Hair and Nail Disorders — MCQs

10 questions

All are nail changes seen in cases of psoriasis except:

A child presenting with localized patches of complete hair loss with normal appearance of scalp. The diagnosis is:

Which of the following conditions is characterized by specific nail changes such as pitting, onycholysis, and oil spots?

Which of the following is characteristically seen in alopecia areata?

All are true about psoriasis except –

Swarm of bees appearance seen in?

Which of the following conditions causes alopecia without scarring -

Which of the following is the location beyond which fungus does not penetrate in tinea capitis ?

Glomus tumor is seen in -

Q10

The following image of lung washing in AIDS positive patient is stained with:

Hair and Nail Disorders 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: A child presenting with localized patches of complete hair loss with normal appearance of scalp. The diagnosis is:

A. Tinea capitis
B. Cradle cap
C. Alopecia areata (Correct Answer)
D. Telogen effluvium

Explanation: ***Alopecia areata*** - This condition is characterized by **localized, well-demarcated patches of complete hair loss** on the scalp. - The underlying skin typically appears **normal, smooth, and healthy**, without inflammation or scaling. *Tinea capitis* - This fungal infection usually presents with **scaly patches**, inflammation, pustules, or "black dots" where hairs have broken off. - The scalp appearance is typically **abnormal** due to scaling and inflammation, unlike the normal scalp seen here. *Cradle cap* - Also known as **seborrheic dermatitis in infants**, it presents as greasy, yellowish, scaly patches on the scalp. - It does not cause **complete hair loss** in localized patches, but rather diffuse scaling and sometimes mild thinning. *Telogen effluvium* - This condition involves **diffuse hair shedding** (increased number of hairs falling out), often triggered by stress, illness, or medications. - It does not present as **localized patches of complete hair loss**, and the hair thinning is generally widespread.

Question 3: Which of the following conditions is characterized by specific nail changes such as pitting, onycholysis, and oil spots?

A. Lichen planus
B. Psoriasis (Correct Answer)
C. Darier disease
D. Onychomycosis

Explanation: ***Psoriasis*** - **Psoriasis** characteristically causes several specific nail changes, including **pitting**, **onycholysis** (separation of the nail plate from the nail bed), and **oil spots** (yellow-brown discoloration resembling an oil drop under the nail). - These nail manifestations are often indicative of underlying psoriatic disease, even in the absence of extensive skin lesions. *Lichen planus* - **Lichen planus** can affect the nails, causing longitudinal ridging, thinning, and sometimes pterygium formation, but typically not pitting, onycholysis, or oil spots. - In severe cases, it can lead to permanent nail loss or scarring. *Darier disease* - **Darier disease** (keratosis follicularis) is characterized by specific nail findings such as longitudinal red and white streaks, V-shaped notching at the distal nail edge, and subungual hyperkeratosis. - It does not present with the classic triad of pitting, onycholysis, and oil spots. *Onychomycosis* - **Onychomycosis** is a fungal infection of the nail that typically causes thickening, discoloration (yellow, brown, white), and crumbling of the nail plate. - While it can cause onycholysis, it does not typically produce pitting or oil spots, which are more specific to psoriasis.

Question 4: Which of the following is characteristically seen in alopecia areata?

A. Fungal infection
B. Traumatic
C. Exclamatory mark hair (Correct Answer)
D. Scarring

Explanation: ***Exclamatory mark hair*** - **Exclamatory mark hairs** are short, broken hairs that get progressively narrower towards the scalp, resembling an exclamation mark. - They are a **pathognomonic sign** of **alopecia areata**, indicating active disease where the hair follicle immune attack is occurring. *Fungal infection* - **Fungal infections** of the scalp (tinea capitis) typically present with **scaling**, inflammation, and often **broken hairs** but not typically exclamatory mark hairs. - Diagnosis is usually confirmed by **KOH microscopy** or fungal culture. *Traumatic* - **Traumatic alopecia** (e.g., traction alopecia, trichotillomania) results from physical damage to the hair shafts or follicles. - It usually presents with **irregular patches** and broken hairs of varying lengths, without the specific exclamatory mark morphology. *Scarring* - **Scarring alopecia** (cicatricial alopecia) involves **permanent destruction** of the hair follicles, leading to irreversible hair loss and replacement by fibrous tissue. - The scalp in these conditions often appears **smooth** and devoid of follicular ostia, distinguishing it from non-scarring alopecia like alopecia areata.

Question 5: 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 6: Swarm of bees appearance seen in?

A. Telogen effluvium
B. Alopecia areata (Correct Answer)
C. Androgenetic alopecia
D. Anagen effluvium

Explanation: ***Alopecia areata*** - The "swarm of bees" appearance refers to the characteristic **peribulbar lymphocytic inflammation** seen on scalp biopsy in active alopecia areata. - This finding represents an **immune response targeting the hair follicles**, leading to non-scarring hair loss. *Telogen effluvium* - Histologically, telogen effluvium is characterized by a high proportion of **telogen hairs** in the hair counts and **no significant inflammation** around the follicles. - The "swarm of bees" peribulbar infiltrate is not a feature of telogen effluvium, which is typically a reaction to a systemic stressor. *Androgenetic alopecia* - Androgenetic alopecia is characterized by **follicular miniaturization**, where vellus hairs replace terminal hairs, and a **decrease in the number of hair follicles**. - It does not show the "swarm of bees" peribulbar lymphocytic infiltrate; instead, there might be subtle inflammation or fibrosis in advanced stages but not the dense peribulbar type. *Anagen effluvium* - Anagen effluvium is characterized by the **sudden shedding of hairs in the anagen phase** due to a toxic or inflammatory insult disrupting hair matrix keratinocyte proliferation. - Histology often shows **dystrophic anagen hairs** and damaged hair shafts, but not the specific "swarm of bees" lymphocytic infiltrate seen in alopecia areata.

Question 7: Which of the following conditions causes alopecia without scarring -

A. DLE
B. Lichen planus pilaris
C. Alopecia areata (Correct Answer)
D. Herpes Zoster

Explanation: ***Alopecia areata*** - This condition is an **autoimmune disorder** that causes non-scarring hair loss, appearing as well-demarcated, circular patches. - The hair follicles are not permanently damaged, allowing for **potential regrowth** of hair. - Classic example of **non-cicatricial (non-scarring) alopecia**. *DLE* - **Discoid Lupus Erythematosus** (DLE) is a chronic inflammatory skin condition that typically leads to **scarring alopecia**. - The inflammatory process causes permanent damage to the hair follicles, resulting in **irreversible hair loss** and scarring. - Classic example of **cicatricial (scarring) alopecia**. *Lichen planus pilaris* - This is a form of **lichen planus** that affects hair follicles, leading to **follicular inflammation** and eventual destruction. - It results in **scarring alopecia** with noticeable follicular plugs and often leaves shiny, atrophic skin. - Another example of **cicatricial (scarring) alopecia**. *Herpes Zoster* - **Herpes Zoster** (shingles) is a viral infection caused by reactivation of varicella-zoster virus, presenting with painful vesicular eruption along a dermatome. - **Not a typical cause of alopecia** (either scarring or non-scarring). - While temporary hair loss may rarely occur in severely affected areas, herpes zoster is not classified as a primary cause of alopecia in standard dermatology literature.

Question 8: Which of the following is the location beyond which fungus does not penetrate in tinea capitis ?

A. Isthmus
B. Infundibulum
C. Adamson's fringe (Correct Answer)
D. Stem

Explanation: ***Adamson's fringe*** - Adamson's fringe is the **critical anatomical boundary** located at the opening of the sebaceous gland duct into the hair follicle. - It represents the zone where **hair keratinization is complete** and marks the transition between the keratinized (dead) upper portion and the living, pre-keratinized hair matrix below. - In tinea capitis, dermatophyte fungi **cannot penetrate beyond Adamson's fringe** because they are keratinophilic organisms that can only invade fully keratinized tissue [1]—they cannot survive in the living hair bulb below this level. - This is the **deepest point of fungal penetration** in the hair follicle. *Isthmus* - The isthmus is the mid-portion of the hair follicle located **between the insertion of the arrector pili muscle and the opening of the sebaceous gland**. - It is **above/superficial to Adamson's fringe**, meaning fungi can and do penetrate through this region as they invade downward toward Adamson's fringe. - Therefore, the isthmus is **not the limiting boundary** of fungal penetration. *Infundibulum* - The infundibulum is the **uppermost segment** of the hair follicle, extending from the skin surface down to the sebaceous gland opening. - This is the **most superficial region** where fungal infection typically begins in tinea capitis. - Fungi are readily present in the infundibulum but penetrate **deeper than this level**, making it not the limiting boundary. *Stem* - "Stem" refers to the **hair shaft itself** (the visible, keratinized hair fiber) rather than a specific anatomical boundary within the follicle. - While fungi do invade the hair stem/shaft, this term does not define the **anatomical limit of penetration within the follicle architecture**—that limit is specifically Adamson's fringe. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Disorders Involving Inflammatory And Haemopoietic Cells, pp. 638-639.

Question 9: 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 10: The following image of lung washing in AIDS positive patient is stained with:

A. Grocott's methenamine silver stain (Correct Answer)
B. Ziehl-Neelsen stain
C. Auramine Rhodamine
D. Giemsa stain

Explanation: ***Grocott's methanamine silver stain*** - This stain is specifically used to visualize fungal organisms, particularly **Pneumocystis jirovecii** (formerly P. carinii), which is a common opportunistic infection in AIDS patients [1,5]. - It stains the **fungal cell walls black**, making them easily identifiable in lung washings or biopsies [1]. *Ziehl-Neelsen stain* - This stain is primarily used for identifying **acid-fast bacilli**, such as **Mycobacterium tuberculosis**. - While tuberculosis can occur in AIDS patients, the image (not provided but implied to show fungi) would not be characteristic of ZN staining. *Auramine Rhodamine* - This is a **fluorescent stain** used for the rapid screening of **acid-fast bacilli** like Mycobacterium tuberculosis. - It is a screening test that requires a fluorescence microscope and is not typically used for fungal identification. *Giemsa stain* - Giemsa stain is commonly used for staining **blood smears** to identify parasites like malaria, and for staining **bone marrow** and **lymph nodes** [2]. - It can also be used to stain some bacteria and fungi, but it is **not the primary or most effective stain** for Pneumocystis jirovecii in lung washings [2]. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Respiratory Tract Disease, pp. 318-319. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Infectious Diseases, p. 362.

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