Autoimmune Skin Diseases Practice Questions

Q: The mode of inheritance of Incontinentia pigmenti is:

X-linked dominant. **Explanation:** **Incontinentia Pigmenti (Bloch-Sulzberger syndrome)** is a rare multisystem neurocutaneous disorder caused by a mutation in the **IKBKG gene** (formerly NEMO). 1. **Why X-linked Dominant is correct:** The inheritance is **X-linked dominant**. The mutation is typically **lethal in males** in utero, which is why the clinical phenotype is seen almost exclusively in females. Affected females survive due to functional mosaicism resulting from **X-chromosome inactivation (Lyonization)**. 2. **Why other options are wrong:** * **Autosomal Dominant/Recessive:** The gene is located on the X chromosome (Xq28), ruling out autosomal inheritance. * **X-linked Recessive:** In recessive conditions, heterozygous females are usually asymptomatic carriers. In IP, a single mutated allele is sufficient to cause the disease phenotype in females. **Clinical Phases (High-Yield for NEET-PG):** The skin lesions characteristically follow the **Lines of Blaschko** and evolve through four distinct stages: 1. **Vesicular stage:** Linear vesicles (present at birth or shortly after). 2. **Verrucous stage:** Hyperkeratotic, wart-like plaques. 3. **Hyperpigmented stage:** "Swirl-like" or "Marble cake" pigmentation (due to melanin incontinence into the dermis). 4. **Hypopigmented/Atrophic stage:** Linear streaks of hypopigmentation and hair loss. **Clinical Pearls:** * **Associated findings:** Peg-shaped (conical) teeth, delayed dentition, seizures, and cicatricial alopecia. * **Histology:** Eosinophilic spongiosis is a characteristic feature of the first stage. * **Key differentiator:** Unlike other X-linked dominant conditions, the male-to-female ratio is heavily skewed due to male lethality.

Q: Gottron's papules are a characteristic clinical finding in which of the following conditions?

Dermatomyositis. **Explanation:** **Dermatomyositis** is the correct answer. Gottron’s papules are considered a **pathognomonic** cutaneous feature of this idiopathic inflammatory myopathy. They are characterized by erythematous to violaceous, flat-topped papules and plaques found symmetrically over the dorsal aspects of the interphalangeal (IP) and metacarpophalangeal (MCP) joints. Pathologically, they represent interface dermatitis similar to lupus but are specific to the bony prominences of the hands. **Why other options are incorrect:** * **Sarcoidosis:** Typically presents with "apple-jelly" nodules, lupus pernio (violaceous plaques on the nose/cheeks), or erythema nodosum. It does not feature Gottron’s papules. * **Scleroderma:** Characterized by skin tightening (sclerodactyly), Raynaud’s phenomenon, and "beaked nose" appearance. While it affects the hands, the pathology involves fibrosis rather than inflammatory papules over joints. * **Fungal infection:** Dermatophytosis (Tinea) usually presents as annular erythematous plaques with central clearing and peripheral scaling, not localized papules over small joints. **NEET-PG High-Yield Pearls:** 1. **Gottron’s Sign:** Symmetrical violaceous erythema (macular) over the knuckles, elbows, or knees (distinguish from *papules*). 2. **Heliotrope Rash:** Violaceous edema of the upper eyelids; another pathognomonic sign. 3. **Shawl Sign & V-Sign:** Photosensitive erythema over the upper back and chest, respectively. 4. **Mechanic’s Hands:** Hyperkeratosis and fissuring of the palms and lateral fingers (associated with **Anti-Jo-1** antibodies and interstitial lung disease). 5. **Malignancy:** Dermatomyositis in adults is frequently associated with internal malignancies (paraneoplastic syndrome).

Q: Which of the following is a common association with Celiac sprue?

Dermatitis herpetiformis. **Explanation:** **Dermatitis Herpetiformis (DH)** is considered the cutaneous manifestation of gluten-sensitive enteropathy (**Celiac sprue**). The underlying pathophysiology involves IgA antibodies directed against **tissue transglutaminase (tTG)** in the gut, which cross-react with **epidermal transglutaminase (eTG)** in the skin. This leads to the characteristic subepidermal blisters and intense pruritus. Nearly 90% of patients with DH have associated gluten-sensitive enteropathy, though many remain asymptomatic for gastrointestinal symptoms. **Analysis of Incorrect Options:** * **A. Herpes Gestationalis (Pemphigoid Gestationis):** This is a pregnancy-associated autoimmune bullous disease caused by IgG antibodies against BP180. It has no association with gluten sensitivity. * **C. Pemphigus Vulgaris:** An intraepidermal blistering disease caused by antibodies against Desmoglein 1 and 3. It is associated with other autoimmune conditions (like Myasthenia Gravis) but not Celiac sprue. * **D. Bullous Pemphigoid:** A subepidermal blistering disease seen primarily in the elderly, targeting BP180 and BP230. It is not linked to gluten-sensitive enteropathy. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Symmetrical, extremely pruritic vesicles on extensors (elbows, knees, buttocks). * **Histopathology:** Neutrophilic microabscesses at the tips of dermal papillae. * **Direct Immunofluorescence (DIF):** **Granular IgA deposits** in the dermal papillae (Gold Standard). * **Treatment:** **Dapsone** is the drug of choice for skin lesions, while a **Gluten-free diet** is essential for long-term management and reducing the risk of intestinal lymphoma (EATL).

Q: Which of the following is NOT a feature of Netherton Syndrome?

Autosomal dominant inheritance. **Explanation:** Netherton Syndrome is a rare, severe multisystem disorder characterized by a classic triad of **ichthyosis linearis circumflexa**, **hair shaft abnormalities**, and **atopic features**. **1. Why Option A is the correct answer:** Netherton Syndrome is inherited in an **Autosomal Recessive** pattern, not autosomal dominant. It is caused by a mutation in the **SPINK5 gene** on chromosome 5q32, which encodes the serine protease inhibitor **LEKTI**. The deficiency of LEKTI leads to overactive epidermal proteases, resulting in premature desquamation and a severely compromised skin barrier. **2. Why the other options are incorrect:** * **B. Ichthyosis:** Patients typically present with **Ichthyosis Linearis Circumflexa (ILC)**, characterized by migratory, erythematous, polycyclic plaques with a unique "double-edged" scale. * **C. Very short hair:** This refers to **Trichorrhexis invaginata** (Bamboo hair), the pathognomonic hair defect. The hair is brittle and breaks easily, leading to short, sparse hair and eyebrows. * **D. Erythroderma:** Most neonates with Netherton Syndrome present at birth with generalized **congenital ichthyosiform erythroderma**, which can lead to life-threatening complications like dehydration and hypernatremia. **High-Yield Clinical Pearls for NEET-PG:** * **Pathognomonic Hair Sign:** "Bamboo hair" (intussusception of the distal hair shaft into the proximal portion). * **The Triad:** Ichthyosis + Trichorrhexis invaginata + Atopy (high IgE levels/asthma). * **Differential Diagnosis:** Often misdiagnosed as Atopic Dermatitis or Omenn Syndrome in infancy. * **Key Gene:** SPINK5 (LEKTI protein).

Q: Salt and pepper dyschromatosis is seen in which of the following conditions?

Scleroderma. **Explanation:** **Salt and pepper dyschromatosis** is a classic clinical sign of **Systemic Sclerosis (Scleroderma)**. It refers to a pattern of diffuse skin pigmentation characterized by areas of **perifollicular sparing** (retained pigment around hair follicles) against a background of depigmentation (leukoderma). The underlying medical concept involves the destruction of melanocytes in the interfollicular epidermis, while the melanocytes within the hair follicle bulbs are preserved. Because hair follicles have a rich capillary network, they are relatively spared from the ischemic changes seen in scleroderma, allowing them to serve as a reservoir for pigment. This sign is often one of the earliest cutaneous markers of the disease, typically appearing on the upper chest, neck, and back. **Analysis of Incorrect Options:** * **Dermatofibrositis:** This is not a standard dermatological term; however, Dermatofibrosarcoma Protuberans (DFSP) presents as a firm, multinodular plaque, not dyschromatosis. * **Systemic Lupus Erythematosus (SLE):** While SLE can cause various pigmentary changes (like post-inflammatory hyperpigmentation or discoid scars), it does not typically manifest with the specific perifollicular sparing seen in the "salt and pepper" pattern. * **Psoriasis:** Characterized by well-demarcated erythematous plaques with silvery-white scales. While it may leave post-inflammatory hypopigmentation, it lacks the specific follicular sparing of scleroderma. **NEET-PG High-Yield Pearls:** * **Salt and Pepper Pigmentation:** Also known as "Scleroderma-associated leukoderma." * **Other Scleroderma Signs:** Microstomia (small mouth), Mouse facies, Raynaud’s phenomenon (earliest symptom), and Sclerodactyly. * **Antibody Association:** Anti-Scl-70 (Diffuse type) and Anti-centromere (Limited/CREST syndrome).

Q: Koenen's periungual fibroma is a feature of which condition?

Bourneville's disease. **Explanation:** **Bourneville’s disease**, also known as **Tuberous Sclerosis Complex (TSC)**, is an autosomal dominant neurocutaneous syndrome characterized by the development of benign tumors (hamartomas) in multiple organs. **Koenen’s tumors** (periungual fibromas) are a pathognomonic cutaneous marker of TSC. These are flesh-colored or reddish, elongated papules or nodules that arise from the nail fold, typically appearing during or after puberty. They represent one of the major clinical criteria for the diagnosis of TSC. **Analysis of Incorrect Options:** * **Kawasaki’s disease:** A pediatric systemic vasculitis. Cutaneous features include a polymorphic rash, strawberry tongue, and characteristic **periungual desquamation** (peeling) during the subacute phase, but not fibromas. * **Refsum disease:** A rare metabolic disorder (phytanic acid storage disease). Its primary dermatological feature is **ichthyosis** (scaly skin), along with retinitis pigmentosa and neuropathy. * **Darier’s disease:** An autosomal dominant genodermatosis characterized by greasy, keratotic papules in seborrheic areas. Nail findings include **V-shaped nicking** at the distal edge and alternating red and white longitudinal bands, but not periungual fibromas. **High-Yield Clinical Pearls for TSC:** * **Vogt’s Triad:** Adenoma sebaceum (angiofibromas), mental retardation, and epilepsy (present in only ~30% of cases). * **Earliest Sign:** Ash-leaf spots (hypopigmented macules), best seen under **Wood’s lamp**. * **Shagreen Patch:** Connective tissue nevus usually found on the lumbosacral area. * **Confetti lesions:** Multiple tiny hypopigmented macules on the limbs. * **Internal findings:** Renal angiomyolipomas, Cardiac rhabdomyomas, and Subependymal giant cell astrocytomas (SEGA).

Q: Coup-de Sabre is commonly associated with which of the following conditions?

Systemic sclerosis. **Explanation:** **Coup-de-Sabre** (En coup de sabre) is a specific morphological subtype of **localized scleroderma (Morphea)**. The term is French for "stroke of the sword," describing a linear, indented scar-like lesion that typically occurs on the forehead or scalp. 1. **Why Systemic Sclerosis is the correct answer:** While "Coup-de-Sabre" is technically a form of localized scleroderma (Linear Morphea), in the context of standard medical examinations like NEET-PG, it is classified under the umbrella of **Scleroderma/Systemic Sclerosis** spectrum diseases. It represents a localized fibrotic process where the skin becomes atrophic, hardened, and hyperpigmented, often involving underlying muscle and bone, leading to a "sabre-cut" appearance. 2. **Why other options are incorrect:** * **Pemphigus:** This is an autoimmune blistering (bullous) disease caused by antibodies against desmogleins. It presents with flaccid bullae and erosions, not linear fibrosis or atrophy. * **Scleroderma (Option A vs C):** In many entrance exams, "Systemic Sclerosis" is used interchangeably with the broader term "Scleroderma." However, if both are present, Systemic Sclerosis is often the preferred clinical term for the disease family involving pathological fibrosis. **Clinical Pearls for NEET-PG:** * **Parry-Romberg Syndrome:** Often associated with Coup-de-Sabre; it involves progressive hemifacial atrophy (loss of subcutaneous fat and muscle on one side of the face). * **Morphea vs. Systemic Sclerosis:** Morphea (localized) typically lacks Raynaud’s phenomenon and internal organ involvement, unlike Systemic Sclerosis. * **Histology:** Both show "squared-off" biopsy specimens due to dense collagen deposition and loss of skin appendages. * **Salt and Pepper Pigmentation:** A classic sign of Systemic Sclerosis (vitiligo-like depigmentation with perifollicular sparing).

Question 1

A 28-year-old female presents with a 3-month history of violaceous, flat-topped papules on her wrists and lower back associated with intense pruritus. Examination reveals white lacy streaks on the buccal mucosa bilaterally. She was recently started on antihypertensive medication 4 months ago. Histopathology shows hyperkeratosis, irregular acanthosis, and band-like lymphocytic infiltrate at the dermoepidermal junction. What is the most appropriate next step in management?

Accepted Answer

Discontinue current antihypertensive and start topical corticosteroids

Answer

Start oral prednisolone 1 mg/kg and continue current antihypertensive

Answer

Start oral methotrexate and continue current antihypertensive

Answer

Perform direct immunofluorescence and continue current medication

Question 2

The mode of inheritance of Incontinentia pigmenti is:

Accepted Answer

X-linked dominant

Answer

Autosomal dominant

Answer

Autosomal recessive

Answer

X-linked recessive

Question 3

A study of persons developing skin lesions following sun exposure is conducted. The lesions are not found on skin protected from ultraviolet light. Biopsies of involved skin show immunoglobulin G deposition along the dermal-epidermal junction, along with vacuolization of the basal layer and a perivascular lymphocytic infiltrate. No other organ involvement is present. Which of the following diseases do these patients most likely have?

Accepted Answer

Discoid lupus erythematosus

Answer

Bullous pemphigoid

Answer

Celiac disease

Answer

Dysplastic nevus syndrome

Question 4

Morphea most commonly occurs in which location?

Accepted Answer

Forehead

Answer

Sternum

Answer

Limbs

Answer

Back

Question 5

Gottron's papules are a characteristic clinical finding in which of the following conditions?

Accepted Answer

Dermatomyositis

Answer

Sarcoidosis

Answer

Scleroderma

Answer

Fungal infection

Question 6

Which of the following is a common association with Celiac sprue?

Accepted Answer

Dermatitis herpetiformis

Answer

Herpes Gestationalis

Answer

Pemphigus vulgaris

Answer

Bullous pemphigoid

Question 7

Which of the following is NOT a feature of Netherton Syndrome?

Accepted Answer

Autosomal dominant inheritance

Answer

Ichthyosis

Answer

Very short hair

Answer

Erythroderma

Question 8

Salt and pepper dyschromatosis is seen in which of the following conditions?

Accepted Answer

Scleroderma

Answer

Dermatofibrositis

Answer

Systemic Lupus Erythematosus (SLE)

Answer

Psoriasis

Question 9

Koenen's periungual fibroma is a feature of which condition?

Accepted Answer

Bourneville's disease

Answer

Kawasaki's disease

Answer

Refsum disease

Answer

Darier's disease

Question 10

Coup-de Sabre is commonly associated with which of the following conditions?

Accepted Answer

Systemic sclerosis

Answer

Scleroderma

Answer

Pemphigus

Answer

None of the above

Autoimmune Skin Diseases — MCQs

Autoimmune Skin Diseases — MCQs

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