Topical Corticosteroids — MCQs
Steroids are used in the Rx of the following diseases EXCEPT:
All of the following are topical steroids EXCEPT ?
Long-term steroid ingestion leads to all of the following except:
A patient developed fixed drug eruptions after taking certain medications. Which of the following drugs is known to cause these skin lesions?
Which of the following is a topical vitamin D analogue?
Which drug is used for intralesional injection in keloids?
Dapsone is used in which of the following conditions?
At the same concentration, which of the following vehicles is most potent for topical steroid delivery?
Which of the following monoclonal antibodies is used in the treatment of atopic dermatitis?
All of the following statements are true regarding warfarin toxicity (skin necrosis) except?
Topical Corticosteroids Indian Medical PG Practice Questions and MCQs
Question 1: Steroids are used in the Rx of the following diseases EXCEPT:
- A. Pemphigus vulgaris
- B. Chronic fungal infection (Correct Answer)
- C. Erythema multiforme
- D. Contact dermatitis
Explanation: ***Chronic fungal infection*** - **Steroids are absolutely contraindicated** in **chronic fungal infections** as they **suppress cell-mediated immunity**, leading to worsening of the infection and potential dissemination. - Corticosteroids promote fungal growth and can convert a localized infection into a systemic, life-threatening condition. - This is the **clearest contraindication** among the options. *Pemphigus vulgaris* - **Pemphigus vulgaris** is an **autoimmune blistering disease** where **high-dose systemic steroids are the first-line treatment**. - Corticosteroids (1-2 mg/kg/day of prednisolone) are essential for controlling autoantibody production and preventing life-threatening complications. - **Steroids are clearly indicated**, not contraindicated. *Erythema multiforme* - **Erythema multiforme** is typically a **self-limiting condition** managed primarily with **supportive care** (antipyretics, antihistamines, topical care). - **Systemic steroids are generally NOT recommended** as standard treatment and their use remains **controversial**. - However, in very rare severe cases with extensive mucosal involvement, some clinicians may consider a short course, making this **not an absolute contraindication** like fungal infections. *Contact dermatitis* - **Contact dermatitis** is commonly treated with **topical corticosteroids** as first-line therapy to reduce inflammation and pruritus. - In severe, widespread cases, a short course of **oral steroids** may be prescribed. - **Steroids are clearly indicated** for this condition.
Question 2: All of the following are topical steroids EXCEPT ?
- A. Fluticasone propionate
- B. Prednisolone (Correct Answer)
- C. Betamethasone valerate
- D. Hydrocortisone valerate
Explanation: ***Prednisolone*** - **Prednisolone** is an **oral/systemic corticosteroid** primarily used for systemic therapy, not as a topical dermatological preparation. - While prednisolone eye drops and ear drops exist, it is NOT a standard topical corticosteroid for skin disorders. - Its high systemic absorption potential makes it unsuitable for dermatological topical applications. *Fluticasone propionate* - **Fluticasone propionate** is a **highly potent synthetic topical corticosteroid** commonly used in dermatology. - Available as creams and ointments for inflammatory skin conditions like eczema, psoriasis, and atopic dermatitis. - Also formulated as nasal spray for allergic rhinitis. *Betamethasone valerate* - **Betamethasone valerate** is a **potent topical corticosteroid** widely used in dermatology. - Available in various formulations (cream, ointment, lotion) for treating inflammatory skin conditions. - Classified as a mid-to-high potency topical steroid, effective for conditions like eczema, psoriasis, and contact dermatitis. *Hydrocortisone valerate* - **Hydrocortisone valerate** is a **moderate-potency topical corticosteroid** derived from hydrocortisone. - Frequently used in dermatological preparations to treat inflammatory skin conditions like dermatitis and eczema. - Safer for prolonged use and application on sensitive areas compared to more potent steroids.
Question 3: Long-term steroid ingestion leads to all of the following except:
- A. Avascular necrosis of head of femur
- B. Growth retardation
- C. Hypoglycemia (Correct Answer)
- D. Cataract
Explanation: ***Hypoglycemia*** - Chronic steroid use primarily leads to **hyperglycemia** due to increased **gluconeogenesis** and **insulin resistance**, not hypoglycemia. - Steroids raise blood glucose levels, potentially inducing or worsening **diabetes mellitus**. *Avascular necrosis of head of femur* - Long-term steroid use is a well-established risk factor for **avascular necrosis**, particularly affecting the **femoral head**. - This occurs due to impaired blood supply to the bone, leading to its death. *Cataract* - **Posterior subcapsular cataracts** are a known ocular complication of prolonged systemic corticosteroid therapy. - The mechanism involves direct effects of steroids on lens metabolism and protein aggregation. *Growth retardation* - In children, chronic corticosteroid therapy can suppress growth, leading to **growth retardation**. - This is due to interference with **growth hormone secretion** and direct effects on bone formation.
Question 4: A patient developed fixed drug eruptions after taking certain medications. Which of the following drugs is known to cause these skin lesions?
- A. Phenolphthalein
- B. Aspirin
- C. Dapsone
- D. All of the above (Correct Answer)
Explanation: **Explanation:** **Fixed Drug Eruption (FDE)** is a unique type of cutaneous drug reaction characterized by the recurrence of a lesion (usually a dusky red or violaceous macule) at the **exact same anatomical site** every time the offending drug is ingested. This occurs due to the persistence of **CD8+ memory T-cells** in the basal keratinocytes at the site of the lesion. **Why Option D is correct:** All three drugs listed are classic and high-yield triggers for FDE: * **Phenolphthalein:** Historically the most common cause (found in older laxatives). * **Aspirin (NSAIDs):** A very frequent trigger in clinical practice. * **Dapsone (Sulfonamides):** Sulfonamides are among the most common drug classes associated with FDE. **Analysis of Options:** * **Phenolphthalein:** Often presents as "bullous" FDE. * **Aspirin:** Along with other NSAIDs (like Ibuprofen and Naproxen), it is a leading cause of multi-focal FDE. * **Dapsone:** As a sulfone, it shares cross-reactivity patterns and is a well-documented cause. **High-Yield Clinical Pearls for NEET-PG:** 1. **Most Common Site:** The **glans penis** is the most common site for FDE, followed by the lips and palms. 2. **Commonest Causes (Overall):** NSAIDs, Sulfonamides (Cotrimoxazole), Tetracyclines, and Anticonvulsants. 3. **Clinical Feature:** Lesions often leave behind **post-inflammatory hyperpigmentation (PIH)** after healing. 4. **Refractory Period:** After an eruption, there is a brief refractory period where the drug may not cause a reaction. 5. **Diagnosis:** Primarily clinical; however, a **Patch Test** performed at the site of the previous lesion (not on the back) can confirm the offending agent.
Question 5: Which of the following is a topical vitamin D analogue?
- A. Cholecalciferol
- B. Doxercalciferol
- C. Calcipotriol (Correct Answer)
- D. Paricalcitol
Explanation: **Explanation:** **Calcipotriol** is a synthetic analog of **1,25-dihydroxyvitamin D3 (Calcitriol)**. In dermatology, it is primarily used as a first-line topical treatment for **Psoriasis vulgaris**. Its mechanism of action involves binding to intracellular vitamin D receptors (VDR), leading to the inhibition of keratinocyte proliferation and the induction of keratinocyte differentiation. It also possesses anti-inflammatory properties by inhibiting T-cell activation. **Analysis of Options:** * **Calcipotriol (Correct):** It is specifically designed for topical use. It is as effective as potent topical corticosteroids but has a better safety profile for long-term maintenance, as it does not cause skin atrophy. * **Cholecalciferol (Option A):** This is Vitamin D3, typically administered orally as a nutritional supplement to treat Vitamin D deficiency. * **Doxercalciferol (Option B) & Paricalcitol (Option D):** These are synthetic Vitamin D analogs administered **systemically** (oral or IV). They are primarily used in the management of secondary hyperparathyroidism in patients with chronic kidney disease (CKD). **High-Yield Clinical Pearls for NEET-PG:** * **Combination Therapy:** Calcipotriol is frequently combined with **Betamethasone dipropionate** (e.g., Daivobet) for synergistic effects in psoriasis. * **Side Effects:** The most common side effect is local skin irritation. Systemic hypercalcemia is rare unless the dose exceeds **100g per week**. * **Contraindication:** It should not be applied to the face (due to irritation) and is generally avoided in patients with pre-existing hypercalcemia. * **Other Topical Analogs:** Tacalcitol and Maxacalcitol are other topical analogs used globally.
Question 6: Which drug is used for intralesional injection in keloids?
- A. Prednisolone
- B. Triamcinolone (Correct Answer)
- C. Androgen
- D. Hydrocortisone
Explanation: **Explanation:** **Triamcinolone acetonide (TAC)** is the gold standard and most commonly used drug for the intralesional treatment of keloids and hypertrophic scars. **Why Triamcinolone is the Correct Answer:** Triamcinolone is a potent, intermediate-acting synthetic corticosteroid. It works by: 1. **Inhibiting Fibroblasts:** It reduces the proliferation of fibroblasts and the synthesis of collagen. 2. **Anti-inflammatory Action:** It decreases the release of inflammatory mediators (like TGF-β) that drive excessive scarring. 3. **Increasing Collagenase:** It reduces levels of alpha-2-macroglobulin, which normally inhibits collagenase, thereby promoting the breakdown of existing collagen. The concentration typically used is **10–40 mg/mL**, injected directly into the mid-dermis of the lesion. **Analysis of Incorrect Options:** * **A & D (Prednisolone & Hydrocortisone):** These are shorter-acting corticosteroids with lower potency. They are highly soluble and rapidly absorbed into the systemic circulation, making them ineffective for maintaining the sustained local concentration required to break down dense keloidal tissue. * **C (Androgen):** Androgens have no role in the treatment of keloids; in fact, hormonal fluctuations (like puberty or pregnancy) are sometimes associated with keloid exacerbation. **High-Yield Clinical Pearls for NEET-PG:** * **Side Effects:** The most common side effects of intralesional TAC include **dermal atrophy, telangiectasia, and hypopigmentation** at the injection site. * **Combination Therapy:** For resistant keloids, TAC is often combined with **5-Fluorouracil (5-FU)** to improve efficacy and reduce atrophy. * **Cryosurgery:** Performing cryotherapy immediately before injection (the "cryo-insult" technique) softens the keloid, making the injection easier and more effective.
Question 7: Dapsone is used in which of the following conditions?
- A. Dermatitis herpetiformis (Correct Answer)
- B. Pityriasis rosacea
- C. Contact dermatitis
- D. Oculocutaneous albinism
Explanation: **Explanation:** **Dapsone (Diaminodiphenyl sulfone)** is the drug of choice for **Dermatitis Herpetiformis (DH)**. DH is an autoimmune blistering disorder characterized by IgA deposits at the dermal papillae, leading to intense pruritus and neutrophilic infiltration. Dapsone works by inhibiting the enzyme myeloperoxidase and preventing the chemotaxis of neutrophils to the skin, providing rapid symptomatic relief (often within 24–48 hours). **Analysis of Options:** * **A. Dermatitis Herpetiformis:** Correct. It is the primary indication for Dapsone in dermatology. * **B. Pityriasis Rosea:** This is a self-limiting inflammatory condition (likely viral/HHV-6,7). Treatment is supportive (antihistamines, topical steroids); Dapsone has no role. * **C. Contact Dermatitis:** This is a Type IV hypersensitivity reaction. Management involves allergen avoidance and topical or systemic corticosteroids. * **D. Oculocutaneous Albinism:** This is a genetic disorder of melanin synthesis. There is no pharmacological "cure"; management focuses on photoprotection and monitoring for skin cancers. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism of Action:** Antifolate (inhibits dihydropteroate synthase) and anti-inflammatory (inhibits neutrophil recruitment). * **Other Indications:** Leprosy (part of MDT), Pemphigoid, Subcorneal Pustular Dermatosis (Sneddon-Wilkinson disease), and Brown Recluse spider bites. * **Mandatory Pre-screening:** Always check **G6PD levels** before starting Dapsone to prevent severe **hemolytic anemia**. * **Side Effects:** Dose-dependent hemolysis, methemoglobinemia (presents as cyanosis), and the "Dapsone Syndrome" (fever, malaise, exfoliative dermatitis, and hepatitis).
Question 8: At the same concentration, which of the following vehicles is most potent for topical steroid delivery?
- A. Ointment (Correct Answer)
- B. Lotion
- C. Cream
- D. Gel
Explanation: **Explanation:** The potency of a topical corticosteroid is determined not only by the active pharmaceutical ingredient but also by its **vehicle**. The vehicle influences the rate of absorption and the depth of penetration into the skin. **Why Ointment is the Correct Answer:** Ointments are primarily oil-based (water-in-oil emulsions) and provide the highest level of **occlusion**. By forming a greasy film on the skin surface, they prevent transepidermal water loss, leading to increased hydration of the stratum corneum. Hydrated skin is significantly more permeable, allowing for maximum penetration of the steroid. Therefore, at the same concentration, an ointment is always more potent than a cream or lotion. **Why Other Options are Incorrect:** * **B. Lotion:** These are liquid-based (often water-based) and evaporate quickly. They have the least occlusive property and thus the lowest potency. They are preferred for hairy areas or oozing lesions. * **C. Cream:** These are oil-in-water emulsions. While they are more cosmetically elegant and easier to wash off, they provide less occlusion than ointments, resulting in moderate potency. * **D. Gel:** Gels are transparent, non-greasy formulations. While they are excellent for the scalp and oily skin, they lack the occlusive "barrier effect" required to match the potency of an ointment. **High-Yield Clinical Pearls for NEET-PG:** * **Rule of Thumb:** Potency ranking by vehicle: **Ointment > Cream > Lotion.** * **Absorption:** Steroid absorption is highest in areas with thin stratum corneum (e.g., eyelids, scrotum, face) and lowest in thick areas (e.g., palms, soles). * **Clinical Choice:** Use **ointments** for dry, thick, or hyperkeratotic lesions (e.g., chronic plaque psoriasis) and **creams/lotions** for moist, intertriginous, or weeping lesions. * **Finger Tip Unit (FTU):** One FTU (0.5g) is enough to cover the area of two adult palms.
Question 9: Which of the following monoclonal antibodies is used in the treatment of atopic dermatitis?
- A. Ipilimumab
- B. Dupilumab (Correct Answer)
- C. Durvalumab
- D. Reslizumab
Explanation: **Explanation:** **1. Why Dupilumab is Correct:** Dupilumab is a fully human monoclonal antibody that targets the **interleukin-4 receptor alpha (IL-4Rα) subunit**. By binding to this subunit, it inhibits the signaling of both **IL-4 and IL-13**. These cytokines are the key drivers of **Type 2 (Th2) inflammation**, which is the primary pathophysiological mechanism in atopic dermatitis. It is currently the first-line systemic biologic approved for moderate-to-severe atopic dermatitis unresponsive to topical therapies. **2. Why the Other Options are Incorrect:** * **Ipilimumab:** A checkpoint inhibitor that targets **CTLA-4**. It is used in the treatment of advanced melanoma and renal cell carcinoma. * **Durvalumab:** A checkpoint inhibitor that targets **PD-L1**. It is primarily used in the treatment of non-small cell lung cancer (NSCLC) and bladder cancer. * **Reslizumab:** An interleukin-5 (**IL-5**) antagonist. It is used as add-on maintenance treatment for severe eosinophilic asthma, not atopic dermatitis. **3. High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Dual inhibitor of IL-4 and IL-13. * **Common Side Effect:** The most characteristic side effect of Dupilumab is **allergic conjunctivitis** and blepharitis. * **Other Indications:** It is also FDA-approved for moderate-to-severe asthma (eosinophilic phenotype) and chronic rhinosinusitis with nasal polyposis. * **Memory Aid:** "Dupi" stops the "D"ermatitis by blocking the "4" and "13" (IL-4/13).
Question 10: All of the following statements are true regarding warfarin toxicity (skin necrosis) except?
- A. Skin necrosis occurs during initiation of therapy.
- B. Most common sites are buttocks and abdomen. (Correct Answer)
- C. Decreased quantity of protein C.
- D. Decreased incidence of adverse effects if therapy with LMWH is started.
Explanation: **Explanation:** Warfarin-induced skin necrosis (WISN) is a rare but severe complication occurring in approximately 0.01% to 0.1% of patients treated with vitamin K antagonists. **Why Option B is the correct answer (The False Statement):** While the buttocks and abdomen are common sites, the **most common sites** for warfarin necrosis are areas with **high subcutaneous fat content**, specifically the **breasts** (in females), followed by the thighs and buttocks. The statement in Option B is considered the "except" because it overlooks the breast as the primary site of predilection. **Analysis of Other Options:** * **Option A:** True. Necrosis typically occurs **3 to 10 days after initiation** of therapy, often due to a large loading dose. * **Option C:** True. Warfarin inhibits Vitamin K-dependent factors (II, VII, IX, X) and anticoagulant proteins (C and S). **Protein C has a shorter half-life** (6 hours) compared to clotting factors. This creates a transient "prothrombotic window" where natural anticoagulants are depleted while procoagulant factors are still active, leading to microvascular thrombosis. * **Option D:** True. Starting **Low Molecular Weight Heparin (LMWH)** as a "bridge" provides immediate anticoagulation, preventing the thrombotic complications during the initial drop in Protein C levels. **Clinical Pearls for NEET-PG:** * **Risk Factor:** Underlying **Protein C deficiency** is the most significant risk factor. * **Clinical Presentation:** Sudden onset of painful, erythematous, or purpuric lesions that rapidly progress to **hemorrhagic bullae and eschar**. * **Management:** Immediate discontinuation of Warfarin, administration of **Vitamin K**, and starting **Heparin** or Protein C concentrates.
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