Occupational Nail Disorders — MCQs
All are true about psoriasis except:
Pterygium of nail is seen in?
All are true about psoriasis except –
Which of the following statements is incorrect regarding nail changes in various conditions?
Which one of the following is the correct description of Mee's lines, seen in chronic arsenic poisoning?
A 30-year-old washerwoman presents with the following lesion. All are correct 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?
Which of the following is not a part of P. versicolor treatment -
A hospital implements a policy to reduce occupational hand dermatitis in healthcare workers. They propose: (A) Switching from latex to nitrile gloves, (B) Installing alcohol-based hand rub dispensers, (C) Providing emollients, (D) Reducing glove use frequency. Synthesize the best evidence-based strategy.
Evaluate the following scenario: A 38-year-old worker in an electronics manufacturing unit develops hand dermatitis. Initial patch testing shows multiple positive reactions to metals (nickel, cobalt, chromium). Despite workplace modifications and protective equipment, the dermatitis persists. Re-evaluation reveals positive patch test to colophony. What is the best strategic approach?
Occupational Nail Disorders Indian Medical PG Practice Questions and MCQs
Question 1: All are true about psoriasis except:
- A. Parakeratosis & acanthosis
- B. Pitting of nails
- C. Very pruritic (Correct Answer)
- D. Joint involvement in 5–30%
Explanation: ***Very pruritic*** - While psoriasis can be itchy, it is generally not characterized as "very pruritic" compared to other dermatological conditions like **eczema** or **scabies**. - **Pruritus** in psoriasis tends to be mild to moderate, and it is not a defining characteristic that differentiates it from other skin disorders. *Parakeratosis & acanthosis* - **Parakeratosis** (retention of nuclei in the stratum corneum) and **acanthosis** (epidermal hyperplasia) are classic histopathological hallmarks of psoriasis. - These features reflect the rapid epidermal turnover characteristic of the condition. *Pitting of nails* - **Nail pitting**, onycholysis, and subungual hyperkeratosis are common and characteristic manifestations of psoriasis, affecting up to 50% of patients. - These nail changes are highly indicative of **psoriatic involvement**. *Joint involvement in 5–10%* - **Psoriatic arthritis**, involving inflammation of the joints, affects approximately 5-30% of individuals with psoriasis. - This statistic makes joint involvement a significant comorbidity of psoriasis.
Question 2: Pterygium of nail is seen in?
- A. Pemphigoid
- B. Psoriasis
- C. Pemphigus
- D. Lichen planus (Correct Answer)
Explanation: ***Lichen planus*** - **Pterygium of the nail** refers to the forward growth of the proximal nail fold over the nail plate, often seen as a V-shaped scarring, which is a characteristic feature of severe **nail lichen planus**. - Other nail changes in lichen planus can include **longitudinal ridging**, thinning, splitting, and anonychia. *Pemphigoid* - Bullous pemphigoid typically affects the **skin with tense blisters** and rarely involves the nails significantly. - Nail changes are uncommon but if present, are usually non-specific, such as **subungual hematomas** or **onycholysis**, not pterygium. *Psoriasis* - Nail psoriasis presents with characteristic features like **pitting**, **onycholysis**, **oil-drop spots**, and **subungual hyperkeratosis**. - While significant nail dystrophy can occur, true pterygium formation from the proximal nail fold is **not a typical finding** in psoriasis. *Pemphigus* - Pemphigus is an autoimmune blistering disorder characterized by **flaccid blisters** and erosions, primarily affecting the skin and mucous membranes. - **Nail involvement is rare** and usually secondary to periungual blistering, leading to non-specific changes like paronychia or onychomadesis, not pterygium.
Question 3: 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 4: Which of the following statements is incorrect regarding nail changes in various conditions?
- A. Onycholysis is seen in Psoriasis.
- B. Mees lines are indicative of Arsenic poisoning.
- C. Pterygium of nails is associated with Lichen Planus.
- D. Koilonychia is associated with Vitamin B12 deficiency. (Correct Answer)
Explanation: ***Koilonychia is associated with Vitamin B12 deficiency.*** - **Koilonychia**, or "spoon nails," is primarily associated with **iron deficiency anemia**, not Vitamin B12 deficiency. - In Koilonychia, the nails become **thin, brittle**, and concave in shape. *Onycholysis is seen in Psoriasis.* - **Onycholysis** refers to the separation of the nail plate from the nail bed, which is a common nail finding in **psoriasis**. - Other nail changes in psoriasis include **pitting**, oil spots, and subungual hyperkeratosis. *Mees lines are indicative of Arsenic poisoning.* - **Mees lines** are transverse white lines or bands that appear across the nail plate, characteristic of severe illness or poisoning. - They are classically associated with **arsenic poisoning**, but can also be seen in other conditions like thallium poisoning or kidney failure. *Pterygium of nails is associated with Lichen Planus.* - **Pterygium unguis** involves the forward growth of the proximal nail fold (cuticle) onto the nail plate, leading to fusion. - It is a prominent and often distinguishing feature of **lichen planus** affecting the nails, which can lead to permanent nail deformity or loss.
Question 5: Which one of the following is the correct description of Mee's lines, seen in chronic arsenic poisoning?
- A. Transverse white lines on the skin of palms and soles
- B. Transverse white lines on nails of fingers and toes (Correct Answer)
- C. Transverse red lines on the nails of fingers and toes
- D. Transverse red lines on the skin of palms and soles
Explanation: ***Transverse white lines on nails of fingers and toes*** - **Mee's lines** are characteristic **white transverse bands** seen specifically on the **nails** of the fingers and toes. - They are typically associated with **arsenic poisoning** but can also be seen in other systemic illnesses. *Transverse white lines on the skin of palms and soles* - While chronic arsenic poisoning can cause **skin pigmentation changes** (melanosis) and **hyperkeratosis** on the palms and soles, it does not typically manifest as distinct white transverse lines on the skin. - Mee's lines are exclusively a **nail finding**. *Transverse red lines on the nails of fingers and toes* - **Red lines on nails** are not characteristic of Mee's lines; Mee's lines are described as **white**. - Red nail changes, such as splinter hemorrhages, are often associated with other conditions, like **endocarditis**. *Transverse red lines on the skin of palms and soles* - This description does not correspond to Mee's lines, which are **white nail changes**, nor is it a typical manifestation of chronic arsenic poisoning on the skin in this specific pattern. - Skin manifestations of arsenic poisoning on palms and soles are usually **hyperpigmentation** and **hyperkeratosis**.
Question 6: A 30-year-old washerwoman presents with the following lesion. All are correct except:
- A. Rule out diabetes mellitus in recurrent episodes
- B. Deformed nail plate
- C. Tinea unguium (Correct Answer)
- D. Caused by normal commensal of GIT
Explanation: ***Tinea unguium*** - **Tinea unguium** (onychomycosis) is a **dermatophyte infection** of the nail plate, typically caused by *Trichophyton* species, not *Candida*. - The image shows **chronic paronychia** caused by *Candida* affecting the nail fold, which is a completely different condition from tinea unguium. *Caused by normal commensal of GIT* - *Candida albicans* is indeed a **normal commensal** of the gastrointestinal tract and can cause chronic paronychia in washerwomen. - Constant **water exposure** allows this opportunistic organism to colonize and infect the periungual tissues. *Rule out diabetes mellitus in recurrent episodes* - **Recurrent candidal infections** warrant screening for **diabetes mellitus** due to impaired immune function and elevated glucose levels. - Diabetic patients have increased susceptibility to **opportunistic fungal infections** including chronic paronychia. *Deformed nail plate* - The image clearly shows **nail dystrophy** with irregular, discolored, and thickened nail plate secondary to chronic inflammation. - **Chronic paronychia** affects the nail matrix, leading to **abnormal nail growth** and permanent deformation.
Question 7: 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 8: Which of the following is not a part of P. versicolor treatment -
- A. Selenium sulfide
- B. Clotrimazole
- C. Ketoconazole
- D. Griseofulvin (Correct Answer)
Explanation: **Griseofulvin (Correct - NOT used for P. versicolor)** - **Griseofulvin** interferes with fungal cell division and is primarily used for dermatophyte infections of the skin, hair, and nails, not superficial yeast infections like *P. versicolor*. - It is systemically absorbed and incorporated into **keratin precursor cells**, offering protection against dermatophytes in newly formed tissue. - *Malassezia* species (causing P. versicolor) are **yeasts**, not dermatophytes, making griseofulvin ineffective. *Selenium sulfide (Incorrect - IS used)* - **Selenium sulfide** is an effective topical antifungal agent commonly used in shampoos and lotions to treat *P. versicolor* by inhibiting the growth of *Malassezia* species. - It works by reducing **sebum production** and having a direct fungistatic effect on the yeast. *Clotrimazole (Incorrect - IS used)* - **Clotrimazole** is a broad-spectrum azole antifungal that is very effective as a topical treatment for *P. versicolor* by inhibiting ergosterol synthesis in the fungal cell membrane. - It works well for localized patches of the infection. *Ketoconazole (Incorrect - IS used)* - **Ketoconazole**, another azole antifungal, is highly effective for *P. versicolor* and can be used topically (shampoos, creams) or orally in more extensive or recalcitrant cases. - It disrupts the fungal cell membrane by inhibiting the synthesis of **ergosterol**.
Question 9: A hospital implements a policy to reduce occupational hand dermatitis in healthcare workers. They propose: (A) Switching from latex to nitrile gloves, (B) Installing alcohol-based hand rub dispensers, (C) Providing emollients, (D) Reducing glove use frequency. Synthesize the best evidence-based strategy.
- A. Implement all four measures as glove occlusion worsens dermatitis
- B. Implement only A and C to reduce costs
- C. Implement A, B, and C; avoiding D as it compromises infection control (Correct Answer)
- D. Focus only on B and C as glove material is not the primary issue
Explanation: ***Implement A, B, and C; avoiding D as it compromises infection control*** - Combining **non-latex (nitrile) gloves**, **alcohol-based rubs**, and **emollients** is the evidence-based triad for reducing **irritant contact dermatitis** and **Type I hypersensitivity** while maintaining skin barrier integrity. - Reducing the frequency of glove use (D) is an inappropriate strategy because it directly **compromises infection control** and increases the risk of **bloodborne pathogen exposure**. *Implement all four measures as glove occlusion worsens dermatitis* - While **glove occlusion** can contribute to dermatitis, intentionally reducing glove use (D) violates standard precautions for **patient and provider safety**. - The goal is to optimize the **type of glove** and **skin care regimen** rather than sacrificing necessary barrier protection. *Implement only A and C to reduce costs* - Excluding **alcohol-based hand rubs (B)** is counterproductive, as frequent washing with water and detergent is actually more **irritating to the skin** than alcohol rubs. - A strategy based solely on cost ignores the clinical evidence that **barrier creams and emollients** work best when integrated with less damaging hand hygiene methods. *Focus only on B and C as glove material is not the primary issue* - This ignores the significant prevalence of **latex allergy** and sensitivity to **accelerants** found in standard gloves, which contributes to **allergic contact dermatitis**. - Switching to **nitrile gloves (A)** is a critical step in a comprehensive occupational policy to eliminate **Type I latex hypersensitivity** risks.
Question 10: Evaluate the following scenario: A 38-year-old worker in an electronics manufacturing unit develops hand dermatitis. Initial patch testing shows multiple positive reactions to metals (nickel, cobalt, chromium). Despite workplace modifications and protective equipment, the dermatitis persists. Re-evaluation reveals positive patch test to colophony. What is the best strategic approach?
- A. The persistent dermatitis indicates evolution to chronic actinic dermatitis
- B. Colophony in soldering flux is the relevant occupational allergen; the metal sensitivities may be cross-reactions or co-sensitization (Correct Answer)
- C. All positive reactions are equally relevant and complete job change is mandatory
- D. The multiple sensitivities indicate systemic contact dermatitis requiring systemic therapy
Explanation: ***Colophony in soldering flux is the relevant occupational allergen; the metal sensitivities may be cross-reactions or co-sensitization*** - **Colophony** (rosin) is a frequent sensitizer in the **electronics industry**, where it is used as a flux in **soldering** to prevent oxidation. - Persistence of symptoms despite metal avoidance highlights the importance of identifying the **relevant allergen** versus incidental background sensitivity or **cross-reactivity**. *The persistent dermatitis indicates evolution to chronic actinic dermatitis* - **Chronic actinic dermatitis** is a photosensitive condition and is not a typical progression of **allergic contact dermatitis** caused by chemical exposure. - There is no clinical evidence of **photosensitivity** or UV-induced lesions mentioned in this occupational scenario. *All positive reactions are equally relevant and complete job change is mandatory* - Not all positive **patch tests** translate to clinical relevance; some may represent **excited skin syndrome** or past, non-relevant exposures. - A **job change** is a last resort; the management focus should be on specific **allergen substitution** or improved engineering controls for the **colophony** exposure. *The multiple sensitivities indicate systemic contact dermatitis requiring systemic therapy* - **Systemic contact dermatitis** occurs when an allergen is medicinally or dietarily ingested, not through **occupational cutaneous contact**. - Primary management involves **allergen avoidance** and topical therapists rather than initiating long-term **systemic immunosuppression** for manageable contactants.
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