Hair and Nail Disorders — MCQs

Hair and Nail Disorders Indian Medical PG Practice Questions and MCQs

Question 41: Moth-eaten alopecia is seen in which of the following conditions?

A. Black dot tinea
B. Telogen effuvium
C. Alopecia areata
D. Secondary syphilis (Correct Answer)

Explanation: **Explanation:** **Moth-eaten alopecia** is a classic, pathognomonic cutaneous manifestation of **Secondary Syphilis** (caused by *Treponema pallidum*). It is characterized by small, patchy, non-scarring areas of hair loss that appear ragged and ill-defined, resembling the way a moth eats through fabric. It most commonly affects the scalp but can also involve the eyebrows (madarosis) and beard. **Analysis of Options:** * **Secondary Syphilis (Correct):** The alopecia is due to an inflammatory response against the spirochetes. It is often associated with other "Great Imitator" signs like generalized lymphadenopathy, condyloma lata, and a maculopapular rash on the palms and soles. * **Black dot tinea:** This is a fungal infection (usually *T. tonsurans*) where hair shafts break at the surface, leaving "black dots." It does not present with the diffuse, ragged "moth-eaten" pattern. * **Telogen effluvium:** This is a functional disorder causing diffuse thinning of hair across the entire scalp, usually triggered by stress, pregnancy, or illness. It does not occur in patches. * **Alopecia areata:** This presents as well-demarcated, smooth, circular patches of hair loss with "exclamation mark hairs" at the margins, rather than the ragged, moth-eaten appearance. **NEET-PG High-Yield Pearls:** * **Syphilitic Alopecia:** Can be "essential" (no other lesions) or "symptomatic" (associated with scalp syphilids). * **Treatment:** A single dose of **Benzathine Penicillin G (2.4 million units IM)** usually leads to complete hair regrowth. * **Differential Diagnosis:** Always screen for HIV in patients presenting with secondary syphilis, as the clinical presentation may be more aggressive.

Question 42: Pseudo-pelade is a synonym for which of the following conditions?

A. Alopecia steatoides
B. Premature alopecia
C. Traction alopecia
D. Cicatricial alopecia (Correct Answer)

Explanation: **Explanation:** **Pseudopelade of Brocq** is a specific clinical pattern of **Cicatricial (scarring) alopecia**. The term is derived from the French word *pelade* (alopecia areata), as it mimics the patchy hair loss of alopecia areata but results in permanent destruction of the hair follicle. 1. **Why the correct answer is right:** Cicatricial alopecia is characterized by the replacement of hair follicles with fibrous tissue (scarring), leading to permanent hair loss. Pseudopelade of Brocq is considered the "end-stage" of various inflammatory scalp conditions (like Lichen Planopilaris or Discoid Lupus) or can occur idiopathically. It presents classically as small, flesh-colored, irregular patches of hair loss described as **"footprints in the snow."** 2. **Why the incorrect options are wrong:** * **Alopecia steatoides:** This is an older term for Seborrheic Dermatitis of the scalp associated with oily scales; it does not cause scarring. * **Premature alopecia:** This usually refers to early-onset Androgenetic Alopecia (male pattern baldness), which is a **non-cicatricial** (non-scarring) form of hair loss. * **Traction alopecia:** This is hair loss caused by chronic tension on the hair shaft (e.g., tight braids). While it can lead to scarring if prolonged, it is a distinct mechanical etiology and not a synonym for Pseudopelade. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Sign:** "Footprints in the snow" appearance (multiple small, white/flesh-colored atrophic patches). * **Key Feature:** Absence of follicular ostia (openings) and lack of significant inflammation in the late stage. * **Differential:** Unlike Alopecia Areata (non-scarring), Pseudopelade shows a smooth, shiny scalp surface with no "exclamation mark" hairs.

Question 43: A young lady presents with lacy lesions in the oral cavity and genitals, and her proximal nail fold has extended onto the nail bed. What is the likely diagnosis?

A. Lichen planus (Correct Answer)
B. Candidiasis
C. Both
D. None

Explanation: **Explanation:** The clinical presentation described is a classic case of **Lichen Planus (LP)**. The diagnosis is based on two pathognomonic features: 1. **Lacy lesions (Wickham Striae):** These are reticulate, white, lacy patterns found on the buccal mucosa and genitals. Oral involvement occurs in about 50% of patients with cutaneous LP. 2. **Pterygium formation:** This is the most characteristic nail finding in LP. It occurs when the **proximal nail fold fuses with the nail matrix and bed**, resulting in a V-shaped extension of skin over the nail. This leads to permanent scarring and destruction of the nail unit. **Why other options are incorrect:** * **Candidiasis:** Typically presents as white, curd-like plaques (thrush) that can be scraped off, leaving an erythematous base. In nails, it causes chronic paronychia (swelling of the nail fold) and onychomycosis, but it does **not** cause pterygium formation. * **Options C & D:** These are incorrect as the clinical triad of mucosal lacy lesions and pterygium is highly specific for Lichen Planus. **High-Yield Clinical Pearls for NEET-PG:** * **The 6 P’s of LP:** Planar (flat-topped), Purple, Polygonal, Pruritic, Papules, and Plaques. * **Koebner Phenomenon:** Development of lesions at sites of trauma (also seen in Psoriasis and Vitiligo). * **Nail LP:** Besides pterygium, look for "angel wing" deformity, longitudinal ridging, and thinning of the nail plate. * **Histopathology:** Characterized by "saw-tooth" rete ridges, Civatte bodies (apoptotic keratinocytes), and a band-like lymphocytic infiltrate at the dermo-epidermal junction.

Question 44: What is the characteristic clinical sign of alopecia areata?

A. Exclamatory mark hair (Correct Answer)
B. Decreased hair diameter
C. Absence of hair follicle
D. A scaly patch of alopecia

Explanation: **Explanation:** **Alopecia Areata (AA)** is an autoimmune, non-scarring type of hair loss where T-cells attack the hair follicle bulbs. **Why Option A is correct:** The pathognomonic clinical sign of Alopecia Areata is the **Exclamation mark hair**. These are short, broken hairs (2–3 mm) that are thicker at the top and become thinner and depigmented near the scalp. This occurs because the inflammatory process weakens the hair shaft as it emerges from the follicle, causing it to fracture during the early telogen or late anagen phase. They are typically found at the active periphery of an expanding bald patch. **Why the other options are incorrect:** * **B. Decreased hair diameter:** This is characteristic of **Androgenetic Alopecia**, where hair follicles undergo "miniaturization" due to the influence of DHT. * **C. Absence of hair follicle:** This defines **Cicatricial (Scarring) Alopecia** (e.g., Lichen Planopilaris or DLE). Alopecia Areata is non-scarring, meaning the follicles are preserved but dormant. * **D. A scaly patch of alopecia:** Scaling is a hallmark of **Tinea Capitis** (fungal infection). Alopecia Areata presents as a smooth, "ivory-white" or flesh-colored patch without any signs of inflammation or scaling. **High-Yield Clinical Pearls for NEET-PG:** * **Nail Findings:** The most common nail change in AA is **geometric pitting** (fine, uniform pits in a grid-like pattern). * **Trichoscopy:** Look for "yellow dots" (follicular plugs) and "black dots" (cadaverous hairs). * **Associations:** Often associated with other autoimmune conditions like Vitiligo and Hashimoto’s thyroiditis. * **Prognosis:** Poor prognostic factors include **Ophiasis pattern** (hair loss along the temporal/occipital hairline), childhood onset, and nail involvement.

Question 45: The Hamilton Norwood scale is used for assessing the extent of which condition?

A. Male androgenetic alopecia (Correct Answer)
B. Female androgenetic alopecia
C. Alopecia areata
D. Telogen effluvium

Explanation: **Explanation:** The **Hamilton-Norwood scale** is the gold-standard clinical classification system used to measure the extent of **Male Androgenetic Alopecia (MAGA)**. It categorizes hair loss into seven stages (I to VII) based on two primary patterns: recession at the temples and thinning at the vertex (crown). This scale is essential for documenting disease progression and planning surgical or medical interventions. **Analysis of Options:** * **A. Male Androgenetic Alopecia (Correct):** Characterized by the action of Dihydrotestosterone (DHT) on genetically susceptible hair follicles, leading to follicular miniaturization in a specific pattern defined by this scale. * **B. Female Androgenetic Alopecia:** While also androgen-dependent, the pattern in women is different (diffuse thinning with preservation of the frontal hairline). It is assessed using the **Ludwig Scale** or the **Sinclair Scale**. * **C. Alopecia Areata:** This is an autoimmune condition characterized by non-scarring, "patchy" hair loss. Severity is typically assessed using the **SALT (Severity of Alopecia Tool) score**. * **D. Telogen Effluvium:** This involves diffuse hair shedding across the entire scalp due to a shift in the hair cycle (premature entry into the telogen phase). It does not follow a patterned scale like Hamilton-Norwood. **High-Yield Clinical Pearls for NEET-PG:** * **Ludwig Scale:** Used for Female Pattern Hair Loss (FPHL). * **Grades of MAGA:** Stage I is minimal loss; Stage VII is the most severe (only a horseshoe-shaped fringe remains). * **Treatment of Choice:** Topical **Minoxidil** (vasodilator) and oral **Finasteride** (5-alpha reductase inhibitor). * **Key Histology:** Increased vellus hairs and decreased terminal hairs (Terminal:Vellus ratio < 4:1).

Question 46: Nail pitting is a characteristic finding in which of the following conditions?

A. Paronychia
B. Ectodermal dysplasia
C. Alopecia areata
D. All the above (Correct Answer)

Explanation: **Explanation:** Nail pitting is a result of **focal parakeratosis** (retained nuclei in the stratum corneum) within the **proximal nail matrix**. As the nail plate grows out, these defective cells shed, leaving behind small depressions or "pits." * **Alopecia Areata:** This is a classic cause of nail pitting. The pits are typically **fine, shallow, and arranged in a regular, geometric, or "grid-like" pattern** (Trachyonychia or "sandpaper nails" may also be seen). * **Ectodermal Dysplasia:** This group of genetic disorders affects structures derived from the ectoderm (hair, teeth, nails, sweat glands). Nail dystrophy, including pitting and ridging, is a common manifestation due to primary matrix defects. * **Paronychia:** While primarily an inflammation of the periungual folds, chronic paronychia frequently involves the underlying nail matrix. This inflammation leads to secondary changes in the nail plate, including transverse ridges (Beau’s lines) and irregular pitting. **Clinical Pearls for NEET-PG:** 1. **Psoriasis vs. Alopecia Areata:** Psoriatic pits are typically **deep, large, and irregularly scattered**, whereas pits in Alopecia Areata are **fine and geometrically regular**. 2. **Oil Spot Sign:** This is pathognomonic for **Nail Psoriasis** (caused by distal matrix/nail bed involvement). 3. **Other causes of pitting:** Eczema (dermatitis), Lichen Planus (though pterygium is more common), and Reiter’s Syndrome. 4. **High-Yield Association:** Pitting is the most common nail finding in Psoriasis, but **Onycholysis** is the most specific.

Question 47: Hair growth is seen in which phase of the hair cycle?

A. Anagen (Correct Answer)
B. Catagen
C. Telogen
D. None of the above

Explanation: The hair follicle undergoes a repetitive, cyclical process of growth and rest. Understanding the distinct phases of the hair cycle is a high-yield topic for NEET-PG. **Correct Option: A. Anagen** Anagen is the **active growth phase** of the hair follicle. During this stage, the cells in the hair bulb divide rapidly (high mitotic activity), leading to the synthesis of the hair shaft. In the scalp, approximately 85-90% of hairs are in the anagen phase at any given time, and this phase can last between 2 to 7 years. **Incorrect Options:** * **B. Catagen:** This is the **involution or transition phase**. It is the shortest phase (lasting 2–3 weeks), where the lower part of the hair follicle regresses and hair growth stops. The follicle shrivels to about 1/6th of its original length. * **C. Telogen:** This is the **resting phase**. The hair is now a "club hair" and remains dormant for about 3 months before eventually shedding (Exogen). Approximately 10-15% of scalp hairs are in this phase. **High-Yield Clinical Pearls for NEET-PG:** 1. **Telogen Effluvium:** A common condition where a physiological stressor (fever, surgery, pregnancy) pushes a large number of anagen hairs prematurely into the telogen phase, leading to diffuse hair shedding 3 months later. 2. **Anagen Effluvium:** Sudden hair loss caused by drugs (e.g., chemotherapy) that interrupt the rapid mitosis of anagen cells. 3. **Memory Aid (ACT):** Remember the sequence **A**nagen (Growth) → **C**atagen (Transition) → **T**elogen (Rest). 4. **Hair Growth Rate:** On average, scalp hair grows at a rate of **0.35 mm/day** or roughly 1 cm per month.

Question 48: A 30-year-old woman presents with scattered scalp lesions that she has had for the past several months and that are causing hair loss. The lesions have hyperpigmented and depigmented areas with follicular plugging and atrophy. Which of the following is the best treatment for this patient?

A. Griseofulvin
B. Ketoconazole cream
C. Ketoconazole shampoo
D. Topical steroids (Correct Answer)

Explanation: ### **Explanation** The clinical presentation of **follicular plugging, atrophy, and alternating hyperpigmentation/depigmentation** (salt-and-pepper appearance) in a patient with scarring alopecia is diagnostic of **Discoid Lupus Erythematosus (DLE)** of the scalp. #### **1. Why Topical Steroids are Correct** DLE is an autoimmune inflammatory condition. The primary goal of treatment is to suppress the lymphocytic inflammation to prevent further destruction of hair follicles and permanent scarring. **High-potency topical steroids** (e.g., Clobetasol propionate) or intralesional steroids (Triamcinolone) are the **first-line treatment** for localized DLE. If the disease is widespread, systemic antimalarials (Hydroxychloroquine) are added. #### **2. Why Other Options are Incorrect** * **A, B, & C (Griseofulvin, Ketoconazole cream/shampoo):** These are antifungal agents. While Tinea Capitis (fungal infection) can cause hair loss and scaling, it does not typically present with the classic triad of follicular plugging, atrophy, and pigmentary changes seen in DLE. Ketoconazole shampoo is used for Seborrheic Dermatitis, which causes diffuse scaling but not scarring or atrophy. #### **3. High-Yield Clinical Pearls for NEET-PG** * **Scarring (Cicatricial) Alopecia:** DLE is a common cause. Look for the absence of follicular ostia (openings) on examination. * **Carpet Tack Sign:** When an adherent scale in DLE is removed, small keratinous projections are seen on the underside (due to follicular plugging). * **Histopathology:** Key features include vacuolar degeneration of the basal layer, basement membrane thickening, and a periadnexal/perivascular lymphocytic infiltrate. * **Direct Immunofluorescence (DIF):** Shows a "Lupus Band"—granular deposits of IgG and C3 along the dermo-epidermal junction. * **Differential Diagnosis:** Lichen Planopilaris (LPP) also causes scarring alopecia but typically presents with **perifollicular erythema and scaling** rather than the atrophy and plugging seen in DLE.

Question 49: Which of the following conditions is a disease of the sweat glands?

A. Fordyce's spot
B. Acne vulgaris
C. Fox-Fordyce's disease (Correct Answer)
D. None of the above

Explanation: **Explanation:** The correct answer is **Fox-Fordyce’s disease**, which is a chronic inflammatory disorder of the **apocrine sweat glands**. **1. Why Fox-Fordyce’s disease is correct:** Also known as *apocrine miliaria*, this condition occurs due to the follicular occlusion of apocrine ducts, leading to the rupture of the intraepidermal portion of the duct and subsequent inflammation. It characteristically affects areas where apocrine glands are abundant, such as the axillae, areolae, and pubic region. It is most common in post-pubertal females and presents as extremely pruritic, skin-colored, dome-shaped follicular papules. **2. Why other options are incorrect:** * **Fordyce’s spots:** These are ectopic **sebaceous glands** (not sweat glands) found on the vermilion border of the lips or oral mucosa. They are asymptomatic, yellowish-white milia-like papules and are considered a normal anatomical variant. * **Acne vulgaris:** This is a chronic inflammatory disease of the **pilosebaceous unit** (comprising the hair follicle and associated sebaceous gland). While it involves oil glands, it does not involve the sweat glands (eccrine or apocrine). **Clinical Pearls for NEET-PG:** * **Key Trigger:** Fox-Fordyce symptoms often worsen with emotional stress or heat, which stimulate apocrine secretion. * **Histology:** Look for "intrafollicular spongiosis" and "mucin" in the dermis. * **Treatment:** First-line treatments include topical retinoids, topical steroids, or oral contraceptives (to suppress glandular activity). * **Distinction:** Do not confuse Fox-Fordyce with **Fordyce spots** (ectopic sebaceous) or **Darier disease** (a keratinization disorder).

Question 50: Finasteride has efficacy in the prevention of male pattern baldness by virtue of its ability to:

A. Competitively antagonize androgen receptors
B. Decrease the release of gonadotropins
C. Inhibit the synthesis of testosterone
D. Reduce the production of DHT (Correct Answer)

Explanation: **Explanation:** **Androgenetic Alopecia (AGA)**, or male pattern baldness, is primarily driven by the action of **Dihydrotestosterone (DHT)** on genetically susceptible hair follicles. DHT causes follicular miniaturization, leading to shorter, thinner hair cycles. **Why the correct answer is right:** Finasteride is a selective **Type II 5-alpha reductase inhibitor**. The enzyme 5-alpha reductase is responsible for converting Testosterone into the more potent androgen, DHT. By inhibiting this enzyme, Finasteride significantly **reduces the production of DHT** (by approximately 70% in serum), thereby halting the miniaturization process and promoting hair regrowth. **Why the incorrect options are wrong:** * **Option A:** Drugs that competitively antagonize androgen receptors include **Spironolactone** or **Flutamide**. Finasteride does not block the receptor; it blocks the conversion of the hormone itself. * **Option B:** Gonadotropin release (FSH/LH) is inhibited by **GnRH agonists/antagonists** or combined oral contraceptives. Finasteride does not act on the hypothalamic-pituitary-gonadal axis. * **Option C:** Testosterone synthesis occurs in the Leydig cells of the testes. Finasteride does not stop testosterone production; in fact, it may cause a slight compensatory increase in serum testosterone levels. **High-Yield Clinical Pearls for NEET-PG:** * **Dosing:** For AGA, the dose is **1 mg/day** orally. (Note: 5 mg/day is used for Benign Prostatic Hyperplasia). * **Dutasteride:** A more potent alternative that inhibits **both Type I and Type II** 5-alpha reductase. * **Side Effects:** Potential sexual dysfunction (decreased libido, erectile dysfunction) and a slight risk of gynecomastia. * **Contraindication:** It is strictly contraindicated in **pregnancy** (Category X) as it can cause feminization of a male fetus.

Practice by Chapter

Hair Growth Cycle and Anatomy

Practice Questions

Alopecia Areata

Practice Questions

Androgenetic Alopecia

Practice Questions

Telogen Effluvium

Practice Questions

Scarring Alopecias

Practice Questions

Hair Shaft Abnormalities

Practice Questions

Hirsutism and Hypertrichosis

Practice Questions

Nail Anatomy and Growth

Practice Questions

Nail Infections

Practice Questions

Nail Psoriasis and Other Inflammatory Nail Disorders

Practice Questions

Nail Tumors

Practice Questions

Management of Hair and Nail Disorders

Practice Questions

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