Atopic Dermatitis in Children — MCQs
Rakesh, a 7-year-old boy, presents with a 3-year history of itchy, excoriated papules on his forehead and exposed parts of his arms and legs. The condition is most severe during the rainy season and improves completely in winter. What is the most likely diagnosis?
A 25-year-old patient presents with chronic itchy, erythematous skin lesions on the flexural areas that have been recurring since childhood. The patient has a family history of asthma. Which of the following is the most important diagnostic criterion for the most likely diagnosis?
A child presented with itchy plaques over the neck, the bilateral popliteal and cubital fossa. What could be the diagnosis?
Which of the following is the MOST contraindicated condition for steroid use?
A child has a rash. His family history is positive for asthma. What could be the most probable diagnosis?
A child presents with itchy lesions and diarrhea and has been advised to follow a gluten-free diet. What is the most likely etiology of this condition?
A child presents with grouped vesicles on an erythematous base on buttocks, knees and elbows. Diagnosis?
A child presents with grouped vesicles on an erythematous base on buttocks, knees and elbows. Diagnosis?
Identify the lesion: (Recent NEET Pattern 2016-17)
A child presents with a history of hypopigmented macules on the back, infantile spasms, and delayed milestones. What is the most likely diagnosis?
Atopic Dermatitis in Children Indian Medical PG Practice Questions and MCQs
Question 1: Rakesh, a 7-year-old boy, presents with a 3-year history of itchy, excoriated papules on his forehead and exposed parts of his arms and legs. The condition is most severe during the rainy season and improves completely in winter. What is the most likely diagnosis?
- A. Insect bite hypersensitivity
- B. Scabies
- C. Atopic dermatitis (Correct Answer)
- D. Urticaria
Explanation: ***Atopic dermatitis*** - The **chronic itchy dermatitis** starting at age 4 and the presence of **excoriated papules** are consistent with atopic dermatitis, which is one of the most common chronic dermatoses in children. - While atopic dermatitis in school-age children typically affects **flexural areas** (antecubital and popliteal fossae), it can also involve the face and extensor surfaces, particularly as a continuation from earlier infantile patterns. - The **seasonal variation** can occur in atopic dermatitis due to changes in humidity, allergen exposure, and temperature, though the pattern of worsening in rainy season is somewhat atypical. - Given the chronic course and age of onset in early childhood with persistent itchy papules, atopic dermatitis remains the most likely diagnosis among the given options. *Insect bite hypersensitivity* - This would typically present with localized **urticarial papules** or **vesicles** at discrete bite sites, not a diffuse chronic condition lasting 3 years. - While insect bites can be seasonal and cause itchy excoriated papules, the **continuous 3-year duration** with consistent distribution patterns is not typical for bite reactions. *Scabies* - Scabies presents with intense itching (worse at night) and **pathognomonic burrows** in characteristic sites: finger webs, wrists, axillae, belt line, and genitalia. - The **distribution** described (forehead and exposed extremities) is not typical for scabies, nor would it show complete improvement seasonally without treatment. - Untreated scabies would not spontaneously resolve completely in winter. *Urticaria* - Urticaria manifests as **transient, migratory wheals** (hives) that typically resolve within 24 hours, even in chronic cases. - The description of persistent **excoriated papules** over 3 years is incompatible with urticaria, which is characterized by evanescent lesions, not fixed papules.
Question 2: A 25-year-old patient presents with chronic itchy, erythematous skin lesions on the flexural areas that have been recurring since childhood. The patient has a family history of asthma. Which of the following is the most important diagnostic criterion for the most likely diagnosis?
- A. Personal or family history of atopy
- B. Elevated serum IgE levels
- C. Early age of onset (before 2 years)
- D. Chronic pruritic eczema with typical morphology and distribution (Correct Answer)
Explanation: ***Chronic pruritic eczema with typical morphology and distribution*** - The patient presents with **chronic**, **itchy**, **erythematous lesions** on the **flexural areas** (e.g., antecubital and popliteal fossae), characteristic of **atopic dermatitis** (eczema). - The **recurrence since childhood** and the typical distribution represent the **major diagnostic criteria** based on clinical morphology and distribution. - **Clinical presentation with typical morphology** is the **primary diagnostic criterion** according to Hanifin and Rajka criteria. *Elevated serum IgE levels* - While **elevated serum IgE** is often associated with atopic dermatitis, it is a **minor criterion** and a **laboratory finding**, not a primary diagnostic feature. - It reflects an **atopic predisposition**, but **clinical morphology and distribution** remain the most important diagnostic factors. *Personal or family history of atopy* - A **family history of asthma** (an atopic condition) is a **minor criterion** that supports the diagnosis of atopic dermatitis. - However, this is a **predisposing/supporting factor**, not as important as the characteristic clinical morphology and distribution. *Early age of onset (before 2 years)* - While atopic dermatitis often begins in **infancy or early childhood**, this is a **minor criterion** in the diagnostic framework. - The question states symptoms **recurring since childhood** but onset timing is less diagnostically important than the characteristic **clinical presentation** with typical morphology and distribution.
Question 3: A child presented with itchy plaques over the neck, the bilateral popliteal and cubital fossa. What could be the diagnosis?
- A. Dermatitis herpetiformis
- B. Psoriasis
- C. Pemphigus vegetans
- D. Atopic dermatitis (Correct Answer)
Explanation: **Atopic dermatitis** - The presentation of **itchy plaques** in the anatomical locations described (neck, bilateral popliteal fossa, and cubital fossa) is highly characteristic of **atopic dermatitis** in children. - Atopic dermatitis typically involves **flexural surfaces** in older children and adults, and is characterized by **intense pruritus**. *Dermatitis herpetiformis* - This condition presents with **extremely itchy, grouped vesicles and papules**, primarily on extensor surfaces, buttocks, and scalp. - It is strongly associated with **celiac disease** and is unlikely to present as plaques in flexural areas. *Psoriasis* - Psoriasis typically presents with **well-demarcated, erythematous plaques** covered with **silvery scales**, often on extensor surfaces (knees, elbows) and the scalp. - While it can occur in flexural areas (inverse psoriasis), **itching is usually less prominent** than in atopic dermatitis, and the characteristic scaling is usually present. *Pemphigus vegetans* - Pemphigus vegetans is a rare variant of pemphigus, characterized by **verrucous, vegetative lesions** and **bullae**, often in intertriginous areas. - This condition is a chronic autoimmune blistering disease and does not typically present as simple itchy plaques in a child.
Question 4: Which of the following is the MOST contraindicated condition for steroid use?
- A. Herpetic keratitis
- B. Exposure keratitis
- C. Atopic dermatitis
- D. Fungal corneal ulcer (Correct Answer)
Explanation: ***Fungal corneal ulcer*** - Steroids are **immunomodulatory** and can suppress the immune response, which is crucial for fighting fungal infections [1]. - Using steroids in cases of fungal keratitis can lead to rapid **worsening of the infection**, potentially causing vision loss or even globe rupture. *Herpetic keratitis* - While steroids can exacerbate active **herpes simplex virus (HSV) epithelial keratitis**, they are often used cautiously in certain forms of herpetic keratitis, such as **stromal keratitis** or **endotheliitis**, under antiviral coverage to control inflammation. - The key is proper diagnosis to differentiate epithelial (contraindicated) from stromal/endothelial (potentially indicated with antivirals) forms. *Exposure keratitis* - This condition is caused by **incomplete eyelid closure** leading to corneal drying and damage, not primarily by inflammation requiring steroid suppression. - Management focuses on **lubrication** and protecting the surface, and steroids are generally not indicated. *Atopic dermatitis* - **Topical corticosteroids** are the mainstay of treatment for atopic dermatitis due to their potent **anti-inflammatory** effects [2]. - This condition is an inflammatory skin disorder, and steroids help to reduce inflammation, itching, and redness [3].
Question 5: A child has a rash. His family history is positive for asthma. What could be the most probable diagnosis?
- A. Seborrheic dermatitis
- B. Atopic dermatitis (Correct Answer)
- C. Allergic contact dermatitis
- D. Erysipelas
Explanation: ***Atopic dermatitis*** - The presence of a rash in a child with a family history of **asthma** strongly suggests atopic dermatitis, as it is part of the **atopic triad** (eczema, asthma, allergic rhinitis). - Atopic dermatitis often presents with **erythematous, pruritic patches** and plaques, commonly affecting flexural areas like the antecubital and popliteal fossae, as well as the face and neck in younger children. *Seborrheic dermatitis* - This condition typically presents with **greasy, yellowish scales** on an erythematous base, often affecting areas rich in sebaceous glands such as the scalp, face (nasolabial folds), and chest. - While it can occur in infants, it does not have the strong association with a family history of asthma seen in atopic dermatitis. *Allergic contact dermatitis* - This rash results from an **exposure to an allergen**, leading to a localized, erythematous, and pruritic eruption, often with vesicles or bullae, at the site of contact. - The history does not provide information about a specific allergen exposure, and while it could produce a similar-looking rash, the family history of asthma points more strongly to atopic diathesis. *Erysipelas* - Erysipelas is a superficial skin infection, usually caused by *Streptococcus pyogenes*, presenting as a **well-demarcated, intensely erythematous, warm, and painful rash** with a raised border. - This is an **acute bacterial infection** and would typically be accompanied by systemic symptoms like fever and chills, which are not mentioned in the child's presentation.
Question 6: A child presents with itchy lesions and diarrhea and has been advised to follow a gluten-free diet. What is the most likely etiology of this condition?
- A. Whipple's disease
- B. Crohn's disease
- C. Dermatitis herpetiformis
- D. Celiac disease (Correct Answer)
Explanation: ***Celiac disease*** - **Celiac disease** is an autoimmune condition triggered by **gluten ingestion**, leading to small intestine damage and nutrient malabsorption. - The combination of **itchy lesions** (dermatitis herpetiformis, a skin manifestation of celiac disease), **diarrhea**, and improvement on a **gluten-free diet** are highly characteristic. - Since the question asks for the **underlying etiology**, celiac disease is the correct answer as it causes both the skin and GI manifestations. *Whipple's disease* - This is a rare systemic infection caused by the bacterium **Tropheryma whipplei**, presenting with **arthralgia, fever, malabsorption, and lymphadenopathy**. - While it can cause diarrhea and malabsorption, it is not associated with itchy skin lesions and does not respond to a gluten-free diet. *Crohn's disease* - **Crohn's disease** is a type of inflammatory bowel disease affecting any part of the GI tract, causing **abdominal pain, diarrhea, and weight loss**. - It is not associated with dermatitis herpetiformis and does not improve with a gluten-free diet (though some patients may have gluten sensitivity). *Dermatitis herpetiformis* - **Dermatitis herpetiformis** is the **cutaneous manifestation of celiac disease**, presenting as intensely itchy, vesicular lesions. - While DH explains the itchy lesions in this case, it is a **symptom/manifestation**, not the underlying **etiology**—the root cause is celiac disease itself, which produces both the intestinal damage (diarrhea) and the skin manifestations (DH).
Question 7: A child presents with grouped vesicles on an erythematous base on buttocks, knees and elbows. Diagnosis?
- A. Bullous impetigo
- B. Herpes simplex
- C. Pemphigus
- D. Dermatitis herpetiformis (Correct Answer)
Explanation: ***Dermatitis herpetiformis*** - This condition presents with **grouped vesicles on an erythematous base**, characteristically affecting the **extensor surfaces** such as the buttocks, knees, and elbows. - It is an **autoimmune blistering disease** strongly associated with **celiac disease**, making treatment with a **gluten-free diet** essential. *Bullous impetigo* - Characterized by **flaccid bullae** that rupture and leave a honey-colored crust, primarily caused by **Staphylococcus aureus**. - Typically not associated with an erythematous base or the specific distribution seen in this case. *Herpes simplex* - Causes **grouped vesicles** on an erythematous base, but usually in a **localized distribution** (e.g., oral or genital) and often preceded by prodromal symptoms like tingling. - While it can cause grouped vesicles, the widespread distribution on buttocks, knees, and elbows is atypical. *Pemphigus* - Pemphigus (e.g., Pemphigus vulgaris) involves **flaccid bullae** and often affects mucous membranes, with a positive **Nikolsky sign**. - It is typically seen in adults and less commonly presents as grouped vesicles on specific extensor surfaces in children.
Question 8: A child presents with grouped vesicles on an erythematous base on buttocks, knees and elbows. Diagnosis?
- A. Dermatitis herpetiformis (Correct Answer)
- B. Pemphigus
- C. Bullous impetigo
- D. Herpes simplex
Explanation: ***Dermatitis herpetiformis*** - The classic presentation of **grouped vesicles on an erythematous base** over the **extensor surfaces** like the buttocks, knees, and elbows is characteristic of **dermatitis herpetiformis**. - This condition is strongly associated with **celiac disease** and is caused by IgA deposition in the dermal papillae. *Pemphigus* - Pemphigus typically involves **flaccid bullae** that rupture easily, often presenting on the **mucous membranes** and skin, but not usually as grouped vesicles on an erythematous base. - It is an **autoimmune blistering disease** caused by autoantibodies against desmoglein, leading to **intraepidermal blistering**. *Bullous impetigo* - Bullous impetigo is a **bacterial skin infection** characterized by **fragile, fluid-filled blisters** (bullae) that can rupture and leave a honey-colored crust, commonly caused by *Staphylococcus aureus.* - While it presents with bullae, it does not typically show the characteristic **grouped vesicles on an erythematous base** seen in dermatitis herpetiformis. *Herpes simplex* - Herpes simplex infection causes **grouped vesicles** on an erythematous base, but these are typically found around the **oral (herpes labialis)** or **genital areas**. - While the morphology is similar, the **distribution on the buttocks, knees, and elbows** in a child points away from herpes simplex as the primary diagnosis.
Question 9: Identify the lesion: (Recent NEET Pattern 2016-17)
- A. Erythema multiforme (Correct Answer)
- B. Gianotti-Crosti syndrome
- C. Pityriasis rosea
- D. Acne rosacea
Explanation: ***Erythema multiforme*** - The image displays characteristic **targetoid lesions** with multiple concentric rings of color (erythema, edema, pallor), typical of **erythema multiforme**. - These lesions often appear suddenly, symmetrically, and commonly on the extremities, often triggered by infections (e.g., **herpes simplex virus**) or medications. *Gianotti-Crosti syndrome* - Characterized by **monomorphic, flesh-colored to erythematous papules** and papulovesicles, often on the cheeks, buttocks, and extensor surfaces of the limbs. - This condition is typically observed in **children** after viral infections and does not usually present with target lesions. *Pityriasis rosea* - Starts with a single **"herald patch,"** followed by smaller, oval, pinkish-red patches with fine scales, often arranged in a **"Christmas tree pattern"** on the trunk. - The morphology of the lesions in the image, specifically the targetoid appearance, is not consistent with pityriasis rosea. *Acne rosacea* - Marked by **facial erythema**, papules, pustules, and telangiectasias, primarily affecting the central face. - It does not present with the widespread, distinct target lesions seen in the image.
Question 10: A child presents with a history of hypopigmented macules on the back, infantile spasms, and delayed milestones. What is the most likely diagnosis?
- A. Neurofibromatosis
- B. Sturge-Weber syndrome
- C. Tuberous sclerosis (Correct Answer)
- D. Nevus anemicus
Explanation: ### Explanation **Correct Answer: C. Tuberous Sclerosis (TSC)** The clinical triad of **hypopigmented macules (Ash-leaf spots)**, **infantile spasms** (West Syndrome), and **delayed milestones** is classic for Tuberous Sclerosis Complex. * **Pathophysiology:** TSC is an autosomal dominant neurocutaneous syndrome caused by mutations in the *TSC1* (Hamartin) or *TSC2* (Tuberin) genes, leading to the overactivation of the mTOR pathway and the formation of hamartomas in multiple organs. * **Dermatological markers:** Ash-leaf spots are often the earliest sign. Other features include Adenoma sebaceum (angiofibromas), Shagreen patches (connective tissue nevi), and periungual fibromas (Koenen tumors). * **Neurological markers:** Cortical tubers and subependymal nodules lead to seizures (infantile spasms) and intellectual disability. **Why Incorrect Options are Wrong:** * **A. Neurofibromatosis:** Characterized by *hyperpigmented* Café-au-lait macules, Lisch nodules, and neurofibromas, rather than hypopigmentation and infantile spasms. * **B. Sturge-Weber Syndrome:** Presents with a Port-wine stain (Nevus Flammeus) in the V1/V2 distribution of the trigeminal nerve, glaucoma, and leptomeningeal angiomas. * **C. Nevus Anemicus:** A localized vascular anomaly presenting as a pale patch due to catecholamine sensitivity. It does not cause systemic neurological symptoms or developmental delay. **High-Yield Clinical Pearls for NEET-PG:** * **Earliest sign:** Ash-leaf spots (best seen under **Wood’s lamp**). * **Most common heart lesion:** Rhabdomyoma (often regresses spontaneously). * **Most common kidney lesion:** Angiomyolipoma. * **Drug of choice for Infantile Spasms in TSC:** Vigabatrin. * **Pathognomonic sign:** Koenen tumors (Periungual fibromas).
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