Psoriasis Practice Questions

Q: Which of the following drugs is NOT used in the management of psoriasis?

Chloroquine. In the management of psoriasis, the goal is to inhibit keratinocyte proliferation and modulate the immune response. **Why Chloroquine is the correct answer:** Chloroquine (and Hydroxychloroquine) is an antimalarial drug that is notoriously known to **exacerbate or trigger psoriasis**. It can induce a flare-up of stable plaque psoriasis or even precipitate a life-threatening **erythrodermic or pustular transformation**. The mechanism is thought to involve the inhibition of the enzyme transglutaminase and the stimulation of interleukin-8, leading to epidermal hyperproliferation. Therefore, it is strictly avoided in psoriatic patients. **Why the other options are incorrect:** * **Psoralens (Option A):** These are photosensitizing agents used in **PUVA (Psoralen + UVA)** therapy. They intercalate into DNA to inhibit rapid cell division. * **Methotrexate (Option C):** A folic acid antagonist that acts as a potent immunosuppressant and cytotoxin. It is a **gold standard systemic treatment** for severe plaque psoriasis, psoriatic arthritis, and erythrodermic psoriasis. * **Coal Tar (Option D):** One of the oldest topical treatments (e.g., Goeckerman regimen). It has anti-inflammatory and keratoplastic properties that help normalize keratinization. **NEET-PG High-Yield Pearls:** * **Drugs that aggravate psoriasis (mnemonic: B-L-A-C-K):** **B**eta-blockers, **L**ithium, **A**ntimalarials (Chloroquine), **C**orticosteroids (withdrawal), and **K** (Potassium) sparing diuretics/NSAIDs. * **First-line for localized psoriasis:** Topical Vitamin D3 analogues (Calcipotriol) and Corticosteroids. * **Drug of choice for Psoriatic Arthritis:** Methotrexate (though biologics like Secukinumab are increasingly used).

Q: Which of the following conditions is characterized by the term 'Acanthosis nigricans'?

Psoriasis. **Explanation:** The term **Acanthosis** refers to the diffuse hyperplasia (thickening) of the stratum spinosum layer of the epidermis. In **Psoriasis**, this is a hallmark histopathological feature. Specifically, Psoriasis exhibits **regular elongation of rete ridges** (often described as "test-tube in a rack" appearance) due to the rapid turnover of keratinocytes. **Analysis of Options:** * **Psoriasis (Correct):** The histopathology is characterized by the triad of **Acanthosis**, **Parakeratosis** (retention of nuclei in the stratum corneum), and **Munro’s microabscesses** (neutrophils in the parakeratotic stratum corneum). * **Dermatomyositis:** Characterized by interface dermatitis, vacuolar degeneration of the basal layer, and dermal mucin. Clinical hallmarks include Gottron papules and Heliotrope rash. * **Systemic Lupus Erythematosus (SLE):** Shows liquefactive degeneration of the basal cell layer and follicular plugging, but not the regular acanthosis seen in psoriasis. * **Tinea versicolor:** A fungal infection (Malassezia) characterized by "spaghetti and meatballs" appearance on KOH mount; histopathology shows minimal epidermal change, primarily hyphae and spores in the stratum corneum. **High-Yield Clinical Pearls for NEET-PG:** * **Acanthosis Nigricans vs. Acanthosis:** Do not confuse "Acanthosis" (a histological term) with "Acanthosis Nigricans" (a clinical condition of hyperpigmented velvety plaques associated with insulin resistance or malignancy). * **Auspitz Sign:** Pinpoint bleeding when psoriasis scales are removed, due to thinning of the suprapapillary plate over dilated capillaries. * **Kogoj’s Pustule:** Neutrophils in the stratum spinosum (seen in pustular psoriasis). * **Grattage Test:** Scraping psoriasis lesions produces a candle-grease-like scale.

Q: Deficiency of which interleukin is associated with Ditra syndrome?

IL36. **Explanation:** **DITRA Syndrome** (Deficiency of IL-36 Receptor Antagonist) is a rare, life-threatening autoinflammatory disease characterized by recurrent episodes of generalized pustular psoriasis (GPP), high fever, and systemic inflammation. 1. **Why IL-36 is correct:** The syndrome is caused by a loss-of-function mutation in the **IL36RN gene**, which encodes the **IL-36 receptor antagonist (IL-36Ra)**. Normally, IL-36Ra acts as a "brake" by binding to the IL-36 receptor and blocking pro-inflammatory signaling. In DITRA, the absence of this antagonist leads to uncontrolled, overactive IL-36 signaling, resulting in massive recruitment of neutrophils and the formation of sterile pustules across the body. 2. **Why other options are incorrect:** * **IL-26:** A member of the IL-10 family involved in mucosal immunity and antimicrobial responses; it is not linked to DITRA. * **IL-46:** This is not a standard interleukin designation (Interleukins currently range from IL-1 to IL-40). * **IL-10:** An anti-inflammatory cytokine. While its deficiency can lead to early-onset inflammatory bowel disease (IBD), it is not the cause of DITRA. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Sudden onset of widespread sterile pustules on an erythematous base (von Zumbusch pattern), triggered by infections, stress, or pregnancy. * **Genetics:** Autosomal recessive inheritance. * **Treatment:** Targeted therapy with **Spesolimab** (an IL-36 receptor monoclonal antibody) is now the specific treatment of choice for GPP flares. * **Differential:** **DIRA** (Deficiency of IL-1 Receptor Antagonist) presents similarly but involves bone lesions (osteomyelitis) and is caused by mutations in the *IL1RN* gene.

Q: What is the definitive indication for systemic steroids in psoriasis?

Impetigo herpetiformis. ### Explanation **Correct Answer: D. Impetigo herpetiformis** **Why it is correct:** Impetigo herpetiformis is a rare, life-threatening variant of **pustular psoriasis occurring during pregnancy** (usually in the third trimester). It is considered a medical emergency due to risks of placental insufficiency, fetal demise, and maternal complications like hypocalcemia or sepsis. While systemic steroids are generally avoided in psoriasis, they are the **first-line systemic treatment** in this specific condition to rapidly control inflammation and protect both the mother and the fetus. **Why the other options are incorrect:** * **A & B (Pustular Psoriasis and Erythroderma):** Systemic steroids are strictly **contraindicated** in these conditions. Although they provide rapid initial clearance, their withdrawal frequently triggers a rebound flare-up, often transforming stable plaque psoriasis into life-threatening generalized pustular psoriasis (Von Zumbusch type). * **C (Psoriatic Arthropathy):** The mainstay of treatment for psoriatic arthritis includes NSAIDs and DMARDs (like Methotrexate or Leflunomide) and biologics (TNF-alpha inhibitors). Systemic steroids are not the definitive treatment and are avoided to prevent skin flares. **High-Yield Clinical Pearls for NEET-PG:** * **The "Steroid Rule":** In dermatology, psoriasis is the classic example where systemic steroids are avoided (except in Impetigo herpetiformis). * **Auspitz Sign:** Pinpoint bleeding on peeling a scale (absent in pustular/erythrodermic variants). * **Woronoff Ring:** A pale halo around a healing psoriasis plaque. * **Drug of Choice for Pustular Psoriasis:** Oral Retinoids (Acitretin) are preferred, but they are strictly contraindicated in pregnancy (teratogenic). This is why steroids are used for Impetigo herpetiformis instead.

Q: What is the best treatment option for psoriasis during pregnancy?

Topical steroids. **Explanation:** The management of psoriasis in pregnancy follows a "step-up" approach, prioritizing fetal safety while maintaining maternal skin health. **Why Topical Steroids are the Correct Answer:** Topical corticosteroids (low to moderate potency) are considered the **first-line treatment** for psoriasis in pregnancy. They have a well-established safety profile with minimal systemic absorption when used appropriately. If topical steroids alone are insufficient, narrowband UVB (NBUVB) phototherapy is the preferred second-line intervention. **Analysis of Incorrect Options:** * **Systemic Cyclosporine:** While it can be used in severe, refractory cases under strict supervision, it is not the first-line choice due to risks of maternal hypertension, renal toxicity, and potential low birth weight. * **PUVA Therapy:** Psoralen is **contraindicated** in pregnancy because it is mutagenic and teratogenic. While UVA itself is less concerning, the systemic psoralen makes this modality unsafe. * **Infliximab:** Although some biologics are used in pregnancy (especially in the first two trimesters), they are generally reserved for severe cases where first-line therapies fail. They are not the "best" or initial option. **High-Yield Clinical Pearls for NEET-PG:** * **Teratogenic Alert:** **Methotrexate** and **Oral Retinoids (Acitretin)** are strictly contraindicated. Acitretin requires a washout period of 3 years before conception. * **Disease Course:** Approximately 40-60% of patients see improvement in psoriasis during pregnancy due to high progesterone levels, though postpartum flares are common. * **Safe Systemic Option:** If a systemic agent is absolutely necessary, **Cyclosporine** is generally preferred over others, but only after topical and NBUVB options are exhausted.

Q: Oral lesions are not seen in which of the following conditions?

Psoriasis. **Explanation:** The correct answer is **Psoriasis**. While psoriasis is a chronic inflammatory dermatosis that can affect the skin, nails, and joints, **oral involvement is extremely rare** and clinically insignificant. When oral lesions are reported (such as "geographic tongue"), they are often considered associated conditions rather than direct psoriatic manifestations. **Analysis of Options:** * **Pemphigoid (Bullous Pemphigoid):** While primarily a subepidermal blistering disease of the skin, oral mucosal involvement occurs in approximately 10–20% of cases (though less frequent than in Pemphigus Vulgaris). Cicatricial pemphigoid specifically targets mucous membranes. * **Stevens-Johnson Syndrome (SJS):** This is a hypersensitivity reaction characterized by extensive mucosal involvement. Hemorrhagic crusting of the lips and painful oral erosions are hallmark features. * **Candidiasis:** This is a fungal infection caused by *Candida albicans*. Oral candidiasis (thrush) is one of the most common clinical presentations, manifesting as white, curd-like plaques. **High-Yield Clinical Pearls for Psoriasis:** * **Auspitz Sign:** Pinpoint bleeding on peeling a scale (due to thinning of the suprapapillary epidermis). * **Koebner Phenomenon:** Development of lesions at sites of trauma (also seen in Vitiligo and Lichen Planus). * **Histology:** Look for **Munro’s microabscesses** (neutrophils in the stratum corneum) and **Kogoj’s pustules** (neutrophils in the stratum spinosum). * **Nail Changes:** Pitting (most common), Oil drop sign (pathognomonic), and subungual hyperkeratosis.

Q: Bleeding spots are seen on removal of of plaques in which of the following conditions?

Psoriasis. The correct answer is **Psoriasis**. ### **Explanation** The phenomenon described is the **Auspitz sign**, a hallmark clinical feature of Psoriasis. **Why it occurs:** In Psoriasis, there is significant epidermal hyperplasia (acanthosis) and thinning of the epidermis overlying the dermal papillae (suprapapillary thinning). Additionally, the blood vessels within the dermal papillae become dilated and tortuous. When a psoriatic plaque is forcibly removed or scraped, these fragile, superficial capillaries are ruptured, resulting in **pinpoint bleeding spots**. ### **Analysis of Incorrect Options** * **Lichen planus:** Characterized by the **6 Ps** (Planar, Purple, Polygonal, Pruritic, Papules, and Plaques) and **Wickham striae** (whitish reticular lines). It does not show Auspitz sign. * **Lichen striatus:** A self-limiting linear dermatosis following **Blaschko’s lines**, typically seen in children. It lacks the vascular changes seen in psoriasis. * **Systemic Lupus Erythematosus (SLE):** Cutaneous SLE (like DLE) is characterized by **carpet tacking sign** (follicular plugging seen when a scale is removed), not pinpoint bleeding. ### **NEET-PG High-Yield Pearls** * **Grattage Test:** The clinical procedure of scraping a lesion with a glass slide to elicit the Auspitz sign. * **Koebner Phenomenon:** Development of new psoriatic lesions at sites of trauma (also seen in Lichen Planus and Vitiligo). * **Woronoff Ring:** A pale halo of blanched skin surrounding a healing psoriatic plaque. * **Munro’s Microabscesses:** Collections of neutrophils in the stratum corneum (histopathological hallmark).

Question 1

Which of the following drugs is NOT used in the management of psoriasis?

Accepted Answer

Chloroquine

Answer

Psoralens

Answer

Methotrexate

Answer

Coaltar

Question 2

A 24-year-old lady with a past history of psoriasis presents with fever and multiple pustular lesions in a generalized distribution. What is the drug of choice for managing her condition?

Accepted Answer

Methotrexate

Answer

Corticosteroids

Answer

Retinoids

Answer

Psoralen with PUVA

Question 3

Which of the following conditions is characterized by the term 'Acanthosis nigricans'?

Accepted Answer

Psoriasis

Answer

Dermatomyositis

Answer

Systemic Lupus Erythematosus (SLE)

Answer

Tinea versicolor

Question 4

Deficiency of which interleukin is associated with Ditra syndrome?

Accepted Answer

IL36

Answer

IL 26

Answer

IL 46

Answer

IL 10

Question 5

What is the definitive indication for systemic steroids in psoriasis?

Accepted Answer

Impetigo herpetiformis

Answer

Pustular psoriasis

Answer

Erythroderma

Answer

Psoriatic arthropathy

Question 6

What is the best treatment option for psoriasis during pregnancy?

Accepted Answer

Topical steroids

Answer

Systemic cyclosporine

Answer

PUVA therapy

Answer

Infliximab

Question 7

Oral lesions are not seen in which of the following conditions?

Accepted Answer

Psoriasis

Answer

Pemphigoid

Answer

Stevens-Johnson syndrome

Answer

Candidiasis

Question 8

What is the primary indication for corticosteroid use in pustular psoriasis?

Accepted Answer

Psoriatic erythroderma during pregnancy

Answer

Psoriasis in a patient with alcoholic cirrhosis

Answer

Moderate arthritis

Answer

Extensive lesions

Question 9

What is the primary treatment for pustular psoriasis?

Accepted Answer

Retinoids

Answer

Thalidomide

Answer

Hydroxyurea

Answer

Methotrexate

Question 10

Bleeding spots are seen on removal of of plaques in which of the following conditions?

Accepted Answer

Psoriasis

Answer

Lichen planus

Answer

Lichen striatus

Answer

Systemic Lupus Erythematosus (SLE)

Psoriasis — MCQs

Psoriasis — MCQs

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