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Nummular Eczema — SCE Dermatology MCQ

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HardInflammatory DermatosesNummular EczemaSCE Dermatology

A patient has slowly progressive pruritic patches on bathing-trunk sites. Two biopsies have shown chronic spongiotic dermatitis, but lesions persist despite appropriate eczema treatment and some are poikilodermatous. What is the best next diagnostic strategy?

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Correct answer: E — Repeat biopsies from representative untreated lesions for clinicopathological correlation and T-cell studies

Explanation lettering: D = shown as B · E = shown as C · C = shown as D · B = shown as E

B is correct. Early mycosis fungoides may mimic eczema clinically and histologically, and initial biopsies can be nondiagnostic. Persistent, treatment-resistant patches in a characteristic distribution, evolution to poikiloderma and clinicopathological discordance justify repeat biopsies from representative untreated lesions. Immunophenotyping and T-cell receptor clonality support interpretation but are not diagnostic in isolation. Empirical systemic immunosuppression can obscure the pathology and is hazardous before CTCL is excluded. Spongiosis on one specimen does not permanently close the differential.

Reference: British Association of Dermatologists and UK Cutaneous Lymphoma Group guideline for cutaneous T-cell lymphoma: https://doi.org/10.1111/bjd.20458