Nail Tumors — MCQs
All are nail changes seen in cases of psoriasis except:
Nail changes are found in about ______ cases of psoriasis:
Glomus tumor is seen in -
All are true about psoriasis except –
A 70 year old farmer, presented to you with complaints of yellowish discolouration of his finger nails for the past 6 months, he also gives history of recurrent episodes of itching in the groin for which he used to take local home made herbal remedy. On examination 3 of his toe nails also show similar change with tunneling. Which among the following is the best test for rapid confirmation of your diagnosis?
A farmer presented with a black mole on the cheek. It increased in size, more than 6mm with irregular borders and a central black lesion, what could be the diagnosis?
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 of the following conditions does NOT cause nail pitting?
A patient presents with focal alopecia areata. All of the following are associations of alopecia areata except:
A young female presented with lacy linear lesions on tongue for a month with elongation of nail fold beyond the nail bed. What is the diagnosis –
Nail Tumors Indian Medical PG Practice Questions and MCQs
Question 1: All are nail changes seen in cases of psoriasis except:
- A. Subungual hyperkeratosis
- B. Oil drop sign
- C. Mees lines (Correct Answer)
- D. Pitting
Explanation: ***Mees lines*** - **Mees lines** (or Aldrich-Mees lines) are **transverse white bands** that appear in the nail plate. - They are typically associated with **heavy metal poisoning** (e.g., arsenic), chemotherapy, or systemic illnesses, not psoriasis. *Subungual hyperkeratosis* - This is a common finding in **psoriasis**, characterized by the **thickening of the nail bed** due to excessive keratin production. - It leads to lifting of the nail plate from the nail bed. *Oil drop sign* - The **oil drop sign** (or salmon patch) is a classic psoriatic nail change, presenting as a **translucent, yellowish-red discoloration** under the nail plate. - It is due to psoriasis of the nail bed. *Pitting* - **Nail pitting** refers to the presence of **small depressions or pits** on the nail surface. - It results from defective keratinization of the nail matrix and is a characteristic sign of nail psoriasis.
Question 2: Nail changes are found in about ______ cases of psoriasis:
- A. Two thirds
- B. One third
- C. One half (Correct Answer)
- D. All cases
Explanation: ***One half*** - Approximately **50% of patients with psoriasis** will experience nail changes, which can be a key diagnostic feature. - Nail involvement is even higher, around **80-90%**, in patients with **psoriatic arthritis**. *Two thirds* - While a significant proportion, **two-thirds (roughly 66%)** is a slight overestimate of the general prevalence of nail changes in psoriasis. - This figure might be seen in specific populations or more severe cases, but not overall. *One third* - **One-third (roughly 33%)** is an underestimation of the frequency of nail changes in psoriasis. - Nail involvement is a very common manifestation of the disease. *All cases* - It is incorrect to state that **all cases of psoriasis** have nail changes. - While common, nail involvement is not universal and can range from mild to severe, or be entirely absent.
Question 3: Glomus tumor is seen in -
- A. Rare locations such as retroperitoneum
- B. Long bones and vertebrae
- C. Proximal portion of digits (less common site)
- D. Distal portion of digits (Correct Answer)
Explanation: ***Distal portion of digits*** - **Glomus tumors** are most commonly found in the **distal extremities**, especially the **subungual region** (under the nail) of the fingers and toes. - This location accounts for over 75% of all glomus tumors, where they originate from specialized **neuromyoarterial glomus bodies** involved in thermoregulation. - The classic clinical triad includes **paroxysmal pain, point tenderness, and cold sensitivity**. *Rare locations such as retroperitoneum* - While glomus tumors can occur in unusual sites, the **retroperitoneum** is an exceptionally rare location for primary glomus tumors. - Extradigital glomus tumors account for approximately 25% of cases and can occur in various soft tissue sites. *Long bones and vertebrae* - Glomus tumors do not typically arise in **bone tissue** as they originate from glomus bodies in soft tissue. - Bone involvement, when present, is usually secondary due to pressure erosion from an adjacent soft tissue tumor rather than primary bone origin. *Proximal portion of digits (less common site)* - While glomus tumors can occasionally be found in less common digital locations, the **proximal portion of digits** is significantly less frequent than the distal, and particularly the subungual, region. - Their primary association remains with the **distal phalanx** and nail bed.
Question 4: All are true about psoriasis except –
- A. Auspitz sign positive
- B. Parakeratosis & acanthosis
- C. Joint involvement in 5–10% (Correct Answer)
- D. Pitting of nails
- E. Koebner phenomenon
Explanation: ***Joint involvement in 5–10%*** - While **psoriasis** is a skin condition, it can involve the joints in about **30% of patients**, leading to **psoriatic arthritis**. - Therefore, stating that joint involvement occurs in only **5-10%** is incorrect, as the percentage is significantly higher. - This is the **FALSE statement** in this EXCEPT question. *Auspitz sign positive* - The **Auspitz sign** (pinpoint bleeding when scales are removed) is a classic feature of psoriasis. - It occurs due to the proximity of dilated capillaries to the thinned suprapapillary epidermis. - This is a **TRUE statement**. *Parakeratosis & acanthosis* - **Parakeratosis** (retention of nuclei in the stratum corneum) and **acanthosis** (epidermal hyperplasia) are classic histopathological features of psoriasis. - These features reflect the **rapid cell turnover** and **thickening of the epidermis** characteristic of psoriatic plaques. - This is a **TRUE statement**. *Pitting of nails* - **Nail pitting** is a common manifestation of psoriasis, affecting up to **50% of patients** with chronic plaque psoriasis and **80% of patients with psoriatic arthritis**. - Other nail changes include **onycholysis**, **subungual hyperkeratosis**, and discoloration. - This is a **TRUE statement**. *Koebner phenomenon* - **Koebner phenomenon** (isomorphic response) is the development of psoriatic lesions at sites of trauma or injury. - This is seen in approximately **25% of patients** with psoriasis and is a well-recognized clinical feature. - This is a **TRUE statement**.
Question 5: A 70 year old farmer, presented to you with complaints of yellowish discolouration of his finger nails for the past 6 months, he also gives history of recurrent episodes of itching in the groin for which he used to take local home made herbal remedy. On examination 3 of his toe nails also show similar change with tunneling. Which among the following is the best test for rapid confirmation of your diagnosis?
- A. Tzanck smear
- B. KOH mount (Correct Answer)
- C. Woods lamp
- D. Biopsy
Explanation: ***KOH mount*** - A **KOH mount** (potassium hydroxide) dissolves keratinocytes, allowing for direct visualization of fungal elements such as **hyphae** and **spores** under a microscope. This is the **most rapid and cost-effective test** for confirming fungal infections like **onychomycosis**. - The patient's presentation with **yellowish discoloration** and **"tunneling"** of nails (suggesting onycholysis and subungual hyperkeratosis), along with a history of recurrent groin itching (potentially **tinea cruris**), strongly points to a fungal infection. *Tzanck smear* - A **Tzanck smear** is primarily used to detect multinucleated giant cells in **herpesvirus infections** (e.g., herpes simplex, varicella-zoster). - It is not useful for identifying fungal elements responsible for nail discoloration or suspected onychomycosis. *Woods lamp* - A **Woods lamp** uses ultraviolet light to detect specific fluorescent substances, particularly useful for diagnosing certain **bacterial infections** (e.g., *Corynebacterium minutissimum* in erythrasma) or some **tinea capitis** species (*Microsporum*). - Most common dermatophytes causing onychomycosis **do not fluoresce** under a Wood's lamp, making it an unreliable diagnostic tool in this scenario. *Biopsy* - A **nail biopsy** (with histology and special stains like PAS) is a highly accurate diagnostic method for onychomycosis, especially when other tests are inconclusive. - However, it is an **invasive procedure**, takes more time for results, and is generally not the **most rapid** initial test compared to a KOH mount.
Question 6: A farmer presented with a black mole on the cheek. It increased in size, more than 6mm with irregular borders and a central black lesion, what could be the diagnosis?
- A. Superficial spreading melanoma (Correct Answer)
- B. Acral lentigo melanoma
- C. Lentigo maligna melanoma
- D. Nodular melanoma
Explanation: ***Superficial spreading melanoma*** - This is the most common type of melanoma and often presents as a **mole with irregular borders**, varying colors, and a diameter greater than 6mm, consistent with the description. - The lesion typically grows **radially** across the skin surface before beginning vertical growth, indicated by the increase in size. *Acral lentigo melanoma* - This type of melanoma primarily affects the **palms, soles, and nail beds**, which is inconsistent with a lesion on the cheek. - It often appears as a **dark brown or black patch** that slowly enlarges, but its location is characteristic. *Lentigo maligna melanoma* - This melanoma typically occurs in **chronically sun-damaged skin** of the elderly, often on the head and neck, but usually presents as a **flat, irregularly shaped, tan or brown patch** with varying shades, which may not fit the description of a central black lesion within a larger mole. - It has a dominant **radial growth phase** and progresses slowly over many years before developing a nodular component. *Nodular melanoma* - This type is characterized by its **rapid vertical growth** and appearance as a **raised, dark, often dome-shaped lesion** from the outset. - While it can be black, the description of an "increased in size" mole with irregular borders and a central black lesion points more towards a spreading type rather than a rapidly growing nodule from the beginning.
Question 7: 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 8: Which of the following conditions does NOT cause nail pitting?
- A. Lichen planus
- B. Fungal infection
- C. Pityriasis Rosea (Correct Answer)
- D. Psoriasis
Explanation: ***Pityriasis Rosea*** - This condition primarily affects the **skin**, causing a distinctive rash of oval, pinkish-red patches, often preceded by a **herald patch**. - It characteristically spares the **nails**, meaning nail pitting is not a feature of pityriasis rosea. - Nail changes are not associated with this self-limiting dermatosis. *Lichen planus* - **Nail lichen planus** can cause various nail changes, including **pitting**, longitudinal ridging, pterygium formation, and thinning of the nail plate. - It is an inflammatory condition affecting the skin, hair, nails, and mucous membranes. - Nail involvement occurs in approximately 10% of patients with cutaneous lichen planus. *Psoriasis* - **Nail psoriasis** is common, affecting up to 50% of patients with psoriasis, and **pitting is the most characteristic nail finding**. - Pitting appears as small punctate depressions on the nail surface due to defects in the proximal nail matrix. - Other nail changes include onycholysis (oil drop sign), subungual hyperkeratosis, and salmon patches. *Fungal infection* - **Onychomycosis** (fungal nail infection) typically causes **thickening, discoloration, onycholysis, and crumbling** of the nail. - **True nail pitting is NOT a characteristic feature** of fungal infections, as pitting results from defects in the proximal nail matrix, not fungal invasion. - Fungal infections affect the nail plate and bed differently, causing destruction rather than the punctate depressions seen in pitting.
Question 9: A patient presents with focal alopecia areata. All of the following are associations of alopecia areata except:
- A. Atopy
- B. Exclamatory mark
- C. Nail pitting
- D. Geographic tongue (Correct Answer)
Explanation: ***Geographic tongue*** - **Geographic tongue** (benign migratory glossitis) is a benign inflammatory condition of the tongue and is generally not associated with alopecia areata. - While its exact cause is unknown, it's typically linked to genetic factors or sensitivities rather than autoimmune hair loss. *Atopy* - **Atopy**, including conditions like **eczema**, **asthma**, and **allergic rhinitis**, is a well-established association with alopecia areata, suggesting a shared immune dysregulation. - Patients with alopecia areata often have a higher prevalence of **atopic diathesis**. *Exclamatory mark* - The presence of **exclamatory mark hairs** (short, broken hairs that are narrower near the scalp) is a **pathognomonic sign** of active alopecia areata. - These hairs indicate ongoing inflammation and destruction of the hair follicles. *Nail pitting* - **Nail pitting**, characterized by small depressions in the nail plate, is a common finding in patients with alopecia areata, reflecting an immune-mediated attack on the **nail matrix**. - Other nail changes, such as **trachyonychia** (roughened nails), can also occur.
Question 10: A young female presented with lacy linear lesions on tongue for a month with elongation of nail fold beyond the nail bed. What is the diagnosis –
- A. Candidiasis
- B. Psoriasis
- C. Geographic tongue
- D. Lichen planus (Correct Answer)
Explanation: ***Lichen planus*** - **Lacy linear lesions on the tongue** are characteristic of **Wickham's striae**, a hallmark feature of oral lichen planus. - **Elongation of the nail fold beyond the nail bed** (known as pterygium formation) is a specific nail finding seen in lichen planus. *Candidiasis* - Oral candidiasis typically presents as **white, creamy patches** that can be scraped off, unlike the lacy lesions described. - It does not typically cause **nail fold elongation** or similar specific nail changes. *Psoriasis* - While psoriasis can affect the tongue (geographic tongue-like lesions) and nails, the classic oral lesions are not described as **lacy linear patterns**. - Nail changes in psoriasis include **pitting, onycholysis, and oil spots**, not usually elongation of the nail fold beyond the nail bed. *Geographic tongue* - Geographic tongue presents as **irregular, depapillated red patches with white borders** that migrate over time. - It is a benign inflammatory condition of the tongue and is not associated with **nail changes** like elongated nail folds.
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