Psoriasis Practice Questions

Q: Which of the following is the drug of choice in the treatment of erythrodermic psoriasis?

Methotrexate. **Explanation:** **Erythrodermic Psoriasis** is a severe, life-threatening form of psoriasis characterized by generalized erythema and scaling involving >90% of the body surface area. It requires prompt systemic intervention. **1. Why Methotrexate is the Correct Answer:** Methotrexate is considered the **first-line systemic treatment (Drug of Choice)** for stable erythrodermic psoriasis. It acts as a folic acid antagonist, inhibiting dihydrofolate reductase, which leads to decreased DNA synthesis and potent immunosuppression. It effectively halts the rapid epidermal cell turnover characteristic of this condition. Other first-line options include Cyclosporine (preferred if rapid onset is needed) and Acitretin. **2. Why the Other Options are Incorrect:** * **Psoralen (Option A):** Psoralen combined with UVA (PUVA) is contraindicated in the acute phase of erythrodermic psoriasis. Phototherapy can trigger further irritation and worsen the erythroderma. * **Systemic Steroids (Option B):** These are generally **avoided** in psoriasis. While they may provide temporary relief, their withdrawal often triggers a severe rebound flare or precipitates **von Zumbusch pustular psoriasis**. * **Estrogen (Option C):** Estrogen has no established role in the treatment of psoriasis. **Clinical Pearls for NEET-PG:** * **Most common trigger:** Sudden withdrawal of systemic steroids. * **Complications:** High-output heart failure, hypothermia, and protein loss (hypoalbuminemia) due to excessive scaling. * **Treatment Hierarchy:** * **Methotrexate:** Standard DOC. * **Cyclosporine:** Fastest acting; used in unstable/severe cases. * **Infliximab:** Highly effective biological agent for rapid control. * **Auspitz Sign:** Usually absent in erythrodermic and pustular psoriasis.

Q: Which of the following is the most serious type of psoriasis?

Generalized pustular psoriasis. **Explanation:** **Generalized Pustular Psoriasis (Von Zumbusch Psoriasis)** is considered the most serious and life-threatening form of the disease. Unlike chronic plaque psoriasis, it is characterized by the sudden onset of widespread sterile pustules on an erythematous base. The severity arises from systemic involvement; patients often present with high-grade fever, malaise, leukocytosis, and electrolyte imbalances. If left untreated, it can lead to fatal complications such as secondary sepsis, acute respiratory distress syndrome (ARDS), and high-output heart failure. **Analysis of Incorrect Options:** * **Chronic Plaque Psoriasis:** This is the most *common* type (affecting ~90% of patients) but is typically stable and localized to extensor surfaces, posing no immediate threat to life. * **Guttate Psoriasis:** Characterized by small, "drop-like" lesions often triggered by a Streptococcal sore throat. It is usually self-limiting or responds well to phototherapy. * **Flexural (Inverse) Psoriasis:** Occurs in skin folds (axilla, groin). While uncomfortable due to maceration and secondary fungal infections, it lacks systemic toxicity. **High-Yield Clinical Pearls for NEET-PG:** * **Erythrodermic Psoriasis** is the other "dermatological emergency" in the psoriasis spectrum, involving >90% of body surface area. * **Trigger:** Sudden withdrawal of systemic steroids is a classic trigger for Generalized Pustular Psoriasis. * **Histology:** Look for **Kogoj’s spongiform pustules** (neutrophils in the stratum spinosum) and **Munro’s microabscesses** (neutrophils in the stratum corneum). * **Treatment of Choice:** Oral Retinoids (Acitretin) are generally preferred for the pustular variant.

Q: Which type of psoriasis is associated with streptococcal throat infection?

Guttate. **Explanation:** **Guttate Psoriasis** is the correct answer because it is classically triggered by an upper respiratory tract infection, most commonly **Group A Beta-hemolytic Streptococcal (GABHS)** pharyngitis. The term "guttate" is derived from the Latin word *gutta* (drop), reflecting its clinical presentation: sudden onset of small, salmon-pink, drop-like papules with fine scales, primarily on the trunk and proximal extremities. This occurs due to molecular mimicry or a superantigen-mediated immune response following the infection. **Analysis of Incorrect Options:** * **Pustular Psoriasis:** Characterized by sterile pustules on an erythematous base. It is typically triggered by the withdrawal of systemic steroids, pregnancy (Impetigo Herpetiformis), or infections, but it lacks the specific, strong association with Streptococcal throat infections seen in the guttate variety. * **Flexural (Inverse) Psoriasis:** Involves skin folds (axilla, groin, sub-mammary). It presents as smooth, erythematous plaques without scaling. It is not typically associated with an acute post-streptococcal trigger. * **Scalp Psoriasis:** A common site for chronic plaque psoriasis. While it can coexist with other forms, it is not the specific subtype defined by a preceding sore throat. **High-Yield Clinical Pearls for NEET-PG:** * **Latency:** The skin eruption typically appears **1–3 weeks** after the throat infection. * **Diagnosis:** Often shows elevated **ASO (Antistreptolysin O) titers** and positive throat cultures. * **Prognosis:** It has a good prognosis and may resolve spontaneously, though it can progress to chronic plaque psoriasis in about 30-40% of cases. * **Treatment:** Management includes treating the underlying infection (Antibiotics), phototherapy (NB-UVB), and topical steroids.

Q: Which of the following statements is true regarding this skin disease?

All of the above.. ***All of the above*** - **Psoriasis** is associated with **cardiovascular comorbidities**, **psoriatic arthritis**, and **pruritus**, making all three statements correct. - This **chronic inflammatory skin disease** has systemic manifestations beyond skin involvement, affecting multiple organ systems. *Can cause premature coronary artery disease* - **Psoriasis** is associated with increased risk of **myocardial infarction** and **cardiovascular mortality** due to chronic systemic inflammation. - Patients with severe psoriasis have a **50% higher risk** of cardiovascular events compared to the general population. *Can cause arthritis* - **Psoriatic arthritis** occurs in approximately **30% of psoriasis patients**, presenting as a **seronegative spondyloarthropathy**. - It can affect **peripheral joints**, **spine**, and cause **dactylitis** (sausage-shaped fingers) and **enthesitis**. *Itching can be present* - **Pruritus** is reported in **70-90% of psoriasis patients** and significantly impacts quality of life. - The itching can be **severe** and is often associated with **stress** and **sleep disturbances**.

Q: Which condition is characterized by arthritis mutilans?

Psoriasis. **Explanation:** **Arthritis mutilans** is a severe, destructive form of inflammatory arthritis characterized by the resorption of bones and the collapse of soft tissue. It is a classic, high-yield manifestation of **Psoriatic Arthritis (PsA)**, occurring in approximately 5% of patients with PsA. The hallmark clinical feature is the **"telescoping finger"** (main en lorgnette), where the digits can be pulled back to their original length due to extensive osteolysis. Radiologically, this presents as the **"pencil-in-cup" deformity**, where the proximal bone erodes into a point that fits into the widened base of the distal bone. **Analysis of Incorrect Options:** * **Lichen planus:** An inflammatory condition of the skin and mucous membranes characterized by the "6 Ps" (Planar, Purple, Polygonal, Pruritic, Papules, and Plaques). It does not involve the joints or cause bone destruction. * **Staphylococcal scalded skin syndrome (SSSS):** A toxin-mediated blistering disease caused by *Staphylococcus aureus*. It affects the superficial epidermis (desmoglein-1) and presents with skin peeling; it has no association with chronic arthritis. * **Eczema:** A broad term for dermatitis characterized by pruritus and inflammation. While it can be chronic, it is limited to the dermo-epidermal layers and does not cause systemic joint destruction. **NEET-PG High-Yield Pearls:** * **Moll and Mason Criteria:** Used for classifying Psoriatic Arthritis. * **HLA Association:** Psoriatic arthritis is strongly associated with **HLA-B27**. * **Nail Changes:** Pitting and onycholysis are strong predictors of joint involvement in psoriasis patients. * **Radiology:** Look for "pencil-in-cup" deformity and "Gull-wing" appearance in the distal interphalangeal (DIP) joints.

Q: Test tube-shaped rete pegs is a feature of which condition?

Psoriasis.. **Explanation:** The correct answer is **Psoriasis**. This question focuses on the classic histopathological features of Psoriasis vulgaris, which are high-yield for NEET-PG. **1. Why Psoriasis is Correct:** In Psoriasis, there is a marked increase in the proliferation of keratinocytes (increased mitotic activity). This leads to **regular elongation of the rete ridges** (the downward projections of the epidermis into the dermis). These elongated ridges appear uniform, thin, and rounded at the base, resembling **"test tubes in a rack."** Other hallmark histopathological features include: * **Parakeratosis:** Retention of nuclei in the stratum corneum. * **Munro’s microabscesses:** Neutrophils within the parakeratotic stratum corneum. * **Kogoj’s spongiform pustules:** Neutrophils in the stratum spinosum. * **Auspitz sign:** Pinpoint bleeding when scales are removed due to thinning of the suprapapillary plate and dilated capillaries. **2. Why other options are incorrect:** * **Reiter’s Syndrome (Reactive Arthritis):** While it can show "psoriasiform" changes (like Munro’s microabscesses), the classic "test tube" description is specifically associated with Psoriasis. * **Geographic Tongue (Benign Migratory Glossitis):** This is considered an oral form of psoriasis and shows similar features, but the question asks for the primary condition where this sign is the diagnostic hallmark. * **OSMF (Oral Submucous Fibrosis):** This is characterized by juxta-epithelial hyalinization and **atrophy** of the epithelium with **flattening** of rete pegs, the exact opposite of the elongation seen in psoriasis. **Clinical Pearls for NEET-PG:** * **Grattage Test:** Scraping the lesion increases the silvery-white scale (candle grease sign). * **Woronoff’s Ring:** A pale halo around a healing psoriatic plaque. * **Koebner’s Phenomenon:** Development of new lesions at sites of trauma (also seen in Vitiligo and Lichen Planus).

Q: Which of the following is NOT true regarding Munro's microabscess?

Debris consists of eosinophils. **Explanation:** The correct answer is **B (Debris consists of eosinophils)** because Munro’s microabscesses are characterized by the accumulation of **neutrophils**, not eosinophils. In the pathogenesis of Psoriasis, there is a marked chemotactic migration of neutrophils from the papillary capillaries into the epidermis. When these neutrophils aggregate within the parakeratotic layers of the **stratum corneum**, they form **Munro’s microabscesses**. If these neutrophils aggregate within the stratum spinosum (forming multilocular pustules), they are referred to as **Kogoj’s spongiform pustules**. **Analysis of other options:** * **Option A:** True. Munro’s microabscesses are specifically located in the **stratum corneum** (horny layer). * **Option C:** True. These microabscesses represent the microscopic equivalent of the clinical pustules seen in variants like pustular psoriasis. * **Option D:** True. Munro’s microabscess is a **pathognomonic** histological feature of Psoriasis. **High-Yield Clinical Pearls for NEET-PG:** * **Kogoj’s Spongiform Pustule:** Neutrophils in the stratum spinosum (seen in Psoriasis and Reiter’s syndrome). * **Psoriasis Histology Mnemonic:** "A-P-A-C-H-E" * **A**canthosis (regular) * **P**arakeratosis (nuclei in stratum corneum) * **A**bsent granular layer (Hypogranulosis) * **C**lubbing of dermal papillae * **H**orny layer microabscess (Munro’s) * **E**longated Rete ridges (Camel-foot appearance) * **Auspitz Sign:** Pinpoint bleeding on peeling a scale, due to thinning of the suprapapillary plate and dilated capillaries.

Q: Which sign is observed on membrane removal of a psoriatic lesion?

Auspitz sign. **Explanation:** **Auspitz sign** is the hallmark clinical sign of Psoriasis. It refers to the appearance of **pinpoint bleeding** when the silvery-white scales (micaceous scales) are scraped off. * **Mechanism:** In psoriasis, there is significant epidermal hyperplasia (acanthosis) and thinning of the epidermis over the dermal papillae (suprapapillary thinning). Additionally, the dermal capillaries are dilated and tortuous. When the "bulk" of the scale (the **Bulkley membrane**) is removed, these fragile, superficial capillaries are ruptured, resulting in pinpoint bleeding. **Analysis of Incorrect Options:** * **A. Gottron’s sign:** Characterized by symmetric, violaceous papules over the dorsal aspect of interphalangeal joints; it is a pathognomonic feature of **Dermatomyositis**. * **B. Darier’s sign:** Refers to the formation of a wheal and flare after stroking a lesion; it is seen in **Mastocytosis** (Urticaria Pigmentosa) due to mast cell degranulation. * **D. Crowe’s sign:** Refers to axillary or inguinal freckling; it is a diagnostic criterion for **Neurofibromatosis Type 1 (NF-1)**. **High-Yield Clinical Pearls for NEET-PG:** * **Grattage Test:** The process of scraping psoriatic scales to demonstrate the "candle grease sign" (scales becoming more white/opaque) followed by the Auspitz sign. * **Koebner Phenomenon:** Appearance of new psoriatic lesions at sites of local trauma (also seen in Vitiligo and Lichen Planus). * **Woronoff Ring:** A pale halo of blanched skin surrounding a healing psoriatic plaque. * **Histopathology:** Look for Munro’s microabscesses (neutrophils in the stratum corneum) and Kogoj’s pustules (neutrophils in the stratum spinosum).

Q: Which of the following biologic agents approved for the treatment of psoriasis or psoriatic arthritis is not anti-TNF-alpha?

Alefacept. ### Explanation The correct answer is **Alefacept**. **1. Why Alefacept is the correct answer:** Alefacept is a recombinant fusion protein (LFA-3-IgG1) that works by a different mechanism than TNF inhibitors. It binds to **CD2** on memory-effector T cells, inhibiting their interaction with LFA-3 on antigen-presenting cells. This leads to the apoptosis of pathogenic T cells, which are central to the development of psoriasis. Note: Alefacept was the first biologic approved for psoriasis but has since been discontinued in many markets due to the emergence of more effective agents. **2. Why the other options are incorrect:** * **Etanercept:** A soluble fusion protein that acts as a decoy receptor, binding to both TNF-α and TNF-β. * **Infliximab:** A chimeric monoclonal antibody (mouse/human) that binds specifically to soluble and transmembrane TNF-α. * **Adalimumab:** A fully human monoclonal antibody directed against TNF-α. **3. High-Yield Clinical Pearls for NEET-PG:** * **TNF-α Inhibitors:** These are the "first-generation" biologics. Before starting these, always screen for **Latent Tuberculosis** (via Mantoux or IGRA) and Hepatitis B/C, as they can cause reactivation. * **IL-17 Inhibitors:** (e.g., **Secukinumab**, Ixekizumab) – Highly effective for psoriasis; watch out for worsening of Inflammatory Bowel Disease (IBD). * **IL-23 Inhibitors:** (e.g., **Guselkumab**, Risankizumab) – Target the p19 subunit. * **IL-12/23 Inhibitor:** **Ustekinumab** (targets the common p40 subunit). * **Apremilast:** An oral **PDE-4 inhibitor** used in psoriasis; common side effects include diarrhea and weight loss.

Q: All of the following nail changes are associated with psoriasis, EXCEPT:

Pterygium formation. **Explanation:** Psoriasis is a chronic inflammatory dermatosis that affects the nails in approximately 50% of patients. The correct answer is **Pterygium formation**, as this is a classic feature of **Lichen Planus**, not psoriasis. Pterygium occurs due to scarring of the nail matrix, leading to the fusion of the proximal nail fold to the nail bed. **Analysis of Options:** * **Pitting (Option A):** The most common nail finding in psoriasis. It results from focal areas of parakeratosis in the **proximal nail matrix**, which leave depressions as the nail grows out. * **Onycholysis (Option B):** This refers to the separation of the nail plate from the nail bed. In psoriasis, it often starts distally and may be surrounded by a yellowish margin (the "oil drop" or "salmon patch" sign). * **Subungual hyperkeratosis (Option D):** Caused by parakeratosis of the **nail bed**, leading to an accumulation of scales under the distal nail plate. **Clinical Pearls for NEET-PG:** * **Oil drop sign/Salmon patch:** Pathognomonic for psoriasis; represents localized nail bed involvement. * **Nail Psoriasis & Arthritis:** Nail involvement is a strong predictor of **Psoriatic Arthritis**, specifically involving the Distal Interphalangeal (DIP) joints. * **Pitting Comparison:** Psoriatic pits are typically deep, large, and irregularly scattered. In contrast, Alopecia Areata presents with fine, shallow, "geometric" pits. * **Differential:** Pterygium is seen in Lichen Planus (Dorsal pterygium) and Systemic Sclerosis/Raynaud's (Ventral pterygium/Hyponychium fusion).

Question 1

Which of the following is the drug of choice in the treatment of erythrodermic psoriasis?

Accepted Answer

Methotrexate

Answer

Psoralen

Answer

Systemic steroid

Answer

Estrogen

Question 2

Which of the following is the most serious type of psoriasis?

Accepted Answer

Generalized pustular psoriasis

Answer

Chronic plaque psoriasis

Answer

Guttate psoriasis

Answer

Flexural psoriasis

Question 3

Which type of psoriasis is associated with streptococcal throat infection?

Accepted Answer

Guttate

Answer

Pustular

Answer

Flexural

Answer

Scalp

Question 4

Which of the following statements is true regarding this skin disease?

Accepted Answer

All of the above.

Answer

Can cause premature coronary artery disease.

Answer

Can cause arthritis.

Answer

Itching can be present.

Question 5

Which condition is characterized by arthritis mutilans?

Accepted Answer

Psoriasis

Answer

Lichen planus

Answer

Staphylococcal scalded skin syndrome

Answer

Eczema

Question 6

Test tube-shaped rete pegs is a feature of which condition?

Accepted Answer

Psoriasis.

Answer

Reiter's syndrome.

Answer

Geographic tongue.

Answer

OSMF.

Question 7

Which of the following is NOT true regarding Munro's microabscess?

Accepted Answer

Debris consists of eosinophils

Answer

Seen in the stratum corneum

Answer

Associated pustule may be present

Answer

Seen in psoriasis

Question 8

Which sign is observed on membrane removal of a psoriatic lesion?

Accepted Answer

Auspitz sign

Answer

Grottron's sign

Answer

Darier's sign

Answer

Crowe's sign

Question 9

Which of the following biologic agents approved for the treatment of psoriasis or psoriatic arthritis is not anti-TNF-alpha?

Accepted Answer

Alefacept

Answer

Etanercept

Answer

Infliximab

Answer

Adalimumab

Question 10

All of the following nail changes are associated with psoriasis, EXCEPT:

Accepted Answer

Pterygium formation

Answer

Pitting

Answer

Onycholysis

Answer

Subungual hyperkeratosis

Psoriasis — MCQs

Psoriasis — MCQs

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