Orris

Answers of each spotter of dermatology exam

Reading File
Running Command

cd /tmp/workspace/attachments/345e48d1-8383-4e0e-864d-d8c124d0cd9b/ && python3 -c " import pdfplumber with pdfplumber.open('OSPE.pdf') as pdf: print(f'Total pages: {len(pdf.pages)}') for i, page in enumerate(pdf.pages): print(f'--- PAGE {i+1} ---') text = page.extract_text() if text: print(text[:3000]) else: print('[No text extracted]') # Check for images imgs = page.images if imgs: print(f'[{len(imgs)} image(s) on this page]') print() "

Running Command

python3 -c " from pypdf import PdfReader import base64, os reader = PdfReader('/tmp/workspace/attachments/345e48d1-8383-4e0e-864d-d8c124d0cd9b/OSPE.pdf') # Extract images from key spotter pages spotter_pages = [12,13,14,15,16, # pages 13-17 (0-indexed: 12-16) 41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68] os.makedirs('/tmp/workspace/spotter_images', exist_ok=True) for pg_idx in spotter_pages: page = reader.pages[pg_idx] if '/XObject' in page['/Resources']: xobjects = page['/Resources']['/XObject'].get_object() for obj_name, obj_ref in xobjects.items(): obj = obj_ref.get_object() if obj.get('/Subtype') == '/Image': if '/Filter' in obj: filt = obj['/Filter'] data = obj.get_data() ext = 'jpg' if filt in ['/DCTDecode', 'DCTDecode'] else 'png' fname = f'/tmp/workspace/spotter_images/page{pg_idx+1}_{obj_name[1:]}.{ext}' with open(fname, 'wb') as f: f.write(data) print(f'Saved: {fname} ({len(data)} bytes)') "

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Reading File
Here are comprehensive answers for every spotter in your dermatology OSPE exam PDF:

DERMATOLOGY OSPE/SPOTTER ANSWERS

EARLY SECTION SPOTTERS (Pages 2-11)

Spotter - Histology (Page 2)

Likely: Pemphigus Vulgaris (based on context of antigens asked below)
  1. Histology: Suprabasal acantholysis - separation of keratinocytes just above the basal layer, forming an intraepidermal blister. Acantholytic cells (Tzanck cells) float in the blister cavity. Basal cells remain attached to the basement membrane ("tombstone" pattern).
  2. Diagnosis: Pemphigus Vulgaris
  3. Conditions with suprabasal acantholysis:
    • Pemphigus Vulgaris
    • Hailey-Hailey disease (Benign Familial Pemphigus)
    • Darier's disease (subcorneal/suprabasal)
    • Grover's disease
  4. Treatment:
    • Oral prednisolone 1 mg/kg/day (mainstay)
    • Steroid-sparing: Azathioprine (2-3 mg/kg/day), Mycophenolate mofetil
    • Rituximab (anti-CD20) - now first-line in moderate-severe disease
    • Dexamethasone-cyclophosphamide pulse (DCP pulse)

Spotter - Organism 1 (Page 3)

Likely: Sarcoptes scabiei (Scabies mite)
  1. Organism: Sarcoptes scabiei var. hominis
  2. Peculiar features:
    • Oval, flat mite, 0.3-0.4 mm
    • Has 4 pairs of legs (front 2 pairs with suckers, rear 2 pairs with bristles)
    • Female burrows in stratum corneum at ~2 mm/day
    • Eggs laid in burrow: 3-4/day, 40-50 total in lifespan of 4-6 weeks
    • 10-14 days for larva to mature
    • Only 10-15 mites per person in classic scabies
    • Norwegian/Crusted scabies: millions of mites
  3. Treatment and latest medicines:
    • Permethrin 5% cream - DOC, apply overnight from neck down, repeat after 1 week
    • Ivermectin - 200 mcg/kg oral, Day 1 and Day 8 (or 1, 2, 8, 9, 15 for crusted scabies)
    • Benzyl benzoate 25% - alternative
    • Sulfur 5-10% - safe in pregnancy and infants
    • Latest: Moxidectin (ivermectin analog) - single oral dose
    • Treat all contacts simultaneously

Spotter - Organism 2 (Page 4)

Likely: Pediculus humanus capitis (Head Louse) OR Phthirus pubis
  1. Organism: Pediculus humanus capitis (Head louse)
  2. Structures:
    • 6 legs with claws for gripping hair shafts
    • 3 pairs of legs
    • Nits (eggs) cemented to hair shaft within 1 cm of scalp
    • Nymphs hatch in 7-10 days
  3. Best treatment modality:
    • Permethrin 1% lotion - DOC (leave 10 min, rinse)
    • Ivermectin 0.5% lotion (topical) or oral Ivermectin 200 mcg/kg
    • Fine-toothed nit comb
    • Malathion 0.5% - second line
    • Benzyl alcohol 5% lotion

Spotter - Pediculosis (Page 5)

Diagnosis stated in PDF: Pediculosis
  1. Diagnosis: Pediculosis capitis; DD: Tinea capitis / Seborrheic dermatitis / Hair casts
  2. Management:
    • Permethrin 1% cream rinse - apply to damp hair, leave 10 min, rinse; repeat in 7-10 days
    • Oral ivermectin 400 mcg/kg (2 doses, 7 days apart) - for resistant cases
    • Wet combing with fine comb every 3-4 days for 2 weeks
    • Treat all household contacts
    • Wash clothes/bedding in hot water (>60°C)

Scabies Answers (Page 11)

(Answers given in PDF itself - confirming and expanding)
  • Female scabies mite lays 3-4 eggs/day; 30-40 total in 4-6 week lifespan; larva matures in 10-14 days
  • 12-15 mites per infested person (classic scabies)
  • Has 4 pairs of legs
  • Circle of Hebra - the distribution of scabies (spares face, neck, scalp in adults)
  • Norwegian/Crusted Scabies: Permethrin 5% topically (long-acting, apply on alternate days) + Ivermectin on Day 1, 2, 8, 9, 15

SPOTTERS SECTION (Pages 13-17)

Spotter 1 (Page 13) - Bullous Pemphigoid

Questions: Name type of lesion and size / Name 3 conditions / Name 2 antigens
Diagnosis: Bullous Pemphigoid
  1. Type of lesion and size: Tense bulla - fluid-filled lesion >5 mm (a blister larger than 5 mm that does not rupture easily due to subepidermal location)
  2. 3 conditions with tense bullae (subepidermal blistering):
    • Bullous Pemphigoid
    • Dermatitis Herpetiformis
    • Linear IgA Bullous Dermatosis (LABD)
    • (Also: Epidermolysis Bullosa, Bullous SLE)
  3. 2 antigens in Bullous Pemphigoid:
    • BP230 (BPAg1) - intracellular, plakin family
    • BP180 (BPAg2 / Type XVII collagen) - transmembrane, most important clinically; anti-BP180 antibodies correlate with disease severity

Spotter 2 (Page 14) - Psoriasis

Questions: Type of lesion and diagnosis / Treatment / 2 Interleukins / Drug acting on them
Diagnosis: Psoriasis (Plaque type / Psoriasis Vulgaris)
  1. Type of lesion and diagnosis:
    • Well-defined, erythematous plaque with silvery-white scales
    • Diagnosis: Psoriasis vulgaris (Plaque psoriasis)
  2. Treatment:
    • Topical: Calcipotriol, Clobetasol, Coal tar, Dithranol
    • Phototherapy: Narrowband UVB (NB-UVB), PUVA
    • Systemic: Methotrexate (DOC for severe), Cyclosporine, Acitretin
    • Biologics: TNF-alpha inhibitors (Adalimumab, Etanercept), IL-17 inhibitors, IL-23 inhibitors
  3. 2 Important Interleukins in pathogenesis:
    • IL-17A - key effector cytokine; drives keratinocyte proliferation
    • IL-23 (IL-12/23p40 subunit) - drives Th17 differentiation
    • Also important: IL-17F, TNF-alpha
  4. Drugs acting on above ILs:
    • Anti-IL-17A: Secukinumab, Ixekizumab, Bimekizumab
    • Anti-IL-17RA: Brodalumab
    • Anti-IL-23 (p19 subunit): Guselkumab, Risankizumab, Tildrakizumab
    • Anti-IL-12/23 (p40): Ustekinumab

Spotter 3 (Page 15) - Discoid Lupus Erythematosus (DLE)

Questions: Describe lesions / 2 DDs / Marker signifying risk of SLE in DLE
Diagnosis: Discoid Lupus Erythematosus (DLE)
  1. Lesion description:
    • Erythematous, discoid (coin-shaped) plaques on face (butterfly distribution), ears, scalp
    • Central atrophy and scarring
    • Follicular plugging (carpet tack sign on dermoscopy)
    • Hyperpigmented border, hypopigmented center
    • Adherent scaling; removal reveals "carpet tack" appearance
  2. 2 Differential Diagnoses:
    • Lichen planus actinicus
    • Polymorphic light eruption (PMLE)
    • Subacute cutaneous lupus (SCLE)
    • Seborrheic dermatitis / Rosacea
  3. Marker signifying risk of SLE in DLE patients:
    • Anti-dsDNA antibody (double-stranded DNA antibody) - most specific for SLE
    • ANA (antinuclear antibody) - sensitive marker; if high titre in DLE, suggests evolution to SLE
    • Low complement (C3, C4) and anti-Sm antibody also indicate risk
    • ~5-10% of DLE patients evolve to SLE

Spotter 4 (Page 16) - Tinea Capitis

Questions: Describe lesion with diagnosis / 2 treatment options / Most common organism
Diagnosis: Tinea Capitis
  1. Lesion + diagnosis:
    • Scaly alopecia patches on scalp with broken hair stubs ("black dot" sign)
    • Erythema, scaling, sometimes kerion (boggy inflammatory mass)
    • Diagnosis: Tinea capitis (scalp ringworm)
  2. 2 Treatment options:
    • Griseofulvin - DOC traditionally; microsize 15-25 mg/kg/day x 6-8 weeks (children); better with fatty meal
    • Terbinafine - DOC for Trichophyton spp. (most common in India); 62.5-250 mg/day x 4 weeks
    • Itraconazole, Fluconazole - alternatives
    • Selenium sulfide shampoo / Ketoconazole shampoo - adjuncts (reduce shedding)
  3. Most common organism for T. capitis:
    • Trichophyton violaceum - most common in India
    • Trichophyton tonsurans - most common worldwide (endothrix)
    • Microsporum canis - most common ectothrix type

Spotter 5 (Page 17) - Cylindroma

Questions: What kind of lesions / 2 DDs / Syndrome with multiple cylindromas
Diagnosis: Cylindroma (Turban Tumour)
  1. Type of lesions:
    • Firm, skin-colored to pink, dome-shaped nodules on scalp and face
    • Smooth surface, well-defined
    • Multiple lesions coalescing on scalp (turban tumour appearance)
  2. 2 Differential Diagnoses:
    • Eccrine spiradenoma
    • Trichoepithelioma
    • Pilomatricoma
    • Dermoid cyst
  3. Syndrome with multiple cylindromas:
    • Brooke-Spiegler Syndrome (BSS) - AD; CYLD gene mutation on chromosome 16q; multiple cylindromas + trichoepitheliomas + spiradenomas
    • Also: Familial Cylindromatosis (CYLD gene)
    • Histology: "Jigsaw puzzle" pattern - islands of basaloid cells in hyalinized sheath

CASE SPOTTERS (Pages 42-69)

Spotter (Page 42) - Lichen Planus

Questions: Describe lesion / Diagnosis / Other sites / Classical histopath findings
Diagnosis: Lichen Planus
  1. Lesion description: Violaceous, flat-topped (planar), polygonal papules with Wickham's striae (fine white lacy lines on surface)
  2. Diagnosis: Lichen Planus (4 Ps - Purple, Pruritic, Polygonal, Planar papules)
  3. Other sites involved:
    • Mucous membranes (oral - most common, reticular white striae on buccal mucosa)
    • Nails (trachyonychia, pterygium unguis)
    • Scalp (lichen planopilaris - scarring alopecia)
    • Genitalia (Wickham's striae)
  4. Classical histopathological findings:
    • Hyperkeratosis with wedge-shaped hypergranulosis
    • Irregular acanthosis ("saw-tooth" rete ridges)
    • Band-like lymphocytic infiltrate at dermoepidermal junction (DEJ)
    • Civatte bodies (colloid/hyaline bodies) - apoptotic keratinocytes at DEJ
    • Liquefactive (vacuolar) degeneration of basal layer

Spotter (Page 43) - Pityriasis Versicolor

Questions: Describe lesions / Diagnosis / Causative agent / Treatment
Diagnosis: Pityriasis Versicolor (Tinea Versicolor)
  1. Lesions: Multiple hypo/hyper pigmented macules with fine branny (flour-like) scales; coalesce into patches; mainly trunk and upper back
  2. Diagnosis: Pityriasis (Tinea) Versicolor
  3. Causative agent: Malassezia furfur (also M. globosa, M. restricta) - lipophilic dimorphic yeast; produces azelaic acid which inhibits melanogenesis
  4. Treatment:
    • Topical: Ketoconazole 2% shampoo (apply for 5-10 min, rinse), Selenium sulfide 2.5% shampoo
    • Topical azoles: Clotrimazole, Miconazole, Econazole
    • Systemic (widespread/recurrent): Itraconazole 200 mg/day x 5-7 days or Fluconazole 300-400 mg single dose
    • Note: Repigmentation takes months

Spotter (Page 44) - Psoriasis / Lichen Simplex Chronicus

Questions: 2 DDs / Most likely treatment
Likely Diagnosis: Psoriasis (plaque)
  1. 2 Differential Diagnoses:
    • Lichen simplex chronicus (LSC)
    • Seborrheic dermatitis
    • Parapsoriasis
    • Cutaneous T-cell lymphoma (mycosis fungoides)
  2. Most likely treatment (Psoriasis):
    • Topical corticosteroids (clobetasol 0.05%) + Calcipotriol combination
    • NB-UVB phototherapy
    • Methotrexate 15-25 mg/week (severe disease)

Spotter (Page 45) - Leprosy

Questions: Describe lesions / Diagnosis / Types of disease / Treatment
Diagnosis: Leprosy (Hansen's Disease)
  1. Lesions: Hypopigmented or erythematous macules/patches with loss of sensation, anhidrosis, and loss of hair. Thickened nerves. (Could also be leproma nodules in LL)
  2. Diagnosis: Leprosy (Hansen's Disease) - caused by Mycobacterium leprae
  3. Types (Ridley-Jopling classification):
    • TT (Tuberculoid) - few well-defined lesions, strong CMI
    • BT (Borderline Tuberculoid)
    • BB (Mid-borderline)
    • BL (Borderline Lepromatous)
    • LL (Lepromatous) - numerous lesions, weak CMI
    • Indeterminate (I) - earliest form
  4. Treatment (MDT - WHO):
    • PB (Paucibacillary - 1-5 lesions): Rifampicin 600 mg/month + Dapsone 100 mg/day x 6 months
    • MB (Multibacillary >5 lesions): Rifampicin 600 mg/month + Clofazimine 300 mg/month + Dapsone 100 mg/day x 12 months
    • Clofazimine 50 mg/day added to MB regimen daily
    • Single Lesion PB: Single Dose Rifampicin + Ofloxacin + Minocycline (ROM)

Spotter (Page 46) - Onychomycosis

Questions: Describe lesions / Diagnosis / Test for diagnosis / 3 drugs
Diagnosis: Onychomycosis
  1. Lesions: Subungual hyperkeratosis, nail plate thickening, onycholysis (separation of nail from nail bed), yellowish-brown/white discoloration, nail crumbling
  2. Diagnosis: Onychomycosis (DLSO - Distal Lateral Subungual Onychomycosis, most common type)
  3. Test for diagnosis:
    • KOH (10-20%) nail clipping - direct microscopy showing hyphae/spores
    • Nail culture (Sabouraud's dextrose agar) - gold standard but slow
    • Periodic Acid-Schiff (PAS) staining of nail clipping (most sensitive)
    • Dermatoscopy (onychoscopy)
  4. 3 Drugs:
    • Terbinafine 250 mg/day x 6 weeks (fingernails), 12 weeks (toenails) - DOC for dermatophytes
    • Itraconazole 200 mg/day x 3 months or pulse (400 mg/day x 1 week/month)
    • Fluconazole 150-300 mg/week x 6-12 months
    • Topical: Amorolfine 5% nail lacquer, Ciclopirox 8% nail lacquer

Spotter (Page 47) - Lepromatous Leprosy (Leonine Facies)

Questions: Name of face type / Diagnosis / Cardinal signs
  1. Name of face: Leonine facies (lion-like face)
  2. Diagnosis: Lepromatous Leprosy (LL)
  3. Cardinal signs of Leprosy (WHO):
    • Hypopigmented/erythematous skin patch with definite sensory loss
    • Thickened peripheral nerve
    • Positive slit skin smear (AFB) / skin biopsy showing M. leprae

Spotter (Page 48) - Vitiligo

Questions: Diagnosis / Write down findings / How many types / Treatments
Diagnosis: Vitiligo
  1. Diagnosis: Vitiligo
  2. Findings:
    • Well-defined, depigmented (chalk-white) macules/patches
    • Convex borders
    • Wood's lamp: brilliant white fluorescence (enhances contrast)
    • May have Koebner's phenomenon
  3. Types:
    • Segmental (unilateral, dermatomal) and Non-segmental (bilateral)
    • Non-segmental subtypes: Focal, Generalized (vulgaris), Acrofacial, Universal, Mixed
    • Special types: Trichrome vitiligo, Inflammatory vitiligo
  4. Treatments:
    • Topical corticosteroids (1st line, localized)
    • Tacrolimus 0.1% / Pimecrolimus 1% (face, genital areas)
    • NB-UVB phototherapy - best for generalized vitiligo
    • PUVA therapy
    • Surgical: Split thickness skin grafting, Suction blister grafting, Melanocyte transplantation
    • JAK inhibitors: Ruxolitinib 1.5% cream (FDA approved 2022) - latest therapy

Spotter (Page 49) - Auspitz sign / Psoriasis

Questions: Diagnosis / Name of sign / DOC
Diagnosis: Psoriasis
  1. Diagnosis: Psoriasis
  2. Name of sign: Auspitz sign - on removing the scales, pin-point bleeding occurs (due to dermal papillae coming close to surface)
    • Also: Candle grease sign (silvery scales scrape off like candle grease), Grattage test
  3. DOC:
    • For mild-moderate: Topical steroids + Calcipotriol
    • For severe/widespread: Methotrexate (traditional DOC)
    • For biological therapy: Secukinumab (IL-17 inhibitor) - highest PASI clearance in head-to-head trials

Spotter (Page 50) - Genital Ulcer

Questions: Describe genital ulcer / 2 DDs / Treatment for both
Likely Diagnosis: Chancroid OR Syphilis
  1. Describe:
    • If painful, soft, ragged, undermined edges with dirty base: Chancroid (soft chancre)
    • If painless, indurated, clean base with regular edges: Primary Syphilis (hard chancre)
  2. 2 DDs for genital ulcer:
    • Primary Syphilis (Treponema pallidum)
    • Chancroid (Haemophilus ducreyi)
    • Herpes genitalis (HSV-2) - multiple, painful vesicles/ulcers
    • LGV, Donovanosis
  3. Treatment:
    • Chancroid: Azithromycin 1g single dose OR Ceftriaxone 250 mg IM single dose OR Ciprofloxacin 500 mg BD x 3 days
    • Syphilis (primary): Benzathine Penicillin G 2.4 MU IM single dose; if penicillin allergic: Doxycycline 100 mg BD x 14 days

Spotter (Page 51) - Tinea Corporis / Dermatophytosis

Questions: Write down findings / Diagnosis / Treatment
Diagnosis: Tinea Corporis
  1. Findings:
    • Annular erythematous plaque with raised, scaly, vesicular border
    • Central clearing (heals from centre)
    • Centrifugal spread
  2. Diagnosis: Tinea corporis (Ringworm of body)
  3. Treatment:
    • Topical: Terbinafine 1% cream x 2-4 weeks (DOC), Clotrimazole, Miconazole
    • Systemic (extensive/resistant): Terbinafine 250 mg/day x 2-4 weeks or Itraconazole 100-200 mg/day x 2-4 weeks
    • Note: Avoid topical steroid-antifungal combinations (TFT - Tinea incognito risk)

Spotter (Page 52) - Urticaria / Allergic Reaction

Questions: Describe findings / Diagnosis / Treatment
Diagnosis: Urticaria
  1. Findings: Evanescent (transient <24h), erythematous, edematous wheals with central pallor; intensely pruritic; no surface changes; disappear without scarring
  2. Diagnosis: Urticaria (Acute or Chronic spontaneous urticaria)
  3. Treatment:
    • 2nd generation non-sedating antihistamines (1st line): Cetirizine, Fexofenadine, Loratadine, Bilastine, Rupatadine
    • Up-dose to 4x standard dose if inadequate response
    • Add H2 blocker (Ranitidine/Famotidine) for refractory cases
    • Omalizumab (anti-IgE) 300 mg SC monthly - for refractory chronic urticaria
    • Short course oral steroids for acute severe episodes

Spotter (Page 53) - Acne Vulgaris

Questions: Acne grading / DOC for grade 4 / 2 complications
  1. Acne Grading (Global Acne Grading System):
    • Grade 1 (Mild): Comedones (open/closed) only
    • Grade 2 (Moderate): Papules and pustules + comedones
    • Grade 3 (Severe): Nodules + papulopustules + comedones
    • Grade 4 (Very Severe): Nodulocystic + Conglobata
  2. DOC for Grade 4 (Nodulocystic/Conglobata): Isotretinoin (13-cis retinoic acid) - 0.5-1 mg/kg/day x 15-20 weeks; total cumulative dose 120-150 mg/kg
  3. 2 Complications of acne:
    • Post-inflammatory hyperpigmentation (PIH)
    • Scarring (ice-pick, rolling, boxcar scars)
    • Acne keloidalis
    • Sinus tracts (in conglobata)

Spotter (Page 54) - Neurofibromatosis

Questions: Diagnosis and types / One mutation / Treatment
Diagnosis: Neurofibromatosis
  1. Diagnosis and types:
    • NF-1 (Von Recklinghausen's disease): Café-au-lait macules (≥6, >1.5 cm), neurofibromas, Lisch nodules, axillary/inguinal freckling (Crowe's sign), optic glioma
    • NF-2: Bilateral acoustic neuromas/schwannomas; meningiomas; fewer skin lesions
    • Schwannomatosis (NF-3)
  2. One mutation:
    • NF-1: Neurofibromin gene mutation - chromosome 17q11.2 (tumor suppressor)
    • NF-2: Merlin/Schwannomin - chromosome 22q12
  3. Treatment:
    • No cure; symptomatic management
    • Surgical excision of troublesome neurofibromas
    • Selumetinib (MEK inhibitor) - FDA approved for NF-1 plexiform neurofibromas in children
    • Regular monitoring for complications (malignant peripheral nerve sheath tumors)

Spotter (Page 55) - Pyogenic Granuloma / Hemangioma

Questions: Diagnosis / Common age group / Growth factor / Treatment
Diagnosis: Infantile Hemangioma (or Pyogenic Granuloma)
If Infantile Hemangioma:
  1. Diagnosis: Infantile Hemangioma (strawberry hemangioma)
  2. Common age group: Presents at 1-4 weeks of age; rapid proliferative phase 1-12 months; involution by 5-7 years
  3. Growth factor involved: VEGF (Vascular Endothelial Growth Factor) - primary driver of proliferation; also GLUT-1 positive (marker)
  4. Treatment:
    • Propranolol 2-3 mg/kg/day oral - DOC (beta-blocker); reduces VEGF
    • Topical timolol 0.5% gel (for superficial, small lesions)
    • Pulsed dye laser (PDL) - 585/595 nm
    • Systemic steroids (older alternative)
If Pyogenic Granuloma:
  1. Diagnosis: Pyogenic granuloma (lobular capillary hemangioma)
  2. Age group: Any age; common in young adults, children, pregnant women
  3. Growth factor: VEGF, bFGF (basic Fibroblast Growth Factor)
  4. Treatment: Shave excision + electrocautery, laser ablation, surgical excision

Spotter (Page 56) - Oral Hairy Leukoplakia

Questions: Findings / Diagnosis / Commonly associated infection
  1. Findings: White corrugated/hairy plaques on lateral border of tongue; cannot be scraped off (unlike candidiasis)
  2. Diagnosis: Oral Hairy Leukoplakia (OHL)
  3. Commonly associated with: HIV infection (AIDS) - CD4 <200 cells/mm³; caused by Epstein-Barr Virus (EBV) reactivation in immunocompromised
    • Also seen in: Other immunocompromised states (organ transplant, lymphoma)

Spotter (Page 57) - Molluscum Contagiosum

Questions: Virus / Treatment / Henderson-Patterson body
  1. Virus: Poxvirus - Molluscum Contagiosum Virus (MCV), subtypes MCV-1 (most common), MCV-2 (STI/adults)
  2. Treatment:
    • Cryotherapy (liquid nitrogen) - common
    • Curettage - mechanical removal
    • Podophyllotoxin 0.5% / Imiquimod 5% cream
    • Trichloroacetic acid (TCA)
    • KOH 5-10% (for children)
    • Cidofovir (IV) for immunocompromised
  3. Henderson-Patterson body:
    • Large eosinophilic intracytoplasmic inclusion bodies seen on histology within molluscum bodies
    • Found in keratinocytes; represent accumulated viral particles
    • Seen as white "core" material expressed from the lesion (on squash preparation/Giemsa stain)

Spotter (Page 58) - SLE

Questions: Define the rash / Diagnosis / Latest criteria name / Name any 6 criteria
Diagnosis: Systemic Lupus Erythematosus (SLE)
  1. Rash: Malar (butterfly) rash - erythematous rash over malar eminences and nasal bridge, sparing nasolabial folds; photosensitive
  2. Diagnosis: SLE
  3. Latest criteria name: EULAR/ACR 2019 Classification Criteria for SLE (replaced the old ACR 1997 criteria; also used: SLICC 2012)
  4. 6 criteria (EULAR/ACR 2019 - requires ANA as entry criterion + domain scoring):
    • Malar rash / Acute cutaneous lupus
    • Discoid lupus / Chronic cutaneous lupus
    • Oral ulcers
    • Non-scarring alopecia
    • Arthritis (synovitis ≥2 joints)
    • Serositis (pleuritis/pericarditis)
    • Renal: Proteinuria >0.5 g/24h or RBC casts
    • Neurological: Seizures, psychosis
    • Hemolytic anemia
    • Leucopenia (<4000) / Lymphopenia (<1000)
    • Thrombocytopenia (<100,000)
    • Complement (low C3, C4)
    • Anti-dsDNA, Anti-Sm, Antiphospholipid antibodies, ANA

Spotter (Page 59) - Morphea / Lichen Sclerosus

Questions: Diagnosis / Associated with / Treatment / Histopath findings
Likely Diagnosis: Morphea (Localized Scleroderma)
  1. Diagnosis: Morphea (Localized Scleroderma) - OR Lichen Sclerosus et Atrophicus
  2. Associated with:
    • Morphea: Borrelia burgdorferi (in Europe), autoimmune thyroid disease, linear morphea with en coup de sabre (ECDS)
    • Lichen Sclerosus: HPV, autoimmunity; risk of SCC (4-5%) in genital LS
  3. Treatment:
    • Morphea: Topical/intralesional corticosteroids, Tacrolimus 0.1%, UVA1 phototherapy, Methotrexate (systemic/linear)
    • Lichen Sclerosus: Ultrapotent topical steroid (Clobetasol propionate 0.05%) - DOC
  4. Histopath findings (Morphea):
    • Thickened hyalinized collagen bundles in dermis
    • Loss of adnexal structures
    • Perivascular lymphocytic infiltrate (early); later - dense sclerosis

Spotter (Page 61) - Basal Cell Carcinoma (BCC)

Questions: Most common type / Histological findings
  1. Most common type of BCC: Nodular BCC (most common, ~60%)
  2. Histological findings:
    • Nests/islands of basaloid cells in dermis
    • Peripheral palisading of nuclei (hallmark)
    • Retraction artifact (clefting between tumor nests and stroma)
    • Myxoid/mucinous stroma
    • Mitoses present
    • "Cheesy" mucin in tumor islands

Spotter (Page 62) - Epidermolysis Bullosa (EB)

Questions: Types / Histological feature / Familial type association / Clinical classification
  1. Types of EB:
    • EB Simplex (EBS) - intraepidermal blistering; mutation in KRT5, KRT14
    • Junctional EB (JEB) - within lamina lucida; mutation in LAMA3, LAMB3, LAMC2 (Laminin-332) or ITGA6, ITGB4
    • Dystrophic EB (DEB) - below lamina densa; mutation in COL7A1 (Type VII collagen)
    • Kindler syndrome - mixed levels; mutation in FERMT1 (Kindlin-1)
  2. Histological feature:
    • EBS: Cytolysis of basal keratinocytes (intraepidermal)
    • JEB: Split within lamina lucida (PAS below blister)
    • DEB: Split below PAS-positive lamina densa
  3. Familial type association:
    • Dominant DEB (DDEB) - COL7A1 dominant negative mutation
    • Recessive DEB (RDEB) - severe generalized (Hallopeau-Siemens) - squamous cell carcinoma risk
  4. Clinical classification: Phenotype-based classification (2020 International EB Consensus) - based on skin fragility level, major/minor subtypes

Spotter (Page 63) - Xanthoma

Questions: Diagnosis / Most common site / Lipid association / Treatment
Diagnosis: Xanthoma (Xanthelasma)
  1. Diagnosis: Xanthoma - Xanthelasma palpebrarum (most common type on eyelids)
  2. Most common site: Eyelids (Xanthelasma)
    • Tendon xanthomas (Achilles, extensors) in Type II (FH)
    • Eruptive xanthomas - hypertriglyceridemia
  3. Mostly associated with which lipid:
    • Xanthelasma: LDL cholesterol (Type IIa - Familial Hypercholesterolemia); though 50% can have normal lipids
    • Eruptive xanthoma: Hypertriglyceridemia (Chylomicrons - Type I, V)
    • Tendon xanthoma: LDL (Type II)
  4. Treatment:
    • Treat underlying hyperlipidemia (statins for LDL, fibrates for TG)
    • Xanthelasma: TCA application, electrocautery, CO2 laser, surgical excision (recurrence common)

Spotter (Page 64) - Ichthyosis / Hair Shaft Disorders

Questions: Diagnosis / Ichthyosis linearis circumscripta / Pili torti / Bamboo hair / Trichorrhexis nodosa / Naxos / Carvajal
Diagnosis: Ichthyosis / Netherton Syndrome (based on clues)
(The answers are actually provided in the PDF itself - here's the complete version)
  • Ichthyosis linearis circumscripta with double-edged scaling: Netherton Syndrome (AR; SPINK5 mutation - Serine protease inhibitor; trichorrhexis invaginata = bamboo hair)
  • Pili torti seen in XLR disease: Menkes Disease (ATP7A mutation - copper transporter; kinky hair, neurodegeneration)
  • Bamboo hair seen in AR disease: Netherton Syndrome (trichorrhexis invaginata = "bamboo hair" / "ball-in-cup" pattern)
  • Trichorrhexis nodosa seen in: Argininosuccinic aciduria (ASA) + also in Trichothiodystrophy, hypothyroidism
  • Naxos disease: ARVC (Arrhythmogenic Right Ventricular Cardiomyopathy) + Palmoplantar keratoderma + Woolly hair (Plakoglobin/JUP mutation, AR)
  • Carvajal syndrome: ALVC (Arrhythmogenic Left Ventricular Cardiomyopathy) + PPK + Woolly hair (Desmoplakin/DSP mutation, AR)

Spotter (Page 65) - Tuberous Sclerosis / Sturge-Weber (images only)

(No text questions - image-based; associated with TSC or neurocutaneous syndrome)
If Tuberous Sclerosis (Ash leaf macule / Shagreen patch / Adenoma Sebaceum):
  • TSC1 (Hamartin, chr 9q34) or TSC2 (Tuberin, chr 16p13.3) mutations
  • Features: Ash leaf macule, Shagreen patch, Periungual fibroma (Koenen's tumor), Adenoma sebaceum (facial angiofibromas)
  • Associated with: Epilepsy, intellectual disability, cortical tubers, renal angiomyolipoma

Spotter (Page 66) - Pellagra

Questions: Capsule content / Treatment for 6-year-old / Hypervitaminosis symptoms / Other nutrients deficient in PD
Diagnosis: Pellagra (Niacin/Vitamin B3 deficiency)
  1. Each capsule contains: 500 mg Nicotinamide (standard niacinamide capsule)
  2. Treatment for 6-year-old child:
    • Nicotinamide (Niacinamide) 50-100 mg TDS orally x 3-4 weeks
    • (Safer than Nicotinic acid - no flushing side effects)
    • Nutritional counseling, balanced diet
  3. Symptoms of Hypervitaminosis (Niacin toxicity):
    • Flushing (prostaglandin-mediated) - most common with nicotinic acid
    • Hepatotoxicity (elevated LFTs)
    • Hyperglycemia, hyperuricemia
    • Peptic ulcer exacerbation
    • Atrial fibrillation (high dose)
  4. Other nutrients deficient in Pellagra/PD:
    • Pellagra = Niacin (Vitamin B3) deficiency; may co-exist with:
    • Tryptophan deficiency (precursor to niacin)
    • Riboflavin (B2) and Pyridoxine (B6) deficiency
    • Iron, Zinc deficiency
    • Carcinoid syndrome traps tryptophan; Isoniazid inhibits B6 (causes secondary pellagra)
    • 4 Ds of Pellagra: Dermatitis, Diarrhea, Dementia, Death

Spotter (Page 67) - Erythropoietic Protoporphyria (EPP)

Questions: Type of lesions / DDs / Photo disorder resembling EPP / DOC
Diagnosis: Erythropoietic Protoporphyria (EPP)
  1. Type of lesions:
    • Burning, stinging, itching on sun-exposed areas (immediate photosensitivity on sun exposure)
    • Erythema, edema, vesicles on face, dorsa of hands
    • Chronic: Waxy/leathery thickening, pitted scarring on nose/knuckles
  2. Differential Diagnoses:
    • Solar urticaria
    • Polymorphic light eruption (PMLE)
    • Hydroa vacciniforme
    • Xeroderma Pigmentosum (XP)
  3. Photo disorder resembling EPP: Solar Urticaria - also causes immediate burning/urticaria on sun exposure; and Hydroa vacciniforme (vesicular scarring lesions in children)
  4. DOC: Afamelanotide (Scenesse) - alpha-MSH analogue; SC implant; increases melanin production, reduces phototoxicity. Older: Beta-carotene (30-180 mg/day), Narrowband UVB hardening

Spotter (Page 68) - Melasma

Questions: Diagnosis / Triple combination / How to apply sunscreens
Diagnosis: Melasma (Chloasma)
  1. Diagnosis: Melasma - symmetric hyperpigmentation on face (malar, centrofacial, mandibular pattern)
  2. Triple combination (Kligman's formula):
    • Hydroquinone 4% (depigmenting)
    • Tretinoin 0.025-0.05% (retinoid - promotes turnover)
    • Fluocinolone acetonide 0.01% (mild steroid - reduces irritation)
    • Applied at night; sun protection mandatory
    • Modified Kligman's: Replace HQ with Kojic acid, Azelaic acid, or Arbutin
  3. How to apply sunscreens:
    • Apply 30 minutes before sun exposure
    • Amount: 2 mg/cm² (fingerprinting units: 2 finger lengths for face and neck)
    • Reapply every 2 hours or after swimming/sweating
    • Use broad-spectrum SPF ≥30 (covers UVA + UVB)
    • In melasma: SPF ≥50+ with visible light protection (iron oxide-containing) preferred
    • Don't miss lips and ears

Spotter (Page 69) - Urticaria (Detailed)

Questions: Define lesions / Diagnosis / Duration: acute vs chronic / 1st gen vs 2nd gen antihistamines (3 each)
  1. Define lesions:
    • Wheal: Superficial, transient, edematous, erythematous, pruritic plaque; lasts <24h, leaves no mark; represents upper dermal edema
    • Flare: Surrounding erythema
  2. Diagnosis: Urticaria (Chronic Spontaneous Urticaria if >6 weeks)
  3. Duration - Acute vs Chronic Urticaria:
    • Acute urticaria: < 6 weeks duration
    • Chronic urticaria: > 6 weeks duration (daily or near-daily episodes)
  4. Antihistamines:
GenerationDrug 1Drug 2Drug 3
1st generation (sedating)Chlorpheniramine (Chlorphenamine)DiphenhydramineHydroxyzine
2nd generation (non-sedating)CetirizineLoratadineFexofenadine
  • Other 2nd gen: Bilastine, Rupatadine, Levocetirizine, Desloratadine
  • Rupatadine and Bilastine are newer 2nd generation with additional PAF-antagonist (Rupatadine) activity

TUBERCULOSIS CUTIS ANSWERS (Pages 31-32)

(Answers already in PDF - completed version below)
  • Commonest type in adults: Lupus Vulgaris (LV)
  • Commonest in children: TBVC (Tuberculosis Verrucosa Cutis)
  • Epithelioid granulomas WITHOUT necrosis: Lupus Vulgaris (LV)
  • Commonest tuberculide: Papulonecrotic tuberculide (PNT) - worldwide; Lichen Scrofulosorum (SFD - Lichen scrofulosorum = "SFD" in Indian context); In India: Lichen Scrofulosorum
  • Strongest Mantoux reaction (20-30mm): Tuberculosis Verrucosa Cutis (TBVC)
FeatureCondition
Apple jelly nodule (diascopy)Lupus Vulgaris (LV)
Hematogenous spreadMiliary TB
Most common tuberculide in IndiaLichen Scrofulosorum (SFD)
Most common tuberculide worldwidePapulonecrotic tuberculide (PNT) - heals with atrophic scarring
PaucibacillaryLV & TBVC

PARTHENIUM DERMATITIS ANSWERS (Pages 39-41)

  • Commonest allergen in Parthenium dermatitis: Sesquiterpene Lactone (STL)
  • Parthenin: Type of STL found in Parthenium hysterophorus (Congress grass/Carrot grass)
  • Glandular trichomes on undersurface of leaves secrete parthenin
  • Patterns of Parthenium dermatitis (8 types):
    1. Classical (eyelids + flexures)
    2. Chronic actinic dermatitis-like
    3. Mixed
    4. Widespread dermatitis
    5. Hand and feet
    6. Photosensitive lichenoid eruption
    7. Prurigo nodularis-like
    8. Other rare (erythroderma, seborrheic)
  • Treatment: Azathioprine (50-150 mg/day, various regimens including weekly pulse 300 mg/week)
Note: Images were extracted from the PDF but could not be visually analyzed with the AI vision tool due to session constraints. The diagnoses above are based on the question context, which contains strong clinical clues for each spotter. If any spotter shows a different image than expected, let me know and I'll adjust the answer accordingly.
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