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CHAPTER 16
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The Skin and Subcutaneous Tissue
1. The area most amenable to salvage by resuscitative
and wound management techniques following thermal
injury is called the:
A. Zone of hyperemia.
B. Zone of coagulation.
C. Zone of stasis.
2. Initial treatment of extensive cellulitis without abscess is:
A. Vancomycin.
B. β-lactam.
C. Linezolid.
D. Clindamycin.
Answer: C
The management of thermal wounds is initially guided by the
concept of three distinct zones of injury. The focus of thermal injury that has already undergone necrosis is known as
the zone of coagulation. Well outside the zone of coagulation
is the zone of hyperemia, which exhibits signs of inflammation but will likely remain viable. In between these two zones
is a zone of stasis with questionable tissue viability, and it is
this area at which proper burn care can salvage viable tissue
and decrease the extent of injury. (See Schwartz 11th ed.,
pp. 521–522.)
Answer: B
Extensive cellulitis is managed in a similar fashion as simple
cellulitis. Initial treatment consists of intravenous antibiotics
that cover β-hemolytic streptococcus, such as cephalosporins, with the addition of methicillin-resistant Staphylococcus
aureus (MRSA) coverage if there is no improvement in symptoms. Vancomycin is typically the first choice for MRSA coverage, but this drug is inferior to β-lactams for coverage of
methicillin-sensitive S. aureus (MSSA). Alternative antibiotics
that are typically effective against MRSA are linezolid, daptomycin, tigecycline, and telavancin. Clindamycin is approved
for use against MRSA, but resistance rates are increasing, and
its use is discouraged if institutional rates of clindamycin resistance are >15%. (See Schwartz 11th ed., p. 525.)
3. A 3-mm, nodular-type basal cell carcinoma (BCC) of the
skin of the trunk should be treated with:
A. Mohs micrographic surgery.
B. Dermatologic laser vaporization.
C. Excision with a 4-mm margin of normal tissue.
D. Electrodesiccation.
Answer: C
Treatment of BCC varies according to size, location, type,
and high or low risk. Treatment options include surgical excision and medical or destructive therapies. Surgical excision
should include 4 mm margins for low-risk lesions. Mohs
microsurgical is indicated for high-risk lesions, especially in
cosmetically sensitive areas. In high-risk lesions in which
Mohs micrographic surgery is not available, excision with
10 mm margin of normal tissue can be considered. (See
Schwartz 11th ed., p. 529.)
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4. The primary risk factor for the development of squamous cell carcinoma (SCC) is:
A. Ultraviolet (UV) radiation exposure.
B. Tobacco use.
C. Exposure to chemical agents.
D. Chronic, nonhealing wounds.
CHAPTER 16
5. Using the ABCDE initialism for melanoma, at what
diameter does a nevus become concerning for malignant
transformation?
A. 2 mm
The Skin and Subcutaneous Tissue
B. 4 mm
C. 6 mm
D. 10 mm
6. What is the most common site of distant metastasis of
cutaneous melanoma?
A. Brain
B. Lung
C. Bone
D. Distant skin
Answer: A
The primary risk factor for the development of SCC is
UV radiation exposure; however, other risks include light
Fitzpatrick skin type (I or II), environmental factors such as
chemical agents, physical agents (ionizing radiation), psoralen, HPV-16 and -18 infections, immunosuppression, smoking, chronic wounds, burn scars, and chronic dermatoses.
Heritable risk factors include xeroderma pigmentosum,
epidermolysis bullosa, and oculocutaneous albinism. (See
Schwartz 11th ed., p. 529.)
Answer: C
Melanoma most commonly manifests as cutaneous disease,
and clinical characteristics of malignant transformation are
often remembered by the initialism ABCDE. These lesions
are typically asymmetric with irregular borders, color variations, a diameter > 6 mm, and are undergoing some sort of
evolution or change. Other key clinical characteristics include
a pigmented lesion that has enlarged, ulcerated, or bled.
Amelanotic lesions appear as raised pink, purple, or fleshcolored skin papules and are often diagnosed late. (See
Schwartz 11th ed., p. 530.)
Answer: B
The most common sites of metastasis of melanoma are the
lung and liver. These are followed by the brain, gastrointestinal tract, distant skin, and subcutaneous tissue. (See Schwartz
11th ed., p. 533.)
7. Which aggressive subtype of melanoma is characterized
by an early vertical growth pattern, often leading to laterstage diagnosis?
A. Superficial spreading
B. Lentigo maligna
C. Acral lentiginous
D. Nodular
Answer: D
The most common subtype of melanoma is superficial
spreading (Fig. 16-1). This accounts for 50% to 70% of melanomas and typically arises from a precursor melanocytic
nevus. Nodular subtype accounts for 15% to 30% of melanomas, and typically arises de novo, most commonly in men and
on the trunk (Figs. 16-2 and 16-3). This subtype is aggressive
with an early vertical growth pattern and is often diagnosed
at a later stage. Up to 5% of these lesions will lack melanin
and can be mistaken for other cutaneous lesions. Lentigo
maligna represents 10% of melanoma cases and is a less
aggressive subtype of melanoma in situ that typically arises
on sun-exposed areas of the head and neck. Acral lentiginous
FIG. 16-1. Primary cutaneous melanoma seen in the scalp
of a 61-year-old man.
FIG. 16-2. Nodular melanoma seen in the leg of
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a 55-year-old man.
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melanoma accounts for 29% to 72% of melanomas in darkskinned individuals, is occasionally seen in Caucasians,
and is found on palmar, plantar, and subungual surfaces.
This subtype is not thought to be due to sun exposure. (See
Schwartz 11th ed., p. 530.)
CHAPTER 16
The Skin and Subcutaneous Tissue
A B
C
FIG. 16-3. A. AP view of advanced melanoma in a
59-year-old man. B. Lateral view. C. After resection and
reconstruction with skin grafting.
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8. Which of the answer choices does NOT represent an
indication for sentinel lymph node biopsy (SLNB) in the
setting of malignant cutaneous melanoma?
A. Breslow depth 0.5 mm with superficial ulceration
B. Clinically positive lymph nodes
C. Breslow depth 1.5 mm without superficial ulceration
D. Breslow depth 1.0 mm with lymphovascular invasion
CHAPTER 16
The Skin and Subcutaneous Tissue
Answer: B
SLNB is a standard staging procedure to evaluate the
regional nodes for patients with clinically node-negative
malignant melanoma. Detecting subclinical nodal metastasis may benefit from lymphadenectomy or adjuvant therapy.
This technique identifies the first draining lymph node from
the primary lesion and has shown excellent accuracy and significantly less morbidity compared to complete resection of
nodal basins. It is almost always performed at the time of initial wide excision, as SLN mapping after lymphatic violation
from surgical excision could decrease the accuracy of the test.
Recently, the results of MSLT-1, an international, multicenter,
phase III trial were published. This study randomized clinically node negative patients to either SLNB at the time of primary melanoma excision (and completion lymphadenectomy
if positive) or nodal basin monitoring (and delayed complete
lymphadenectomy for recurrent lymph node disease). The
results of this study demonstrated that SLNB, with immediate lymphadenectomy if positive, improved disease-free survival by 7% and 10% in patients with intermediate thickness
(1.2–3.5 mm) and thick (>3.5 mm) lesions, respectively. The
latest NCCN guidelines suggest consideration of SLNB in
clinically stage I/II patients with Breslow depth > 1.0 mm or
>0.8 mm with high-risk features (ulceration, mitotic index
> 2/mm2, or lymphovascular invasion). A patient with clinically positive nodes would not be a candidate for screening
SLNB. (See Schwartz 11th ed., p. 531.)
9. Which surgical margins are appropriate for excision of a
primary cutaneous melanoma that has a Breslow depth
of 1.5 mm?
A. 5 mm margins
B. 10 mm margins
C. 30 mm margins
D. 1.5 mm margins
10. What is the source of regenerative keratinocytes in the
epithelialization of partial thickness wounds of the skin?
A. Langerhans cell conversion to keratinocytes
B. Fibroblast conversion to keratinocytes
C. Extravasation of stem cells from the blood stream
D. Keratinocytes from the lining of epidermal appendages
Answer: B
The appropriate excision margin for cutaneous melanoma
is based on primary tumor thickness. Several retrospective
studies suggest that for melanoma in situ, 0.5 to 1 cm margins are sufficient. 1-cm margins should be obtained in anatomically feasible areas given the possibility of an incidental
finding of a small invasive component in permanent sections.
Several studies compared 1- to 3-cm margins and 2- to 5-cm
margins in melanoma <2 mm thick, and 2- to 4-cm margins
in melanoma lesions 1 to 4 mm thick and found no difference. A British trial suggested that there is a limit to how
narrow margins can be for melanomas >2 mm thick by showing that 1-cm margins provide worse outcomes compared to
3-cm margins. Tumors <1 mm thick require 0.5 to 1 cm margins. Tumors 1 to 2 mm thick require 1 to 2 cm margins, and
tumors >2 mm thick require 2-cm margins. (See Schwartz
11th ed., p. 532.)
Answer: D
The stratum basale, or germinative layer, is a deep, single
layer of asynchronous, continuously replicating cuboidal to
columnar epithelial cells and is the beginning of the life cycle
of the keratinocytes of the epidermis. This layer is bound to
its basement membrane by complexes made of keratin filaments and anchoring structures called hemidesmosomes.
They are bound to other keratinocytes by structures called
desmosomes. High mitotic activity and thus large nuclei and
basophilic staining characterize the stratum basale on light
microscopy. This layer also lines the epidermal appendages
that reside largely within the substance of the dermis and later
serves as a regenerative source of epithelium in the event of
partial thickness wounds. (See Schwartz 11th ed., p. 514.)
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11. What cell type are characterized by rod- or racketshaped Birbeck granules, takes up antigens for presentation to T-cells, and makes up 3% to 6% of the cells of the
epidermis?
A. Langerhans cell
B. Melanocyte
C. Merkel cell
D. Mast cell
12. What type of gland is typically influenced by sex hormones and undergoes a secretion process that involves
decapitation of the part of the cell?
A. Hair follicle
B. Sebaceous gland
C. Apocrine sweat gland
D. Eccrine sweat gland
Answer: A
Of the cells in the epidermis, 3% to 6% are immune cells
known as Langerhans cells. Typically found within the stratum
spinosum, these mobile, dendritic cells interdigitate between
keratinocytes of the epidermis to create a dense network,
sampling any antigens that attempt to pass through the cutaneous tissue. Through use of their characteristic rod- or racketshaped Birbeck granules, they take up antigens for presentation
to T-cells. These monocyte-derived cells represent a large
part of the skin’s adaptive immunity. (See Schwartz 11th ed.,
p. 515.)
Answer: C
One type of sweat gland, known as the apocrine sweat gland,
is found around the axilla, anus, areola, eyelid, and external
auditory canal. The cells in this gland undergo an excretion
process that involves decapitation of part of the cell. These
apocrine glands are typically activated by sex hormones
and thus activate around the time of puberty. The secretion
from apocrine glands is initially odorless, but bacteria in the
region may cause an odor to develop. Pheromone production may have been a function of the apocrine glands, but this
may now be vestigial. While eccrine sweat glands are activated by the cholinergic system, apocrine glands are activated
by the adrenergic system. (See Schwartz 11th ed., p. 515.)
CHAPTER 16
The Skin and Subcutaneous Tissue
13. In the Hurley classification of hidradenitis suppurativa,
which stage is characterized by diffuse disease with interconnected sinus tracts and recurrent abscesses?
A. Hurley stage IV
B. Hurley stage III
C. Hurley stage II
D. Hurley stage I
14. What mucocutaneous disorder, thought to be a reaction
to various drugs, is characterized by mucocutaneous
destruction at the dermoepidermal junction affecting
<10% of the cutaneous epithelium?
A. Nikolsky syndrome
B. Toxic epidermal necrolysis (TEN)
C. Hidradenitis suppurativa
D. Stephens-Johnson syndrome (SJS)
15. A 55-year-old otherwise healthy man presents 1 hour
after a human bite to his hand. After thoroughly washing
out the wound, are prophylactic antibiotics necessary? If
so, what antibiotic regimen is most appropriate?
A. No antibiotic prophylaxis indicated
B. 3–7 days of cephalexin
C. 3–7 days of amoxicillin/clavulanate
D. 3–7 days of vancomycin and piperacillin/tazobactam
Answer: B
The diagnosis of hidradenitis is clinical, and the presentation
is most commonly categorized by the Hurley classification
system, divided into three stages. Single or multiple nodules
or abscesses without any sinus tracts or scarring would be
classified as stage I disease. As abscesses recur and sinus tracts
and scarring form, the disease is classified as Hurley stage II.
Stage III is the most advanced stage, with diffuse disease and
interconnected sinus tracts and abscesses. Hurley stage IV is
nonexistent. (See Schwartz 11th ed., p. 517.)
Answer: D
Epidermal necrolysis (EN) is a rare mucocutaneous disorder
characterized by cutaneous destruction at the dermoepidermal junction. EN is commonly referred to as either SJS or
TEN depending on the extent of skin involvement present.
SJS refers to cases in which <10% of total body surface area
is involved, while cases with >30% involvement are considered TEN, with an SJS-TEN overlap syndrome referring to
all cases in between. A positive Nikolsky sign is often present,
in which lateral pressure on the skin causes separation of the
epidermis from the dermis. (See Schwartz 11th ed., p. 518.)
Answer: C
Bacteria colonizing human bites are those present on the skin
or in the mouth. These include the gram-positive aerobic
organisms Staphylococcus aureus, Staphylococcus epidermidis,
and Streptococcus species, and anaerobes including Peptococ-
cus species, Peptostreptococcus species, Bacteroides species,
and Eikenella corrodens (facultative anaerobe). Human bites
are characterized by a higher bacterial load (>105). Antibiotic prophylaxis after a human bite is recommended as it has
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been shown to significantly decrease the rate of infection. A
course of 3 to 7 days of amoxicillin/clavulanate is typically
used. Alternatives are doxycycline or clindamycin with ciprofloxacin. (See Schwartz 11th ed., p. 519.)
16. Following caustic injury with a strong alkaline solution,
what is the appropriate treatment?
A. Neutralization with a weakly acidic solution for
CHAPTER 16
30 minutes
B. Irrigation with normal saline for 30 minutes
C. Irrigation with normal saline for 120 minutes
D. Immediate coverage with light compressive dressing
The Skin and Subcutaneous Tissue
17. How long does it take to get irreversible tissue damage
with external pressure greater than double capillary perfusion pressure?
A. 1 hour
B. 2 hours
C. 3 hours
D. 4 hours
18. Pressure-induced ischemia to cutaneous tissue resulting
in nonblanching erythema with intact epidermis represents which stage of injury?
A. Does not yet qualify as pressure-induced tissue injury
B. Stage I
C. Stage II
D. Stage III
Answer: C
Treatment for acidic or alkaline chemical burns is first and
foremost centered around dilution of the offending agent,
typically using distilled water or saline for 30 minutes for
acidic burns and 2 hours for alkaline injuries. Attempting to
neutralize the offending agent is typically discouraged, as it
does not offer an advantage over dilution and the neutralization reaction could be exothermic, increasing the amount of
tissue damage. After removal of the caustic agent, the burn
is treated like other burns and is based on the depth of tissue
injury. (See Schwartz 11th ed., p. 521.)
Answer: B
The average perfusion pressure of the microcirculation is
about 30 mm Hg, and pressures greater than that cause local
tissue ischemia. In animal models, pressure greater than twice
the capillary perfusion pressure produces irreversible tissue
necrosis in just 2 hours. Tissues with a higher metabolic
demand are typically susceptible to insult from tissue hypoperfusion more rapidly than tissues with a lower metabolic
demand. Because of this, it is possible to have muscle necrosis
beneath cutaneous tissue that has yet to develop signs of irreversible damage. (See Schwartz 11th ed., p. 523.)
Answer: B
Pressure ulcers can present in several ways depending on the
stage at presentation. They are typically grouped into four
stages: stage I, nonblanching erythema over intact skin; stage II,
partial-thickness injury with blistering or exposed dermis;
stage III, full-thickness injury extending down to, but not
including, fascia and without undermining of adjacent tissue; and stage IV, full-thickness skin injury with destruction
or necrosis of muscle, bone, tendon, or joint capsule. (See
Schwartz 11th ed., p. 523.)
19. What type of necrotizing soft tissue infection (NSTI) is
characterized by a monomicrobial source of β-hemolytic
Streptococcus or Staphylococcus species?
A. Type I
B. Type II
C. Type III
D. Type IV
Answer: B
There are three types of NSTIs when classified by the offending agent. The most common is type 1, which is caused by
a polymicrobial source including gram-positive cocci, gramnegative rods, and anaerobic bacteria, specifically Clostridium
perfringens and C. septicum. Type 2 is caused by a monomicrobial source of β-hemolytic Streptococcus or Staphylococcus
species, with methicillin-resistant Staphylococcus aureus
(MRSA) contributing to the increasing number of communityacquired NSTIs. A history of trauma is often elicited and can
be associated with toxic shock syndrome. Type III is a rare
but fulminant subset resulting from a Vibrio vulnificus infec-
tion of traumatized skin exposed to a body of salt water. (See
Schwartz 11th ed., p. 525.)
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20. What subtypes of the human papilloma virus (HPV)
confer the highest risk for malignancy?
A. Types 16 and 18
B. Types 6 and 11
C. Types 6 and 8
D. Types 3 and 4
21. What cystic lesion is a benign, congenital occurrence
caused by persistent epithelium across embryonic fusion
lines, most commonly between the forehead and tip of
the nose?
A. Trichilemmal cyst
B. Epidermoid cyst
C. Dermoid cyst
D. Nevus
Answer: A
Mucosal HPV types cause lesions in the mucosal or genital
areas and behave like sexually transmitted infections. The
most common mucosal types are HPV-6, -11, -16, -18, -31,
and -33. These lesions present as condylomata acuminata,
genital or veneral warts, papules that occur on the perineum,
external genitalia, anus, and can extend into the mucosal surfaces of the vagina, urethra, and rectum. These lesions are at
risk for malignant transformation, with types 6 and 11 conferring low risk, and types 16, 18, 31, and 33 conferring a high
risk. The recently developed quadrivalent HPV vaccine, targeting HPV types -6, -11, -16, and -18, is now available to
both males and females age 9 to 26 and is associated with an
up to 90% reduction of infections from those HPV types. (See
Schwartz 11th ed., p. 526.)
Answer: C
Dermoid cysts are congenital variants that occur as the result
of persistent epithelium within embryonic lines of fusion.
They occur most commonly between the forehead and nose
tip, and the most frequent site is the eyebrow. They can lie
in the subcutaneous tissue or intracranially, and often communicate with the skin surface via a small fistula. These cystic structures contain epithelial tissue, hair, and a variety of
epidermal appendages. Treatment for these cystic structures
includes surgical excision with care taken to remove the cyst
lining to prevent recurrence. (See Schwartz 11th ed., p. 527.)
CHAPTER 16
The Skin and Subcutaneous Tissue
22. What subtype of basal cell carcinoma (BCC) is the most
common, characterized by raised, pearly pink papules
with telangiectasias and occasionally a depressed tumor
center with raised borders?
A. Micronodular
B. Infiltrating
C. Superficial spreading
D. Nodular
Answer: D
There are multiple variants of BCC, and presentation can
range from red, flesh-colored, or white macule or papule
to nodules and ulcerated lesions. Growth patterns of these
lesions can either be well-circumscribed or diffuse and
the most common types of BCC are nodular and micronodular, superficial spreading, and infiltrative. The most common subtype is the nodular variant, characterized by raised,
pearly pink papules with telangiectasias and occasionally a
depressed tumor center with raised borders giving the classic “rodent ulcer” appearance. Superficial spreading BCC is
confined to the epidermis as a flat, pink, scaling or crusting
lesion, often mistaken for eczema, actinic keratosis, fungal
infection, or psoriasis. This subtype typically appears on the
trunk or extremities and the mean age of diagnosis is 57 years.
The infiltrative form appears on the head and neck in the late
60s, often at embryonic fusion lines, with an opaque yellowwhite color that blends with surrounding skin and has no
raised edges. The morpheaform subtype represents 2% to 3%
of all BCC and is the most aggressive subtype. It usually presents as an indurated macule or papule with the appearance of
an enlarging scar. The clinical margins are often indistinct,
and the rate of positive margins after excision is high. There
is also a pigmented variant of BCC that can be difficult to
distinguish from certain melanoma subtypes. (See Schwartz
11th ed., pp. 528–529.)
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23. Which of these skin lesions can represent a precursor
lesion to squamous cell carcinoma?
A. Seborrheic keratosis
B. Actinic keratosis
C. Congenital nevus
D. Acrochordons
CHAPTER 16
The Skin and Subcutaneous Tissue
Answer: B
Actinic keratoses are neoplasms of epidermal keratinocytes
that represent a range in a spectrum of disease from sun
damage to squamous cell carcinoma. They typically occur
in fair-skinned, elderly individuals in primarily sun-exposed
areas, and ultraviolet (UV) radiation exposure is the greatest risk factor. There are multiple variants, and they can present as erythematous and scaly to hypertrophic, keratinized
lesions. They can become symptomatic, causing bleeding,
pruritus, and pain. They can regress spontaneously, persist
without change, and transform into invasive squamous cell
carcinoma. It is estimated that approximately 10% of actinic
keratoses will transform into invasive squamous cell carcinoma, and that progression takes about 2 years on average.
About 60% to 65% of squamous cell carcinomas are believed
to originate from actinic keratoses. Congenital nevi can rarely
transform into malignant melanoma. Seborrheic keratoses
and acrochordons do not carry malignant potential. (See
Schwartz 11th ed., p. 528.)
CHAPTER 17
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Breast
1. Which of the following changes in the breast is not associated with pregnancy?
A. Accumulation of lymphocytes, plasma cells, and
eosinophils within the breast
B. Enlargement of breast alveoli
C. Release of colostrum
D. Accumulation of secretory products in minor duct
lumina
2. Which of the following statements is incorrect?
A. Level I lymph nodes are those that are lateral to the
pectoralis minor muscle.
B. Level II lymph nodes are located deep to the pectora-
lis minor muscle.
C. Level Ill lymph nodes are located medial to the pecto-
ralis minor muscle.
D. Level IV lymph nodes are the ipsilateral internal
mammary lymph nodes.
Answer: C
With pregnancy, the breast undergoes proliferative and developmental maturation. As the breast enlarges in response to
hormonal stimulation, lymphocytes, plasma cells, and eosinophils accumulate within the connective tissues. The minor
ducts branch and alveoli develop. Development of the alveoli
is asymmetric, and variations in the degree of development
may occur within a single lobule. With parturition, enlargement of the breasts occurs via hypertrophy of alveolar epithelium and accumulation of secretory products in the lumina
of the minor ducts. Alveolar epithelium contains abundant
endoplasmic reticulum, large mitochondria, Golgi complexes, and dense lysosomes. Two distinct substances are produced by the alveolar epithelium: (a) the protein component
of milk, which is synthesized in the endoplasmic reticulum
(exocrine secretion); and (b) the lipid component of milk
(apocrine secretion), which forms as free lipid droplets in the
cytoplasm. Milk released in the first few days after parturition is called colostrum and has low lipid content but contains
considerable quantities of antibodies. (See Schwartz 11th ed.,
p. 548.)
Answer: D
Axillary lymph node groups are as follows: Level I includes
lymph nodes located lateral to the pectoralis minor muscle;
level II includes lymph nodes located deep to the pectoralis
minor; and level Ill includes lymph nodes located medial to
the pectoralis minor. (See Schwartz 11th ed., p. 547.)
3. Concerning gynecomastia, which of the following is
TRUE?
A. During senescence gynecomastia is usually unilateral.
B. During puberty gynecomastia is usually bilateral.
C. Gynecomastia is associated with breast cancer in
Klinefelter syndrome patients.
D. Gynecomastia is classified as per a three-grade system.
Answer: C
In gynecomastia, the ductal structures of the male breast
enlarge, elongate, and branch with a concomitant increase in
epithelium. During puberty, the condition often is unilateral
and typically occurs between ages 12 and 15 years. In contrast, senescent gynecomastia is usually bilateral. Gynecomastia generally does not predispose the male breast to cancer.
However, the hypoandrogenic state of Klinefelter syndrome
(XXY), in which gynecomastia is usually evident, is associated with an increased risk of breast cancer. Gynecomastia is
graded based on the degree of breast enlargement, the position
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