Lupus Erythematosus: Cutaneous Forms — MCQs
Which one of these should not be used in severe widespread psoriasis?
Nail involvement is not a feature of –
A child with history of fever, photosensitivity, rash sparing nasolabial fold presents to OP. Identify the condition?
A lesion was seen on the face of a 42 year old patient as shown below. Which of the following would be ideal management for this condition?
A 20-year-old female has an erythematous rash over her face, including both cheeks and the bridge of her nose, which is exacerbated by sunlight exposure when she is outdoors. In addition to the rash, she has experienced muscle and joint pain for several months. Although radiographs of the joints do not reveal any abnormalities, she has normal joint mobility without deformity. Which laboratory test finding is most characteristic of systemic lupus erythematosus (SLE)?
A patient with typical cutaneous lesions, slightly elevated red or purple macules often covered by gray or yellow adherent scales. Forceful removal of the scale reveals numerous ‘carpet tack’ extensions. The lesion is:
Limited cutaneous systemic sclerosis have the following characteristic autoantibody positivity:
Lady presents with joint pain in both knees and low-grade fever, which occurs intermittently. On examination, she has a rash on sun-exposed areas. What is the clinical diagnosis?
A 35 years old male came with a progressive plaque over buttock for the last 2 years. The plaque is annular in shape with scarring in centre. Most likely diagnosis is:
A 26-year-old female patient presented with oral ulcers, sensitivity to light and rash over the malar area of the face sparing the nasolabial folds of both sides. Which of the following is most characteristic of this condition?
Lupus Erythematosus: Cutaneous Forms Indian Medical PG Practice Questions and MCQs
Question 1: Which one of these should not be used in severe widespread psoriasis?
- A. Methotrexate
- B. Oral retinoids
- C. Cyclosporin
- D. Oral glucocorticoids (Correct Answer)
Explanation: ***Oral glucocorticoids*** - While they may provide temporary relief, **oral glucocorticoids** can exacerbate psoriasis upon withdrawal, leading to a severe flare-up or **pustular psoriasis**. - Their long-term use is associated with numerous side effects, making them unsuitable for widespread, chronic conditions like severe psoriasis. *Methotrexate* - **Methotrexate** is a systemic agent commonly used for severe psoriasis due to its immune-modulating and anti-proliferative effects. - It is effective in reducing inflammation and slowing down epidermal cell turnover. *Oral retinoids* - **Oral retinoids** like acitretin are effective systemic treatments for severe widespread psoriasis, especially **pustular** and **erythrodermic** forms. - They work by normalizing keratinocyte proliferation and differentiation. *Cyclosporin* - **Cyclosporin** is a potent immunosuppressant widely used for severe psoriasis, particularly when rapid disease control is needed. - It works by inhibiting T-cell activation and is highly effective in clearing psoriatic lesions.
Question 2: Nail involvement is not a feature of –
- A. Psoriasis
- B. Lichen planus
- C. Dermatophytosis
- D. DLE (Correct Answer)
Explanation: ***DLE (Discoid Lupus Erythematosus)*** - **DLE** primarily affects the skin, causing **coin-shaped (discoid) lesions**, scarring, and changes in pigmentation. - While other forms of lupus (e.g., systemic lupus erythematosus) can have nail involvement, **DLE itself typically does not** manifest with primary nail changes. *Psoriasis* - **Psoriasis** frequently affects the nails, causing various changes such as **pitting, onycholysis, subungual hyperkeratosis, and oil spots**. - Nail involvement can occur in up to 50% of patients with chronic plaque psoriasis and 90% of those with psoriatic arthritis. *Lichen planus* - **Lichen planus** can affect the nails in about 10% of cases, leading to characteristic findings like **longitudinal ridging, pterygium formation, and nail thinning or shedding**. - **Twenty-nail dystrophy** is a severe form of nail lichen planus affecting all 20 nails. *Dermatophytosis* - **Dermatophytosis**, specifically **onychomycosis**, is a common fungal infection of the nails. - It causes thickening, discoloration (yellow-brown), and crumbling of the nails, often starting at the distal or lateral nail plate.
Question 3: A child with history of fever, photosensitivity, rash sparing nasolabial fold presents to OP. Identify the condition?
- A. SLE (Correct Answer)
- B. Polymorphous light eruption
- C. Discoid lupus
- D. Skin tuberculosis
Explanation: ***SLE*** - The combination of **fever**, **photosensitivity**, and a **rash sparing the nasolabial folds** (malar rash or butterfly rash) is highly characteristic of Systemic Lupus Erythematosus (SLE). - Childhood-onset SLE can present with similar mucocutaneous and systemic features as adult-onset disease. *Polymorphous light eruption* - This condition is primarily characterized by **photosensitive skin lesions** but typically does not involve systemic symptoms like fever. - While it presents with rash in sun-exposed areas, it generally lacks the distinct malar rash appearance and systemic involvement seen in SLE. *Discoid lupus* - Discoid lupus is a form of **cutaneous lupus** characterized by chronic, scaly, disfiguring plaques, often on the face and scalp. - It usually **lacks systemic symptoms** like fever and does not present as a widespread malar rash sparing nasal folds. *Skin tuberculosis* - Skin tuberculosis (lupus vulgaris or scrofuloderma) presents with **nodular, plaque-like lesions** or cold abscesses, often with ulceration and scarring. - It is not typically associated with **photosensitivity** or a malar rash, and fever, if present, is usually due to systemic Mycobacterium infection.
Question 4: A lesion was seen on the face of a 42 year old patient as shown below. Which of the following would be ideal management for this condition?
- A. Topical retinoids
- B. Oral steroids
- C. Start on MDT for leprosy
- D. Start on ATT (Correct Answer)
Explanation: ***Start on ATT*** - The presented image shows a **gummy lesion** on the face, which is characteristic of **tuberculosis cutis colliquativa**, a form of cutaneous tuberculosis. - **Anti-tubercular therapy (ATT)** is the primary and most effective treatment for all forms of tuberculosis, including cutaneous manifestations. *Topical retinoids* - Topical retinoids are primarily used for **acne vulgaris** and certain **disorders of keratinization** and are not indicated for infectious granulomatous conditions. - They work by **regulating cell growth and differentiation**, which is not the mechanism required to treat tuberculosis. *Oral steroids* - Oral steroids are **immunosuppressive** and generally contraindicated in active infections like tuberculosis, as they can worsen the disease. - While they might be used short-term in some inflammatory skin conditions, they would **not address the underlying tuberculous infection**. *Start on MDT for leprosy* - **Multi-drug therapy (MDT)** is the standard treatment for leprosy, which also presents with skin lesions and nerve involvement. - However, the image shows a **single, nodular, ulcerated lesion** more typical of cutaneous tuberculosis rather than the varied forms of leprosy (macular, papular, nodular lesions, or nerve thickening).
Question 5: A 20-year-old female has an erythematous rash over her face, including both cheeks and the bridge of her nose, which is exacerbated by sunlight exposure when she is outdoors. In addition to the rash, she has experienced muscle and joint pain for several months. Although radiographs of the joints do not reveal any abnormalities, she has normal joint mobility without deformity. Which laboratory test finding is most characteristic of systemic lupus erythematosus (SLE)?
- A. Elevated anti-streptolysin 0 (ASO) titer
- B. HLA-B27 genotype
- C. Markedly decreased serum level of immunoglobulin G (IgG)
- D. Antibodies to double-stranded DNA (Correct Answer)
Explanation: A 20-year-old female has an erythematous rash over her face, including both cheeks and the bridge of her nose, which is exacerbated by sunlight exposure [1]. In addition to the rash, she has experienced muscle and joint pain for several months. Although radiographs of the joints do not reveal any abnormalities, she has normal joint mobility without deformity. Which laboratory test finding is most characteristic of systemic lupus erythematosus (SLE)? ***Antibodies to double-stranded DNA*** - In **systemic lupus erythematosus (SLE)** [2], which fits the description, the presence of **anti-double-stranded DNA antibodies** is a hallmark finding. - This antibody is associated with **renal involvement** and correlates with disease activity, making it a critical laboratory finding [2]. *Elevated anti-streptolysin 0 (ASO) titer* - This test indicates recent **streptococcal infection**, not related to the symptoms or autoimmune features of SLE. - It is mainly used in the context of **rheumatic fever** and **post-streptococcal glomerulonephritis**. *Markedly decreased serum level of immunoglobulin G (IgG)* - Decreased IgG levels do not specifically indicate **SLE**, which often shows **increased overall immunoglobulin levels** due to chronic inflammation. - Hypogammaglobulinemia can occur in various conditions but is not characteristic of lupus. *HLA-B27 genotype* - This genotype is primarily associated with **spondyloarthropathies** (e.g., ankylosing spondylitis), not systemic lupus erythematosus [2]. - It is not relevant to the **cutaneous symptoms** or the autoimmune nature of the presented disease.
Question 6: A patient with typical cutaneous lesions, slightly elevated red or purple macules often covered by gray or yellow adherent scales. Forceful removal of the scale reveals numerous ‘carpet tack’ extensions. The lesion is:
- A. Scleroderma
- B. DLE (Correct Answer)
- C. SLE
- D. Lichen planus
Explanation: ***DLE*** - **Discoid lupus erythematosus (DLE)** lesions are characterized by **erythematous-to-violaceous plaques**, often with **follicular plugging** and a **firmly adherent scale**. - The "carpet tack" sign refers to the painful, prickly projections observed on the undersurface of a removed scale, indicating keratinous plugs within hair follicles, which is highly suggestive of DLE. *Scleroderma* - **Scleroderma** involves **fibrosis** of the skin, leading to hardening and thickening, often preceded by Raynaud's phenomenon. - It does not typically present with elevated red or purple macules with adherent scales or the "carpet tack" sign. *SLE* - **Systemic lupus erythematosus (SLE)** is a multi-system autoimmune disease that can have cutaneous manifestations, but these are often more diffuse (**malar rash**, photosensitivity) or non-scarring. - While DLE can occur in SLE patients, the description specifically points to the localized, scarring nature of DLE rather than the systemic features of SLE itself. *Lichen planus* - **Lichen planus** typically presents with **pruritic, polygonal, planar, purple papules and plaques** (the "6 Ps"). - While it can have scaling, it does not exhibit the "carpet tack" sign or the distinct follicular plugging seen in DLE.
Question 7: Limited cutaneous systemic sclerosis have the following characteristic autoantibody positivity:
- A. Anti-RNA polymerase III
- B. Anti Topoisomerase I
- C. Anti-U3-RNP (fibrillarin)
- D. Anticentromere (Correct Answer)
Explanation: ***Anticentromere*** - **Anticentromere antibodies (ACA)** are highly specific for **limited cutaneous systemic sclerosis (lcSSc)**, also known as **CREST syndrome** [1]. - Their presence correlates with a lower risk of **internal organ fibrosis** but a higher risk of **pulmonary hypertension** and **primary biliary cholangitis** [1]. *Anti-RNA polymerase III* - **Anti-RNA polymerase III antibodies** are typically associated with the **diffuse cutaneous systemic sclerosis (dcSSc)** subtype. - They are linked to an increased risk of **renal crisis** and **malignancy**. *Anti Topoisomerase I* - Also known as **anti-Scl-70 antibodies**, these are strongly associated with **diffuse cutaneous systemic sclerosis (dcSSc)**. - They indicate a higher risk of **pulmonary fibrosis** and **severe skin disease**. *Anti-U3-RNP (fibrillarin)* - **Anti-U3-RNP (fibrillarin) antibodies** are found in a subset of patients with **diffuse cutaneous systemic sclerosis (dcSSc)**. - They are associated with a higher likelihood of **myositis**, **pulmonary hypertension**, and **cardiac involvement**.
Question 8: Lady presents with joint pain in both knees and low-grade fever, which occurs intermittently. On examination, she has a rash on sun-exposed areas. What is the clinical diagnosis?
- A. Systemic lupus erythematosus (SLE) (Correct Answer)
- B. Rheumatoid arthritis (RA)
- C. Photodermatitis
- D. Porphyria cutanea tarda
Explanation: ***Systemic lupus erythematosus (SLE)*** - The combination of **polyarthralgia (joint pain)**, **low-grade fever**, and a **photosensitive rash** is highly characteristic of SLE. [1] - SLE is a **multisystem autoimmune disease** that can affect joints, skin, and cause constitutional symptoms like fever. [1] *Rheumatoid arthritis (RA)* - While RA causes **joint pain**, it typically presents with **symmetrical polyarthritis** primarily affecting small joints, and a photosensitive rash is not a common feature. [2] - **Fever** can be present in severe RA, but the triad of symptoms in this case points away from RA as the primary diagnosis. *Photodermatitis* - **Photodermatitis** is a skin inflammation caused by sunlight exposure, resulting in a rash. - This diagnosis does not account for the **joint pain** or **low-grade fever**, which are systemic manifestations. *Porphyria cutanea tarda* - This condition primarily affects the skin, causing **photosensitivity**, blistering lesions, and increased fragility, especially on sun-exposed areas. - It does **not typically present with joint pain or fever**, differentiating it from the presented symptoms.
Question 9: A 35 years old male came with a progressive plaque over buttock for the last 2 years. The plaque is annular in shape with scarring in centre. Most likely diagnosis is:
- A. Kala azar
- B. Lupus vulgaris (Correct Answer)
- C. Borderline leprosy
- D. Tinea corporis
Explanation: ***Lupus vulgaris*** - This is a chronic and progressive form of **cutaneous tuberculosis** characterized by plaques that often have a distinctive **annular shape** and can lead to **scarring, atrophy**, or even **ulceration** in the center. - The slow, progressive nature over two years, with a central scar, aligns well with the typical presentation of lupus vulgaris, especially in areas like the buttocks or face. *Kala azar* - Also known as **visceral leishmaniasis**, it primarily affects internal organs and is characterized by **fever, hepatosplenomegaly**, and **pancytopenia**. - While it can present with dermal lesions (post-kala azar dermal leishmaniasis), these are typically **nodular** or **macular**, not annular plaques with central scarring in the initial presentation. *Borderline leprosy* - Leprosy presents with diverse skin lesions, but these are typically characterized by **hypopigmented** or **erythematous patches/plaques** with **sensory loss**. - The lesions of borderline leprosy are generally not described as annular plaques with prominent central scarring in the absence of other typical neurological features. *Tinea corporis* - This is a superficial fungal infection of the skin, commonly presenting as an **annular (ring-shaped)** lesion with an **erythematous, scaly border** and central clearing. - However, tinea corporis rarely causes **significant scarring** and chronic, progressive plaques over two years are atypical for this condition, which is usually more acute and responsive to antifungal treatment.
Question 10: A 26-year-old female patient presented with oral ulcers, sensitivity to light and rash over the malar area of the face sparing the nasolabial folds of both sides. Which of the following is most characteristic of this condition?
- A. Butterfly rash sparing the nasolabial folds (Correct Answer)
- B. Heliotrope rash on upper eyelid, bilateral hilar lymphadenopathy
- C. Port-wine stain with CNS malformations
- D. Silvery scales or plaques
Explanation: ***Butterfly rash sparing the nasolabial folds*** - The patient's presentation with oral ulcers, sensitivity to light (photosensitivity), and a rash over the malar area **sparing the nasolabial folds** is highly characteristic of **Systemic Lupus Erythematosus (SLE)**, a condition where a butterfly rash is a hallmark. - This specific distribution of the malar rash is a key diagnostic feature differentiating it from other facial rashes. *Heliotrope rash on upper eyelid, bilateral hilar lymphadenopathy* - A **heliotrope rash** on the upper eyelids is characteristic of **dermatomyositis**, which also presents with muscle weakness, not typically oral ulcers or a malar rash. - **Bilateral hilar lymphadenopathy** is a classic finding in **sarcoidosis**, a granulomatous disease, not directly related to the patient's symptoms. *Port-wine stain, CNS malformations: seen in Sturge-Weber syndrome* - A **port-wine stain** (nevus flammeus) is a congenital capillary malformation, often on the face, and is a principal feature of **Sturge-Weber syndrome**, which involves CNS malformations and seizures. - This condition has no association with oral ulcers, photosensitivity, or the described malar rash. *Silvery scales or plaques: seen in psoriasis* - **Silvery scales or plaques** are the characteristic dermatological lesions of **psoriasis**, a chronic inflammatory skin condition. - Psoriasis typically presents with well-demarcated erythematous plaques and is not associated with oral ulcers, photosensitivity, or a lupus-specific malar rash.
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