A writer's rash

39 y, white man, working as a writer with a publishing company, no significant PMH, no h/o tobacco, alcohol or illicit drugs, in a monogamous relationship for the past year, presents with intensely pruritic, spreading rash involving the lateral aspects of the trunk, Rt more than left for the past few days.
Apparently, he had a two small macular eruptions in the Rt axilla, about 5-6 weeks ago, that responded to topical emollients.
Does not recall any exposure to new chemicals; travel outside Baltimore or recent febrile illness. HIV test done few months ago was negative.
Exam shows erythematous maculopapular rash extending from the axilla to the iliac crest.

Which of the following statements regarding the pathology is incorrect?

1. The most likely mechanism of the rash is contact irritation.
2. This pathology is an important common cause of occupational disability
3. About 1/3rd of patients with chronic venous stasis develop contact dermatitis to neomycin.
4. Treatment includes avoidance of exposure and medium to strong potency topical steroids.
5. Patch testing is helpful in diagnosis of chronic cases to identify specific allergens.

Man with a lesion in his mouth

53y, AA man, with PMH of GERD, Insomnia, Erectile dysfunction and primary syphilis (diagnosed and treated at least 25 years ago), presents to the office frustrated by recurrent painful mouth sores, which are not preceded by blisters. For the past several years, he has been told to have recurrent herpes labialis and is being treated with Valacyclovir suppressive treatment.
On exam, he has few round sub-centimeter superficial ulcers on an erythematous base scattered on the palate and upper lip.
Which of the following statements about this pathology is false?

1. The pathogenesis of these lesions is not clearly identified, although it could be predisposed by stress, immune dysfunction or toothpaste detergent.
2. It would not be inappropriate to culture the base of the ulcer and send for Tzanck smear and culture.
3. Given the history of syphilis in the past, a diagnosis of oral syphilis can be made based on the history and exam- CORRECT ANSWER
4. Although Amlexaonox is slightly more expensive than Triamcinolone in Orabase, it is considered to be more effective and should be used as first-line agent.
5. The diagnosis of HSV appears dubious and Valacyclovir should be discontinued.

Discoloration of toes

65 y, white man, with h/o CAD and tobacco dependence, presents to the ER with dyspnea and angina. He is compliant with his medication regimen, which includes ASA, Enalapril, Metoprolol and Lovastatin. On exam, his vital signs were stable and no cardio-pulmonary abnormalities were noted. Extremities show brownish-black discoloration of his toes, with evidence of dry gangrene. Peripheral lower extremity pulses are absent. On further questioning, he mentions developing the discoloration 2 years ago. Which of the following historical clue is the most important in determining the likely cause of the pathology?

1. History of PTCA- CORRECT ANSWER.
2. Tobacco dependence, 3 ppd for 40 years.
3. History of Rt sided endocarditis
4. History of Frostnip 2 years ago, while on a cruise to Alaska