the brain, gastro-intestinal tract, or distant skin will be cured with resection or gamma kni e radiation. Liver metastases are better dealt with-out surgical resection unless they arise rom an ocular pri-mary. (See Schwartz 10th ed., p. 491.)
11. In the ABCDE o melanoma, the D stands or diameter
Melanoma most commonly mani ests as cutaneous disease, and clinical characteristics include an Asymmetric out-line, changing irregular Borders, Color variations, Diam-eter greater than 6 mm, and Elevation (ABCDE). Other key clinical characteristics include a pigmented lesion that has enlarged, ulcerated, or bled. Amelanotic lesions appear as raised pink, purple, or normal-colored skin papules and are o ten diagnosed late. (See Schwartz 10th ed., p. 488.)
10. T e primary risk actor or the development o squamous
Squamous cell carcinoma (SCC) is the second most common skin cancer, accounting or approximately 100,000 cases each year and generally a licting individuals o lighter skin color.
he primary risk actor and driving orce or the development o this common cancer is UV exposure; however, other risks include environmental actors such as chemical agents, physi-cal agents (ionizing radiation), psoralen and UVA (PUVA), HPV-16 and -18 in ections (immunosuppression), and smok-ing. Chronic nonhealing wounds, burn scars, and chronic dermatosis are other risk actors, and many darker skin indi-viduals who develop SCC o ten have a history o one o these risk actors. Heritable conditions such as xeroderma pigmen-tosum, epidermolysis bullosa, and oculocutaneous albinism are predisposing risk actors. (See Schwartz 10th ed., p. 487.) 9. More than hal o patients treated or BCC will experience
It is critical or each patient to have routine annual ollow-up that includes ull-body skin examinations. Sixty-six percent o recurrences develop within 3 years, and with a ew excep-tions occurring decades a ter initial treatment, the remaining recur within 5 years o initial treatment. A second primary BCC may develop a ter treatment and, in 40% o cases, pres-ents within the irst 3 years a ter treatment. (See Schwartz 10th ed., p. 487.)
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16. What is the most common melanoma in patients with dark skin?
A. Nodular
B. Super cial spreading C. Acral lentiginous D. Lentigo maligna
Answer: C
Nodular melanoma accounts or 15 to 30% o melanomas, and this variant is unique because it begins with a vertical growth phase that partly accounts or its worse prognosis. Lentigo maligna is typically ound in older individuals and primar-ily located in the head and neck region. he acral lentiginous variant accounts or 29 to 72% o melanomas in dark-skinned individuals, is occasionally seen in Caucasians, and is ound on palmar, plantar, and subungual sur aces. (See Schwartz
B. It is characterized by a rapidly growing, esh-colored papule.
C. reatment should begin with examination o nodal basins.
D. Recurrence is uncommon.
Answer: D
his is a rare and aggressive neuroendocrine tumor o the skin most commonly ound in white men and diagnosed at a mean age o 70 years. Risk actors include UV radiation, PUVA, and immunosuppression. Approximately one in three cases present on the ace, with the remainder occurring on sun-exposed skin. A rapidly growing, lesh-colored papule or plaque characterizes the disease. Regional lymph nodes are involved in 30% o patients, and 50% will develop systemic disease (skin, lymph nodes, liver, lung, bone, brain). here are no standardized diagnostic imaging studies or staging, but computed tomography (C ) o the chest, abdomen, and pelvis and octreotide scans may provide use ul in ormation when clinically indicated. A ter examining the entire skin or other lesions, treatment should begin by evaluating the nodal basins.
Recurrence is common, and one study o 95 patients showed a 47% recurrence, with 80% o recurrences occurring within 2 years and 96% occurring within 5 years. Regional lymph node disease is common, and 70% o patients will have nodal spread within 2 years o disease presentation. Five-year overall sur-vival o head and neck disease in surgically treated patients is between 40 and 68%. (See Schwartz 10th ed., p. 492.)
14. Ocular melanoma
A. Exclusively metastasizes to the lungs B. Exclusively metastasizes to the brain
C. Exclusively metastasizes to regional lymph nodes D. Exclusively metastasizes to the liver
Answer: D
Ocular melanoma is the most common noncutaneous disease site, and treatment includes photocoagulation, partial resec-tion, radiaresec-tion, or enucleation. Ocular melanomas exclu-sively metastasize to the liver and not regional lymph nodes, and some patients bene it rom liver resection. (See Schwartz 10th ed., p. 491.)
17. Kaposi sarcoma
A. Excision is the treatment o choice B. Is predominantly ound on the skin C. Appears as rubbery, blue nodules
D. Is most of en seen in patients in their f h decade o li e
Answer: A
Kaposi sarcoma is diagnosed a ter the i th decade o li e and predominantly ound on the skin but can occur anywhere in the body. In North America, the Kaposi sarcoma herpes virus is transmitted via sexual and nonsexual routes and predomi-nantly a ects individuals with compromised immune systems such as those with HIV and transplant recipients on immune-suppressing medications. Clinically, Kaposi sarcoma appears as multi ocal, rubbery blue nodules. reatment o acquired immunode iciency syndrome (AIDS)-associated Kaposi sar-coma is with antiviral therapy, and many patients experience a dramatic treatment response. hose individuals who do not respond and have limited mucocutaneous disease may bene it rom cryotherapy, photodynamic therapy, radiation therapy, intralesional injections, and topical therapy. Surgical biopsy
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19. A patient with a 5-mm deep melanoma o the thigh and no clinically positive nodes should undergo which procedure?
A. Resection o the primary only
B. Super cial emoral node resection
C. Super cial and deep emoral node resection D. Resection o emoral and inguinal nodal basins
Answer: A
Nonmetastatic in-transit disease should undergo excision to clear margins when easible. However, disease not amenable to complete excision derives bene it rom isolated limb per usion (ILP) and isolated limb in usion (ILI) (Fig. 16-1). hese two modalities are used to treat regional disease, and their purpose is to administer high doses o chemotherapy, commonly melpha-lan, to an a ected limb while avoiding systemic drug toxicity. ILI was shown to provide a 31% response rate in one study, while hyperthermic ILP provided a 63% complete response rate in an independent study. (See Schwartz 10th ed., Figure 16-15, p. 491.) 18. T e ollowing is NO a prognostic indicator or patients
with a sentinel node containing metastatic melanoma A. Patient age
B. Site o metastasis
C. Number o positive nodes
D. T ickness, mitotic rate, and ulceration o primary tumor
Answer: B
Melanoma is characterized according to the American Joint Committee on Cancer (AJCC) as localized disease (stage I and II), regional disease (stage III), or distant metastatic disease (stage IV). Overall tumor thickness, ulceration, and mitotic rate are the most important prognostic indicators o survival.
I a sentinel node contains metastatic melanoma, the number o positive nodes; thickness, mitotic rate, and ulceration o the primary tumor; and patient age determine prognosis. With clinically positive nodes, the number o positive nodes, primary tumor ulceration, and patient age determine prognosis. he site o metastasis is strongly associated with prognosis or stage IV disease, and elevated lactate dehydrogenase (LDH) is associated with a worse prognosis. (See Schwartz 10th ed., p. 488.)
is important or disease diagnosis, but given the high local recurrence and the act that Kaposi sarcoma represents more o a systemic rather than local disease, the bene it o surgery is limited and generally should not be pursued except or pallia-tion. (See Schwartz 10th ed., p. 492.)
FIG. 16-1. Isolated limb infusion. Schematic of isolated limb infusion of lower extremity.
(From Thompson JF, Kam PC. Isolated limb infusion for melanoma: a simple but effective alternative to isolated limb perfusion. J Surg Onc. 2004;88:1-3. Copyright 2004 John Wiley and Sons. Reprinted with permission.)
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22. Correct statements about toxic epidermal necrolysis ( EN) include all o the ollowing EXCEP
A. oxic epidermal necrolysis is believed to be an immu-nologic problem.
B. Lesions are similar in appearance to partial thickness burns.
C. T e process develops at the dermoepidermal junction.
D. Corticosteroid use is a primary part o therapy.
Answer: D
hese in lammatory diseases represent a spectrum o an autoimmune reaction to stimuli such as drugs that result in structural de ects in the epidermal-dermal junction. he cutaneous mani estations o toxic epidermal necrolysis syn-drome ( ENS) ollow a prodromal period reminiscent o an upper respiratory tract in ection. A symmetrical macular eruption ollows starting rom the ace and trunk and spread-ing to the extremities. ypically, a Nikolsky sign develops in which lateral pressure causes the epidermis to detach rom the basal layer. he macular eruption evolves into blisters, caus-ing an extensive super icial partial-thickness skin injury with exposed dermis. (See Schwartz 10th ed., p. 477.)
21. T e chronic in ammatory disease presenting as pain ul subcutaneous nodules is
A. Pyoderma gangrenosum
B. oxic epidermal necrolysis syndrome C. Hidradenitis suppurative
D. Steven-Johnson syndrome
Answer: C
Hidradenitis suppurativa is a chronic in lammatory disease pre-senting as pain ul subcutaneous nodules. Patients experience appreciable physical, psychological, and economical hardship and decreased quality o li e when compared with patients who su er rom other chronic dermatologic disease such as psoria-sis and alopecia. It is characterized by multiple abscesses, inter-networking sinus tracts, oul-smelling exudate rom draining sinuses, in lammation in the dermis, both atrophic and hypertro-phic scars, ulceration, and in ection, which may extend deep into the ascia. he diagnosis is made clinically without the need or imaging or laboratory tests. (See Schwartz 10th ed., p. 467.)
20. A 65-year-old patient who spends winters in Florida presents with a painless, ulcerated lesion on his right cheek. T e lesion has been present or 1 year. Physical examination o the patient’s neck reveals no lymph node enlargement. T e most likely diagnosis is
A. Melanoma characterized by raised, pearly pink papules and occasionally a depressed tumor center with raised borders giving the classic
“rodent ulcer” appearance. his variant tends to develop in sun-exposed areas o individuals older than 60 years. Super icial BCC accounts or 15% o BCC, is diagnosed at a mean age o 57 years, and typically appears on the trunk as a pink or erythematous plaque with a thin pearly border. he in iltrative orm appears on the head and neck in the late 60s with similar clinical appearance to the nodular variant. An important variant to keep in mind is the pigmented variant o nodular BCC because this may be di icult to di erentiate rom nodular melanoma. Other important subtypes include the morphea orm variant, accounting or 3% o cases and characterized by indistinct borders with a yellow hue, and ibroepithelioma o Pinkus. Histologic subtypes o BCC include nodular and micronodular (50%), super icial (15%), and in iltrative. (See Schwartz 10th ed., p. 486.)
23. T e rare adenocarcinoma o the apocrine gland that of en appears as a nonpigmented plaque is
A. Angiosarcoma
B. Extramammary Paget disease C. Malignant brous histiocytoma D. Dermato brosarcoma protuberans
Answer: B
his rare adenocarcinoma o apocrine glands arises in perianal and axillary regions and in genitalia o men and women. Clinical presentation is that o erythematous or nonpigmented plaques with an eczema-like appearance that o ten persist a ter ailed treatment rom other therapies. An important characteristic and one that the surgeon must be acutely aware o is the high inci-dence o concomitant other malignancies with this cutaneous disease. Forty percent o cases are associated with primary
his rare adenocarcinoma o apocrine glands arises in perianal and axillary regions and in genitalia o men and women. Clinical presentation is that o erythematous or nonpigmented plaques with an eczema-like appearance that o ten persist a ter ailed treatment rom other therapies. An important characteristic and one that the surgeon must be acutely aware o is the high inci-dence o concomitant other malignancies with this cutaneous disease. Forty percent o cases are associated with primary