Dermatitis and Eczema Practice Questions

Q: Dennie-Morgan fold is indicative of:

Atopic dermatitis. ***Atopic dermatitis*** - A **Dennie-Morgan fold** is an extra crease or fold in the skin below the lower eyelid, which is a common but not exclusive indicator for **atopic dermatitis**, also known as **eczema**. - Its presence suggests chronic inflammation and edema around the eyes, characteristic of this allergic skin condition. *Leprosy* - **Leprosy** primarily affects nerves, skin, eyes, and the upper respiratory tract but does not typically cause **Dennie-Morgan folds**. - Its characteristic skin lesions involve nodules, macules, and loss of sensation. *Dermatitis herpetiformis* - **Dermatitis herpetiformis** is an intensely itchy, chronic blistering skin condition associated with **celiac disease**. - It presents with symmetrical papules and vesicles, predominantly on extensor surfaces, and is not linked to periorbital folds. *TB* - **Tuberculosis (TB)** is a bacterial infection primarily affecting the lungs but can manifest in other organs. - Skin manifestations of TB, like lupus vulgaris or scrofuloderma, are rare and do not include the **Dennie-Morgan fold**.

Q: A patient comes to you with skin reactions after visiting the hair dresser. What will you do to confirm the diagnosis of contact dermatitis?

Patch Test. ***Patch Test*** - A **patch test** is the gold standard for diagnosing **allergic contact dermatitis** by directly applying suspected allergens to the skin. - This test identifies specific substances that cause a delayed hypersensitivity reaction, which is characteristic of contact dermatitis. *S IgE* - **Serum IgE** levels are primarily indicative of **Type I hypersensitivity** reactions, such as allergic rhinitis or asthma. - Contact dermatitis is a **Type IV delayed hypersensitivity reaction**, not mediated by IgE antibodies. *Allergy Test* - The term "allergy test" is broad and can refer to various methods including skin prick tests, IgE blood tests, or patch tests. - Without specifying **patch testing**, other forms of allergy tests are less appropriate for diagnosing contact dermatitis, as they target different immune mechanisms. *VDRL* - **VDRL (Venereal Disease Research Laboratory)** test is used to screen for **syphilis**, a sexually transmitted infection. - It has no relevance to the diagnosis of contact dermatitis, which is an inflammatory skin condition caused by contact with an allergen or irritant.

Q: A 70-year-old man comes to the emergency department because of a skin rash and severe itching. He appears ill; there is a generalized skin rash that is scaly, erythematous, and thickened. His palms, soles, and scalp are also involved. Which of the following is the most likely diagnosis?

erythroderma (exfoliative dermatitis). ***erythroderma (exfoliative dermatitis)*** - Erythroderma is characterized by a **generalized erythematous (red), scaly, and thickened skin rash** covering more than 90% of the body surface, accompanied by **severe itching**. - This condition is often associated with a **systemic illness**, and the patient's description of "appears ill" further supports this diagnosis. *pemphigus vulgaris* - Pemphigus vulgaris typically presents with **flaccid blisters** and erosions, particularly affecting mucous membranes, which are not described here. - While it can be widespread, the primary lesion is a **blister** rather than diffuse erythema and scaling. *dermatitis herpetiformis* - Dermatitis herpetiformis is characterized by intensely **pruritic (itchy) papules and vesicles** typically found on the extensor surfaces (e.g., elbows, knees, buttocks). - It is strongly associated with **celiac disease** and does not present as a generalized scaly, erythematous thickening. *rosacea* - Rosacea primarily affects the **face**, causing **erythema**, flushing, papules, and pustules, often sparing the palms, soles, and scalp. - It is not characterized by generalized scaling, thickening, or severe itching over the entire body.

Q: A patient with atopic dermatitis shows the following findings. Which indicates POOR prognosis? 1. Onset before age 2 2. Flexural involvement 3. Palmar hyperlinearity 4. Filaggrin mutation

4 only. ***4 only*** - A **filaggrin mutation** is a strong genetic risk factor for **persistent and more severe atopic dermatitis**, often associated with an impaired skin barrier, making it an indicator of poor long-term prognosis. - Patients with this mutation tend to have a higher likelihood of developing **asthma and allergic rhinitis** (atopic march), further complicating the disease course. *1 only* - **Onset before age 2** is typical for atopic dermatitis and is generally associated with a *better prognosis*, as many children outgrow the condition by school age or adolescence. - Early onset itself does not indicate poor prognosis; rather, persistence into adulthood or severe early disease points to worse outcomes. *2 only* - **Flexural involvement** is a common and characteristic presentation of atopic dermatitis in older children and adults, but it does not inherently indicate a poor prognosis compared to other forms of disease presentation. - While it can be bothersome, it describes the *location* of the rash rather than its severity or genetic underpinnings for persistence. *3 and 4* - **Palmar hyperlinearity** is a common cutaneous manifestation in atopic dermatitis patients, reflecting chronic skin changes rather than a direct predictor of severe or persistent disease. - While **filaggrin mutation** (4) is a poor prognostic indicator, palmar hyperlinearity alone does not carry the same weight as a poor prognostic factor.

Q: A patient with atopic dermatitis shows poor response to topical steroids. Next best step is:

Topical tacrolimus. ***Topical tacrolimus*** - When **topical steroids** are insufficient or contraindicated for atopic dermatitis, **topical calcineurin inhibitors** like tacrolimus are the next recommended step due to their anti-inflammatory and immunomodulating effects. - Tacrolimus helps reduce inflammation and itching in the skin without the risk of **steroid-induced skin atrophy** or systemic side effects seen with prolonged steroid use. *Oral antihistamines* - While **oral antihistamines** can help alleviate itching, they do not address the underlying inflammation and immune dysregulation characteristic of atopic dermatitis. - They are often used as an adjunct for symptomatic relief of pruritus, but not as the primary treatment when topical steroids fail. *Systemic steroids* - **Systemic steroids** are typically reserved for severe, widespread, or acute flares of atopic dermatitis due to their significant potential for short-term and long-term side effects such as **immunosuppression**, **Cushing's syndrome**, **osteoporosis**, and **adrenal suppression**. - They are not considered a "next best step" after topical steroids for routine management due to these risks. *UV phototherapy* - **UV phototherapy** (e.g., narrowband UVB) is an effective treatment option for moderate to severe atopic dermatitis, especially when other topical treatments have failed. - However, it typically requires specialized equipment and multiple clinic visits, making it less accessible and generally considered after topical calcineurin inhibitors or in more extensive cases.

Q: Topical steroids are most effective in:

Eczematous dermatitis. ***Eczematous dermatitis*** - Topical steroids are the **first-line treatment** for eczematous dermatitis due to their potent **anti-inflammatory** and **immunosuppressive** properties. - They effectively reduce **itching**, **redness**, and **inflammation** associated with eczema. *Bullous lesions due to HSV* - **Topical steroids are contraindicated** in herpes simplex virus (HSV) infections as they can exacerbate viral replication and worsen the lesions, potentially leading to widespread infection. - **Antiviral medications** like acyclovir are the appropriate treatment for HSV infections. *Herpes Zoster* - Similar to HSV, herpes zoster is a **viral infection** (reactivation of varicella-zoster virus), and topical steroids can worsen the condition by suppressing the immune response. - **Antiviral drugs** (e.g., valacyclovir, famciclovir) are the primary treatment for herpes zoster. *Dermal atrophy* - Dermal atrophy is a **side effect** of prolonged or potent topical steroid use, not a condition treated by them. - It involves **thinning of the skin**, **telangiectasias**, and **striae**, indicating skin damage from steroid exposure.

Q: A patient presents with erythematous, well-demarcated plaques with greasy scales on the scalp and central face. What is the most likely diagnosis?

Seborrheic dermatitis. ***Seborrheic dermatitis*** - Characterized by **erythematous, well-demarcated plaques** with **greasy, yellowish scales**, commonly affecting the **scalp, face (especially nasolabial folds, eyebrows), and chest**. - The distribution and characteristic greasy scales are highly indicative of seborrheic dermatitis, often associated with *Malassezia* yeast overgrowth. *Psoriasis* - Typically presents with **silvery, thick scales** on erythematous plaques, often located on extensor surfaces (elbows, knees) and the scalp. - While it can affect the scalp, the scales are usually silvery and dry, not greasy. *Lichen planus* - Manifests as **pruritic, purple, polygonal, planar papules and plaques** (the 6 Ps), commonly on the flexor surfaces of wrists, ankles, and oral mucosa. - The appearance of lesions (purple, polygonal) and typical locations differ significantly from the patient's presentation. *Tinea capitis* - A **fungal infection** of the scalp, presenting with **scaling, alopecia, and often inflammation or pustules**. - While it can cause scaling on the scalp, greasy scales on the central face are not typical, and it primarily presents as an infection rather than an inflammatory condition with the characteristic greasy scales of seborrheic dermatitis.

Q: A 35-year-old woman presents with erythematous, scaly plaques in the nasolabial folds, eyebrows, and scalp. What is the most likely diagnosis?

Seborrheic dermatitis. ***Seborrheic dermatitis*** - This condition is characterized by **erythematous, scaly plaques** in areas rich in sebaceous glands, such as the **nasolabial folds, eyebrows, and scalp**, matching the patient's presentation. - It's a common, **chronic inflammatory dermatosis** influencing areas with high sebum production. *Psoriasis* - While psoriasis also causes **erythematous, scaly plaques**, they are typically **sharply demarcated** and often found on extensor surfaces (elbows, knees), and the lower back, which is not the primary presentation here. - Psoriasis scales are often described as **silvery-white**, distinct from the usually greasy yellow scales seen in seborrheic dermatitis. *Tinea corporis* - This is a **fungal infection** (ringworm) that presents as **annular (ring-shaped) lesions** with a raised, erythematous border and central clearing. - The distribution in the nasolabial folds, eyebrows, and scalp is **atypical for tinea corporis**, which usually affects the trunk or limbs. *Rosacea* - Rosacea primarily involves **facial erythema, telangiectasias (visible small blood vessels), papules**, and pustules, predominantly affecting the central face. - It typically **lacks the prominent scaling** seen in the described plaques and does not commonly affect the scalp in this manner.

Question 1

Dennie-Morgan fold is indicative of:

Accepted Answer

Atopic dermatitis

Answer

Leprosy

Answer

Dermatitis herpetiformis

Answer

TB

Question 2

A patient comes to you with skin reactions after visiting the hair dresser. What will you do to confirm the diagnosis of contact dermatitis?

Accepted Answer

Patch Test

Answer

S IgE

Answer

Allergy Test

Answer

VDRL

Question 3

A 70-year-old man comes to the emergency department because of a skin rash and severe itching. He appears ill; there is a generalized skin rash that is scaly, erythematous, and thickened. His palms, soles, and scalp are also involved. Which of the following is the most likely diagnosis?

Accepted Answer

erythroderma (exfoliative dermatitis)

Answer

pemphigus vulgaris

Answer

dermatitis herpetiformis

Answer

rosacea

Question 4

A patient with atopic dermatitis shows the following findings. Which indicates POOR prognosis?
1. Onset before age 2
2. Flexural involvement
3. Palmar hyperlinearity
4. Filaggrin mutation

Accepted Answer

4 only

Answer

2 only

Answer

3 and 4

Answer

1 only

Question 5

A patient with atopic dermatitis shows poor response to topical steroids. Next best step is:

Accepted Answer

Topical tacrolimus

Answer

Oral antihistamines

Answer

Systemic steroids

Answer

UV phototherapy

Question 6

A 45-year-old woman with poorly controlled type 2 diabetes (HbA1c 9.2%) and chronic kidney disease presents with intensely pruritic nodules on extensor surfaces for 8 months. Previous treatments with topical steroids, antihistamines, and gabapentin provided minimal relief. Skin biopsy shows acanthosis, compact orthokeratosis, and increased nerve fibers. CBC shows eosinophilia. Most appropriate next step is:

Accepted Answer

Initiate dupilumab

Answer

Begin phototherapy

Answer

Start oral cyclosporine

Answer

Trial of oral doxepin

Question 7

Topical steroids are most effective in:

Accepted Answer

Eczematous dermatitis

Answer

Bullous lesions due to HSV

Answer

Herpes Zoster

Answer

Dermal atrophy

Question 8

A 5-year-old boy presents with a red, itchy rash on his cheeks and the flexural surfaces of his limbs. What is the likely diagnosis?

Accepted Answer

Atopic dermatitis

Answer

Psoriasis

Answer

Contact dermatitis

Answer

Tinea corporis

Question 9

A patient presents with erythematous, well-demarcated plaques with greasy scales on the scalp and central face. What is the most likely diagnosis?

Accepted Answer

Seborrheic dermatitis

Answer

Psoriasis

Answer

Lichen planus

Answer

Tinea capitis

Question 10

A 35-year-old woman presents with erythematous, scaly plaques in the nasolabial folds, eyebrows, and scalp. What is the most likely diagnosis?

Accepted Answer

Seborrheic dermatitis

Answer

Psoriasis

Answer

Tinea corporis

Answer

Rosacea

Dermatitis and Eczema — MCQs

Dermatitis and Eczema — MCQs

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