Geriatric Dermatology — MCQs
A 40 year old woman presents with a 2 year history of erythematous papulopustular lesions on convexities of the face. There is a background of erythema & telangiectasia. The most likely diagnosis is –
Actinic keratoses are associated with
A 60-year-old female presents with eczematous itching lesions. Biopsy revealed a subepidermal cleft with Direct Immunofluorescence showing Linear C3 & IgG deposition along the basement membrane zone. What is the likely diagnosis?
A patient presents with a skin rash that is exaggerated on sun exposure. What is the repair mechanism involved in this condition?
A 25-year-old male presents with a cluster of vesicles along the dermatome on his chest and back. He complains of burning pain in the same area. What is the most likely diagnosis?
A male patient presented with a 0.3 cm nodule on the left nasolabial fold. A pathological examination revealed a basaloid appearance with peripheral palisading. What is the most likely diagnosis?
A patient presents with the skin lesions shown in the image. While evaluating for possible blistering disorders, all of the following conditions could present with similar morphology EXCEPT:
Which of the following is the MOST characteristic feature of skin tags (acrochordons)?
Which sign is pathognomonic for neurofibromatosis?
What is the primary lesion in lichen planus?
Geriatric Dermatology Indian Medical PG Practice Questions and MCQs
Question 1: A 40 year old woman presents with a 2 year history of erythematous papulopustular lesions on convexities of the face. There is a background of erythema & telangiectasia. The most likely diagnosis is –
- A. Polymorphic light eruption
- B. Acne vulgaris
- C. Acne rosacea (Correct Answer)
- D. SLE
Explanation: ***Acne rosacea*** - This condition presents with **erythematous papulopustular lesions**, background **erythema**, and **telangiectasias** predominantly on the convexities of the face, which is a classic presentation for rosacea. - The absence of **comedones** (blackheads/whiteheads) helps differentiate it from acne vulgaris. *Polymorphic light eruption* - This is a recurring skin rash triggered by **sun exposure**, presenting as itchy papules, plaques, or vesicles, usually appearing a few hours after exposure. - Unlike rosacea, it does not typically feature permanent facial erythema or telangiectasias and is more directly linked to UV exposure episodes. *Acne vulgaris* - While it features papules and pustules, **acne vulgaris** is characterized by the presence of **comedones** (blackheads and whiteheads), which are not described in the patient's presentation. - It also does not typically involve the prominent background erythema and telangiectasias seen in rosacea. *SLE* - Systemic lupus erythematosus (SLE) can cause a **malar or 'butterfly' rash** across the nose and cheeks, but it is typically a fixed erythema, sometimes with scaling, and does not usually involve papulopustular lesions or telangiectasias as a primary feature. - SLE often has systemic symptoms (e.g., joint pain, fatigue) that are not mentioned, and skin lesions can be photosensitive but are not typically pustular.
Question 2: Actinic keratoses are associated with
- A. Keratoacanthoma
- B. Basal cell carcinoma (BCC)
- C. Squamous cell carcinoma (SCC) (Correct Answer)
- D. Malignant melanoma
Explanation: ***Squamous cell carcinoma (SCC)*** - **Actinic keratoses** are considered a **premalignant lesion** and are the most common precursor to invasive cutaneous SCC. - They represent **atypical keratinocytes** that have the potential to progress to SCC, particularly with continued sun exposure. *Basal cell carcinoma (BCC)* - While BCC is also a **sun-related skin cancer**, it typically develops de novo and is **not directly associated** with actinic keratoses as a precursor. - BCC usually arises from the **basal layer of the epidermis** or hair follicles, unlike SCC which originates from keratinocytes. *Malignant melanoma* - **Melanoma** originates from **melanocytes**, not keratinocytes, and is not associated with actinic keratoses. - Its precursors include **dysplastic nevi** or de novo development, distinct from the epidermal changes seen in actinic keratosis. *Keratoacanthoma* - **Keratoacanthoma** is a rapidly growing, dome-shaped tumor that can resemble SCC, and some consider it a **low-grade SCC variant**. - While it may share some features with SCC, actinic keratoses are more broadly recognized as precursors directly to typical invasive SCC rather than specifically to keratoacanthoma.
Question 3: A 60-year-old female presents with eczematous itching lesions. Biopsy revealed a subepidermal cleft with Direct Immunofluorescence showing Linear C3 & IgG deposition along the basement membrane zone. What is the likely diagnosis?
- A. Pemphigus foliaceus
- B. Pemphigus Vulgaris
- C. Dermatitis herpetiformis
- D. Bullous Pemphigoid (Correct Answer)
Explanation: ***Bullous Pemphigoid*** - The presence of **eczematous itching lesions**, a **subepidermal cleft**, and **linear C3 and IgG deposition along the basement membrane zone** on direct immunofluorescence (DIF) are classic diagnostic features of Bullous Pemphigoid. - This autoimmune blistering disease typically affects older individuals and is characterized by antibodies targeting components of the **hemidesmosomes**, specifically BP180 and BP230. *Pemphigus foliaceus* - This condition involves **intraepidermal blistering**, specifically within the granular layer, rather than a subepidermal cleft. - DIF in Pemphigus foliaceus shows **intercellular IgG deposition** in the epidermis, not linear deposition along the basement membrane zone. *Pemphigus Vulgaris* - Pemphigus Vulgaris is characterized by **intraepidermal blistering** above the basal cell layer (**suprabasal clefting**), leading to fragile bullae that rupture easily. - DIF typically reveals **intercellular IgG and C3 deposition** in a "chicken wire" pattern throughout the epidermis, which differs from the linear pattern seen in this case. *Dermatitis herpetiformis* - While Dermatitis herpetiformis is also an autoimmune blistering disease with itching lesions, its characteristic DIF finding is **granular IgA deposition** in the dermal papillae, not linear C3 and IgG at the basement membrane zone. - Histopathology in Dermatitis herpetiformis shows **subepidermal vesicles** with neutrophil infiltration in the dermal papillae, but the direct immunofluorescence pattern is distinct.
Question 4: A patient presents with a skin rash that is exaggerated on sun exposure. What is the repair mechanism involved in this condition?
- A. Nucleotide excision repair (Correct Answer)
- B. Base excision repair
- C. Mismatch repair
- D. Double stranded DNA break repair
Explanation: ***Nucleotide excision repair*** - This mechanism is responsible for repairing **bulky lesions** in DNA, such as **pyrimidine dimers** caused by **UV radiation** from sun exposure. - Patients with defects in nucleotide excision repair (e.g., **xeroderma pigmentosum**) are highly sensitive to sunlight and develop skin rashes, pigment changes, and skin cancers. *Base excision repair* - This pathway primarily corrects **small damaged bases** that do not cause significant distortion of the DNA helix, such as deaminated, oxidized, or alkylated bases. - It does not primarily address the bulky lesions induced by UV light that cause exaggerated sun sensitivity. *Mismatch repair* - This system corrects errors, like **mismatched base pairs**, that are incorporated during DNA replication. - It is not directly involved in repairing DNA damage caused by environmental factors like UV radiation. *Double stranded DNA break repair* - This mechanism repairs **double-strand breaks** in DNA, which are highly deleterious lesions caused by ionizing radiation or oxidative stress. - While critical for genome stability, it is not the primary repair pathway for UV-induced DNA lesions or the direct cause of sun sensitivity.
Question 5: A 25-year-old male presents with a cluster of vesicles along the dermatome on his chest and back. He complains of burning pain in the same area. What is the most likely diagnosis?
- A. Herpes zoster (Correct Answer)
- B. Contact dermatitis
- C. Herpes simplex
- D. Impetigo
Explanation: ***Herpes zoster*** - The classic presentation of **vesicular rash along a dermatome** with **burning pain** is highly characteristic of herpes zoster (shingles). - This condition is caused by the **reactivation of the varicella-zoster virus (VZV)**, which lies dormant in sensory ganglia. *Contact dermatitis* - This condition typically presents as an **itchy, erythematous rash** that appears after contact with an allergen or irritant. - While vesicles can be present, the rash is usually not strictly confined to a single dermatome and **burning pain is less common** than itching. *Herpes simplex* - Herpes simplex virus (HSV) typically causes **localized clusters of vesicles** on mucosal surfaces (e.g., oral, genital) or skin. - It does not usually present with a **dermatomal distribution** on the trunk as described in the vignette. *Impetigo* - Impetigo is a **bacterial skin infection** characterized by **honey-crusted lesions** or pustules. - While it can involve vesicles, it does not follow a **dermatomal pattern** and is caused by bacteria, not a viral reactivation.
Question 6: A male patient presented with a 0.3 cm nodule on the left nasolabial fold. A pathological examination revealed a basaloid appearance with peripheral palisading. What is the most likely diagnosis?
- A. Basal cell carcinoma (Correct Answer)
- B. Melanoma
- C. Squamous cell carcinoma
- D. Nevus
Explanation: ***Basal cell carcinoma*** - The description of a **basaloid appearance with peripheral palisading** on pathological examination is a classic histological feature of basal cell carcinoma (BCC). - BCC commonly presents as a nodule on sun-exposed areas like the **nasolabial fold** and is the most common skin cancer. *Melanoma* - Melanoma is characterized by the **malignant proliferation of melanocytes** and histologically shows atypical melanocytes with pagetoid spread or nest formation. - While it can appear as a nodule, the described **basaloid appearance with peripheral palisading** is not characteristic of melanoma. *Squamous cell carcinoma* - Squamous cell carcinoma typically shows **atypical keratinocytes** with keratinization, intercellular bridges, and sometimes desmoplasia. - It usually presents as an **erythematous, scaly patch** or nodule, often with ulceration, and the described histology does not match. *Nevus* - A nevus (mole) is a benign proliferation of melanocytes, showing **uniform nests of melanocytes** with maturation as they descend into the dermis. - The term **basaloid appearance** refers to cells resembling basal keratinocytes, which is not typical for a nevus.
Question 7: A patient presents with the skin lesions shown in the image. While evaluating for possible blistering disorders, all of the following conditions could present with similar morphology EXCEPT:
- A. Pemphigus vulgaris
- B. Pemphigus erythematosus
- C. Bullous pemphigoid (Correct Answer)
- D. Pemphigus vegetans
Explanation: ***Bullous pemphigoid*** - Presents with **tense bullae** on an erythematous base, typically in elderly patients, unlike the **umbilicated papules** seen in this image. - Involves **subepidermal blistering** with **linear IgG deposition** at the basement membrane zone, not the viral inclusions of Molluscum contagiosum. *Pemphigus vegetans* - A rare variant of pemphigus vulgaris characterized by **vegetating plaques and pustules** in intertriginous areas, not discrete umbilicated lesions. - Shows **intraepidermal acantholysis** with **suprabasal clefting**, histologically distinct from the viral cytopathic changes in Molluscum contagiosum. *Pemphigus vulgaris* - Presents with **flaccid bullae** and painful **mucosal erosions** due to **autoantibodies against desmoglein 1 and 3**. - The **Nikolsky sign** is positive, and lesions are erosive rather than the solid, pearl-like papules characteristic of Molluscum contagiosum. *Pemphigus erythematosus* - Features **erythematous, scaly, crusted lesions** primarily on the **face and upper trunk** with a butterfly distribution. - Combines features of **lupus erythematosus** and pemphigus foliaceus, showing superficial blistering unlike the viral papules in this case.
Question 8: Which of the following is the MOST characteristic feature of skin tags (acrochordons)?
- A. They commonly occur on the neck and axilla.
- B. They have malignant potential.
- C. They are associated with seborrhoeic keratosis.
- D. They are typically pedunculated. (Correct Answer)
Explanation: ***They are typically pedunculated.*** - **Skin tags (acrochordons)** are benign soft tissue tumors characterized by their **pedunculated morphology** - they are attached to the skin by a narrow stalk or pedicle. - This **pedunculated appearance** is the **most characteristic** and **defining feature** that distinguishes them from other benign skin lesions. - They are typically **soft, flesh-colored or hyperpigmented**, and range from 1-5 mm in size. *They commonly occur on the neck and axilla.* - While **skin tags** frequently occur in areas of friction such as the neck, axilla, eyelids, groin, and inframammary folds, this **location is not specific**. - Many other skin conditions also favor these sites, so location alone is not a characteristic diagnostic feature. *They are associated with seborrhoeic keratosis.* - There is **no established clinical association** between skin tags and seborrheic keratoses. - Both are common **benign skin growths** in adults but represent different pathological entities with different clinical appearances. *They have malignant potential.* - This is **incorrect**. Skin tags are **benign fibrous polyps** with **no malignant potential**. - They do not require removal unless symptomatic or for cosmetic reasons.
Question 9: Which sign is pathognomonic for neurofibromatosis?
- A. Cafe-au-lait macules
- B. Axillary freckling (Correct Answer)
- C. Shagreen patch
- D. None of the above
Explanation: **Explanation:** **Neurofibromatosis Type 1 (NF1)**, also known as von Recklinghausen disease, is an autosomal dominant multisystem disorder. The correct answer is **Axillary freckling (Crowe sign)** because it is considered highly specific (pathognomonic) for NF1. 1. **Axillary Freckling (Crowe Sign):** These are small, 1–3 mm hyperpigmented macules found in intertriginous areas (axilla or groin). Unlike solar lentigines, they appear in areas not exposed to the sun. Their presence is a hallmark diagnostic criterion for NF1. 2. **Cafe-au-lait macules (CALMs):** While these are often the first sign of NF1, they are **not pathognomonic**. CALMs can be seen in healthy individuals, McCune-Albright syndrome, Fanconi anemia, and Legius syndrome. In NF1, the presence of 6 or more macules (>5mm in prepubertal; >15mm in postpubertal) is required for diagnosis. 3. **Shagreen patch:** This is a connective tissue nevus (leathery plaque) typically found on the lower back. It is a characteristic feature of **Tuberous Sclerosis**, not Neurofibromatosis. **High-Yield Clinical Pearls for NEET-PG:** * **Lisch Nodules:** Iris hamartomas (seen on slit-lamp exam) are the most common ocular finding in NF1. * **Optic Glioma:** The most common CNS tumor associated with NF1. * **Sphenoid Wing Dysplasia:** A classic skeletal deformity in NF1. * **Genetics:** NF1 is caused by a mutation in the *NF1* gene on **Chromosome 17** (encodes Neurofibromin), while NF2 is linked to **Chromosome 22** (encodes Merlin).
Question 10: What is the primary lesion in lichen planus?
- A. Macule
- B. Papule (Correct Answer)
- C. Vesicle
- D. Bullae
Explanation: **Explanation:** The primary lesion in **Lichen Planus (LP)** is classically described by the **"6 Ps"**: **P**lanar (flat-topped), **P**urple (violaceous), **P**olygonal, **P**ruritic, **P**apules, and **P**laques. 1. **Why Papule is Correct:** A papule is a solid, raised lesion less than 1 cm in diameter. In LP, the characteristic lesion is a violaceous, flat-topped papule. These papules often coalesce to form larger **plaques**. The surface of these papules typically shows fine, white, lace-like patterns known as **Wickham striae**, which are a hallmark diagnostic feature. 2. **Why Other Options are Incorrect:** * **Macule:** This is a flat, non-palpable change in skin color. While post-inflammatory hyperpigmentation (macules) is common after LP heals, the active primary lesion is always raised. * **Vesicle/Bullae:** These are fluid-filled blisters (vesicles <0.5 cm; bullae >0.5 cm). While a rare variant called "Bullous Lichen Planus" exists, these are not the *primary* or most common presentation of the disease. **High-Yield Clinical Pearls for NEET-PG:** * **Histopathology:** Look for the "saw-tooth" appearance of rete pegs, basal cell degeneration (liquefaction necrosis), and a band-like lymphocytic infiltrate at the dermo-epidermal junction. * **Koebner Phenomenon:** LP shows a positive Koebner phenomenon (lesions appearing at sites of trauma). * **Associations:** Often associated with **Hepatitis C** infection. * **Civatte Bodies:** These are apoptotic keratinocytes found in the lower epidermis/upper dermis, also known as colloid or cytoid bodies.
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