Nummular Eczema — MCQs
A 10-year-old boy presented with painful boggy swelling of scalp, multiple sinuses, with purulent discharge, easily pluckable hair and lymph nodes enlarged in occipital region. Which will be most helpful for diagnostic evaluation?
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?
Treatment of choice for Nodulocystic Acne is:
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?
Spongiosis is a characteristic histological finding in which of the following conditions?
The UK refinement of Hannifin and Rajka criteria is used in the diagnosis of which condition?
What is the most common site of Atopic dermatitis?
Nummular Eczema Indian Medical PG Practice Questions and MCQs
Question 1: A 10-year-old boy presented with painful boggy swelling of scalp, multiple sinuses, with purulent discharge, easily pluckable hair and lymph nodes enlarged in occipital region. Which will be most helpful for diagnostic evaluation?
- A. Tests for allergic, bacterial, and viral causes
- B. KOH mount (Correct Answer)
- C. Microbiological culture
- D. Histopathological examination
Explanation: ***KOH mount*** - The clinical presentation of a **painful boggy scalp swelling**, **purulent discharge**, **easily pluckable hair**, and **occipital lymphadenopathy** is highly suggestive of **kerion**, a severe inflammatory form of **tinea capitis**. - A **KOH mount** is the most rapid and cost-effective diagnostic test for confirming a fungal infection by directly visualizing fungal elements (hyphae, spores) in hair shafts and scales. *Tests for allergic, bacterial, and viral causes* - While other infections might cause scalp swelling, the specific features of **easily pluckable hair** and a **boggy swelling with purulent discharge** point away from common bacterial or viral infections. - Allergic reactions typically present with itching and erythema, not necessarily with purulent discharge or hair loss. *Microbiological culture* - **Fungal culture** is indeed important for species identification and guiding treatment; however, it takes several days to yield results. - A **KOH mount** provides immediate confirmation of fungal infection, which is crucial for initiating timely treatment in a condition like kerion. *Histopathological examination* - A **biopsy with histopathological examination** can confirm fungal infection and assess the extent of inflammation. - However, it is an invasive procedure and not the first-line diagnostic test for suspected tinea capitis with kerion, especially given the ease and speed of a KOH mount.
Question 2: 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 3: 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 4: Treatment of choice for Nodulocystic Acne is:
- A. Isotretinoin (Correct Answer)
- B. Erythromycin
- C. PUVA
- D. Tetracycline
Explanation: ***Isotretinoin*** - **Isotretinoin** is a systemic retinoid that targets all four major pathogenic factors of acne: **sebum production**, **follicular hyperkeratinization**, **Propionibacterium acnes growth**, and **inflammation**. - It is considered the most effective medication for **severe, nodulocystic acne**, often leading to long-term remission. *Erythromycin* - **Erythromycin** is a topical or oral antibiotic primarily used for its antibacterial and anti-inflammatory properties against *P. acnes*. - While useful for milder inflammatory acne, it is generally **insufficient for severe nodulocystic acne** and carries risks of **antibiotic resistance**. *PUVA* - **PUVA (Psoralen plus ultraviolet A)** therapy is a form of photochemotherapy primarily used for severe **psoriasis**, **eczema**, and **cutaneous T-cell lymphoma**. - It is **not a treatment for acne** and has significant side effects, including increased risk of **skin cancer**. *Tetracycline* - **Tetracycline** is an oral antibiotic often used to treat moderate to severe inflammatory acne due to its anti-inflammatory effects and reduction of *P. acnes*. - While effective for some inflammatory acne, it is typically **less potent than isotretinoin** for severe, **nodulocystic acne** and may not provide a permanent cure.
Question 5: 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 6: 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 7: 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 8: Spongiosis is a characteristic histological finding in which of the following conditions?
- A. Acute eczema (Correct Answer)
- B. Lichen planus
- C. Psoriasis
- D. Pemphigus
Explanation: **Explanation:** **Spongiosis** is the hallmark histological feature of **Acute Eczema**. It refers to **intercellular edema** within the epidermis. As fluid accumulates between keratinocytes, the desmosomes (intercellular bridges) become stretched and prominent, giving the epidermis a "sponge-like" appearance. If the fluid accumulation is severe, it leads to the formation of intraepidermal vesicles. **Analysis of Options:** * **A. Acute Eczema (Correct):** Spongiosis is the defining pathological process in all forms of eczematous dermatitis (atopic, contact, seborrheic). In the acute stage, spongiosis is maximal, often leading to clinical weeping and crusting. * **B. Lichen Planus:** Characterized by **interface dermatitis**. Key findings include "saw-tooth" rete ridges, basal cell degeneration (liquefaction necrosis), and Civatte bodies (apoptotic keratinocytes). * **C. Psoriasis:** Characterized by **regular acanthosis** (test-tube-like elongation of rete ridges), parakeratosis, Munro’s microabscesses (neutrophils in the stratum corneum), and Kogoj’s pustules. * **D. Pemphigus:** Characterized by **Acantholysis** (loss of intercellular connections leading to detached, rounded keratinocytes), not spongiosis. **High-Yield Clinical Pearls for NEET-PG:** * **Spongiotic Dermatitis** is a synonym for Eczema. * **Acanthosis** (thickening of the stratum spinosum) is seen in *Chronic* Eczema (Lichen Simplex Chronicus). * **Acantholysis vs. Spongiosis:** Acantholysis is the *primary failure* of adhesions (Pemphigus); Spongiosis is the *mechanical stretching* of adhesions due to fluid (Eczema). * **Munro’s Microabscess** is a classic "spotter" for Psoriasis on pathology slides.
Question 9: 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 10: What is the most common site of Atopic dermatitis?
- A. Scalp
- B. Elbow
- C. Trunk
- D. Ante-cubital fossa (Correct Answer)
Explanation: **Explanation:** Atopic Dermatitis (AD) is a chronic, relapsing inflammatory skin condition characterized by intense pruritus and a morphology that evolves with age. The distribution of lesions is the most important clinical clue for diagnosis. **1. Why Ante-cubital fossa is correct:** In the **childhood and adolescent/adult phases**, the distribution of AD shifts from extensor surfaces to **flexural surfaces**. The **ante-cubital fossa** (front of the elbow) and the popliteal fossa (behind the knee) are the most characteristic and common sites involved due to sweat retention and friction in these folds, which triggers the "itch-scratch cycle." **2. Analysis of Incorrect Options:** * **Scalp:** While the scalp can be involved in the infantile phase (often confused with seborrheic dermatitis), it is not the most common site overall across the age spectrum. * **Elbow:** The **extensor** aspect of the elbow is typically involved in the **infantile phase** (birth to 2 years) as infants crawl and rub their limbs. However, the flexural involvement (ante-cubital) is more pathognomonic for the classic presentation of AD. * **Trunk:** The trunk can be involved in severe cases (erythroderma), but it is rarely the primary or most common site of localized AD. **3. Clinical Pearls for NEET-PG:** * **Infantile Phase:** Characterized by "Edematous, weepy" lesions on the **face (cheeks)** and extensor surfaces. The diaper area is usually spared. * **Adult Phase:** Characterized by **lichenification** (thickening of skin) primarily on flexures, hands, and eyelids. * **Hertoghe’s Sign:** Thinning of the lateral third of the eyebrows (due to rubbing). * **Dennie-Morgan Fold:** An extra fold of skin under the lower eyelid. * **Treatment of Choice:** Topical corticosteroids (for flares) and topical calcineurin inhibitors (Tacrolimus) for maintenance.
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