Photobiology and Photosensitivity Disorders1) What mutation is responsible for this clinical presentation in a patient with thyroid dysfunction and chronic candidal infections?

A. LYST

B. PTEN

C. AIRECorrect Choice

D. TRP1

E. fumarate hydratase

APECED syndrome named for the clinical features of autoimmune polyendocrinopathy, candidiasis, ectodermal dystrophy and is caused by a mutation in AIRE (autoimmune regulator). 13% of these patient have vitigo

2) Treatment of this condition might include:

A. Cyclosporin

B. Antimalarials Correct Choice

C. Cytoxan

D. Azathioprine

E. All of these answers are correct

Sun avoidance, sunblocks, protective clothing, and topical steroids are sufficient for most patients with PMLE. Other patients may require hardening with UVB or PUVA. Rare patients require antimalarials

3) Immediate pigment darkening:

A. Is caused by an increase in tyrosinase activity

B. Is predominately brought on by UVA and visible light Correct Choice

C. Is associated with an increase in melanocyte number

D. Start 45-60 minutes after exposure

E. Is predominately brought on by UVB

Immediate pigment darkening appears almost as soon as irradiation occurs. It is due to photo-oxidation of preexisting melanin

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4) A patient present with blue-gray pigmentation on sun-exposed areas but does not have involvement of the sclerae, lunulae or mucous membranes. Which of the following medications is could be causing this pigmentation?

A. Sertraline

B. Fluoxetine

C. ChlorpromazineCorrect Choice

D. Clindamycin

E. Ciprofloxacin

Amiodarone, chlorpromazine and tricyclic antidepressants all are capable of causing blue-gray pigmentation on sun-exposed areas without involvement of the sclerae, lunulae or mucous membranes

5) UVB acts on what compound to form pre-Vitamin D3 ?

A. 7-deoxycholesterol

B. 9-hydrocholesterol

C. 5-dehydrocholesterol

D. 7-hydrocholesterol Correct Choice

E. DNA

UVB converts 7-dehydrocholesterol in the skin to pre-Vitamin D3, which then thermally isomerizes to form Vitamin D3

6) Which of the following statements regarding phototesting is correct?

A. To test for a visible light reaction, a slide projector is used as a light sourceCorrect Choice

B. Repeated MEDs to UVB or UVA, given to different test sites over several days can be used to reproduce lesions of polymorphous light eruption

C. The UVA MED is performed using a narrowband UVA source

D. A single large dose of visible light is the best way to reproduce lesions of polymorphous light eruption

E. The UVB MED is performed using narrowband UVB light sources

Phototesting is done prior to initiating phototherapy or during provocative induction. To test for a visible light reaction, a slide projector is used as a light source. The other choices are incorrect. The UVB MED and UVA MED is performed using BROADBAND UVB and BROADBAND UVA light sources

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respectively. Repeated MED's to UVB or UVA given to the SAME site may be used to reproduce lesions of PMLE. Alternatively a single large dose of UVA or UVB can be used to reproduce PMLE

7) The main contributor to erythema of the skin with exposure to the sun is:

A. UVC

B. Visible light

C. UVA2

D. UVA1

E. UVBCorrect Choice

UVB in natural sunlight is the main contributor to erythema. UVB erythema reaches a maximum in 6-24 hours. UVA accounts for 15-20% of sunlight erythema despite that there is much more UVA than UVB in sunlight

8) Treatment of CAD might include:

A. All of these answers are correctCorrect Choice

B. PUVA

C. UV filters for car windows

D. Incandescent bulbs for home and office lighting

E. Broad spectrum sunblock to which the patient is not allergic

CAD patients are exquisitely sensitive to UVB, often sensitive to UVA, and sometimes sensitive to visible light. Answers a, b, and c are correct because those treatments prevent UV and visible radiation from reaching the patient. PUVA hardens and desensitizes the skin

9) The xenon arc solar simulator, whose spectrum is in this slide, is useful for:

A. MED-B testing and MED-A testing Correct Choice

B. MED-A testing

C. Photopatch testing

D. MED-B testing, MED-A testing, and Photopatch testing

E. MED-B testing

Solar simulator radiation contains both UVB and UVA in sufficient quantities to be useful for MED-B and MED-A testing. The field size is too small for photopatch testing

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10) Rare cases of which photosensitivity disorder have been associated with erythropoietic protoporphyria?

A. Solar urticariaCorrect Choice

B. Chronic actinic dermatitis

C. Actinic prurigo

D. Hydroa vacciniforme

E. Polymorphous light eruption

Rare cases of solar urticaria have been associated with erythropoietic protoporphyria (EPP), lupus erythematosus (LE), and with certain drugs. Blood tests for LE and EPP should be performed in patients with this diagnosis

11) Fluorescent UVA bulbs used for phototesting or PUVA therapy have a peak emission at:

A. 254 nm

B. 468 nm

C. 311 nm

D. 312 nm

E. 352 nmCorrect Choice

254 nm is the wavelength of the radiation emitted by mercury vapor lamps. Narrowband UVB emits 311-312 nm. Fluorescent UVA bulbs used for phototesting or PUVA therapy have a peak emission at 352 nm

12) A patient that rarely burns and usually tans is which of the following skin types?

A. Type IV

B. Type IIICorrect Choice

C. Type I

D. Type V

E. Type II

Skin type I always burns and never tansSkin type II usually burns and rarely tansSkin type III rarely burns and usually tansSkin type IV never burns and alway tansSkin types V,VI are highly pigmented individuals

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13) The wavelength range that most effectively induces cutaneous immunosuppression is:

A. 400-410nm

B. 320-340nm

C. 290-320nmCorrect Choice

D. 340-400nm

E. 200-290nm

290-320nm (UVB) is most effective in suppressing cutaneous immunity; mechanisms include depletion of Langerhans cells, induction of regulatory T cells, and keratinocyte secretion of such immunosuppressive cytokines as IL-10 and TNF-alph

14) Which of the following statements is true regarding pseudoporphyria?

A. None of these answers are correct

B. It has been associated with furosemide

C. All of these answers are correctCorrect Choice

D. Clinically it may be indistinguishable from porphyria cutanea tarda

E. Porphyrins may be normal

Pseudoporphyria is a phototoxic reaction that clinically and histologically resembles porphyria cutanea tarda. In pseudoporphyria, however, there is no porphyrin abnormality. It has been associated with numerous medications, including nalidixic acid, tetracyclines, amiodarone, furosemide, and ketoprofen

15) Oral PUVA has been used to treat which of the following diseases:

A. All of these answers are correctCorrect Choice

B. Graft-versus-host disease

C. CTCL

D. Mastocytosis

E. Generalized granuloma annulare

PUVA has been reported to have helped patients with all the diseases listed

16) Regarding renal transplant recipients, which of the following statements is correct:

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A. Should have skin cancer screening at the same rate as the general population

B. Have a 36-fold increased risk of BCC

C. Have rates of SCC similar to the general population

D. Have an decreased risk for melanoma

E. Have a 36-fold increased risk of SCCCorrect Choice

The rates of SCC in renal cell transplant recipients is increased at a rate of 36x. The rates of skin cancer are higher than in the general population

17) The usual dose of UVR given for photopatch testing is approximately:

A. 10 Joules of UVA

B. 4 millijoules of UVB

C. 4 Joules of UVB

D. 2 Joules of UVA Correct Choice

E. 10 Joules of UVB

UVA is absorbed by the chemicals that cause photoallergic contact dermatitis; therefore, it is UVA that is used for photopatch testing. In patients who are UVA-sensitive, one-half of their MEDA is used for photopatch testing

18) A patient presents with signs of porphyria cutanea tarda. Porphyrin screens are negative. Which of the following medications on the patient's medication list is your top choice for discontinuation?

A. Fenofibrate

B. Multivitamin

C. NaproxenCorrect Choice

D. Chloroquine

E. Enalapril

NSAIDs are a frequent offender in causing pseudoporphyria. The other listed medications are not frequent causes of this type of skin reaction

19) The typical patients with polymorphous light eruption are:

A. Fair-skinned females in their teens and 20’s. Correct Choice

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B. Type V-skinned females in their 20’s and 30’s.

C. Fair-skinned males in their 20’s and 30’s.

D. Fair-skinned females in their 40’s and 50’s.

E. Type IV-skinned males in their 40’s and 50’s.

PMLE most commonly appears in fair-skinned females during the first three decades of life. It may be related to type IV hypersensitivity

20) All of the following statements regarding chronic actinic dermatitis are true EXCEPT:

A. Azathioprine has been used successfully to treat this disorder

B. The MEDB on phototesting is markedly diminished in patients with this condition

C. Many cases begin as photoallergic contact dermatitis or drug photosensitivity

D. Fluorescent bulbs are safer for these patients than are incandescent bulbsCorrect Choice

E. Many patients have a lowered threshold to shorter wavelength visible light

Chronic actinic dermatitis (CAD) usually occurs in middle-aged to elderly males who present with a chronic, eczematous dermatitis in a photodistribution, though there is no history of current exposure to a photosensitizer. Phototesting is very helpful in diagnosing CAD. The MEDB is markedly diminished, and the MEDB site may show an eczematous or infiltrated appearance. Many of the patients have a lowered MEDA as well, and may have a lowered threshold to shorter wavelength visible light in the blue-violet end of the spectrum. Many cases of this idiopathic disorder are thought to have begun as photoallergic contact dermatitis or as a drug photosensitivity with broadening of the photosensitivity to include the UVB range. It is unclear why photosensitivity persists when the photosensitizer is no longer present. Treatment includes strict sun avoidance and sun protection. Incandescent bulbs with longer wavelengths, far from the blue-violet end of the visible spectrum, should be used instead of fluorescent bulbs, which have significant blue-violet radiation. Topical and oral steroids, oral azathioprine and cyclosporine, and PUVA have all been used to treat patients with CAD

21) Treatment of polymorphous light eruption includes all of the following EXCEPT:

A. None of these answers are correctCorrect Choice

B. PUVA therapy

C. Systemic corticosteroids

D. Antimalarials

E. Topical steroids

Most patients with PMLE have mild disease that can be treated by sun avoidance and sun protection. Topical steroids can be used to treat clinical lesions. For severe cases, hardening and desensitization can be accomplished with UVB, UVB plus UVA, or PUVA. Antimalarials can be used for resistant cases. A short course of prednisone (20-40 mg) is effective for brief, sunny vacations

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22) Which of the following statements about ultraviolet C is incorrect?

A. UV-C is absorbed by atmospheric ozone

B. UV-C has an electromagnetic spectrum from 200-290 nm

C. UV-C has a higher wavelength than UV-BCorrect Choice

D. UV-C has higher energy than UV-B

E. UV-C does not reach the earth's surface

UV-C has wavelengths of 200 - 290 nm. UV-B has wavelengths of 290 - 320 nm. UV-C has a lower wavelength, not higher. All of the other listed statements about UV-C are correct

23) Which of the following statements about the spectrums of UVR that cause of solar urticaria is MOST correct?

A. Visible light causes solar urticaria

B. UVA causes solar urticaria

C. UVB causes solar urticaria

D. Both UVA and UVB cause solar urticaria

E. Patients can react to visible light, UVA and/or UVBCorrect Choice

Some patients react with wheals to either visible light or UVA or UVB. Others react to both UVA and visible radiation. Some react to both UVB and UVA, and some patients react to UVB, UVA and visible light

24) Patients with chronic actinic dermatitis (CAD) typically show on phototesting:

A. Lowered MEDB, usually normal MEDA, sometimes positive photopatch tests

B. Lowered MEDB, usually lowered MEDA, sometimes positive photopatch tests Correct Choice

C. Normal MEDB, lowered MEDA, sometimes positive photopatch tests

D. Normal MEDB, normal MEDA, sometimes positive photopatch tests

E. None of the above

The hallmark of CAD is a lowered MEDB. Often the patients have a lowered MEDA. It is felt that many of CAD patients began with photoallergic contact dermatitis, so some have positive photopatch tests

25) Most patients with PMLE require treatment with:

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A. Sunscreen and sun avoidance between 11 am and 3pmCorrect Choice

B. Cyclophosphamide

C. Chloroquine

D. UVB hardening/desensitization

E. Prednisone

Most patients have mild disease that can be treated by sun avoidance, especially between 11 am and 3pm; a broad spectum sunscreen and clothing with a tight weave. In more severe cases, UV hardening, antimalarials or prednisone can be used. Cyclophosphamide is not used in PMLE

26) The histology of the patient in question 42 is the following slide. It mimics the histology of:

A. CTCL Correct Choice

B. Pityriasis rosea

C. Psoriasis

D. Tuberculoid leprosy

E. SLE

The histology of the actinic reticuloid variety of CAD mimics that of mycosis fungoides with a band-like infiltrate with atypical mononuclear cells

27) The highest energy visible photons are in which portion of the visible spectrum?

A. All of these answers are correct

B. Green

C. Yellow

D. Blue-violet Correct Choice

E. Red-Orange

In the visible spectrum, the blue-violet portion has the shortest wavelength and the highest energy. The red-orange portion has the longest wavelength and the lowest energy

28) In solar urticaria wheals typically:

A. Begin at 1-2 h. and last 2-4 h

B. Begin at 15-30 minutes and last 1 h Correct Choice

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C. Begin at 45 minutes after exposure and last 2 hours (h.)

D. Begin at 15-30 seconds and last about 15 minutes

E. Begin at 30-60 minutes and last 1-4 h

The wheals of solar urticaria begin 10-15 minutes after exposure and last for about an hour. Solar urticaria is usually idiopathic. Rare cases are associated with EPP, SLE, and certain medications

29) Currently the most common cause of photoallergic contact dermatitis is:

A. Musk ambrette

B. Halogenated salicylanilides

C. Mercaptobenzothiazole

D. 6-methylcoumarin

E. Sunscreens Correct Choice

Halogenated salicylanilides, musck ambrette and 6-methylcoumarin used to cause most of the cases of photoallergic contact dermatitis. They have been essentially eliminated from soaps and fragrances. Sunscreen ingredients are now the most common cause

30) The potent photosensitizer, 5-methoxypsoralen, is contained in which of the following contact allergens?

A. Eugenol

B. Oil of BergamotCorrect Choice

C. Usnic acid

D. Balsam of Peru

E. Tuliposide A

Oil of Bergamot contains 5-methoxypsoralen and may cause of 'Berloque dermatitis,' an intense post-inflammatory hyperpigmentation due to an antecedent phytophotodermatitis that may be subclinical

31) A common cause of medication induced photoallergy is:

A. Naproxen

B. Acitretin

C. Psoralens

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D. PiroxicamCorrect Choice

E. Ibuprofen

All of the listed medications are causes of photosensitivity, but only piroxicam is a cause of photoallergy

32) Phototesting of PMLE patients reveals:

A. Normal MEDB, reduced MEDA.

B. Normal MEDB, elevated MEDA.

C. Normal MEDB, normal MEDA. Correct Choice

D. Lowered MEDB, normal MEDA.

E. Lowered MEDB, lowered MEDA.

The MEDB and MEDA are normal in PMLE patients. Only with multiples of the MEDB or MEDA can one often reproduce the lesions

33) Ultraviolet radiation from the sun cause which of the following acute effects EXCEPT?

A. Increased immune surveillance Correct Choice

B. Immediate pigment darkening

C. Epidermal thickening

D. Sunburning

E. Photosynthesis of vitamin D

UV radiation causes acute effects including: photosynthesis of vitamin D, sunburning, immediate pigment darkening, delayed tanning, epidermal thickening and immunologic effects such as DECREASED immune surveillance

34) A 40-year-old patient presents with widespread plaque-type psoriasis without arthritis. She had already applied potent topical steroids, calcipotriene, and tazarotene. The treatment of choice would be:

A. Methotrexate

B. Narrowband UVB Correct Choice

C. Etretinate

D. Cyclosporine

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E. PUVA

The other choices involve internal medications and therefore have the potential for more side effects than with narrowband UVB. Phototherapy may be impractical for some patients, and therefore systemic therapies should be offered

35) Which of the following is true regarding actinic prurigo?

A. Lesions generally continue through late adulthood

B. Cheilitis is frequently seenCorrect Choice

C. Thalidomide has been ineffective for the majority of patients

D. Lesions persist for 1-2 days

E. Lesions never occur on non-sun-exposed areas

Actinic prurigo is an idiopathic photosensitivity disorder. Lesions are excoriated papules and nodules that begin in childhood and remit in puberty. They can last for several months and may occur on non-sun-exposed areas. Thalidomide has been very effective for treating the majority of patients with actinic prurigo.

36) The irradiance of a UV source is measured in:

A. Joules

B. Seconds

C. Millijoules

D. Centimeters

E. Watts Correct Choice

The irradiance of a UV source in watts x the time in seconds equals the UV dose in joules

37) A patient presents with solar urticaria. What tests should be considered initially?

A. ESR

B. ANACorrect Choice

C. CXR

D. ANCA

E. Urinalysis

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Solar urticaria is an idiopathic, type I photosensitivity disorder. Rare cases have been associated with erythropoietic protoporphyria (EPP) and lupus erythematosus (LE). Blood tests for LE and appropriate screening for EPP should be performed including ANA, Ro/La, Urine & Stool porphyrins

38) The best location for phototesting patients suspected of photosensitivity is:

A. Unaffected skin of the upper back

B. Effected skin of the ventral forearm

C. Effected skin of the buttock

D. Unaffected skin of the lower backCorrect Choice

E. Unaffected skin of the outer thighs

Patients with suspected photosensitivity can be tested on unaffected skin of the buttocks, lower back or ventral forearm. Effected skin should not be used for testing

39) Blue-gray pigmentation of the lunulae:

A. Is a rare side effect of treatment with tricyclic antidepressants

B. None of these answers are correct

C. Occurs only after many years of treatment with chlorpromazine

D. Is seen in argyria and not in most medication photosensitivitiesCorrect Choice

E. Can be seen in patients on amiodarone

Blue-gray pigmentation on sun-exposed areas can be seen during treatment with amiodarone, chlorpromazine, and tricyclic antidepressants. In these medication photosensitivities, there is no involvement of the sclera, lunulae, or mucous membranes, as in argyria (prolonged contact with or ingestion of silver salts

40) The best definition for a MED is:

A. The dose of ultraviolet radiation that produces pronounced erythema that completely fills the test square

B. The dose of ultraviolet radiation that is one step below the first visible erythema

C. The dose of ultraviolet radiation that produces bullae that completely fills the test square

D. The dose of ultraviolet radiation that produces a easily visible "sunburn"

E. The dose of ultraviolet radiation that produces barely perceptible erythema that completely fills the test squareCorrect Choice

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An MED is the dose of ultraviolet radiation that produces barely perceptible erythema that completely fills the test square. The remaining options are incorrect

41) The image shown is diagnostic of which of the following conditions?

A. Bullous pemphigoid

B. Pemphigus vulgaris

C. Chronic actinic dermatitis

D. Polymorphous light eruptionCorrect Choice

E. Pseudoporphria cutanea tarda

The pathologic image shown is that of polymorphous light eruption. The histology shows a lymphocytic infiltrate around the superficial vascular plexuses with subepidermal edema and minimal epidermal changes are present

42) Photoexacerbated genodermatoses include all except:

A. Hartnup Disease

B. Darier's Disease

C. Hailey-Hailey Disease

D. Cockayne's Syndrome

E. Tuberous sclerosis Correct Choice

Tuberous sclerosis is not associated with photosensitivity

43) Which of the following statements is correct regarding antigen presenting cells after UVR exposure?

A. Have increased ability to prime UV-irradiated mice to subcutaneously injected hapten

B. UV-irradiated mice have normal antigen presentation, allowing a normal delayed-type hypersensitivity response

C. APC's have increased ability to prime UV-irradiated mice to subcutaneously injected protein

D. APC's have increased ability to prime UV-irradiated mice to applied contact-sensitizing agents

E. There is a decrease in the number of antigen presenting cellsCorrect Choice

APC's have depressed ability to prime UV-irradiated mice to subcutaneously injected hapten or protein and to applied contact-sensitizing agents. UV-irradiated mice have defective antigen

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presentation, preventing a normal delayed-type hypersensitivity response. There is a REDUCTION in number of antigen presenting cells

44) The UVAII portion of the electromagnetic spectrum extends from:

A. 290-320 nm

B. 320-340 nmCorrect Choice

C. 320-400 nm

D. None of these answers are correct

E. 200-290 nm

UVA extends from 320-400nm. UVA is further subdivided into UVAII (320-340nm) and UVA1 (340-400nm

45) Which of the following statements about UVR and DNA is correct?

A. Pyrimidine dimers can not activate oncogenes

B. UVA is most effective in producing pyrimidine dimer

C. UVA is much more efficient than UVB in inducing DNA damage

D. Cells from patients with actinic keratoses have more DNA repair capacity than controls

E. UVR alters DNACorrect Choice

UVR alters DNA. UVB is much more efficient than UVA in inducing DNA damage. It can create pyrimidine dimers that may activate oncogenes and lead to cancer. Cells from patients with actinic keratoses have less DNA repair capacity than controls

46) Ultraviolet light spectrum most completely encompasses which of the following spectrums?

A. 760 - 1200 nm

B. 290 - 400 nm

C. 10 - 400 nmCorrect Choice

D. 400 - 700 nm

E. 200 - 400 nm

The ultraviolet spectrum encompasses Vacuum UV from 10-200nm, UV-C from 200-290nm, UV-B from 290-320nm and UV-A from 320-400nm. The visible light spectrum is from 400-700nm. 700-1200 nm is part of the infrared spectrum

47) Which of the following is true about UV light:

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A. Clouds absorb most UVA light

B. Sunlight early in the morning and late in the day contains relatively more UVB

C. UVB radiation is 1000 times more erythrogenic than UVACorrect Choice

D. UVAII light is 340-400nm

E. UVA radiation is 1000 times greater than UVB during midday hours

UVA light is found b/w 320 and 400nm and is broken up into UVAI(340-400nm) and UVAII((320-340nm). UVB light is found between 290 and 320nm. UVA radiation is 100 times greater than UVB during midday hours and sunlight early in the morning and late in the day contains relatively more UVA. UVB radiation is 1000 times more erythrogenic than UVA. Cloud cover is a poor UV absorber

48) Which of the following hypoglycemics is the most common cause of photosensitivity?

A. Thiazolidinediones (i.e. rosiglitazone)

B. Metformin

C. Insulin

D. Piroxicam

E. SulfonylureasCorrect Choice

The sulfonylurea hypoglycemics for diabetes are the most common type of medication of this class of medications. Piroxicam is not a hypoglycemic agent, but a common NSAID cause of photoallergy

49) The most helpful phototest to document this photosensitivity disorder would be:

A. MEDBB

B. Repeated doses of UVA and UVB Correct Choice

C. Photopatch tests

D. MEDNB

E. All of these answers are correct

Repeated doses of ultraviolet radiation can sometimes elicit lesions of PMLE. More patients react to UVA radiation than to UVB radiation

50) Hereditary PMLE of Native Americans:

A. Often presents with chelitis and conjunctivitisCorrect Choice

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B. Rarely persists into adulthood

C. All of these answers are correct

D. Is not treated with thalidomide

E. Is more similar to PMLE than to actinic prurigo

Hereditary PMLE of Native Americans is similar to actinic prurigo but persists much more frequently into adulthood. 75% of patients have a positive family history. It presents with a papular, excoriated, eczematous dermatitis that occurs predominantly on the face. Chelitis and conjunctivitis are common. It may be treated with thalidomide

51) Solar urticaria:

A. Rarely lasts for more than 6 months to 1 year

B. Is not benefitted by antihistamines

C. Can present with headache, nausea, and syncopeCorrect Choice

D. Is an idiopathic, type IV photosensitivity disorder

E. Usually occurs to only UVB radiation

Solar urticaria is an idiopathic, type I photosensitivity disorder. Mediator release during widespread whealing may result in headache, nausea, wheezing, faintness, and syncope. It usually lasts for many years. Some patients react with wheals to either visible light or UVA or UVB. Others react to both UVA and visible radiation. Some react to both UVB and UVA, and some patients react to UVB, UVA, and visible radiation. Treatment includes sun avoidance and protection, and H-1 antihistamines may be of partial benefit

52) Most bulbs used for PUVA have a peak output predominantly in the following range:

A. 320 nm – 340 nm

B. 390 nm – 410 nm

C. 340 nm – 400 nm

D. 350 nm – 360 nm Correct Choice

E. 290 nm – 320 nm

The UVA emitted by these bulbs is absorbed by psoralens, causing covalent bonding of psoralens to DNA

53) The active spectrum for cutaneous vitamin D3 synthesis is:

A. 320-400nm

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B. 400-410nm

C. 290-320nmCorrect Choice

D. 410-450nm

E. 220-290nm

The source states that vitamin D3 synthesis occurs at wavelengths < 320 making choices 220-290nm and 290-320nm correct

54) When solar urticaria is a consideration for phototesting:

A. 7 test squares of increasing UV doses should be exposed

B. An MED (B) and MED (A) should not be performed

C. The lower back should not be used for testing

D. Visible light will not evoke the lesions

E. An additional reading at 15 minutes after exposure should be performedCorrect Choice

When solar urticaria is a consideration, an additional reading at 15 minutes after exposure is important, as wheals begin within 10-30 minutes after exposure and last for about one hour. The face and hands may not show lesions as they are chronically exposed to sun. Some patients react to either visible light or UVA or UVB. Others react to both UVB and UVA, both UVA and visible light, or all three

55) Which of the following statements regarding hereditary PMLE of Native Americans is true?

A. Specific HLA types predominate in Native AmericansCorrect Choice

B. Cheilits and conjunctivitis are uncommon

C. 5-10% of patients have a family history of this eruption

D. It will remit in puberty

E. Patients have an urticarial erupion.

Native Americans have a high rate of PMLE and there is some evidence of a genetic predisposition. It tends to have a specific HLA predominance, continues through adulthood, and commonly presents as a papular, excoriated, eczematous dermatitis predominantly on the face. Cheilitis and conjunctivitis are common. Up to 75% of patients have a positive family history

56) The portion of the electromagnetic spectrum that produces a particular biologic effect is known as the:

A. Photobiologic spectrum

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B. Minimal erythema dose

C. Active spectrum

D. Action spectrumCorrect Choice

E. Absorption spectrum

The action spectrum is the portion of the electromagnetic spectrum that products a particular biologic effect (e.g. erythema, delayed tanning). The absorption spectrum is the portion of the electromagnetic spectrum that is absorbed by a particular absorbing molecule, or chromophore. The minimal erythema dose is the dose of UV radiatino that produces barely perceptible erythema during phototesting

57) A patient presents with onycholysis after sun exposure. Which of the following medications would you rule out as a cause of this presentation?

A. Quinolones

B. Quinine

C. ChlorpromazineCorrect Choice

D. Tetracyclines

E. Psoralens

Chlorpromazine is associated with blue-gray pigmentation on sun-exposed areas and is not associated with photoonycholysis. Quinolones, tetracyclines, psoralens and quinine can cause photoonycholysis

58) Phytophotodermatitis can be seen with the following fruits / vegetables:

A. Potatoes and leeks

B. Tomatoes and bananas

C. Celery and radishes

D. Parsnips and limesCorrect Choice

E. Lemons and pears

Psoralens in certain plants, fruits, and vegetables can cause phytophotodermatitis. The most common ones are limes, figs, parsley, parsnip, bergamot oranges, and celery

59) Narrow band UVB consists of what wavelength?

A. 308-310nm

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B. 311-313nmCorrect Choice

C. 300-306nm

D. 312-320nm

E. 320-330nm

Narrowband UVB is much less erythemogenic with regard to physical units (mJ/cm2) than broadband UVB. Narrowband UVB is 311-313nm

60) Absorption of UV radiation generates singlet oxygen in the skin by which chromophore?

A. Melanin

B. Water

C. Hemoglobin

D. Keratin

E. Urocanic acidCorrect Choice

Urocanic acid and DNA are biologically important chromophores. DNA absocrbs uVB directly inducing changes between adjacent pyrimidine bases on one strand of DNA. Cyclopyrimidine dimers, particularly thymine dimers or less commonly (6-4) photoproducts may be generated. Urocanic acid is a second biologically important chromophore in the skin and is a by-product of filaggrin breakdown. One photon of light contains enough energy to generate singlet oxygen.

61) Which of the following cell types induce susceptibility to tumor growth?

A. NK cells

B. Langerhans cells

C. Helper T-cells

D. Suppressor T-cellsCorrect Choice

E. Mast cells

The suppressor T-cells induce susceptibility to tumor. These cells appear to arise in UV-irradiated hosts prior to tumor developing, and play a role in carcinogenesis

62) Possible treatments for this patient with vitiligo include all of the following except:

A. Topical steroids

B. AcitretinCorrect Choice

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C. Narrowband UVB

D. Oral PUVA

E. Broadband UVB

Topical steroids and all the UV choices have been used to treat vitiligo. Soriatane does not benefit vitiligo

63) The solar simulator is not useful for phototherapy because of its:

A. Low output of UVB

B. High output of infrared radiation

C. Small field sizeCorrect Choice

D. Low level of ionizing radiation

E. High output of ultraviolet radiation

The coin-sized field of the solar simulator prevents this source from being useful for phototherapy. It is useful in MED testing

64) All of the following are true regarding actinic reticuloid except:

A. Is a premalignant conditionCorrect Choice

B. CD8+ T cells in lesional skin

C. Generalized lymphadenopathy common

D. Atypical dermal mononuclear cell infiltrate

E. Affects elderly men

Actinic reticuloid is a type of chronic actinic dermatitis. Ive et al. introduced the disease as a severe dermatosis with no apparent photoallergen. It generally affects elderly males and is characterized by infiltrated erythematous plaques on an eczematous background in exposed sites with lymphadenopathy. Histopathologically, it may resemble cutaneous T cell lymphoma. However, there is a trend towards a lower CD4+/CD8+ ratio. It is not considered a premalignant condition

65) Which medication reactivates UVB- and PUVA-induced erythema?

A. MethotrexateCorrect Choice

B. 5-FU

C. None of these answers are correct

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D. Dacarbazine

E. Vinblastine

Methotrexate reactivates UVB- and PUVA-induced erythema

66) The patient demonstrates a positive photopatch test to musk ambrette and a lowered MEDB. The correct diagnosis is most likely:

A. Solar urticaria

B. Photoallergic contact dermatitis

C. CAD Correct Choice

D. Actinic prurigo

E. PMLE

Only chronic actinic dermatitis (CAD) has a lowered MEDB. That finding helps distinguish CAD from photoallergic contact dermatitis in which one sees a positive photopatch test also

67) A joule is a measurement of:

A. Wavelength

B. Power

C. EnergyCorrect Choice

D. Irradiance

E. Distance

A joule is a measurement of energy dose or fluence. Power or irradiance is measured in watts. These are related by the formula Joules/cm2=Watts/cm2xseconds

68) What is the most likely cause of these lesions on the cheek of this 8 year-old boy?

A. Varicella

B. Herpes simplex

C. Polymorphous light eruption

D. Acne

E. Hydroa vacciniformeCorrect Choice

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Hydroa vacciniforme is a rare photodermatosis of childhood which occurs on areas of sun-exposed skin. The lesions leave depressed and atrophic scars. The condition tends to spontaneously resolve in adulthood

69) Lesions of PMLE typically appear:

A. Immediately

B. Hours to days after exposureCorrect Choice

C. About one hour after exposure

D. Days to two weeks after exposure

E. 15-30 minutes after exposure

The history of a delay of several hours to several days after exposure is important to the diagnosis

70) The following compound exerts immunosuppressive effects in the skin following exposure to UV-radiation:

A. Cis-urocanic acidCorrect Choice

B. Delta aminolevulinic acid

C. IL-12

D. Amino-levulinic acid

E. 7-dehydrocholesterol

Trans-urocanic acid is an epidermal chromophore that isomerizes to cis-urocanic acid following exposure to UV radiation. Cis-urocanic acid has been shown to be immunosuppressive, for example, by impairing the induction of contact allergy in mouse models. The mechanism of this immunosuppressive effect is unclear

71) UVA II encompasses which wavelengths ?

A. 290-320 nm

B. 340-400 nm

C. 400-450 nm

D. 320-340 nm Correct Choice

E. 320-400 nm

UVA can be divided into UVA II (320-340 nm) and UVA I (340-400 nm)

72) In solar urticaria wheals may be brought on by:

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A. UVA, UVB and Visible light Correct Choice

B. UVB

C. UVC

D. UVA

E. Visible light

Some patients react to visible light or UVA or UVB. Others react to combinations of visible light, UVA, and UVB

73) All of the following are true about UVA radiation except:

A. penetrates to a greater depth in the dermis than UVB

B. virtually all blocked by car window glassCorrect Choice

C. responsible for phototoxic drug reactions

D. 10 times more abundant than UVB

E. approximately 50% of exposure occurs in the shade

The UVA band extends from 320 to 400 nm. This spectrum is further subdivided into UVA-2 (320 to 340 nm) and UVA-1 (340 to 400 nm). The UVA spectrum is recognized as a cause of immediate and delayed tanning reaction of skin, and several other effects including photoaging, skin photosensitization, and immunosuppression. The majority of the ultraviolet radiation at the earth's surface is UVA (95 to 98%) with only 2 to 5% comprised of UVB. As UVC is completely absorbed by the stratospheric ozone layer, it does not comprise ultraviolet radiation hitting the earth's surface. Much of the UV radiation after reaching the atmosphere becomes scattered by the time it hits the earth's surface. Due to this "sky radiation", it is possible to sunburn even if one is exposed only to the shade. Notably, window glass filters out ultraviolet wavelengths shorter than 320 nm, so only UVB (290 to 320 nm) and UVC (200 to 290 nm) are effectively filtered by car window glass. Although UVA penetrates deeper into the dermis than UVB, UVB radiation is much more erythmogenic. Finally, most common photosensitizers have action spectrums in the UVA range, and, as a result, UVA radiation is responsible for most phototoxic drug reactions

74) This malnourished individual presented with crusting and hyperpigmentation in a photodistribution. The best diagnosis is:

A. PMLE

B. Photoallergic contact dermatitis

C. Scurvy

D. CAD

E. Pellagra Correct Choice

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Pellagra is characterized by the triad of diarrhea, dermatitis, and dementia. The dermatitis begins as a burning erythema in sun-exposed areas. There may be bullae and erosions. This is followed by a dry, brittle, scaling and hyperpigmented phase. Pellagra is due to a deficiency of niacin and tryptophan

75) Medication photosensitivity is caused by all except:

A. Cephalosporins Correct Choice

B. Thiazides

C. Phenothiazenes

D. Doxycycline

E. Quinolones

Cephalosporins do not cause drug photosensitivity. Neither do the penicillins

76) Which of the following statements about electromagnetic radiation is MOST correct?

A. Electromagnetic radiation is measured in watts

B. The energy of photons is proportional to the wavelength

C. The energy of photons is inversely proportional to the frequency

D. Longer wavelengths penetrate the skin more deeplyCorrect Choice

E. Electromagnetic radiation can be conceptualized as packets of power called photons

Longer wavelengths penetrate the skin more deeply. Electromagnetic radiation can be conceptualized as packets of ENERGY called photons. The energy of photons is proportional to the FREQUENCY and inversely proportional to WAVELENGTH. Electromagnetic radiation is measured in wavelength

77) A MED phototest should be read at:

A. 24 hoursCorrect Choice

B. 12 hours

C. 48 hours

D. 96 hours

E. 2 hours

MED testing should be read 24 hours after delivery of the doses. An additional reading at 15 minutes is important when solar urticaria is a consideration

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78) Lichen planus-like lesions on sun-exposed areas may be seen in patients being treated with:

A. None of these answers are correct

B. All of these answers are correct

C. Quinolones

D. Ketoprofen

E. FenofibrateCorrect Choice

Lichenoid medication photosensitivity, with LP-like lesions on sun-exposed areas has been associated with treatment with antimalarials, thiazides, demethylchlortetracycline, fenofibrate, enalapril, quinine, and quinidine

79) Photoonycholysis has been attributed to:

A. Tricyclic antidepressants

B. QuinineCorrect Choice

C. Furosemide

D. Chlorpromazine

E. Amiodarone

Photoonycholysis is a manifestation of medication photosensitivity that has been attributed to quinolones, tetracyclines, psoralens, and quinine

80) The immunologic effects of UVR include all of the following except:

A. Decrease in IL-1, IL-6, TNF-á Correct Choice

B. Alteration of lymphocyte population

C. Suppression of delayed-type hypersensitivity

D. Alteration of Langerhans cell function

E. Alteration of Langerhans cell morphology

UVR causes an increase of circulating cytokines (IL-1, IL-6, TNF-a).

81) Regarding the UVR effects on contact dermatitis and delayed-type hypersensitivity, which of the following statements is correct?

A. There are increases in production of Th2 type cytokines

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B. There are increased delayed-type hypersensitivity responses

C. Induction of sensitization is increased

D. Mice exposed to long-term, high-dose UVR demonstrate increased splenic APC function

E. There are diminished contact hypersensitivity responsesCorrect Choice

Mice exposed to short-term, high-dose UVR demonstrate decreased splenic APC function. There are diminished delayed-type hypersensitivity and contact hypersensitivity responses. Induction of sensitization is decreased. Th2 cytokines are not increased following UVR exposure

82) This patient’s MEDB was less than 1 mJ/cm2. His medications were Lipitor, digoxin, and Coumadin. The most likely diagnosis is:

A. Photoallergic contact dermatitis

B. SLE

C. CAD Correct Choice

D. PMLE tested

E. Drug photosensitivity

CAD is the most likely cause of such a low MEDB. Drug photosensitivity can show a lowered MEDA and on occasion a lowered MEDB, but none of the patient’s drugs cause photosensitivity

83) Phototoxic reactions:

A. Rarely occur on the first exposure to the chemical

B. Resolve with hyperpigmentationCorrect Choice

C. Occur only in predisposed individuals

D. Are immunologically mediated

E. Are called "photoreactive" if they produce damage through reactive oxygen species

A phototoxic reaction appears as a exaggerated sunburn with erythema and sometimes blistering, resolving with hyperpigmentation. It is a nonimmunologic reaction that could occur in all individuals given enough of the chemical and enough UVR. It can occur on the first exposure to the chemical and the UVR. Phototoxic reactions that produce damage through reactive oxygen species are called "photodynamic."

84) Initial treatment of this disease should include:

A. Hydroxychloroquine

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B. Sun avoidance, sunblocks, desensitization

C. Car UV filters, PUVA, sunblocks

D. Sun avoidance, sunblocks, beta carotene

E. Sun avoidance, sunblock, antihistamines Correct Choice

Treatment of solar urticaria is difficult. Sun avoidance is the most important aspect of treatment. A broad-spectrum sunblock and antihistamines

85) UVB converts 7-dehydrocholesterol in the skin to:

A. Previtamin D3Correct Choice

B. Calcitriol

C. 1,25-dihydroxyvitamin D

D. None of the above

E. 25-hydroxyvitamin D

UVB converts 7-dehydrocholesterol in the skin to previtamin D3, which then thermally isomerizes to form vitamin D3. It is hydroxylated in the liver and then in the kidney to form 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D, respectively

86) Lichen planus like lesions on sun-exposed areas may be seen in patients receiving which medication?

A. Alprazolam

B. Griseofulvin

C. FenofibrateCorrect Choice

D. All of these answers are correct

E. None of these answers are correct

LP-like lesions (which may be confluent) on sun-exposed areas have been seen in patients receiving antimalarials, thiazides, demethylchlortetracycline, fenofibrate, enalapril, quinine, and quinidine

87) Common side effects of PUVA include all of the following except:

A. Painful erythema

B. Squamous cell carcinoma

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C. Hair loss Correct Choice

D. Prolonged pruritus

E. Nausea

Alopecia is not a usual side effect of PUVA treatment

88) Which of the following statements about the light sources for phototesting/phototherapy is correct?

A. The mercury vapor is excited by electric current and emits a line spectrum of 254 nmCorrect Choice

B. Phototherapy bulbs are low-pressure sulfur vapor lamps with the inner surface coated by a specific phosphor

C. The phosphor emits a discoherent spectrum of various wavelengths

D. The most common light sources are incandescent bulbs

E. Broadband UVB bulbs emit throughout the UVB range and also include some UVC

Fluorescent bulbs are commonly used for phototherapy. These bulbs are low-pressure mercury vapor lamps with the inner surface coated by a specific phosphor. The phosphor emits a continuous spectrum of various wavelengths. The mercury vapor is excited by electric current and emits a line spectrum of 254 nm. Broadband UVB bulbs emit throughout the UVB range and also include some UVA, not UVC.

89) Lumisterol is an inactive epidermal reservoir of which vitamin?

A. E

B. K

C. A

D. DCorrect Choice

E. C

Lumisterol and tachysterol are inert byproducts created during the biosynthesis of vitamin D. When Previtamin D3 is exposed to light, it can result in photoisomerization of previtamin D3 to lumisterol and tachysterol. If previatmin D3 is depleted, lumisterol and tachysterol can become converted back to previtamin D3

90) Oxsoralen plus UVA results in the following except:

A. Has immunomodulating effects

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B. Suppresses DNA synthesis

C. Forms monofunctional adducts

D. Binds to purine bases Correct Choice

E. Can form DNA crosslinks

Oxsoralen, in the presence of UVA, forms covalent bonds to pyrimidine bases on DNA

91) Advantages of narrowband UVB over PUVA therapy are the following except:

A. No nausea

B. Safe in pregnancy

C. No need for protective eyewear

D. Safe in childhood

E. More effective in treating thick plaques of CTCL Correct Choice

UVB, both narrowband and broadband, is less penetrating into the skin than UVA. Therefore, PUVA is more effective for thick plaques of CTCL. The UVB does not reach to the bottom of the plaques

92) This middle-aged man demonstrates infiltrated, dusky plaques on all sun-exposed areas. The most likely diagnosis is:

A. Actinic prurigo

B. CAD Correct Choice

C. Drug photosensitivity

D. Photoallergic contact dermatitis

E. PMLE

The thick, infiltrated plaques on sun-exposed areas are typical of the actinic reticuloid variety of CAD

93) Which of the following statements about the hypothetical effect of UVR on cancer induction is correct?

A. UVR alters APC function, by increasing the number of antigen-presenting cells

B. Suppressor T-cells are suppressed

C. UVR induces transformation of keratinocytes with expression of tumor-associated antigensCorrect Choice

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D. UVR increases the ability of Langerhans cells to present antigen

E. UVR inhibits the release of immunosuppressive factors

UVR induces transformation of keratinocytes with expression of tumor associated antigens. It alters APC function by reducing the number of antigen presenting cells. It also promotes the release of immunosuppressive factors, induce suppressor t-cells, and decreases the ability of Langerhans cells to present antigen

94) A watt is a measurement of:

A. PowerCorrect Choice

B. Fluence

C. Energy

D. Distance

E. Irradiance

A watt is a measurement of power or irradiance of a UV source. Fluence and energy is measured in joules. These are related by the formula Joules/cm2=Watts/cm2xseconds

95) A patient presents with erythematous pruritic papules on exposed areas that appear in the spring. They appear between 2 hours and 2 days after exposure. Which of the following statements is NOT correct?

A. The pathogenesis is unclear, but may be related to type IV hypersensitivity reactions

B. It is more common in fair-skinned females

C. Vesicles and eczematous dermatitis is uncommon

D. The diagnosis described above is solar urticariaCorrect Choice

E. This is an idiopathic disease that appears in the first three decades of life

The diagnosis described above is polymorphous light eruption. The time to development of lesions is important in distinguishing between PMLE and solar urticaria. Solar urticaria usually develops 10-30 minutes after UVR exposure

96) Ultraviolet radiation from the sun causes all of the following acute effects in the skin EXCEPT:

A. Photooxidation of preexisting melanin

B. Redistribution of melanosomes from a perinuclear position into dendrites

C. Epidermal thickening

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D. Mast cell degranulation

E. None of these answers are correct Correct Choice

All of these statements are acute effects of UV raditation on the skin. Immediate pigment darkening, which fades within minutes after exposure, is brought on by UVA and visible light. It is caused by photooxidation of preexisting melanin and a redistribution of melanosomes from a perinuclear position into dendrites. Epidermal thickening is mainly a UVB-induced phenomenon. Mast cell degranulation, with release of histamine and other mast cell products, also occurs as a result of UV radiation

97) The portion of the electromagnetic spectrum that produces a particular biologic effect is called the:

A. Spectral Activity

B. Cutaneous Effect Spectrum

C. Action Spectrum Correct Choice

D. Effective Spectrum

E. Absorption Spectrum

The action spectrum is the wavelengths that produce a certain biologic effect. The action spectrum for photosensitivity from exogenous chemicals is usually in the UVA range. The radiation that is absorbed by those chemicals is called their absorption spectrum

98) Which of the following genodermatoses is NOT worsened by sunlight?

A. Darier's disease

B. Kindler syndrome

C. Rothmund-Thompson syndrome

D. Hartnup disease

E. Job syndromeCorrect Choice

Many genodermatoses can be exacerbated by sunlight including Darier's, Kindler, Rothmund Thompson, Hartnup (pellagra changes

99) Actinic prurigo (AP) differs from PMLE in all of the following except:

A. Cheilitis is rare in AP and common in PMLE Correct Choice

B. The lesions of AP occur on all sun-exposed areas

C. Outbreaks of AP are not as clearly related to sun exposure

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D. Lesions of AP may occur on non-sun exposed areas

E. The lesions of AP begin in childhood

Cheilitis is common in actinic prurigo and not a usual accompaniment in PMLE.

100) The MPD of Oxsoralen plus UVA is:

A. Tested on the patient’s calf or abdomen

B. Equal to one-half the patients MEDA

C. None of these answers are correct

D. Helpful in starting PUVA therapy Correct Choice

E. Measured at 24 hours

MPD stands for the minimal phototoxic dose. For Oxsoralen plus UVA, the MPD is measured at 48-72 hours. Testing is done on the upper buttock or forearm

101) The most common presentation of a patient with medication photosensitivity is:

A. Lichenoid eruptions

B. Photoonycholysis

C. Fixed erythematous patch

D. Pseudoporphyria

E. Diffuse erythema in sun-exposed areasCorrect Choice

Most patients with medication photosensitivity present with diffuse erythema in sun-exposed areas. In some patients, the eruption is eczematous and covered areas are spared. Photoonycholysis, lichenoid eruptions and pseudoporphyria do occur with mediation photosensitivity, but are not the most common presentation. Fixed erythematous patch is not seen with this type of reaction

102) Which of the following is the most common photodermatosis?

A. Polymorphous light eruptionCorrect Choice

B. Hydroa vacciniforme

C. Solar urticaria

D. Actinic prurigo

E. Chronic actinic dermatitis

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Polymorphous light eruption is the most common photodermatosis. It is a idiopathic disease that usually appears in the first three decades of life and is more common in fair-skinned females. The pathogenesis is unclear, but is believed to be related to a type IV hypersensitivity reaction. Most lesions are erythematous pruritic papules, with the plaque form being less common. Lesions appear symetrically on exposed areas after a delay of several hours to several days. Patients with mild disease are treated with sun avoidance and a broad spectrum sunscreen. In more severe cases, hardening and desensitization can be accomplished or antimalarials can be used for resistant cases. For brief, sunny vacations, a short course of prednisone can be helpful.

The other options are less common forms of idiopathic photosensitivity disorders

103) UVB is about how many times more erythermogenic than UVA ?

A. 1000 Correct Choice

B. 5

C. 10000

D. 10

E. 100

Though UVB is 1000 times more erythermogenic than UVA, UVA is much more plentiful in sunlight. Therefore, UVA does contribute to sunlight erythema

104) Phototoxicity and photoallergy from exogenous agents typically involve absorption of:

A. UVB, UVA and visible light

B. UVA Correct Choice

C. UVB

D. UVA and visible light

E. UVB and UVA

Topical and systemic agents that produce phototoxicity and/or photoallergy usually have action spectra in the UVA range

105) The UVC portion of the electromagnetic spectrum extends from:

A. 10-200 nm

B. 200-290 nmCorrect Choice

C. 400-760 nm

D. None of these answers are correct

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E. 290-320 nm

Ultraviolet C does not reach the earth's surface. It is filtered out by the ozone layer. It extends from 200-290 nm

106) Ultraviolet radition has been shown to do all of the following in in vitro and in vivo studies EXCEPT:

A. Increase circulating levels of IL-6

B. Suppress the induction of delayed-type hypersensitivity

C. Decrease circulating levels of IL-1Correct Choice

D. Induce suppressor T-cells

E. Alter the ability of antigen-presenting cells to present antigen

UV-irradiated mice have been shown to have defective antigen presentation and a decreased number of antigen-presenting cells, which prevents a normal delayed-type hypersensitivity response. UVR causes the release of immunosuppressive factors, with induction of suppressor T-cells and increases in circulating levels of cytokines, including IL-1, IL-6, and TNF

107) Narrowband UVB bulbs emit predominantly at:

A. 290-320 nm

B. 305 nm

C. 360 nm

D. 311 nm Correct Choice

E. 352 nm

Narrowband UVB (311-312 nm) is more effective than broadband UVB for psoriasis, vitiligo, and other skin disorders

108) Which of the following is not true about UVB radiation?

A. Responsible for sunburn

B. Decreased with high wind velocityCorrect Choice

C. Virtually all blocked by car window glass

D. Peaks at noon

E. More intense in the summer than winter months

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The UVB band extends from 290 to 320 nm. The UVB spectrum is recognized as the primary cause of sunburn, skin cancer, and other harmful effects on humanskin. The UVA band extends from 320 to 400 nm. This spectrum is further subdivided into UVA-2 (320 to 340 nm) and UVA-1 (340 to 400 nm). The UVA spectrum is recognized as a cause of immediate and delayed tanning reaction of skin, and several other effects including photoaging, skin photosensitization, and immunosuppression. UVC radiation comprises wavelengths shorter than 290 nm (from 200 to 290 nm). Notably, window glass filters out ultraviolet wavelengths shorter than 320 nm, so both UVB and UVC are effectively filtered by car window glass. UVB radiation is more intense during summer months compared to winter months and peaks during midday hours. It has been postulated that physical factors such as high temperature, high humidity, and wind can all increase susceptibility to UV-induced carcinogenesis

109) Which of the following statements about UVR in vivo is correct?

A. decreases circulating levels of cytokins (IL-1, IL-6 and TNF)

B. normalizes Langerhans cell morphology and function

C. normalizes cell trafficking

D. normalizes proportions of lymphocyte subtypes in peripheral blood

E. induces skin cancersCorrect Choice

UVR can induce skin cancer. UVR in vivo INCREASES circulating levels of cytokins (IL-1, IL-6 and TNF) and alters Langerhans cell morphology, cell trafficking, and the proportion of lymphocyte subtypes in peripheral blood

110) Which of the following is NOT true regarding polymorphous light eruption?

A. It may occur through windowglass, which filters out UVB

B. Usually appears in the first three decades

C. Not all exposed areas show lesions

D. May be a manifestation of a type IV hypersensitivity reaction

E. Vesicles and an eczematous dermatitis are a common presentationCorrect Choice

Polymorphous light eruption is the most common photodermatosis. It is an idiopathic disease that usually appears in the first three decades. Pathogenesis is unclear but it may be related to a type IV hypersensitivity reaction. Most lesions are erythematous, pruritic papules. The plaque form is less common, and vesicles and an eczematous dermatitis are rare. Not all exposed areas show lesions, but the same areas are affected year after year. It may improve as the summer progresses. It may occur through windowglass, which filters out UVB

111) What is the wavelength of a Wood's light?

A. 365nmCorrect Choice

B. 410nm

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C. 290nm

D. 311nm

E. 330nm

A Wood's light emits ultaviolet light at a wavelenth of 365nm and is produce by bassing light through a Wood's filter which is composed of nickel oxide containing glass

112) The most common cause(s) of topical phototoxicity today in the United States is(are):

A. 6-methyl-coumarin

B. Musk ambrette

C. PABA and non-PABA sunscreen ingredients

D. PsoralensCorrect Choice

E. Halogenated salicylanilides

Topical phototoxicity is most commonly caused by psoralens. Topical 8-methoxypsoralen is used therapeutically to treated psoriasis, localized vitiligo, and hand/foot eczema. Psoralens in certain plants, fruits, and vegetables can produce phytophotodermatitis. Topical photoallergy has in the past been caused by halogenated salicylanilides, as well as musk ambrette and 6-methyl-coumarin in fragrances. These compounds produced photoallergic contact dermatitis, and have been removed from marketed products. PABA, its esters, and non-PABA sunscreen ingredients are the most common causes of topical photoallergy, not topical phototoxicity

113) Which of the following statements is true regarding ultraviolet carcinogenesis?

A. UVA is most effective in producing pyrimidine dimers, which may activate oncogenes

B. Cells from patients with actinic keratoses have normal DNA repair capacity

C. Suppressor T-cells arise in UV-irradiated hosts only after tumors have developed

D. UVA, when added to UVB, may accelerate carcinogenesisCorrect Choice

E. Mid-range ultraviolet radiation is less efficient in inducing neoplasia in mice that is long wave UVR

Mid-range UVR (280-320 nm) is more efficient in inducing neoplasia in mice, but long wave UVA, when added to UVB, may accelerate carcinogenesis. Suppressor T-cells induce susceptibility to tumors, and appear to arise in UV-irradiated hosts prior to tumors developing, thus playing a role in carcinogenesis. Cells from patients with AKs have less DNA repair capacity than controls. UVB is most effective in producing pyrimidine dimers, which may activate oncogenes, particularly in the formation of BCCs and SCCs

114) A patient presents with purple polygonal pruritic papules on sun exposed areas. Which of the following of his medication would not be suspect for causing this eruption?

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A. Hydrochlorothiazide

B. Enalapril

C. Quinidine

D. FurosemideCorrect Choice

E. Fenofibrate

Furosemide (Lasix) is not a cause of lichenoid drug reactions, but can cause pseudoporphyria. The others listed are causes of lichenoid drug reactions. Others are antimalarials, demethylchlortetracycline and quinine

115) Which of the following drugs is commonly known to produce photosensitivity?

A. Griseofulvin

B. All of these answers are correctCorrect Choice

C. Sulfonylureas

D. Quinidine

E. None of these answers are correct

Quinidine, sulfonlyureas, and griseofulvin are all known to cause photosensitivity

116) The differential diagnosis of this patient would include:

A. Chronic actinic dermatitis

B. All of these answers are correct Correct Choice

C. Airborne contact dermatitis

D. Photoallergic contact dermatitis

E. Drug photosensitivity

NEEDS EXPLANATION

117) The action spectrum for photoallergy is mostly in which spectrum?

A. 400-760nm

B. 311-312nm

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C. 200-290nm

D. 290-320nm

E. 320-425nmCorrect Choice

The action spectrum for photoallergic dermatoses refers to the specific wavelengths of light that evoke the photosensitive reaction. This falls mostly within the UVA region and may spill into the visible light region for photoallergy (320-425nm). 200-290nm refers to the UVC region; 290-320nm refers to the UVB region; 311-312nm refers to narrowband UVB region; and 400-769nm refers to the visible light region

118) This disease can be brought on by:

A. UVA I

B. All of these answers are correctCorrect Choice

C. Visible light

D. UVA II

E. UVB

Solar urticaria can be brought on by UVB or UVA or visible light or combinations of those wavelengths

119) All of the following are true regarding polymorphous light eruption except:

A. Anti-Ro antibody positiveCorrect Choice

B. Hardening occurs with subsequent episodes

C. Abnormal metabolism of arachidonic acid

D. Pruritic

E. Lesions heal without scarring

Polymorphous light eruption is the most common photodermatosis that is characterized clinically by the abnormal occurrence of pruritic, erythematous, edematous papules following exposure to UV radiation. Lesions heal without scarring. It tends to affect women 2-3x more than men. Positive Anti-ro antibodies should raise the suspicious for subacute cutaneous lupus erythematosus (tends also to be less pruritic

120) Most fluorescent UV sources are:

A. Low pressure xenon arc lamps

B. Low pressure mercury vapor lamps Correct Choice

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C. Low pressure argon lamps

D. High pressure tungsten lamps

E. High pressure xenon arc lamps

The mercury vapor in the fluorescent bulbs is excited by electric current. Then the mercury emits radiation at 254 nm. This radiation is absorbed by the phosphor lining the bulb

121) Actinic prurigo (AP) differs from polymorphous light eruption (PMLE) in that:

A. Lesions of PMLE occur on all sun-exposed areas

B. Lesions of AP usually begin after puberty

C. Lesions of AP may persist for months, even into the winterCorrect Choice

D. Chelitis is more frequently seen in PMLE

E. Lesions of PMLE may occur on non-sun-exposed areas

Actinic prurigo (AP) may be a distinct entity, or an HLA-restricted subset of polymorphous light eruption (PMLE). AP differs from PMLE in that the lesions of AP always begin in childhood and often remit in puberty, the lesions of AP occur on all sun-exposed areas and may persist for months, even into the winter, and the lesions of AP may occur on non-sun-exposed areas. In addition, outbreaks of AP are not as clearly related to sun exposure, and chelitis is frequently seen in AP, not PMLE

122) This patient presented with hyperpigmented streaks after a vacation in the Caribbean. The most likely diagnosis is:

A. Actinic prurigo

B. CAD

C. PMLE

D. Phytophotodermatitis Correct Choice

E. Melasma

Phytophotodermatitis requires exposure to certain plants or fruits followed by sunlight. Parsnips, parsley, figs, limes, celery, bergamot oranges, and others contain psoralens that react with UVA. Initially there is erythema and blistering followed by streaked hyperpigmentation

123) Which of the following is the most likely cause of photosensitivity?

A. Penicillin V

B. Quinolones

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C. Sulfonamides

D. DoxycyclineCorrect Choice

E. Minocycline

Doxycycline is the tetracycline derivative most likely to cause photosensitivity. Quinolones and sulfonamides will also cause this with ingestion. Minocycline is the least photosensitizing of the tetracycline derivatives. Penicillin is not a common cause of photosensitivity

124) Which of the following is true regarding immediate pigment darkening?

A. Becomes prominent 48 hr after exposure

B. Contributes to constitutive skin color

C. Caused by UVA radiationCorrect Choice

D. Requires the synthesis of new melanin

E. Prominent in lightly pigmented individuals

Tanning develops in two phases, early (transitory) and late (stable). The immediate darkening is in response to UVA and is related to photo-oxidation of pre-existing melanin

125) Which of the following statements is true regarding UV radiation, erythema, and pigmentation?

A. Delayed tanning, which becomes visible about 72 hours after exposure, is largely brought on by UVA.

B. UVB erythema reaches a maximum in 24-36 hours

C. The chromophores involved with UVB erythema are melanosomes

D. Immediate pigment darkening is brought on by UVA and visible lightCorrect Choice

E. Immediate pigment darkening fades within 12-24 hours after exposure

UVB in natural sunlight is the main contributor to erythema. UVB erythema reaches a maximum in 6-24 hours. The chromophores involved with UVB erythema are not clear but appear to involve nucleic acids. Immediate pigment darkening is brought on by UVA and visible light, and fades within minutes after exposure. Delayed tanning becomes visible about 72 hours after UVB exposure. UVA contributes to a lesser extent to delayed tanning

126) The main condition on the differential for polymorphous light eruption is lupus erythematosus. Which of the following tests should NOT be performed to help make this distinction?

A. Anti-SSA

B. Antinuclear antibody

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C. SED rateCorrect Choice

D. Anti-SSB

E. Skin biopsy for routine staining and direct immunofluorescence

All of the listed tests are helpful in distinguishing between PMLE and lupus except a SED rate, which is a non-specific marker of systemic inflammation

127) As a result of ultraviolet radiation:

A. Prostaglandins are increased

B. None of these answers are correct

C. There is mast cell degranulation and release of histamine

D. Epidermal thickening occurs

E. All of these answers are correctCorrect Choice

Effects of ultraviolet radiation include mast cell degranulation with release of histamine and other mast cell products, increases in certain prostaglandins and interleukins, and epidermal thickening, which is mainly a UVB-induced phenomenon

128) Which spectrum of UV is responsible for the conversion of 7-dehydrocholesterol in the skin to pre-vitamin D3?

A. 290-320 nmCorrect Choice

B. 10-200 nm

C. 340-400 nm

D. 320-340 nm

E. 200-290 nm

Ultraviolet B with the spectrum of 290-320 nm is responsible for the conversion of 7-dehydrocholesterol in the skin to pre-vitamin D3

129) What range of ultraviolet radiation has been shown to be most efficient in inducing neoplasia in mice?

A. 280-320nmCorrect Choice

B. >760nm

C. 400-760nm

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D. 340-400nm

E. 320-340nm

Midrange UVR 280-320nm (UVB range) has been shown to be most efficient in inducing neoplasia in mice. Long-wave UVA, when added to UVB may accelerate carcinogenesis

130) A normal MEDB on untanned Caucasian skin ranges from approximately:

A. 20-70 mJ/cm2 Correct Choice

B. 2-6 mJ/cm2

C. 140-200 mJ/cm2

D. 15-40 mJ/cm2

E. 70-140 mJ/cm2

The MEDB can vary from institution to institution. In one institution, it may range from 20-70 mJ/cm2. In another institution, it may range from 30-90 mJ/cm2

131) Phototoxicity from exogenous agents is characterized by all of the following except:

A. There may be apoptotic cells histologically

B. There is cross-reactivity to similar exogenous agents Correct Choice

C. It appears as an exaggerated sunburn and heals with hyperpigmentation

D. Occurs in most individuals given enough of the drug and enough UVR

E. It can occur on first exposure to drug and UVR

With photoallergy, not phototoxicity, there can be cross-reactivity among similar agents

132) A patient with a personal and family history of multiple fibrofolliculomas may have:

A. Tuberous sclerosis

B. Muir-Torre syndrome

C. Gardner's syndrome

D. Birt-Hogg-Dube syndromeCorrect Choice

E. Basal cell nevus syndrome

Fibrofolliculomas are small, benign, yellow or flesh colored papules that are usually inherited in an autosomal dominant fashion and have a predilection for the face, neck and upper trunk. Birt-Hogg-

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Dube syndrome is an autosomal dominant condition characterized by multiple fibrofolliculomas, trichodiscomas, acrochordons, collagenomas. This condition is important to recognize due to its association with renal cell carcinoma. In addition, lung cysts and bullous emphysema are also features of the condition with spontaneous pneumothorax being a potential complication.Muir-Torre syndrome is an autosomal dominant condition caused by a defect in hMSH2 gene. This condition is associated with sebaceous neoplasms including sebaceous carcinoma, sebaceous hyperplasia, sebaceous epithelioma, sebaceous adenoma as well as keratoacanthomas. These can be markers for underlying malignancy in this condition; notably adenocarcinoma of the colon, breast, urinary tract, lung and endometrium. Gardner syndrome is an autosomal dominant condition caused by a defect in the APC familial adenomatous polyposis gene in which patients have multiple hamartomatous polyps of the colon with a high rate of malignant transformation. Cutaneous clues to the diagnosis include multiple epidermoid cysts, fibromas, and desmoid tumors. Other manifestations include osteomas, supernumary teeth, and congential hypertrophy of the retinal pigment epithelium.Tuberous sclerosis, (TS),also known as Bourneville's syndrome is caused by defects in hamartin and tuberin, found on chromosome 9 and 16, respectively. Patients with TS are at increased risk of muliple neoplasms including retinal hamartomas, angiomyolipomas, and cardiac rhabdomyomas. Cutaneous manifestations include ash-leaf macules, shagreen patchs, café-au-lait macules, confetti macules, facial angiofibromas, and periungual fibromas.As the name implies, basal cell nevus syndrome is associated with multiple basal cell carcinomas. In addition palmoplantar pitting, multiple milia and epidermoid cysts are seen. It is autosomal dominantly inherited and caused by a defect in the patched gene

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