Treatment Strategies for Eczematous Disorders — MCQs
Which of the following are treatment options for acne vulgaris?
Which of the following is a contraindication to topical steroids?
Treatment of choice for Pustular psoriasis is:
Statement 1 - A 59-year-old patient presents with flaccid bullae. Histopathology shows a suprabasal acantholytic split. Statement 2 - The row of tombstones appearance is diagnostic of Pemphigus vulgaris.
Which drug is used in treatment of vertigo?
Which of the following statements about the DOTS treatment for tuberculosis is correct?
Under the DOTS strategy of Revised National Tuberculosis Programme, the recommended line of management in Category I patients, if the sputum is positive after 2 months of Intensive Phase treatment with 4 drugs, is to
A patient presents with the skin lesions shown in the image. All of the following are routinely indicated for the treatment of this condition EXCEPT:
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?
Treatment Strategies for Eczematous Disorders Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following are treatment options for acne vulgaris?
- A. Isotretinoin
- B. All of the options (Correct Answer)
- C. Topical erythromycin
- D. Oral Minocycline
Explanation: ***All of the options*** - All listed options (Isotretinoin, Topical erythromycin, and Oral Minocycline) are well-established and commonly used **treatment options for acne vulgaris**, depending on the severity and type of acne. - The choice of treatment often follows a stepped approach, starting with topical agents for mild to moderate acne and progressing to oral medications like antibiotics or isotretinoin for more severe or resistant cases. *Isotretinoin* - **Isotretinoin** is a powerful oral retinoid primarily used for **severe, recalcitrant nodular acne** that has not responded to other treatments. - It works by reducing sebum production, follicular hyperkeratinization, inflammation, and the growth of *P. acnes*. *Topical erythromycin* - **Topical erythromycin** is an **antibiotic** used to treat mild to moderate inflammatory acne by reducing the growth of *Cutibacterium acnes* (formerly *Propionibacterium acnes*) and decreasing inflammation. - It is often combined with other topical agents like benzoyl peroxide to minimize the development of **antibiotic resistance**. *Oral Minocycline* - **Oral minocycline** is a **tetracycline antibiotic** used for moderate to severe inflammatory acne. - It reduces bacterial populations on the skin and exhibits **anti-inflammatory properties**, making it effective for widespread or deeper lesions.
Question 2: Which of the following is a contraindication to topical steroids?
- A. Dendritic ulcer (Correct Answer)
- B. Herpetic stromal keratitis without epithelial defect
- C. Elevated intraocular pressure
- D. Non-infectious anterior uveitis
Explanation: ***Dendritic ulcer*** - A **dendritic ulcer** is characteristic of **herpes simplex keratitis**, which is an active viral infection of the cornea. - **Topical steroids** are contraindicated because they can suppress the immune response, leading to viral replication, corneal melt, and potentially severe vision loss or perforation. *Herpetic stromal keratitis without epithelial defect* - In cases of **stromal keratitis**, where the infection is deeper and an intact epithelium is present, topical steroids may be used cautiously in conjunction with antiviral agents to reduce inflammation and scarring. - The primary concern with steroids in herpes simplex keratitis is activating viral replication in the presence of an **epithelial defect**, which is not present here. *Elevated intraocular pressure* - **Elevated intraocular pressure** is a known side effect of topical steroid use, especially with prolonged administration, but it is not an absolute contraindication in itself. - It necessitates careful monitoring and may require concurrent glaucoma treatment, but the primary condition needing steroids may still warrant their use. *Non-infectious anterior uveitis* - **Topical corticosteroids** are the **mainstay of treatment** for non-infectious anterior uveitis to reduce inflammation and prevent complications such as synechiae and vision loss. - The benefits of controlling inflammation in uveitis generally outweigh the risks associated with judicious steroid use.
Question 3: Treatment of choice for Pustular psoriasis is:
- A. Methotrexate (Correct Answer)
- B. Psoralen - UV therapy
- C. Systemic steroid
- D. Estrogen
Explanation: ***Methotrexate*** - **Methotrexate** is a systemic immunosuppressant often considered the first-line treatment for severe forms of **pustular psoriasis** due to its efficacy in reducing inflammation and hyperproliferation of skin cells. - It works by inhibiting **dihydrofolate reductase**, thereby interfering with DNA synthesis and cell division, which is crucial in rapidly dividing cells like those found in psoriasis. *Psoralen - UV therapy* - **Psoralen and ultraviolet A (PUVA)** therapy can be used for chronic plaque psoriasis, but it is generally **contraindicated or used with extreme caution** in pustular psoriasis due to the risk of exacerbating the disease or causing irritation. - **UV light therapy** can sometimes trigger or worsen pustular flares, especially in acute generalized pustular psoriasis. *Systemic steroid* - While systemic steroids can provide temporary relief by addressing inflammation, their use in pustular psoriasis is generally **not recommended for long-term management** due to the high risk of severe rebound flares upon withdrawal. - Withdrawal of **systemic corticosteroids** can precipitate or worsen generalized pustular psoriasis, making them a less desirable long-term treatment option. *Estrogen* - **Estrogen** has no direct role in the treatment of psoriasis. Psoriasis is an inflammatory skin condition, and its pathophysiology is not directly influenced by estrogen levels. - Hormonal therapies are not indicated for the management of psoriasis, including its pustular forms.
Question 4: Statement 1 - A 59-year-old patient presents with flaccid bullae. Histopathology shows a suprabasal acantholytic split. Statement 2 - The row of tombstones appearance is diagnostic of Pemphigus vulgaris.
- A. Statements 1 & 2 are correct, 2 is not explaining 1 (Correct Answer)
- B. Statements 1 and 2 are correct and 2 is the correct explanation for 1
- C. Statements 1 and 2 are incorrect
- D. Statement 1 is incorrect
Explanation: ***Correct: Statements 1 & 2 are correct, 2 is not explaining 1*** **Analysis of Statement 1:** - A 59-year-old patient with **flaccid bullae** and **suprabasal acantholytic split** on histopathology is the classic presentation of **Pemphigus vulgaris** - The flaccid (easily ruptured) nature of bullae distinguishes it from tense bullae seen in bullous pemphigoid - The suprabasal location of the split (just above the basal layer) with acantholysis (loss of cell-to-cell adhesion) is pathognomonic - **Statement 1 is CORRECT** ✓ **Analysis of Statement 2:** - The **"row of tombstones" or "tombstone appearance"** is indeed a diagnostic histopathological feature of Pemphigus vulgaris - This appearance results from basal keratinocytes remaining attached to the basement membrane while suprabasal cells separate due to acantholysis - The intact basal cells standing upright resemble a row of tombstones - **Statement 2 is CORRECT** ✓ **Does Statement 2 explain Statement 1?** - Statement 2 describes a **histopathological appearance** (tombstone pattern) that is a **consequence** of the suprabasal split - However, it does NOT explain the **underlying cause** of the flaccid bullae or the suprabasal split - The true explanation involves **IgG autoantibodies against desmoglein 3 (and desmoglein 1)**, which attack intercellular adhesion structures (desmosomes), causing **acantholysis** - Therefore, **Statement 2 does NOT explain Statement 1** ✗ *Incorrect: Statement 2 is the correct explanation for Statement 1* - While both statements describe features of Pemphigus vulgaris, the tombstone appearance is a descriptive finding, not an explanatory mechanism *Incorrect: Statements 1 and 2 are incorrect* - Both statements are medically accurate descriptions of Pemphigus vulgaris features *Incorrect: Statement 1 is incorrect* - Statement 1 correctly describes the cardinal clinical and histopathological features of Pemphigus vulgaris
Question 5: Which drug is used in treatment of vertigo?
- A. Metoclopramide
- B. Cisapride
- C. Cinnarizine (Correct Answer)
- D. None of the options
Explanation: ***Cinnarizine***- **Cinnarizine** is an antihistamine and calcium channel blocker known for its anti-vertigo and anti-emetic properties [2].- It works by suppressing the **vestibular system** and reducing the excitability of sensory hair cells in the inner ear [1].*Metoclopramide*- **Metoclopramide** is a **dopamine receptor antagonist** primarily used as an anti-emetic and for treating gastroparesis.- While it can alleviate nausea and vomiting associated with vertigo, it does not directly treat the underlying sensation of **vertigo** itself by acting on the vestibular system.*Cisapride*- **Cisapride** is a **serotonin 5-HT4 receptor agonist** that acts as a gastroprokinetic agent, enhancing gastrointestinal motility [3].- It is not used for vertigo and has been associated with serious **cardiac arrhythmias**, leading to restricted use in many countries [3].*None of the options*- This option is incorrect because **Cinnarizine** is a well-established medication used in the treatment of vertigo [2].- Other options are not primarily indicated for vertigo treatment.
Question 6: Which of the following statements about the DOTS treatment for tuberculosis is correct?
- A. Case finding 80%, cure rate 85%
- B. Case finding 80%, cure rate 80%
- C. Case finding 70%, cure rate 75%
- D. Case finding 70%, cure rate 85% (Correct Answer)
Explanation: ***Case finding 70%, cure rate 85%*** - The **DOTS strategy** set a global target of detecting at least **70% of new sputum smear-positive TB cases** and curing at least **85% of these cases**. - Achieving these targets was considered crucial for controlling the spread of **tuberculosis** at a population level. *Case finding 80%, cure rate 85%* - While a **cure rate of 85%** is a key target of the DOTS strategy, the **case finding target was not 80%**. - Setting a higher case finding target might be desirable, but the **established goal** for DOTS was slightly lower to be more achievable. *Case finding 80%, cure rate 80%* - Neither the **case finding target nor the cure rate target** for DOTS was 80%. - The **cure rate target** was specifically emphasized as being higher to ensure effective treatment outcomes and prevent drug resistance. *Case finding 70%, cure rate 75%* - While **case finding 70%** aligns with the DOTS target, the **cure rate target was higher than 75%**. - A lower cure rate would indicate less effective treatment management, potentially leading to **treatment failures** and the emergence of **multidrug-resistant TB**.
Question 7: Under the DOTS strategy of Revised National Tuberculosis Programme, the recommended line of management in Category I patients, if the sputum is positive after 2 months of Intensive Phase treatment with 4 drugs, is to
- A. Add one more drug, that is, to use 5 drugs until the sputum becomes negative
- B. Continue the Intensive Phase of treatment with 4 drugs until the sputum becomes negative
- C. Continue the Intensive Phase of treatment with 4 drugs for 1 more month only, regardless of sputum positivity after that (Correct Answer)
- D. Start the continuation phase with INH and Rifampicin
Explanation: ***Continue the Intensive Phase of treatment with 4 drugs for 1 more month only, regardless of sputum positivity after that*** - In the **DOTS strategy** under earlier RNTCP guidelines, for Category I patients whose sputum remains positive after 2 months of the Intensive Phase, the recommended action was to **extend the Intensive Phase by one additional month**. - This step aimed to maximize the bactericidal effect of the four drugs (isoniazid, rifampicin, pyrazinamide, ethambutol) before transitioning to the Continuation Phase, even if sputum conversion was not achieved by the end of the third month. - **Note:** Current NTEP guidelines recommend sputum examination at 3 months, with drug susceptibility testing if positive, rather than automatic extension. *Add one more drug, that is, to use 5 drugs until the sputum becomes negative* - **Adding a fifth drug** is not the standard recommendation for a Category I patient who remains sputum positive after 2 months of the initial Intensive Phase. - This approach might be considered in cases of confirmed drug resistance after appropriate testing, which would typically involve more extensive evaluation beyond a single sputum result. *Continue the Intensive Phase of treatment with 4 drugs until the sputum becomes negative* - **Continuing the Intensive Phase indefinitely** until sputum conversion was not the standard protocol under DOTS. - Prolonged use of the intensive phase drugs beyond the specified duration can increase the risk of side effects and may not be more effective if underlying issues like drug resistance are present. *Start the continuation phase with INH and Rifampicin* - **Transitioning to the Continuation Phase** with only isoniazid (INH) and rifampicin (RMP) while sputum is still positive after 2 months of the Intensive Phase is inappropriate. - This would risk selecting for drug-resistant strains and lead to treatment failure due to insufficient bactericidal activity.
Question 8: A patient presents with the skin lesions shown in the image. All of the following are routinely indicated for the treatment of this condition EXCEPT:
- A. Rituximab (Correct Answer)
- B. Topical vitamin D
- C. Cyclosporine
- D. Acitretin
Explanation: ***Rituximab*** - The image displays **plaque psoriasis**, characterized by erythematous plaques with silvery scales. Rituximab, an anti-CD20 monoclonal antibody, targets B-cells and is primarily used in conditions like **lymphoma, leukemia, and rheumatoid arthritis**, not typically for psoriasis. - While some off-label uses or investigational studies might explore its role, it is **not routinely indicated** for the treatment of psoriasis. *Topical vitamin D* - **Topical vitamin D analogs** (e.g., calcipotriene, calcitriol) are a common first-line treatment for mild to moderate plaque psoriasis. They work by **inhibiting keratinocyte proliferation** and promoting their differentiation. - These agents are often used alone or in combination with topical corticosteroids to reduce inflammation and scaling. *Cyclosporine* - **Cyclosporine** is a calcineurin inhibitor used as a systemic treatment for severe psoriasis, especially in cases that are refractory to topical therapies or phototherapy. - It works by **suppressing the immune system**, thereby reducing the inflammation and rapid cell turnover seen in psoriasis. *Acitretin* - **Acitretin** is an oral retinoid indicated for severe psoriasis, particularly **pustular and erythrodermic psoriasis**, and in some cases of chronic plaque psoriasis. - It normalizes epidermal cell growth and differentiation, effective for extensive or difficult-to-treat forms of the disease.
Question 9: 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 10: 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.
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