Nummular Eczema — MCQs
A 7 year old boy with boggy swelling of the scalp with multiple discharging sinuses with cervical lymphadenopathy with easily pluckable hair. What would be done for diagnosis?
A 54-year-old man presents with well-demarcated, erythematous plaques covered with silvery-white scales on the extensor surfaces of his elbows and knees. What is the most likely diagnosis?
A child presents with a rash in the neck folds as shown in the image. The area appears erythematous with satellite lesions and maceration. What is the most likely diagnosis?
Most common precipitant of contact dermatitis is?
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?
A 22-year-old woman develops an acute contact dermatitis to a household-cleaning agent. Which of the following treatments is most appropriate during the bullous, oozing stage?
Nummular Eczema Indian Medical PG Practice Questions and MCQs
Question 1: A 7 year old boy with boggy swelling of the scalp with multiple discharging sinuses with cervical lymphadenopathy with easily pluckable hair. What would be done for diagnosis?
- A. Pus for culture
- B. Biopsy
- C. KOH mount (Correct Answer)
- D. None of the options
Explanation: ***KOH mount*** - A **KOH mount** (potassium hydroxide wet mount) is the most appropriate **initial rapid diagnostic test** for suspected **tinea capitis** with **kerion formation**, allowing immediate visualization of fungal elements (hyphae and spores). - The clinical presentation of boggy scalp swelling, discharging sinuses, cervical lymphadenopathy, and easily pluckable hair is classic for **kerion**, a severe inflammatory form of tinea capitis caused by dermatophytes (commonly *Trichophyton* or *Microsporum* species). - KOH mount is **quick, inexpensive, and readily available**, making it ideal for immediate diagnosis in clinical practice, though fungal culture may be performed subsequently for species identification. *Pus for culture (bacterial)* - While bacterial culture might be performed to rule out **secondary bacterial infection**, it does not diagnose the underlying **fungal etiology** of kerion. - The primary pathogen in kerion is a dermatophyte fungus, not bacteria, though secondary bacterial infection can occur. *Biopsy* - A **biopsy** is usually reserved for cases that are atypical, treatment-resistant, or when there is diagnostic uncertainty with other conditions (e.g., dissecting cellulitis, bacterial abscess). - It is an **invasive procedure** and not the first-line diagnostic approach for a clinically obvious case of kerion. *None of the options* - Given the classic clinical presentation of kerion, a definitive diagnostic method (KOH mount) is required to confirm the fungal infection and guide appropriate systemic antifungal treatment. - Therefore, choosing "None of the options" would be incorrect.
Question 2: A 54-year-old man presents with well-demarcated, erythematous plaques covered with silvery-white scales on the extensor surfaces of his elbows and knees. What is the most likely diagnosis?
- A. Pityriasis rosea
- B. Psoriasis (Correct Answer)
- C. Eczema
- D. Lichen planus
Explanation: ***Psoriasis*** - **Psoriasis** classically presents with **scaly plaques** that often appear on the **extensor surfaces** such as the elbows and knees. - The scales are typically silvery-white and can be itchy or painful, consistent with the characteristic presentation of chronic plaque psoriasis. *Pityriasis rosea* - This condition presents with a **herald patch** followed by smaller, oval, pinkish-red patches with fine scales, often distributed in a **Christmas tree pattern** on the trunk. - It primarily affects the trunk and proximal extremities, rarely involving the extensor surfaces in the same way as psoriasis. *Eczema* - **Eczema**, particularly atopic dermatitis, typically presents with **itchy, erythematous patches** that are often ill-defined and can be dry or weeping. - While it can occur on extensor surfaces, it is more commonly found on flexural surfaces in adults and lacks the distinct, thick silvery scales characteristic of psoriasis. *Lichen planus* - **Lichen planus** is characterized by **pruritic, purple, polygonal, planar papules and plaques** (**the 6 P's**). - It usually affects the flexural surfaces, wrists, ankles, and oral mucosa, rather than predominantly presenting as scaly plaques on extensor surfaces.
Question 3: A child presents with a rash in the neck folds as shown in the image. The area appears erythematous with satellite lesions and maceration. What is the most likely diagnosis?
- A. Intertrigo (Correct Answer)
- B. Heat rash
- C. Eczema
- D. Impetigo
Explanation: ***Intertrigo*** - The image shows a reddened, inflamed rash in skin folds (neck creases), which is characteristic of **intertrigo**. This condition results from skin-on-skin friction, moisture, and warmth. - The rash appears to have satellite lesions and a somewhat macerated appearance, which would be consistent with secondary fungal (e.g., Candida) or bacterial infection, common complications of intertrigo. *Heat rash* - **Heat rash (miliaria)** typically presents as small, itchy red bumps or clear blisters, often found in areas prone to sweating. - While it can occur in skin folds, the diffuse, raw-looking erythema and presence of potential satellite lesions shown in the image are less typical for simple heat rash. *Eczema* - **Eczema (atopic dermatitis)** is characterized by dry, itchy, inflamed skin, often with scaling, crusting, or lichenification during chronic stages. - While eczema can affect skin folds, the appearance in the image (intense redness, maceration, potential satellite lesions) is more suggestive of an irritant or infectious process like intertrigo rather than typical eczema. *Impetigo* - **Impetigo** is a bacterial skin infection characterized by honey-colored crusts, vesicles, or bullae, typically appearing anywhere on the body, especially around the nose and mouth. - The rash in the image lacks the characteristic honey-colored crusts or vesiculobullous lesions associated with impetigo.
Question 4: Most common precipitant of contact dermatitis is?
- A. Gold
- B. Silver
- C. Iron
- D. Nickel (Correct Answer)
Explanation: ***Nickel*** - **Nickel** is the most frequent cause of **allergic contact dermatitis**, commonly found in jewelry, belt buckles, and zippers. - Exposure leads to a **Type IV hypersensitivity reaction**, characterized by erythema, itching, and vesiculation. *Gold* - While gold can cause contact dermatitis, it is **far less common** than nickel allergy. - Reactions to gold are often seen with prolonged skin contact, such as with jewelry. *Silver* - **Silver** is a **rare cause** of allergic contact dermatitis. - Allergic reactions to silver are typically observed in individuals with extensive exposure, such as jewelers. *Iron* - **Iron** is **not a common precipitant** of contact dermatitis. - Allergic reactions to iron are exceedingly rare, as iron is an essential element found naturally in the body.
Question 5: 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 6: 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 7: 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 8: 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 9: 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.
Question 10: A 22-year-old woman develops an acute contact dermatitis to a household-cleaning agent. Which of the following treatments is most appropriate during the bullous, oozing stage?
- A. Wet dressings (Correct Answer)
- B. Systemic corticosteroids
- C. Topical anesthetics
- D. Systemic antibiotics
Explanation: **Explanation:** The management of dermatitis is guided by the **morphology and stage of the lesion**. This patient is in the **acute stage** of contact dermatitis, characterized by vesicles, bullae, and oozing (weeping). **1. Why Wet Dressings are Correct:** In the acute, exudative phase, the primary goal is to "dry" the lesion and reduce inflammation. **Wet dressings** (using saline or Burow’s solution) work via evaporation, which causes vasoconstriction, reduces pruritus, and debrides crusts. The dermatological rule of thumb is: *"If it’s wet, dry it; if it’s dry, wet it."* Topical ointments are contraindicated here as they trap moisture and can cause maceration. **2. Why Other Options are Incorrect:** * **Systemic Corticosteroids:** While effective for severe or generalized cases, they are not the first-line treatment for localized acute contact dermatitis. Topical therapy is preferred initially unless the involvement is >20% of the body surface area. * **Topical Anesthetics:** These are generally avoided because they are potent sensitizers and can trigger a secondary **allergic contact dermatitis**, worsening the condition. * **Systemic Antibiotics:** These are only indicated if there is evidence of a secondary bacterial infection (e.g., honey-colored crusting, pustules, or lymphadenopathy). Oozing alone is a sign of primary inflammation, not necessarily infection. **Clinical Pearls for NEET-PG:** * **Acute Stage:** Oozing/Vesicles → Treatment: Wet compresses/dressings. * **Subacute Stage:** Redness/Scaling → Treatment: Creams. * **Chronic Stage:** Lichenification/Dryness → Treatment: Ointments (occlusive). * **Patch Test:** The gold standard investigation for Allergic Contact Dermatitis (Read at 48 and 72/96 hours). * **Most common cause of ACD worldwide:** Nickel (Type IV Hypersensitivity).
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