BASIC SCIENCE AND IMMUNOLOGY

1. Langerhans cells originate from:

A. Ectoderm
B. Neural crest
C. Mesoderm
D. Lymph nodes

Correct answer: (C) Mesoderm

Explanation: Langerhans cells originate from mesoderm.
(A) Ectoderm is where Merkel cells arise.
(B) Neural crest is where Melanocytes arise.
(D).Langerhans cells are derived from the bone marrow, rather than lymph nodes

2. What makes up the majority of the protein envelope of epidermal keratinocytes?

A. Loricrin
B. Involucrin
C. Envoplakin
D. Filaggrin
E. Transglutaminase

Correct answer: (A) Loricrin.

Explanation: Loricrin constitutes 75% of the cornified cell envelope and defects are associated with a
variant of Vohlwinkel syndrome. (B) Involucrin does constitute part of the cornified cell envelope but
does not constitute the majority. (C) Envoplakin does constitute part of the cornified cell envelope but
does not constitute the majority. (D) Filaggrin is converted from profilaggrin, which are part of
keratohyalin granules and interact with keratin intermediate filaments. Mutations affecting filaggrin
are seen in ichthyosis vulgaris. (E) Transglutaminase is altered in patients with Lamellar Ichthyosis
and is involved in normal cross-linking of protein and lipid envelope proteins.

3. Desmosomes are multi-protein complexes that function as cell–cell adhesion structures (or
junctions) in epidermal cells. Which molecule or group of molecules is an extracellular
components of the desmosome?
A. Keratin filament
B. Desmoglein and desmocollin
C. Plakoglobin and plakophilin
D. Desmoplakin
E. E- and P-cadherin

1
 Correct answer: (B) Desmoglein and desmocollin.
Explanation: The desmosome is a multi-protein complexe that functions as a cell–cell adhesion
structure
(or junction) in epidermal cells. It is composed of the following molecules (from inside to outside of
the keratinocyte):
- Keratin filament are found within the keratinocyte.
- Desmoplakin – It links the keratin filament to plakoglobin and plakophilin within the keratinocyte.
- Plakoglobin and plakophilin – Still found within the keratinocyte, they link to desmoglein and
desmocollin.
- Desmoglein and desmocollin – They are mainly found outside of the keratinocyte but a portion of
them is found within the cell, to attach to plakoglobin.
- E- and P-cadherin are found in adherens junctions, another type of cell junction, but are not
found in desmosomes.

4. Which of the following toll-like receptor is involved in recognizing lipopolysaccharide?

A. TLR3
B. TLR4
C. TLR5
D. TLR7

Correct answer: (B) TLR4.

Explanation: TLR4 recognizes lipopolysaccharide.
(A) TLR3 recognizes viral dsRNA.
(C) TLR5 recognizes flagellin.
(D) TLR7 recognizes viral ssRNA and binds imiquimod.

5. Which of the following form part of adherens junctions?

A. Connexins
B. E-cadherin
C. Desmocollin
D. Desmoglein

Correct answer: (B) E-cadherin.

Explanation: E-cadherins are part of a family of calcium-dependent cell-cell adhesion molecules that
make up adherens junctions. Plakoglobin is also a protein of the zonaadherens . It is the only protein
which is found in both the desmosone and Adherens junction. (A) Connexins help constitute gap
junctions. (C) Desmocollin is a protein that constitutes part of desmosomes. Desmosomes are a type
of adhesion molecules between keratinocytes that serve as attachment sites for the cytoskeleton. (D)
Desmoglein is a protein that constitutes part of desmosomes. Desmosomes are a type of adhesion
molecule between keratinocytes that serve as attachment sites for the cytoskeleton.

2
6. Which of the following antigen-presenting cell (APC) surface molecules interacts with the T-cell
surface molecule LFA-1?
A. ICAM-1
B. CD40
C. MHC-2
D. CD80/CD86
E. LFA-3

Correct answer: (A) ICAM-1.

Explanation: ICAM-1 is an APC cell-surface molecule that interacts with the T-cell surface molecule
LFA-1.
(B) CD40 is an APC cell-surface molecule that interacts with the T-cell surface molecule CD40L.
(C) MHC-2 is an APC cell-surface molecule that interacts with the T-cell surface molecule CD4.
(D) CD80/CD86 is an APC cell-surface molecule that interacts with the T-cell surface molecule CD28.
(E) LFA-3 is an APC cell-surface molecule that interacts with the T-cell surface molecule CD2.

7. What is the most abundant amino acid in collagen?

A. Proline
B. Hydroxyproline
C. Lysine
D. Hydroxylysine
E. Glycine

Correct answer: (E) Glycine.

Explanation: Collagen is composed of three chains in a triple helix configuration. It consists of Gly-
x-y repeats with glycine the most abundant amino acid in collagen since it is always the third residue.
x is most often proline and y is usually hydroxylysine or hydroxyproline.

8. What is the main lipid in the cornified layer?

A. Cholesterol
B. Free fatty acids
C. Loricrin
D. Ceramides
E. Involucrin

Correct answer: (D) Ceramides.

Explanation: Ceramides account for the majority of the cornified layer.
Incorrect answers:
(A) Cholesterol is a component of the cornified layer, but does not constitute the majority.
(B) Free fatty acids are a component of the cornified layer, but does not constitute the majority.
(C) Loricrin is a protein component of the cornified envelope.
(E) Involucrin is a protein component of the cornified envelope.

3
9. What anesthetic would you give to a patient with an amide allergy for a punch biopsy?
A. Lidocaine
B. Benzocaine
C. Prilocaine
D. Procaine
E. Mepivacaine

Correct answer: (D) Procaine.

Explanation: Amide anesthetics have two “I’s” in their name. A patient with an allergy should avoid
other amides but may try ester anesthetics. Answer (B) (Benzocaine) and Answer (D) (Procaine) are
both ester anesthetics but since Benzocaine is mostly used as a topical anesthetic, Procaine would be
the better answer.

10. Which of the following is the cytoskeletal anchor in the adherens junctions?
A. Plectin
B. Actin
C. Alpha-catenin
D. E-cadherin
E. Myosin

Correct answer: (B) Actin.

Explanation: The actin microfilament cytoskeleton connects to transmembrane proteins via adherens
junctions, which are made of cadherins and alpha/beta/gamma catenins.

11. Which description is correct regarding the study of samples from a larger population compared to
surveys of the entire population?
A. Samples are often less accurate than surveys of larger populations.
B. Samples usually increase heterogeneity compared to population surveys.
C. Samples may allow estimations of error in resulting statistics.
D. Samples are most representative of the larger population when using
nonprobability sampling.
E. Samples are most representative of the larger population when using nonrandom
sampling.

ANSWER: C.
Explanations:
* C. TRUE: Research is typically conducted on a sample of subjects who represent a larger
population. When selected using random sampling, the study sample is most representative of the
overall population. The use of samples rather than populations provides many advantages. Samples
are, by definition, smaller and can be studied more quickly and at a lower cost. The use of samples
may be the only feasible approach when the study of populations is impossible or impractical. It

4
 would not be possible, for example, to obtain blood samples from every US resident. Often, results
from samples are more accurate than those of a population, and more time and costly resources can
be invested in each research staff member or subject.
An MRI is more accurate than an x-ray in detecting certain abnormalities, but this would only be
financially feasible to perform in a smaller sample. When samples are appropriately selected,
methods can be used to estimate the error of the resulting statistics, which allows the calculation of
probabilities regarding study observations. Samples may be selected in ways that reduce
heterogeneity. If studying a certain aspect of migraines, for instance, an investigator may not want to
study the entire population with migraines, as there is great variability in presentation. Instead, he or
she may wish to select subjects with certain features that are appropriate for the study.
* A. FALSE: Sampling may produce more accurate results than a population survey.
* B. FALSE: Samples may be selected to reduce heterogeneity.
* D. FALSE: Nonprobability sampling techniques base selection on the subjective judgment of the
researcher, which can result in samples that are not representative of the entire population.
* E. FALSE: Nonrandom sampling techniques cannot be used to make inferences about the entire
population.

12. Sebaceous glands of the superficial eyelid margin are known as?
A. Moll’s gland
B. Gland of Zeis
C. Meibomian gland
D. Montogomery tubercle
E. Tyson’s gland

Correct answer: (B) Gland of Zeis.

Explanation: Gland of Zeis is a sebaceous gland of the superficial eyelid margin. (A) Moll’s glands
are apocrine glands of the eyelids. (C) Meibomian gland is a sebaceous gland of the tarsal plate of
eyelids. (D) Montogomery tubercles are sebaceous glands of the nipple/areola. (E) Tyson’s glands are
sebaceous glands of the genitalia.

13. Which of the following cytokines is involved in stimulating adaptive immunity?

A. IL-1
B. IL-2
C. IL-10
D. IFN-alpha

Correct answer: (B) IL-2.

Explanation: IL-2 is a T cell stimulator and thus involved in adaptive immunity.
(A) IL-1 is a proinflammatory cytokine that triggers host innate inflammatory responses.
(C) IL-10 is not involved in stimulating adaptive immunity.
(D) IFN-alpha is an anti-proliferative cytokine and not involved in stimulating adaptive immunity.

5
14. Which of the following lasers is in the infrared spectrum?
A. Erbium YAG
B. Excimer
C. Q-switched Ruby
D. Frequency Doubled Nd:Yag
E. Variable Pulsed KTP

Correct answer: (A) Erbium YAG.

Explanation: Erbium YAG lasers typically emit light with a wavelength of 2940 nm, which is
infrared light. There is also an 1540 nm erbium glass laser.Erbium lasers fall within the infrared
spectrum, which runs from 700nm to 1mm.
(B) Excimer lasers are at 308nm.
(C) Q-switched Ruby lasers are at 694nm.
(D) Frequency Doubled Nd:Yag lasers are at 532nm.
(E) Variable Pulsed KTP lasers are at 532nm.

15. What cells are part of the innate immune system?

A. Natural Killer (NK) cells
B. B cells
C. Th1 cells
D. Th2 cells

Correct answer: (A) Natural Killer (NK) cells.

Explanation: Natural Killer (NK) cells are part of the innate immune system, along with macrophages,
neutrophils, eosinophils, mast cells, cytokines, complement, and antimicrobial peptides.
Incorrect answers:
(B) B cells are considered part of the adaptive immune response.
(C) Th1 cells are considered part of the adaptive immune response.
(D) Th2 cells are considered part of the adaptive immune response.

16. At which earliest gestational age is epidermal development most likely to be complete?
A. 12 weeks
B. 15 weeks
C. 16 weeks
D. 22 weeks
E. 28 weeks

Correct answer: (D) 22 weeks.

6
 Explanation: 22 weeks gestational age correlates with complete epidermal development.
(A) 12 weeks gestational age correlates with formation of the dermo-epidermal junction (DEJ).
(B) 15 weeks gestational age correlates with melanin production.
(C) 16 weeks gestational age correlates with hair follicle keratinization.

17. The protein product of the gene PTCH1 is which of the following?
A. A toll-like receptor
B. A membrane-bound receptor
C. Receptor kinase
D. A G-protein-coupled receptor
E. A ligand

Correct answer: (B) A membrane-bound receptor.

Explanation: The PTCH1 gene product, is a transmembrane protein. PTCH1 is mutated in Gorlin’s
Syndrome, also known as Basal Cell Nevus Syndrome. It is characterized by autosomal dominant
inheritance, mutation in PTCH1 gene coding the SHH sonic hedgehog membrane receptor protein.
Key features include multiple basal cell carcinomas, medulloblastomas, palmar pits, jaw cysts, frontal
bossing, bifid ribs, calcification of falxcerebri, agenesis of corpus collosum, hypertelorism, and
ovarian fibromas/osteofibrosarcomas.

18. What is the closest approximation of the normal concentration of melanocytes in the basal cell
layer of the human skin?
A. 1 melanocyte for each keratinocyte
B. 1 melanocyte for 5 keratinocytes
C. 1 melanocyte for 10 keratinocytes
D. 1 melanocyte for 20 keratinocytes
E. 1 melanocyte for 50 keratinocytes

Correct answer: (C) 1 melanocyte for 10 keratinocytes.

Explanation: In normal skin, approximately every tenth cell in the basal layer is a melanocyte.
Melanosomes are transferred from the dendrites of the melanocyte into neighboring keratinocytes of
the epidermis, hair matrices and mucous membranes. It is interesting to recognize that there is
variation in the density of epidermal melanocytes per square millimeter when different regions of the
body are analyzed via DOPA-stained epidermal sheets. The density of melanocytes is greater in the
genital region (1500/mm2) compared with the back (900/mm2). This is despite the wide variation in
pigmentation seen within the human race. In other words, a person who has minimal baseline
pigmentation and an inability to tan has a similar density of melanocytes when compared with a
person whose skin is dark brown to black in color.

7
19. Which of the following is part of the alternative complement cascade system?
A. C1
B. C1 INH
C. C3
D. C5b
E. Anaphylatoxin

Correct answer: (C) C3.

Explanation: All of the above are involved in the classical complement pathway. C3, however, is also
a part of the alternate complement pathway.

20. Which of the following is most closely related to melanoma?

A. p16
B. p53
C. PTCH1
D. p24
E. Lewis Y antigen

Correct answer: (A) p16.

Explanation: p16 is a protein product, along with p14, of CDKN2A, and approximately 2% of
cutaneous melanomas can be specifically caused by germline mutations in this gene. (B) p53 is the
most frequently mutated gene in human cancer and controls signaling pathways involved in cell
division and apoptosis. (C) PTCH gene, which controls proliferation and differentiation, is disrupted
in the development of basal cell carcinoma. (D) p24 is a viral protein marker of HIV infection. (E)
Lewis Y Antigen is a placenta-associated vascular antigen.

21. What is the primary component of sebum?

A. Cholesterol
B. Cholesterol esters
C. Squalene
D. Wax esters
E. Triglycerides

Correct answer: (E) Triglycerides.

Explanation: All of the above are components of sebum, but glycerides make up the largest
component.Components of sebum include f triglycerides (≈41%), wax esters (≈26%), squalene
(≈12%), and free fatty acids (≈16%).[6] The composition of sebum varies across species. Wax esters
and squalene are unique to sebum and not produced as final products anywhere else in the body.
Sapienic acid is a sebum fatty acid that is unique to humans, and is implicated in the development of
acne

8
22. During pregnancy, around 25 weeks of gestation, a cell layer is lost and contributes to the
formation of the vernixcaseosa, a gelatinous layer coating the newborn. What is the name of that
lost layer?
A. Intermediate layer
B. Periderm
C. Spinous layer
D. Granular layer
E. Cornified layer

Correct answer: (B) Periderm.

Explanation: The development of the epidermis arises from the surface ectoderm. Initially, a single-
layer epithelium covers the developing embryo. Through changes in gene expression, cells of the
surface ectoderm adopt an epidermal fate, resulting in the formation of the basal layer of the
epidermis. These basal cells subsequently give rise to the periderm. The latter is a cell layer that
covers the developing epidermis until cornification occurs. Epidermal stratification then begins with
the formation of a highly proliferative intermediate layer between the basal layer and the periderm.
The intermediate layer becomes several cells thick over the next few weeks. The intermediate cell
layer ultimately matures and differentiates into spinous and granular keratinocytes. The periderm is
sloughed at 24-26 weeks of gestation, in the second trimester, and is replaced by the cornified cell
layer. The periderm remnants contribute to forming the vernixcaseosa that coats newborns.

23. What test is most appropriate to identify a new genetic mutation?

A. Nucleic acid arrays
B. Western blot
C. Polymerase chain reaction
D. Reverse transcription PCR
E. DNA sequencing

Correct answer: (E) DNA sequencing.

Explanation: DNA sequencing can determine the sequence of nucleotides (A, G, C, T) in a stretch of
DNA. It can be used to identify an unknown gene that may be the cause of disease. The other
techniques listed all require knowledge of the specific nucleic acid sequence or gene associated with a
disease.Nucleic acid amplification testing selectively amplifies a specific sequence of DNA or RNA in
a test sample. Western blot uses antibodies to identify specific proteins in a sample. Polymerase chain
reaction (PCR) one of several methods used to amplify a sequence of genetic material. Reverse
transcription PCR amplifies a specific sequence of RNA or mRNA after conversion to complementary
DNA (cDNA) using reverse transcriptase.

9
24. Eosinophils are activated by which interleukin?
A. IL-1
B. IL-2
C. IL-3
D. IL-4
E. IL-5

Correct answer: (E) IL-5.

Explanation: IL-5 acts as an eosinophil stimulator.
(A) IL-1 is a proinflammatory cytokine that triggers host innate inflammatory responses.
(B) IL–2 is a T cell stimulator.
(C) IL-3 is a cytokine that promotes mast cell growth, enhances basophil production, and stimulates
myeloid cells.
(D) IL-4 increases TH2 response of B/T cells.

25. What mutation does UVB induce?

A. C → T
B. T → C
C. A → G
D. G → A

Correct answer: (A) C → T.

Explanation: The majority of p53 mutations in cutaneous SCCs and their precursors are C --> T
single base transition mutations.

26. Which of the following is associated with more severe psoriatic disease activity?
A. beta-defensin 1
B. beta-defensin 2
C. beta-defensin 4
D. beta-defensin 5
E. beta-defensin 6

Correct answer: (B) Beta-defensin 2.

Explanation: Psoriatic lesions have higher beta-defensin 2 and is associated with more severe disease
activity.

27. Which of the following is positive or elevated in a patient with Wegener’s Granulomatosis?
A. Proteinase 3 (c-ANCA)
B. p-ANCA
C. IgE
D. Cryoglobulins
E. anti-C1q antibody

10
 Correct answer: (A) Proteinase 3 (c-ANCA).
Explanation: Proteinase 3 (c-ANCA) is elevated in Wegener’s Granulomatosis, along with ESR, and
white blood cell count.
(B) p-ANCA is elevated in Churg-Strauss.
(C) IgE is elevated in Churg-Strauss.
(D) Cryoglobulins are elevated in cryoglobulinemia.
(E) Anti-C1Q antibody is elevated in urticarial vasculitis.

28. What is the key enzyme in the melanin biosynthetic pathway?

A. Tyrosinase
B. 5,6-dihydroxyindole (DHI) oxidase
C. 5,6-dihydroxyindole-2-carboxylic acid (DHICA) polymerase
D. Dihydroxyphenylalanine synthase
E. Tyrosinase-related protein 1

Correct answer: (A) Tyrosinase.

Explanation: Tyrosinase is the key enzyme in the melanin biosynthetic pathway. Other listed enzymes
are also important in the synthesis of melanin, but not key. If one of the other enzymes dysfunctions,
another type of melanin will be produced (DHICA-eumelanin, DHI-eumelanin or pheomelanin) but
pigment will still be produced. In the complete absence of tyrosinase, no pigment is produced and
oculo-cutaneous albinism of type 1A occurs. The cascade (simplified for the purpose of this question)
is the following:
- Tyrosine Enzymes: Tyrosine hydroxylase/tyrosinase →Results in DOPA
- Enzymes: DOPA oxidase/tyrosinase → Results in DOPAquinone
- DOPAquinone can then be turned to either DOPAchrome or CysteinylDOPA :
- DOPAchrome (with two distinct enzymatic pathways) :-
Enzymes: DHICA oxidase/TYRP1/tyrosinase/DHICA polymerase →Results in: DHICA-melanin
(brown, slightly soluble, intermediate molecular weight)
Enzymes: DHI oxidase/ tyrosinase →Results in: DHI-melanin (black, insoluble, high molecular
weight)
- CysteinylDOPA →To become: Pheomelanin (yellow/red, alkali- soluble, low molecular weight)

29. Langerhans cells do not express which of the following markers?

A. CD35
B. CD1a
C. MHCII
D. CD54
E. CD80/86

Correct answer: (A) CD 35

Explanation: Langerhans cells express all of the following except for CD35, which is expressed by
follicular dendritic cells.

11
30. The inability of the majority of red-haired individuals to develop a tan following exposure to UVR
can be explained, at least in part, by what?
A. A reduced quantity of melanocytes
B. A dysfunction in the tyrosinase enzyme
C. A dysfunction in the myosin Va protein
D. A dysfunction of the melanocortin-1 receptor (MC1-R) on their melanocytes
E. A dysfunction in the PAX3 gene

Correct answer: (D) A dysfunction of the melanocortin-1 receptor (MC1-R) on their melanocytes.
Explanation: The inability of the majority of red-haired individuals to develop a tan following
exposure to UVR can be explained, at least in part, by dysfunction of the melanocortin-1 receptor
(MC1-R) on their melanocytes. This phenomenon, along with the production of oxygen radicals
following the UV irradiation of pheomelanin, probably contributes to the increased incidence of both
cutaneous melanoma and non-melanoma skin cancers in persons with red hair. A dysfunction in the
myosin Va protein causes Griscelli syndrome (other mutations also cause it: RAB27A and
melanophilin). A dysfunction of the tyrosinase enzyme will cause oculo-cutaneous albinism of type
1A or 1B. A reduced quantity of melanocytes can be seen in vitiligo but is not seen in red-haired
individuals. A dysfunction in the PAX3 gene can be the cause of Waardenburg syndrome (as well as
MITF, SOX10).

31. Which of the following is true of apocrine glands?

A. Present on all cutaneous surfaces, with the highest density of palms and soles
B. Associated with long, thin ducts that open to the skin surface
C. Associated with short, thick ducts that open into the upper part of the follicular canal
D. A & B
E. A & C

Correct answer: (C) Associated with short, thick ducts that open into the upper part of the
follicular canal.
Explanation: Apocrine glands are androgen-dependent and primarily located in the axillae,
anogenital regions, external ear canal (ceruminous glands), eyelids (Moll's glands), breast
(mammary glands) and periumbilical region. They have short, thick ducts that open into the upper
part of the follicular canal. They are under adrenergic control (in response to emotive stimuli-
epinephrine/norepinephrine) and exhibit decapitation secretion. Apocrine glands become active
around puberty. (A) Eccrine (not apocrine) glands are distributed along most cutaneous surfaces
with highest density of palmoplantar surfaces (which lack sebaceous and apocrine glands). Eccrine
glands are absent in skin that lacks cutaneous appendages: vermillion border of the lips, labia
minora, glans penis and nail beds. Eccrine glands are under cholinergic control, innervated by
postganglionic sympathetic fibers. They exhibit merocrine secretion (via exocytosis). Both eccrine
and apocrine glands stain positive with S100, keratin and CEA. (B) Eccrine (not apocrine) glands
have long, thin ducts that open to the skin surface.

12
32. Which interleukin is responsible for neutrophil chemotaxis?
A. IL-1
B. IL-5
C. IL-8
D. IFN-alpha
E. TGF-beta

Correct answer: (C) IL-8.

Explanation: IL-8 is responsible for neutrophil chemotaxis.
(A) IL-1 is a proinflammatory cytokine that triggers host innate inflammatory responses.
(B) IL-5 acts as an eosinophil stimulator.
(D) IFN-alpha is an anti-proliferative cytokine.
(E) TGF-beta is an anti-inflammatory cytokine.

33. Innate immunity serves to recognize invading microorganisms and then induce a host defense
response. It comprises many components, including toll-like receptors (TLR). Which TLR
recognizes lipopolysaccharides (LPS)?
A. TLR1 with TLR2
B. TLR4
C. TLR5
D. TLR6 with TLR2
E. TLR7

Correct answer: (B) TLR4.

Explanation: Innate immunity serves to recognize invading microorganisms and then induce a host
defense response. Several families of pattern recognition receptors (PRRs) mediate responses to
pathogen-associated molecular patterns (PAMPs). The PAMPS are are expressed by the
microorganisms. Toll-like receptors (TLRs) are one such family of PRRs. Ten (10) TLRs have been
identified to date.
The following TLRs (TLR1, 2, 4, 5 and 6) are located on the cell membrane and are internalized
upon ligand interaction:
- The TLR2/TLR1 dimer recognizes triacylated lipoproteins.
- The TLR2/TRL6 dimer interacts with diacylated lipoproteins.
- TLR5 recognizes flagellin.
- TLR4 recognizes lipopolysaccharide (LPS).
TLR3, TLR7, TLR8 and TLR9 are located on intracellular membranes of endosomes and lysosomes:
- TLR3 recognizes viral double-stranded RNA (dsRNA)
- TLR7 and TLR8 viral single-stranded RNA (ssRNA)
- TLR9 bacterial and viral hypomethylated DNA (CpG motifs)
- TLR7 and TLR8 also bind to synthetic compounds (imidazoquinolones)
Both the ligand and signaling pathway of TLR10 are still unknown.

13
34. Which pair of keratins is expressed by mitotic keratinocytes in the basal layer?
A. K1 and K10
B. K1 and K9
C. K3 and K12
D. K4 and K13
E. K5 and K14

Correct answer: (E) K5 and K14.

Explanation:K5 and K14 is the pair of keratins that is expressed by mitotic keratinocytes in the basal
layer. K1 and K10 is the pair of keratins that is specifically expressed in the suprabasal cells of
interfollicular skin (but not palmoplantar, see below). K1 and K9 is the pair of keratins that is
specifically expressed in the suprabasal cells of palmoplantar skin. K3 and K12 is the pair expressed
on the cornea. K4 and K13 is the pair expressed on non-cornified mucosa. It is also mutated in the
white sponge nevus.

35. Which component of the skin is mutated in ichthyosis vulgaris and is also a major predisposing
factor for atopic dermatitis when it has a loss of function mutation?
A. Keratin 1
B. Filaggrin
C. Corneodesmosin
D. Plakoglobin
E. Desmoplakin

Correct answer: (B) Filaggrin.

Explanation: Filaggrin is a component of the cornified cell envelope. It is responsible for the
aggregation of keratin filaments. Loss-of-function mutations in filaggrin cause ichthyosis vulgaris
(IV). Loss-of-function mutations in the filaggrin gene FLG, including R501X and 2282del4 cause
ichthyosis vulgaris, the most common inherited disorder of keratinization. IV is a semidominant
condition with incomplete penetrance (roughly 90% in homozygotes and 60% in heterozygotes).
These mutations are associated with a severe phenotype of X-linked recessive ichthyosis and
pachyonychiacongenita. The same mutations are major risk factors for atopic dermatitis and other
skin and allergic diseases including irritant contact dermatitis, asthma, and food allergy.
Patients with a heterozygous filaggrin mutation display mild scaling or no phenotype. Patients with
homozygous or compound heterozygous mutations have more severe ichthyosis vulgaris.
Desmoplakin, when mutated, causes: striate palmoplantarkeratoderma (PPK), Carvajal syndrome,
skin fragility/woolly hair syndrome and lethal acantholyticepidermolysisbullosa.
Plakoglobin mutations can result in Naxos disease, cardiomyopathy with alopecia and PPK,
acantholytic ectodermal dysplasia and lethal congenital epidermolysisbullosa.
A mutation in corneodesmosin causes two diseases: hypotrichosis simplex of the scalp and
inflammatory peeling skin syndrome.
A mutation in Keratin 1 is the cause of: epidermolyticichthyosis, ichthyosishystrix of Curth–Macklin,
diffuse non-epidermolyticpalmoplantarkeratoderma and diffuse epidermolytic PPK.

14
36. There are five types of human immunoglobulins(Ig) antibodies, IgA, IgD, IgE, IgG and IgM. Each
of them has a typical physical conformation. What type of physical conformation does the IgM
type usually have?
A. Monomeric
B. Dimeric
C. Trimeric
D. Pentameric
E. Hexameric

Correct answer: (D) Pentameric.

Explanation: IgM antibodies usually have a pentameric conformation (a group of 5
immunoglobulins that are linked in their center which gives them a snowflake appearance). They
sometimes can be hexameric (a group of 6 antibodies) but this is less frequent than pentameric. An
IgM molecule has a size of approximately 900 Da. It is the largest immunoglobulin. IgM is the major
immunoglobulin produced in the primary immune response. Upon binding to its antigen, IgM
induces agglutination and activates the classical complement pathway. IgA antibodies usually take a
dimeric conformation (a group of two antibodies) and sometimes comes as a monomer (no grouping).
Other antibodies, IgD, IgE and IgG are monomeric. Trimeric conformation (a group of 3) is a
distractor. No Ig conformation is known to be trimeric.

37. Which of the following is false about melanin synthesis?

A. Pheomelanin has oval-shaped structure
B. Melanin precursors are dependent on copper-requiring enzyme
C. Eumelanin is brown or black in color
D. Tyrosinase is the rate-limiting step in melanin synthesis
E. Chronic sun exposure causes larger melanosomes to be created

Correct answer: (A) Pheomelanin has oval-shaped structure.

Explanation: Pheomelanin has a round-shaped structure and is red-yellow in color. Eumelanin is
oval-shaped and brown or black in color. (B) Melanin precursors are dependent on a copper-
requiring enzyme. (C) Eumelanin is brown or black in color. (D) Tyrosinase is the rate-limiting step
in melanin synthesis. (E) Chronic sun exposure causes larger melanosomes to be created.

38. A 32-year-old female presents complaining of a new rash that developed a few days after picking
up her kitten that was playing in the woods near her home. The rash began as small, red, raised
bumps that began to drain clear fluid. This patient is most likely experiencing which type of
hypersensitivity?
A. Type I
B. Type II
C. Type III
D. Type IV
E. This is not a hypersensitivity reaction.

15
 ANSWER: D.
EXPLANATIONS:
D. TRUE: This patient is most likely experiencing contact dermatitis from poison ivy oils on the fur
of her kitten. Type IV hypersensitivity, also known as delayed hypersensitivity, is mediated by the
action of T cells. A sensitized T cell encounters its antigen and releases lymphokines while activating
macrophages. Unlike the other types, it is not antibody-mediated; it is a type of cell-mediated
response. The reaction occurs when CD4+ helper T cells recognize an antigen class 2 major
histocompatibility complex. The antigen-presenting cells in type IV are macrophages that secrete IL-
12, which stimulates the production of more CD4+ Th1 cells. These CD4+ T cells secrete IL-2 and
IFN-gamma. Examples of type IV hypersensitivity include TB skin tests and contact dermatitis.
A. FALSE: Symptoms of a type I hypersensitivity reaction range from hives, itchiness, and swelling to
anaphylaxis and sudden death. In type I hypersensitivity, an antigen is presented to Th2 cells that are
specific to the antigen that stimulates B cell production of IgE antibodies. This IgE is then attached
to mast cells. Later exposure to the same allergen cross-links the bound IgE on sensitized mast cells,
resulting in degranulation and the secretion of histamine, leukotrienes, and prostaglandins that act
on the surrounding tissues. The principal effects of these products are vasodilation and smooth
muscle contraction.
B. FALSE: In type II hypersensitivity (cytotoxic hypersensitivity), antibodies are produced against
antigens on the patient's cell surfaces. Damage is mediated in several ways: (1) opsonization of the
cells, leading to phagocytosis or complement activation; (2) complement-mediated lysis of cells; and
(3) antibody-dependent cell-mediated cytotoxicity due to natural killer cells or macrophages.
Examples of type II hypersensitivity include bullous pemphigoid and pemphigus vulgaris.
C. FALSE: Type III hypersensitivity is due to the deposition of immune complexes in tissues.
Immune complexes are composed of antigens bound to antibodies. These immune complexes activate
complement, which attracts neutrophils. The action of neutrophils mediates the damage in type III
hypersensitivity. An example of type III hypersensitivity is systemic lupus erythematosus.

39. The delayed tanning response in skin is attributed to which of the following?
A. UVA - redistribution of existing melanin
B. UVB – redistribution of existing melanin
C. UVA –increased transfer of melanosomes to keratinocytes
D. UVB - increased transfer of melanosomes to keratinocytes
E. Hyperproliferation of the epidermis

Correct answer: (D) UVB - increased transfer of melanosomes to keratinocytes.

Explanation: UVB induced delayed tanning is due to increased epidermal melanocytes and increased
transfer of melanosomes to keratinocytes. Tanning of human skin is dependent on wavelength. There
are two types of tanning response: 1) Immediate pigment darkening which occurs within minutes
after UV exposure 2) Delayed tanning which takes several days to become apparent. (A) (B)
Immediate tanning is attributed to exposure to UVA which causes melanosomal relocation into the
melanocyte dendrites. (C) Delayed tanning is due to both UVA (320-400 nm) and UVB (280-320 nm),
however UVB is far more effective than UVA.

16
40. Which of the following is needed by tyrosinase to function?
A. Zinc
B. Iron
C. Selenium
D. Magnesium
E. Copper

Correct answer: (E) Copper.

Explanation: Tyrosinase is a copper-requiring enzyme with two copper binding sites. Tyrosinase is
the key regulatory enzyme in melanin synthesis.

41. Which of the following would you most expect to see in urticarial vasculitis?
A. Hypocomplementemia
B. SRP antibodies
C. Anemia
D. Elevated LDH
E. Elevated anti-double stranded DNA antibodies

Correct answer: (A) Hypocomplementemia.

Explanation: The most common abnormalities in urticarial vasculitis include elevated ESR
(erythrocyte sedimentation rate); hypocomplementemia (usually decreased C1q, C3, and C4);
circulating immune complexes by the C1q solid phase test and/or anti-C1q antibody assay; and
positive ANA.

42. Which of the following epidermal processes requires calcium?

A. Cross-linking keratinocytes via Tissue Transglutaminase
B. Conversion of Profilaggrin to Filaggrin
C. Terminal differentiation of keratinocytes
D. Formation of Cell-Cell Adhesion Proteins in the Adherens Junction
E. All of the above require calcium

Correct answer: (E) All of the above require calcium.

Explanation: All of the aforementioned processes require calcium for the normal function and
maturation of keratinocytes in the epidermis. Additionally, the conversion of profilaggrin to filaggrin
as well as the cross-linking of keratinocytes via tissue transglutaminase is necessary for normal
functionality of the stratum corneum and its barrier functions.

17
43. Which of the following are markers on dendritic cells?
A. CD20
B. CD86
C. CD 8
D. CD 33

Correct answer: (B) CD86.

Explanation: CD86 is a marker on dendritic cells.
(A) CD20 is a B cell marker.
(C) CD 8 is a T cell marker.
(D) CD 33 is a transmembrane receptor expressed on the myeloid lineage.

44. Which of the following markers would be most helpful in diagnosis of infantile hemangioma?
A. Vitronectin
B. Basic fibroblast growth factor (bFGF)
C. Vascular endothelial growth factor (VEGF)
D. Tissue inhibitor of matrix metalloproteinases-1
E. GLUT-1

Correct answer: (E) GLUT-1.

Explanation: All of the above are markers of proliferating and involutinghemangiomas. However,
GLUT-1 expression is usually seen in vessels with blood-tissue barrier functions such as the placenta,
thus GLUT-1 staining is useful in diagnosis of infantile hemangioma because it is absent in other
types of vascular tumors and vascular malformations.

45. What is the spectrum of UVA2 light?

A. 460-400nm
B. 400-340nm
C. 340-320nm
D. 320-290nm
E. 290-200nm

Correct answer: (C) 340-320 nm.

Explanation: UV wavelengths (340 to 400 nm) reduce the risk of sunburn reactions associated with
the shorter-wavelength UVA2 (320 to 340 nm) and UVB (290 to 320 nm).
UVA (400-320 nm) is split into UVA1(400-340nm) and UVA2(340-320nm), UVB(320nm-290nm),
and UVC (290-200nm).

18
46. Pain is detected by which of the following?
A. Pacini corpuscles
B. Meissner’s corpuscles
C. Ruffini corpuscles
D. C-type fibers
E. Merkel cells

Correct answer: (D) C-type fibers.

Explanation: C-type fibers detect pain. (A) Pacini corpuscles detect deep pressure and vibration. (B)
Meissner’s corpuscles detect light touch. (C) Ruffini corpuscles detect continuous pressure. (E)
Merkel cells detect touch.

47. Which of the following is implicated in the pathogenesis of the condition below?

A. IL-1
B. IL-2
C. IFN-gamma
D. TGF-beta

Correct answer: (D) TGF-beta.

Explanation: TGF-beta controls proliferation and cell differentiation. Over-expression of TGF-beta
promotes fibroblast proliferation and collagen synthesis, and has been shown to play an important
role in keloid formation.
(A) IL-1 is a pro-inflammatory cytokine that is not implicated in keloid formation.
(B) IL-2 is necessary for the growth, proliferation, and differentiation of T-cells. It is not implicated
in keloid formation.
(C) IFN-gamma is a key cytokine that is important in innate and adaptive immunity. It is not
implicated in keloid formation.

48. Which of the following is the most potent anaphylatoxin?

A. C1
B. C3a
C. C3b
D. C5a
E. C5b

Correct answer: (D) C5a.

19
 Explanation: C5a is the most potent anaphylatoxin.
(A) C1 is involved in recruiting C2 and C4 to form C3 convertase.
(B) C3a is involved eosinophil recruitment.
(C) C3b is involved in opsonization.
(E) C5b forms the membrane attack complex (MAC) when combined with C6, 7, 8 and 9.

49. 5-alpha-reductase converts testosterone to which of the following?

A. Androstenedione
B. Dihydrotestosterone
C. DHEA
D. 17-alpha hydroxyprogesterone
E. 17-alpha-hydroxypregnenoline

Correct answer: (B) Dihydrotestosterone.

Explanation: Dihydrotestosterone is converted from testosterone by 5-alpha-reductase.
(A) Androstenedione is a testosterone precursor.
(C) DHEA is a precursor to androstenedione.
(D) 17-alpha hydroxyprogesterone is a precursor to DHEA.
(E) 17-alpha-hydroxypregnenoline is a precursor to androstenedione and 11-deoxycortisol.

50. Which of the following is most closely associated with psoriasis?

A. HLA-B8
B. HLA-DR2
C. HLA-DQ8
D. HLA-DR6
E. HLA-Cw6

Correct answer: (E) HLA-Cw6.

Explanation: HLA-Cw6 is most closely associated with psoriasis. (A) HLA-B8 is most closely
associated with oral lichen planus and dermatitis herpetiformis. (B) HLA-DR2 is most closely
associated with lupus. (C) HLA-DQ8 is most closely associated with dermatitis herpetiformis and
chronic urticaria. (D) HLA-DR6 is most closely associated with pemphigus vulgaris.

51. At how many weeks does the fetal basement membrane begin to develop?
A. 3 weeks
B. 7 weeks
C. 9 weeks
D. 12 weeks
E. 16 weeks

Correct answer: (B) 7 weeks.

20
 Explanation: 7 weeks gestational age correlates with development of the fetal basement membrane as
well as primordial teeth. (A) 3 weeks gestational age correlates with development of a single layer of
ectoderm. (C) 9 weeks gestational age correlates with the beginning of epidermal stratification and
the appearance of melanocytes, Langerhans cells, and merkel cells. (D) 12 weeks gestational age
correlates with formation of the dermo-epidermal junction (DEJ). (E) 16 weeks gestational age
correlates with hair follicle keratinization.

52. Cicatricialpemphigoid with adenocarcinoma is associated with autoantibodies in:

A. Desmoglein 3
B. Laminin-332 (V)
C. Connexin 26
D. Plakoglobin
E. Loricrin

Correct answer: (B) Laminin-332 (V).

Explanation: Laminin-332 (V) is involved in pathogenesis of cicatricialpemphigoid.
(A) Desmoglein 3 is the antigen involved in pathogenesis of the autoimmune condition, pemphigus
vulgaris.
(C) Connexin 26 mutation is associated with KID syndrome, Vohwinkel syndrome, and PPK with
deafness.
(D) Plakoglobin mutation is associatd with Naxos disease.
(E) Loricrin mutation is associated with a variant of Vohwinkel Disease and progressive symmetric
erythrokeratoderma.

53. Which of the following is not a pre-formed mediator of mast cells?

A. Tryptase
B. Leukotriene C4
C. Heparin
D. Histamine
E. Cathepsin G

Correct answer: (B) Leukotriene C4.

Explanation: Pre-formed mast cell mediators include proteases (e.g. tryptase, chymase,
carboxypeptidase-A, cathepsin G), Heparin, and Histamine. Newly-formed mediators include
prostaglandin D2, leukeotrienes C4, D4, E4, and platelet-activating factor.

54. Granulation tissue is initially composed of which of the following?

A. Collagen I
B. Collagen II
C. Collagen III
D. Collagen IV
E. Collagen VI

21
 Correct answer: (C) Collagen III.
Explanation: Collagen III is located in fetal skin and blood vessels, but also comprises granulation
tissue in the first stages. Later, granulation tissue is slowly replaced by Collagen I.
(A) Collagen I is located in dermis, bone, ligaments and tendons.
(B) Collagen II is located in cartilage and vitreous humor.
(D) Collagen IV is located in the basement membrane.
(E) Collagen VI is located in the aorta and placenta.

55. Which of the following is able to cross the placenta?

A. IgA
B. IgD
C. IgE
D. IgG
E. IgM

Correct answer: (D) IgG.

Explanation: IgG is the only immunoglobulin able to cross the placenta.

56. Cicatricialpemphigoid with ocular scarring is associated with autoantibodies against which of the
following:
A. alpha 6 beta 4 integrin
B. Desmocollin 1
C. Transglutaminase
D. Plectin
E. BPAG1

Correct answer: (A) Alpha 6 beta 4 integrin.

Explanation: Alpha 6 beta 4 integrin abnormality is associated with cicatricialpemphioid with ocular
scarring as well as junctionalepidermolysisbullosa with pyloric atresia. (B) Desmocollin 1
abnormality is associated with subcornealpustulardermatosis. (C) Transglutaminase abnormality is
associated with lamellar ichthyosis. (D) Plectin abnormality is associated with epidermolysisbullosa
simplex with muscular dystrophy and paraneoplastic pemphigus. (E) BPAG1 abnormality is
associated with bullous pemphigoid.

57. What of the following is the most inner portion of the hair?
A. Henle’s layer
B. Hair shaft cuticle
C. Inner root sheath
D. Huxley’s layer
E. Glassy membrane

22
 Correct answer: (B) Hair shaft cuticle.
Explanation: Hair shaft anatomy from the outer to inner layer is as follows: Glassy membrane →
Outer Root Sheath → Henle’s Layer (Inner Root Sheath) → Huxley’s Layer (Inner Root Sheath) →
Cuticle (Inner Root Sheath) → Hair Shaft Cuticle → Cortex → Medulla.

58. Imiquimod increases production of which cytokine?

A. IL-3
B. IL-5
C. TGF-beta
D. IFN-alpha

Correct answer: (D) IFN-alpha.

Explanation: IFN-a is an antiproliferative cytokine that is increased by imiquimod. Imiquimod
activates toll-like receptor 7 which results in the production of multiple cytokines that enhance cell
mediated (Th1) immunity for antitumor and antiviral effects. (A) IL-3 is a cytokine that promotes
mast cell growth, enhances basophil. (B) IL-5 acts as an eosinophil stimulator. (C) TGF-beta is an
anti-inflammatory cytokine.

23