Dermatitis and Eczema Practice Questions

Q: 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?

erythroderma (exfoliative dermatitis). ***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.

Q: A patient with atopic dermatitis shows the following findings. Which indicates POOR prognosis? 1. Onset before age 2 2. Flexural involvement 3. Palmar hyperlinearity 4. Filaggrin mutation

4 only. ***4 only*** - A **filaggrin mutation** is a strong genetic risk factor for **persistent and more severe atopic dermatitis**, often associated with an impaired skin barrier, making it an indicator of poor long-term prognosis. - Patients with this mutation tend to have a higher likelihood of developing **asthma and allergic rhinitis** (atopic march), further complicating the disease course. *1 only* - **Onset before age 2** is typical for atopic dermatitis and is generally associated with a *better prognosis*, as many children outgrow the condition by school age or adolescence. - Early onset itself does not indicate poor prognosis; rather, persistence into adulthood or severe early disease points to worse outcomes. *2 only* - **Flexural involvement** is a common and characteristic presentation of atopic dermatitis in older children and adults, but it does not inherently indicate a poor prognosis compared to other forms of disease presentation. - While it can be bothersome, it describes the *location* of the rash rather than its severity or genetic underpinnings for persistence. *3 and 4* - **Palmar hyperlinearity** is a common cutaneous manifestation in atopic dermatitis patients, reflecting chronic skin changes rather than a direct predictor of severe or persistent disease. - While **filaggrin mutation** (4) is a poor prognostic indicator, palmar hyperlinearity alone does not carry the same weight as a poor prognostic factor.

Q: A patient with atopic dermatitis shows poor response to topical steroids. Next best step is:

Topical tacrolimus. ***Topical tacrolimus*** - When **topical steroids** are insufficient or contraindicated for atopic dermatitis, **topical calcineurin inhibitors** like tacrolimus are the next recommended step due to their anti-inflammatory and immunomodulating effects. - Tacrolimus helps reduce inflammation and itching in the skin without the risk of **steroid-induced skin atrophy** or systemic side effects seen with prolonged steroid use. *Oral antihistamines* - While **oral antihistamines** can help alleviate itching, they do not address the underlying inflammation and immune dysregulation characteristic of atopic dermatitis. - They are often used as an adjunct for symptomatic relief of pruritus, but not as the primary treatment when topical steroids fail. *Systemic steroids* - **Systemic steroids** are typically reserved for severe, widespread, or acute flares of atopic dermatitis due to their significant potential for short-term and long-term side effects such as **immunosuppression**, **Cushing's syndrome**, **osteoporosis**, and **adrenal suppression**. - They are not considered a "next best step" after topical steroids for routine management due to these risks. *UV phototherapy* - **UV phototherapy** (e.g., narrowband UVB) is an effective treatment option for moderate to severe atopic dermatitis, especially when other topical treatments have failed. - However, it typically requires specialized equipment and multiple clinic visits, making it less accessible and generally considered after topical calcineurin inhibitors or in more extensive cases.

Q: Topical steroids are most effective in:

Eczematous dermatitis. ***Eczematous dermatitis*** - Topical steroids are the **first-line treatment** for eczematous dermatitis due to their potent **anti-inflammatory** and **immunosuppressive** properties. - They effectively reduce **itching**, **redness**, and **inflammation** associated with eczema. *Bullous lesions due to HSV* - **Topical steroids are contraindicated** in herpes simplex virus (HSV) infections as they can exacerbate viral replication and worsen the lesions, potentially leading to widespread infection. - **Antiviral medications** like acyclovir are the appropriate treatment for HSV infections. *Herpes Zoster* - Similar to HSV, herpes zoster is a **viral infection** (reactivation of varicella-zoster virus), and topical steroids can worsen the condition by suppressing the immune response. - **Antiviral drugs** (e.g., valacyclovir, famciclovir) are the primary treatment for herpes zoster. *Dermal atrophy* - Dermal atrophy is a **side effect** of prolonged or potent topical steroid use, not a condition treated by them. - It involves **thinning of the skin**, **telangiectasias**, and **striae**, indicating skin damage from steroid exposure.

Q: A patient presents with erythematous, well-demarcated plaques with greasy scales on the scalp and central face. What is the most likely diagnosis?

Seborrheic dermatitis. ***Seborrheic dermatitis*** - Characterized by **erythematous, well-demarcated plaques** with **greasy, yellowish scales**, commonly affecting the **scalp, face (especially nasolabial folds, eyebrows), and chest**. - The distribution and characteristic greasy scales are highly indicative of seborrheic dermatitis, often associated with *Malassezia* yeast overgrowth. *Psoriasis* - Typically presents with **silvery, thick scales** on erythematous plaques, often located on extensor surfaces (elbows, knees) and the scalp. - While it can affect the scalp, the scales are usually silvery and dry, not greasy. *Lichen planus* - Manifests as **pruritic, purple, polygonal, planar papules and plaques** (the 6 Ps), commonly on the flexor surfaces of wrists, ankles, and oral mucosa. - The appearance of lesions (purple, polygonal) and typical locations differ significantly from the patient's presentation. *Tinea capitis* - A **fungal infection** of the scalp, presenting with **scaling, alopecia, and often inflammation or pustules**. - While it can cause scaling on the scalp, greasy scales on the central face are not typical, and it primarily presents as an infection rather than an inflammatory condition with the characteristic greasy scales of seborrheic dermatitis.

Q: A 35-year-old woman presents with erythematous, scaly plaques in the nasolabial folds, eyebrows, and scalp. What is the most likely diagnosis?

Seborrheic dermatitis. ***Seborrheic dermatitis*** - This condition is characterized by **erythematous, scaly plaques** in areas rich in sebaceous glands, such as the **nasolabial folds, eyebrows, and scalp**, matching the patient's presentation. - It's a common, **chronic inflammatory dermatosis** influencing areas with high sebum production. *Psoriasis* - While psoriasis also causes **erythematous, scaly plaques**, they are typically **sharply demarcated** and often found on extensor surfaces (elbows, knees), and the lower back, which is not the primary presentation here. - Psoriasis scales are often described as **silvery-white**, distinct from the usually greasy yellow scales seen in seborrheic dermatitis. *Tinea corporis* - This is a **fungal infection** (ringworm) that presents as **annular (ring-shaped) lesions** with a raised, erythematous border and central clearing. - The distribution in the nasolabial folds, eyebrows, and scalp is **atypical for tinea corporis**, which usually affects the trunk or limbs. *Rosacea* - Rosacea primarily involves **facial erythema, telangiectasias (visible small blood vessels), papules**, and pustules, predominantly affecting the central face. - It typically **lacks the prominent scaling** seen in the described plaques and does not commonly affect the scalp in this manner.

Q: Which of the following is the most characteristic feature of atopic dermatitis?

Itching. ***Itching*** - **Pruritus (itching)** is the cardinal and most bothersome symptom of **atopic dermatitis**, often described as "the itch that rashes." - Itching can be severe, leading to **scratching**, which then causes the characteristic skin lesions like erythema and lichenification. *Erythematous plaques* - While **erythematous plaques** are commonly seen in atopic dermatitis, they are a secondary feature resulting from scratching and inflammation. - Other conditions like psoriasis can also present with prominent erythematous plaques, making it less specific to atopic dermatitis. *Scaling* - **Scaling** can occur in atopic dermatitis, particularly in chronic lesions due to lichenification. - However, scaling is a prominent feature in many other dermatological conditions such as **psoriasis** and **seborrheic dermatitis**, making it non-specific. *Pustules* - **Pustules** are typically indicative of a bacterial infection, such as impetigo, or certain inflammatory conditions like pustular psoriasis. - They are not a primary or characteristic feature of uncomplicated atopic dermatitis.

Q: A 5-year-old child presents with intense itching and erythematous papules on the extensor surfaces of the arms and legs. What is the most likely diagnosis?

Atopic dermatitis. ***Atopic dermatitis*** - **Atopic dermatitis** (eczema) is the most likely diagnosis given the **intense itching** (pruritus is the hallmark feature) and **erythematous papules**. - In children aged **2-5 years**, atopic dermatitis commonly affects **extensor surfaces** of the arms and legs, representing the transition from infantile to childhood patterns. - While flexural involvement becomes more typical in older children (>5 years), extensor distribution at age 5 is still very common and characteristic. - The intense pruritus described is pathognomonic for atopic dermatitis. *Psoriasis* - **Psoriasis** does present on extensor surfaces with well-demarcated **erythematous plaques with silvery scales**, particularly on elbows and knees. - However, **intense itching is NOT a primary feature** of psoriasis; it is typically mildly pruritic or non-pruritic. - The prominent pruritus in this case makes psoriasis unlikely. *Contact dermatitis* - **Contact dermatitis** results from exposure to an **allergen or irritant**, causing a localized rash. - The distribution typically conforms to the contact area and would be less likely to present symmetrically on multiple extensor surfaces without a clear exposure history. - The pattern described is more consistent with an endogenous dermatitis. *Scabies* - **Scabies** causes intense itching (worse at night) with characteristic **burrows, papules, and excoriations**. - Typical sites include **interdigital spaces, wrists, axillae, waistline, and genitalia**, not primarily extensor surfaces of arms and legs. - The distribution pattern does not fit scabies.

Q: A 27-year-old woman presents with a painful blistering rash on her right shoulder after a hiking trip. She reports recent exposure to poison ivy. What is the most likely diagnosis?

Contact dermatitis. ***Contact dermatitis*** - The patient's history of **recent exposure to poison ivy** and the development of a **painful blistering rash** are classic signs of allergic contact dermatitis. - Poison ivy contains **urushiol oil**, a potent allergen that triggers a **type IV hypersensitivity reaction** characterized by inflammation, pruritus, erythema, and vesicles or bullae. *Impetigo* - Impetigo is a **bacterial skin infection** characterized by **honey-crusted lesions** or pustules, often associated with *Staphylococcus aureus* or *Streptococcus pyogenes*. - It usually occurs in children and is not typically linked to environmental allergen exposure or a primary blistering rash in this manner. *Herpes zoster* - Herpes zoster (shingles) is caused by the **reactivation of the varicella-zoster virus** and presents as a **painful vesicular rash** in a **dermatomal distribution**. - While blistering can occur, the key differentiator here is the lack of a dermatomal pattern and the clear history of direct exposure to an irritant (poison ivy). *Bullous pemphigoid* - Bullous pemphigoid is an **autoimmune blistering disease** that typically affects **elderly individuals** with large, tense bullae on an erythematous or non-erythematous base. - It does not usually present acutely after environmental exposure like poison ivy, nor is it common in a 27-year-old.

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?

Accepted Answer

erythroderma (exfoliative dermatitis)

Answer

pemphigus vulgaris

Answer

dermatitis herpetiformis

Answer

rosacea

Question 2

A patient with atopic dermatitis shows the following findings. Which indicates POOR prognosis?
1. Onset before age 2
2. Flexural involvement
3. Palmar hyperlinearity
4. Filaggrin mutation

Accepted Answer

4 only

Answer

2 only

Answer

3 and 4

Answer

1 only

Question 3

A patient with atopic dermatitis shows poor response to topical steroids. Next best step is:

Accepted Answer

Topical tacrolimus

Answer

Oral antihistamines

Answer

Systemic steroids

Answer

UV phototherapy

Question 4

Topical steroids are most effective in:

Accepted Answer

Eczematous dermatitis

Answer

Bullous lesions due to HSV

Answer

Herpes Zoster

Answer

Dermal atrophy

Question 5

A 5-year-old boy presents with a red, itchy rash on his cheeks and the flexural surfaces of his limbs. What is the likely diagnosis?

Accepted Answer

Atopic dermatitis

Answer

Psoriasis

Answer

Contact dermatitis

Answer

Tinea corporis

Question 6

A patient presents with erythematous, well-demarcated plaques with greasy scales on the scalp and central face. What is the most likely diagnosis?

Accepted Answer

Seborrheic dermatitis

Answer

Psoriasis

Answer

Lichen planus

Answer

Tinea capitis

Question 7

A 35-year-old woman presents with erythematous, scaly plaques in the nasolabial folds, eyebrows, and scalp. What is the most likely diagnosis?

Accepted Answer

Seborrheic dermatitis

Answer

Psoriasis

Answer

Tinea corporis

Answer

Rosacea

Question 8

Which of the following is the most characteristic feature of atopic dermatitis?

Accepted Answer

Itching

Answer

Erythematous plaques

Answer

Scaling

Answer

Pustules

Question 9

A 5-year-old child presents with intense itching and erythematous papules on the extensor surfaces of the arms and legs. What is the most likely diagnosis?

Accepted Answer

Atopic dermatitis

Answer

Contact dermatitis

Answer

Scabies

Answer

Psoriasis

Question 10

A 27-year-old woman presents with a painful blistering rash on her right shoulder after a hiking trip. She reports recent exposure to poison ivy. What is the most likely diagnosis?

Accepted Answer

Contact dermatitis

Answer

Impetigo

Answer

Herpes zoster

Answer

Bullous pemphigoid

Dermatitis and Eczema — MCQs

Dermatitis and Eczema — MCQs

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