Lichen Simplex Chronicus — MCQs
A 70-year-old man comes to the emergency department because of a skin rash and severe itching. He appears ill; there is a generalized skin rash that is scaly, erythematous, and thickened. His palms, soles, and scalp are also involved. Which of the following is the most likely diagnosis?
A child presented with asymptomatic lesions on the forearm and on the shaft of the penis. The lesions on the forearm are shown below. What is the most likely diagnosis?
Scabies oral treatment of choice:
The following is an important feature of psoriasis:
Lines of Blaschko are related to?
A 22-year-old female presents with dry papules in the seborrheic areas, especially in the summer. Her father also has a history of similar lesions. What is the most probable diagnosis?
The UK refinement of Hannifin and Rajka criteria is used in the diagnosis of which condition?
Commonest site of Atopic dermatitis is:
Dennie Morgan folds are seen in which of the following conditions?
A boy presents with erythematous scaly papules with crusting over on the antecubital fossa. He was applying a petroleum-based emollient in the shower. What is the next step in management?
Lichen Simplex Chronicus Indian Medical PG Practice Questions and MCQs
Question 1: A 70-year-old man comes to the emergency department because of a skin rash and severe itching. He appears ill; there is a generalized skin rash that is scaly, erythematous, and thickened. His palms, soles, and scalp are also involved. Which of the following is the most likely diagnosis?
- A. erythroderma (exfoliative dermatitis) (Correct Answer)
- B. pemphigus vulgaris
- C. dermatitis herpetiformis
- D. rosacea
Explanation: ***erythroderma (exfoliative dermatitis)*** - Erythroderma is characterized by a **generalized erythematous (red), scaly, and thickened skin rash** covering more than 90% of the body surface, accompanied by **severe itching**. - This condition is often associated with a **systemic illness**, and the patient's description of "appears ill" further supports this diagnosis. *pemphigus vulgaris* - Pemphigus vulgaris typically presents with **flaccid blisters** and erosions, particularly affecting mucous membranes, which are not described here. - While it can be widespread, the primary lesion is a **blister** rather than diffuse erythema and scaling. *dermatitis herpetiformis* - Dermatitis herpetiformis is characterized by intensely **pruritic (itchy) papules and vesicles** typically found on the extensor surfaces (e.g., elbows, knees, buttocks). - It is strongly associated with **celiac disease** and does not present as a generalized scaly, erythematous thickening. *rosacea* - Rosacea primarily affects the **face**, causing **erythema**, flushing, papules, and pustules, often sparing the palms, soles, and scalp. - It is not characterized by generalized scaling, thickening, or severe itching over the entire body.
Question 2: A child presented with asymptomatic lesions on the forearm and on the shaft of the penis. The lesions on the forearm are shown below. What is the most likely diagnosis?
- A. Lichen planus
- B. Lichen nitidus (Correct Answer)
- C. Scabies
- D. Scrofuloderma
Explanation: ***Lichen nitidus*** - Presents as **multiple, asymptomatic, tiny (1-2 mm), shiny, dome-shaped papules** that are often skin-colored or slightly hypopigmented, as seen in the image and described. - Common sites include the **forearms, penis, abdomen, and flexural areas**, consistent with the case presentation. *Lichen planus* - Characterized by **purplish, polygonal, planar, pruritic papules and plaques**, often with **Wickham's striae**, which are not seen in the image. - While it can affect the penis, its lesions are typically more intensely colored and often symptomatic (**itchy**), unlike the asymptomatic lesions described. *Scabies* - Presents with intensely **pruritic papules, vesicles, and burrows**, especially in the web spaces of fingers, wrists, axillae, and genitalia, which are very symptomatic and not usually described as shiny papules. - The primary symptom is **severe itching**, which is absent in this patient. *Scrofuloderma* - A form of **cutaneous tuberculosis** presenting as cold abscesses that eventually rupture to form ulcers, sinuses, and scars. - The image shows distinct, small papules, not ulcerating or scarring lesions characteristic of scrofuloderma.
Question 3: Scabies oral treatment of choice:
- A. Benzyl Benzoate
- B. Ivermectin (Correct Answer)
- C. Lindane
- D. Permethrin
Explanation: ***Ivermectin*** - **Ivermectin** is the **oral treatment of choice** for scabies, especially in cases of crusted (Norwegian) scabies, immunocompromised patients, or when topical treatments fail. - It works by disrupting the **neurotransmitter system** of parasites, leading to paralysis and death of the scabies mites. *Benzyl Benzoate* - **Benzyl benzoate** is a **topical scabicide** and acaricide, used as a lotion or emulsion. - It is not available as an oral formulation and is typically reserved for cases where other topical agents are ineffective or contraindicated. *Lindane* - **Lindane** (gamma-hexachlorocyclohexane) is a topical scabicide but is **not recommended as a first-line treatment** due to potential **neurotoxicity** (seizures) especially in infants, children, and individuals with extensive skin excoriations. - It is used topically and has significant systemic absorption, making its use limited. *Permethrin* - **Permethrin** cream is considered the **first-line topical treatment** for scabies, showing high efficacy and a good safety profile. - It is not an oral medication; it is applied topically to the skin to kill mites.
Question 4: The following is an important feature of psoriasis:
- A. Erythematous macules
- B. Crusting
- C. Silvery Scaling (Correct Answer)
- D. Coarse bleeding
Explanation: ***Silvery Scaling*** - **Silvery scaling** is a hallmark clinical feature of **psoriasis**, resulting from the rapid turnover of skin cells. - These scales often appear on **erythematous plaques** and can be easily scraped off, sometimes revealing pinpoint bleeding underneath (**Auspitz sign**). *Erythematous macules* - While psoriasis does involve **erythema** (redness), the primary lesions are typically **plaques**, not macules (flat, discolored spots). - Macules are seen in other dermatological conditions such as drug eruptions or early viral exanthems, but not as the definitive feature of psoriasis. *Crusting* - **Crusting** is a feature of conditions involving exudation and drying of serum, blood, or pus, such as **impetigo** or **eczema** with secondary infection. - It is not a characteristic primary lesion of psoriasis, although secondary infection of psoriatic plaques could theoretically lead to crusting. *Coarse bleeding* - **Coarse bleeding** is not a primary feature of psoriasis; however, when psoriatic scales are removed, pinpoint bleeding known as the **Auspitz sign** can occur. - This is distinct from frank, coarse bleeding and is a diagnostic clue rather than a characteristic lesion in itself.
Question 5: Lines of Blaschko are related to?
- A. Keratinocytes (Correct Answer)
- B. Blood vessels
- C. Nerves
- D. Bones
Explanation: ***Keratinocytes*** - **Lines of Blaschko** represent the migratory pathways of embryonic cells, primarily **keratinocytes**, in the skin. - These lines are not visible under normal conditions but become apparent in various **genetic skin disorders** where abnormal cells follow these specific patterns. *Blood vessels* - While blood vessels are extensively present in the skin, they do not follow the specific **migratory patterns** described by the Lines of Blaschko. - Their arrangement is more related to **vascular networks** and anatomical supply rather than embryonic cell migration. *Nerves* - **Nerves** in the skin have specific distributions, often following dermatomal patterns, which are distinct from the **Lines of Blaschko**. - Nerve distribution is related to their segmental origin from the **spinal cord**, not the migratory paths of epidermal cells. *Bones* - **Bones** are part of the skeletal system and are not found in the skin, making them unrelated to the **Lines of Blaschko**. - These lines describe epidermal cell migration, which is a feature of the **integumentary system**.
Question 6: A 22-year-old female presents with dry papules in the seborrheic areas, especially in the summer. Her father also has a history of similar lesions. What is the most probable diagnosis?
- A. Pemphigus foliaceus
- B. Keratosis pilaris
- C. Darier's disease (Correct Answer)
- D. Seborrheic dermatitis
Explanation: ### Explanation **Correct Answer: C. Darier’s Disease** **Why it is correct:** Darier’s disease (Keratosis Follicularis) is an autosomal dominant genodermatosis caused by a mutation in the **ATP2A2 gene**, which encodes the **SERCA2 calcium pump**. This defect leads to a loss of cell-to-cell adhesion (acantholysis) and abnormal keratinization. * **Clinical Presentation:** It typically manifests as greasy, crusted, "dirty-looking" **malodorous papules** in a **seborrheic distribution** (chest, back, forehead, and scalp). * **Exacerbating Factors:** A classic hallmark is **photo-exacerbation**; lesions characteristically flare up during the **summer** due to heat, humidity, and UV exposure. The positive family history in this case further supports an inherited condition. **Why the other options are incorrect:** * **A. Pemphigus foliaceus:** While it involves acantholysis and affects seborrheic areas, it presents with superficial blisters and erosions rather than persistent keratotic papules, and it lacks a strong genetic/hereditary pattern. * **B. Keratosis pilaris:** Presents as "goose-flesh" papules on the extensor surfaces of arms and thighs. It is not typically found in seborrheic areas and does not flare specifically with summer heat. * **D. Seborrheic dermatitis:** Though it occurs in the same distribution, it presents as erythematous plaques with greasy yellow scales (dandruff-like) rather than discrete keratotic papules, and it usually improves or remains stable in summer rather than worsening. **High-Yield Clinical Pearls for NEET-PG:** * **Nail Findings:** Pathognomonic **"V-shaped" nicking** at the distal margin and longitudinal red/white bands. * **Mucosal Findings:** "Cobblestone" appearance of the oral mucosa. * **Histopathology:** Look for **"Corps ronds"** (in the stratum spinosum) and **"Grains"** (in the stratum corneum). * **Hand Findings:** Palmar pits and punctate keratosis.
Question 7: The UK refinement of Hannifin and Rajka criteria is used in the diagnosis of which condition?
- A. Atopic dermatitis (Correct Answer)
- B. Nummular Eczema
- C. Eczema Herpeticum
- D. Contact dermatitis
Explanation: **Explanation:** The **UK Refinement of the Hanifin and Rajka Criteria** is the most widely used clinical tool for diagnosing **Atopic Dermatitis (AD)** in epidemiological studies and clinical practice. While the original Hanifin and Rajka criteria (1980) are considered the gold standard, they were deemed too cumbersome for routine use. The UK Working Party simplified these into a more practical set of criteria. To meet the UK diagnostic criteria, a patient must have an **itchy skin condition (pruritus)** plus three or more of the following: 1. History of involvement of the skin creases (flexural dermatitis). 2. Personal history of asthma or hay fever (or history of atopic disease in a first-degree relative if the child is under 4). 3. History of a general dry skin in the last year. 4. Visible flexural eczema. 5. Onset under the age of 2 years. **Analysis of Incorrect Options:** * **B. Nummular Eczema:** Characterized by coin-shaped, well-demarcated plaques; diagnosis is purely clinical and does not use these specific criteria. * **C. Eczema Herpeticum:** A viral complication (HSV-1) of AD; diagnosis is clinical or via Tzanck smear/PCR. * **D. Contact Dermatitis:** Diagnosed via history and **Patch Testing**, not the UK refinement criteria. **High-Yield Clinical Pearls for NEET-PG:** * **Hanifin & Rajka Criteria:** Consists of 4 Major and 23 Minor criteria (3 of each required for diagnosis). * **Atopic March:** The typical progression from Atopic Dermatitis → Food Allergy → Asthma → Allergic Rhinitis. * **Dennier-Morgan Fold:** An extra fold of skin under the lower eyelid, a minor criterion for AD. * **Filaggrin (FLG) Mutation:** The most common genetic association with Atopic Dermatitis.
Question 8: Commonest site of Atopic dermatitis is:
- A. Scalp
- B. Elbow
- C. Ante-cubital fossa (Correct Answer)
- D. Trunk
Explanation: **Explanation:** Atopic Dermatitis (AD) is a chronic, relapsing inflammatory skin condition characterized by intense pruritus and a characteristic age-dependent distribution. The correct answer is **Ante-cubital fossa** because it represents the classic **flexural involvement** seen in the childhood and adult phases of the disease. **Why Ante-cubital fossa is correct:** In patients beyond infancy (children, adolescents, and adults), the morphology of AD shifts from exudative lesions to lichenified plaques. These lesions characteristically involve the flexural surfaces, specifically the **ante-cubital** and **popliteal fossae**, the neck, and the wrists. This is a hallmark diagnostic feature in the Hanifin and Rajka criteria. **Why other options are incorrect:** * **Scalp:** While the scalp can be involved in infantile AD (often confused with seborrheic dermatitis), it is not the "commonest" or most characteristic site across the broader age spectrum. * **Elbow:** The **extensor** aspect of the elbow is typically involved in **psoriasis**. In AD, extensor involvement is usually limited to the infantile phase; as the child grows, the disease "moves" to the flexures. * **Trunk:** While the trunk can be affected in severe or generalized cases (erythroderma), it is rarely the primary or most common site of localization compared to the limbs. **High-Yield Clinical Pearls for NEET-PG:** * **Infantile Phase (<2 years):** Characteristically involves the **face (cheeks)** and extensor surfaces. The diaper area is usually spared. * **Childhood/Adult Phase:** Characteristically involves **flexures** (ante-cubital/popliteal). * **Dennie-Morgan fold:** An extra fold of skin under the lower eyelid, a classic sign of atopy. * **Filaggrin (FLG) mutation:** The most common genetic defect associated with skin barrier dysfunction in AD. * **Serum IgE:** Usually elevated in the "extrinsic" type of Atopic Dermatitis.
Question 9: Dennie Morgan folds are seen in which of the following conditions?
- A. Lichen planus
- B. Atopic dermatitis (Correct Answer)
- C. Keratosis pilaris
- D. Nummular eczema
Explanation: **Explanation:** **Dennie-Morgan folds** (also known as Dennie-Morgan lines or infraorbital folds) are a characteristic clinical sign of **Atopic Dermatitis (AD)**. They are defined as single or double symmetrical folds or lines situated below the lower eyelid margin. These folds result from chronic inflammation and edema of the lower eyelid, often exacerbated by frequent rubbing of the eyes due to the intense pruritus associated with the "itch-scratch cycle" in atopic individuals. **Analysis of Options:** * **Atopic Dermatitis (Correct):** It is a chronic, relapsing inflammatory skin disease. Dennie-Morgan folds are considered a minor diagnostic criterion (Hanifin and Rajka criteria) for AD, along with other signs like xerosis, ichthyosis, and keratosis pilaris. * **Lichen Planus:** Characterized by the "6 Ps" (Planar, Purple, Polygonal, Pruritic, Papules, and Plaques) and Wickham striae. It does not typically involve infraorbital fold formation. * **Keratosis Pilaris:** While frequently associated with atopy (comorbidity), it refers specifically to keratinous plugging of hair follicles, usually on the extensor surfaces of the arms and thighs ("chicken skin"). * **Nummular Eczema:** Presents as coin-shaped, well-demarcated eczematous plaques. It lacks the systemic stigmata and specific facial signs like Dennie-Morgan folds. **Clinical Pearls for NEET-PG:** * **Hertoghe’s Sign:** Thinning or loss of the outer third of the eyebrows; also seen in Atopic Dermatitis (and Hypothyroidism). * **Pityriasis Alba:** Hypopigmented, slightly scaly patches on the face; a common minor feature of AD in children. * **Hyperlinear palms:** Increased skin markings on the palms, often seen in AD patients with associated Ichthyosis vulgaris (FLG gene mutation). * **Dermatographism:** Patients with AD often show **white dermatographism** (vasoconstriction) instead of the typical red response.
Question 10: A boy presents with erythematous scaly papules with crusting over on the antecubital fossa. He was applying a petroleum-based emollient in the shower. What is the next step in management?
- A. Decrease the frequency of petroleum-based emollient application.
- B. Decrease the frequency of showering.
- C. Apply mupirocin 1% topically.
- D. Apply triamcinolone cream topically. (Correct Answer)
Explanation: ### Explanation **Diagnosis: Atopic Dermatitis (Exacerbation)** The clinical presentation of erythematous scaly papules with crusting in the **antecubital fossa** (a classic flexural site) in a young patient is hallmark for **Atopic Dermatitis (AD)**. While the use of petroleum-based emollients is standard for maintenance, the presence of active inflammation (erythema, scaling) indicates an acute flare-up that requires pharmacological intervention beyond simple hydration. **1. Why Option D is Correct:** **Topical Corticosteroids (TCS)**, such as **Triamcinolone cream**, are the first-line treatment for acute flares of Atopic Dermatitis. They work by reducing inflammation, suppressing the immune response, and relieving pruritus. In the "step-up" management of AD, emollients are used for maintenance, but topical steroids are mandatory once clinical lesions (papules/scaling) appear. **2. Why Other Options are Incorrect:** * **Option A:** Decreasing emollient frequency is counterproductive. Emollients are the cornerstone of AD therapy to repair the skin barrier (filaggrin deficiency); however, they alone cannot suppress an active inflammatory flare. * **Option B:** While excessive hot water can irritate the skin, "decreasing the frequency of showering" is not the primary management for active lesions. Short, lukewarm showers followed immediately by emollients ("soak and seal") are actually recommended. * **Option C:** Mupirocin is an antibiotic. While "crusting" can suggest secondary *Staphylococcus aureus* infection (impetiginization), the primary pathology here is the underlying eczematous flare. Unless there is frank purulence or systemic symptoms, topical steroids (often combined with antibiotics if needed) are the priority. **Clinical Pearls for NEET-PG:** * **Distribution by Age:** Infants (Extensors/Face); Children/Adults (Flexures like antecubital/popliteal fossae). * **Major Criteria (Hanifin & Rajka):** Pruritus, Typical morphology/distribution, Chronic/relapsing course, Personal/family history of atopy. * **Steroid Sparing Agents:** Topical Calcineurin Inhibitors (Tacrolimus/Pimecrolimus) are used for maintenance or sensitive areas (face/folds) to avoid steroid-induced skin atrophy. * **The "Atopic March":** AD usually precedes allergic rhinitis and asthma.
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