Psoriasis Practice Questions

Q: All of the following are used in the management of Psoriasis except?

Reslizumab. ### Explanation **Correct Answer: C. Reslizumab** **1. Why Reslizumab is the Correct Answer:** Reslizumab is a humanized monoclonal antibody that binds to **Interleukin-5 (IL-5)**. IL-5 is the primary cytokine responsible for the growth, activation, and survival of **eosinophils**. Therefore, Reslizumab is indicated for the add-on maintenance treatment of **severe eosinophilic asthma**, not psoriasis. Psoriasis is primarily a Th1/Th17 mediated disease, whereas IL-5 is associated with Th2-mediated eosinophilic inflammation. **2. Analysis of Incorrect Options (Used in Psoriasis):** * **Secukinumab (Option A):** A fully human monoclonal antibody that inhibits **IL-17A**. It is highly effective and FDA-approved for moderate-to-severe plaque psoriasis and psoriatic arthritis. * **Ixekizumab (Option B):** Another potent **IL-17A inhibitor**. Like Secukinumab, it is a mainstay in the biological management of recalcitrant psoriasis. * **Guselkumab (Option D):** A monoclonal antibody that targets the **p19 subunit of IL-23**. By inhibiting IL-23, it prevents the maintenance of Th17 cells, making it a first-line biological agent for chronic plaque psoriasis. **3. NEET-PG Clinical Pearls:** * **IL-17 Inhibitors:** Secukinumab, Ixekizumab, Brodalumab (targets IL-17 receptor). *Caution: Can exacerbate Inflammatory Bowel Disease (IBD).* * **IL-23 Inhibitors:** Guselkumab, Tildrakizumab, Risankizumab. * **IL-12/23 Inhibitor:** Ustekinumab (targets the p40 subunit). * **TNF-α Inhibitors:** Infliximab, Adalimumab, Etanercept. * **Apremilast:** An oral **PDE-4 inhibitor** used in psoriasis management. * **First-line systemic drug (Non-biological):** Methotrexate remains the most commonly used systemic agent for extensive psoriasis in the Indian context.

Q: What is the drug of choice for pustular psoriasis in pregnancy?

Systemic steroids. **Explanation:** **Pustular psoriasis in pregnancy** (historically known as *Impetigo Herpetiformis*) is a rare but life-threatening dermatosis. It typically occurs in the third trimester and is characterized by sterile pustules on an erythematous base, often accompanied by systemic symptoms like fever, malaise, and electrolyte imbalances (hypocalcemia). **Why Systemic Steroids are the Correct Choice:** Systemic corticosteroids (e.g., Prednisolone) are the **first-line treatment** (Drug of Choice) for this condition. They are effective in rapidly controlling the acute inflammatory surge and are considered relatively safe for the fetus compared to other potent antipsoriatic agents. Prompt treatment is vital to prevent placental insufficiency and fetal distress. **Why the Other Options are Incorrect:** * **Methotrexate (A):** It is strictly **contraindicated** in pregnancy (Category X) due to its potent teratogenic effects and risk of fetal death. * **Ciclosporin (B):** While it can be used as a second-line agent in refractory cases, it is not the primary drug of choice due to risks of pregnancy-induced hypertension and low birth weight. * **Azathioprine (D):** It is generally not used for the acute management of pustular psoriasis as its onset of action is slow and it is less effective than steroids for this specific indication. **High-Yield Clinical Pearls for NEET-PG:** * **Impetigo Herpetiformis** is now considered a variant of generalized pustular psoriasis triggered by hormonal changes. * **Key Lab Abnormality:** Hypocalcemia is frequently associated and must be corrected to prevent maternal seizures. * **Retinoids (Acitretin):** The drug of choice for *non-pregnant* pustular psoriasis, but absolutely contraindicated in pregnancy (teratogenic for 3 years post-discontinuation). * **First-line for Chronic Plaque Psoriasis in pregnancy:** Narrowband UVB (NBUVB) or topical steroids.

Q: The oil drop sign of the nail is seen in which condition?

Psoriasis. **Explanation:** The **Oil drop sign** (also known as the salmon patch) is a pathognomonic clinical feature of **Psoriasis** affecting the nails. It occurs due to the accumulation of glycoprotein and inflammatory exudate in the nail bed, resulting from focal parakeratosis. This appears as a translucent, yellowish-red discoloration beneath the nail plate, resembling a drop of oil. **Analysis of Options:** * **Psoriasis (Correct):** In addition to the oil drop sign, other characteristic nail findings include **pitting** (deep, irregular, and randomly distributed), **onycholysis** (separation of the nail plate from the bed), and **subungual hyperkeratosis**. * **Lichen Planus:** Typically presents with **pterygium formation** (V-shaped scarring of the cuticle), longitudinal ridging, and thinning of the nail plate. It does not show oil drop signs. * **Dermatophytes (Onychomycosis):** Characterized by subungual debris, yellow-white discoloration, and nail thickening. While it can mimic psoriasis, it lacks the specific salmon-patch appearance. * **Lupus Vulgaris:** This is a form of cutaneous tuberculosis. It typically presents with "apple-jelly nodules" on diascopy, not specific nail matrix or bed changes. **High-Yield Clinical Pearls for NEET-PG:** * **Psoriatic Pitting:** Caused by focal parakeratosis in the **proximal nail matrix**. * **Oil Drop Sign:** Caused by involvement of the **nail bed**. * **Auspitz Sign:** Pinpoint bleeding upon removal of psoriatic scales (due to dilated capillaries in dermal papillae). * **Koebner Phenomenon:** Development of lesions at sites of trauma (also seen in Lichen Planus and Vitiligo).

Q: A 30-year-old male presents with silvery, scaling plaques on his elbows and knees. His mother has a history of the same condition. What is the most likely diagnosis?

Psoriasis vulgaris. **Explanation:** The clinical presentation of **silvery, scaling plaques** on extensor surfaces (**elbows and knees**) in a young adult with a positive family history is the classic hallmark of **Psoriasis vulgaris**. **Why Psoriasis vulgaris is correct:** Psoriasis is a chronic, T-cell-mediated inflammatory dermatosis characterized by epidermal hyperproliferation. The "silvery-white" scale (micaceous scale) results from parakeratosis (retention of nuclei in the stratum corneum). Its predilection for extensor surfaces and strong genetic association (linked to HLA-Cw6) confirms the diagnosis in this patient. **Why the other options are incorrect:** * **Acne rosacea:** Typically presents with facial flushing, telangiectasia, and papulopustules. It lacks the thick silvery scales and extensor distribution seen here. * **Acne vulgaris:** Characterized by comedones (blackheads/whiteheads), papules, and pustules, primarily on the face, back, and chest; not scaling plaques on limbs. * **Pemphigus vulgaris:** An autoimmune blistering disease characterized by fragile, intraepidermal bullae and painful oral erosions. It involves a positive Nikolsky sign, not scaling plaques. **NEET-PG High-Yield Pearls:** * **Auspitz Sign:** Pinpoint bleeding occurs when scales are forcibly removed (due to thinning of the suprapapillary epidermis). * **Koebner Phenomenon:** Development of psoriatic lesions at sites of local trauma (also seen in Vitiligo and Lichen Planus). * **Histopathology:** Look for **Munro’s microabscesses** (neutrophils in the stratum corneum) and **Kogoj’s pustules** (neutrophils in the stratum spinosum). * **Guttate Psoriasis:** Often triggered by a Streptococcal sore throat.

Q: Formation of multiple pinpoint bleeding spots on scratching the skin is characteristic of which condition?

Psoriasis. **Explanation:** The correct answer is **Psoriasis**. The phenomenon described—multiple pinpoint bleeding spots upon scratching or removing a scale—is known as **Auspitz sign**. **Why it occurs:** In psoriasis, there is marked epidermal hyperplasia (acanthosis) and thinning of the epidermis over the dermal papillae (suprapapillary thinning). Additionally, the dermal capillaries become dilated and tortuous. When the silvery-white scales are scraped off, the thin suprapapillary plate is breached, leading to the rupture of these underlying dilated capillaries, which results in pinpoint bleeding. **Analysis of Incorrect Options:** * **Pemphigus vulgaris:** Characterized by intraepidermal blisters due to acantholysis. The hallmark sign is **Nikolsky’s sign** (dislodgement of intact superficial epidermis by shear force). * **Lupus erythematosus:** Chronic Cutaneous LE (Discoid LE) shows "carpet tack" or "tin tack" signs (follicular plugging), but not pinpoint bleeding. * **Herpangina:** A viral infection (Coxsackie A) presenting with painful vesicles and ulcers in the posterior pharynx, unrelated to scaling or Auspitz sign. **NEET-PG High-Yield Pearls:** * **Grattage Test:** The clinical procedure of scraping a psoriatic lesion to elicit Auspitz sign. * **Candle Grease Sign:** As the scale is scraped, it becomes white and opaque, resembling a drop of candle wax. * **Koebner Phenomenon:** Development of new psoriatic lesions at sites of skin trauma (also seen in Vitiligo and Lichen Planus). * **Woronoff’s Ring:** A pale halo of blanched skin surrounding a healing psoriatic plaque.

Q: Limpet-like cone-shaped lesions in psoriasis refer to which of the following conditions?

Rupioid psoriasis. **Explanation:** **Rupioid psoriasis** is the correct answer because it is characterized by highly inflammatory, thick, hyperkeratotic, and crusty lesions that are **cone-shaped or "limpet-like"** (resembling a mollusk shell). These lesions are typically circular, elevated, and have a dark, dirty appearance. They are often associated with severe disease or co-morbidities like HIV. **Analysis of Incorrect Options:** * **Elephantine psoriasis (B):** This refers to a chronic, stable form of psoriasis characterized by very large, thick, persistent plaques, usually on the lower limbs or trunk. It lacks the specific cone-shaped morphology of rupioid psoriasis. * **Ostraceous psoriasis (C):** These lesions are characterized by thick, exuberant scales that are concave and resemble an **oyster shell**. While similar to rupioid, the key distinction is the shape: Ostraceous is flatter and shell-like, whereas Rupioid is distinctly conical/limpet-like. * **Inverse psoriasis (D):** Also known as flexural psoriasis, this occurs in skin folds (axilla, groin). It is characterized by smooth, erythematous plaques **without scaling** due to the moist environment. **High-Yield Clinical Pearls for NEET-PG:** * **Auspitz Sign:** Pinpoint bleeding on removal of scales (due to thinning of suprapapillary plate). * **Grattage Test:** Scraping the lesion increases the visibility of silvery-white scales (candle grease sign). * **Koebner Phenomenon:** Development of psoriatic lesions at sites of trauma (also seen in Lichen Planus and Vitiligo). * **Histopathology:** Key features include **Munro’s microabscesses** (neutrophils in the stratum corneum) and **Kogoj’s pustules** (neutrophils in the stratum spinosum).

Q: All of the following are seen in psoriasis except?

It is a premalignant disease. ### Explanation **Psoriasis** is a chronic, immune-mediated inflammatory skin disorder characterized by epidermal hyperproliferation. **Why Option C is the Correct Answer:** Psoriasis is **not a premalignant disease**. Unlike conditions such as Actinic Keratosis or Bowen’s disease, psoriasis does not inherently progress to malignancy. While chronic inflammation and certain treatments (like PUVA therapy) may slightly increase the risk of skin cancers (SCC/BCC), the disease itself is benign in nature. **Analysis of Incorrect Options:** * **A. Auspitz sign:** This is a classic diagnostic feature. When silvery scales are removed, pinpoint bleeding occurs due to the thinning of the suprapapillary epidermis and the presence of dilated, tortuous capillaries in the dermal papillae. * **B. 10% of cases are associated with arthritis:** Psoriatic arthritis (PsA) occurs in approximately **10–30%** of patients. It is typically seronegative (RF negative) and often involves the distal interphalangeal (DIP) joints. * **D. Worsening of disease during winter:** Psoriasis typically improves in summer due to beneficial UV radiation (which induces apoptosis of T-cells) and worsens in winter due to cold, dry air and lack of sunlight. **Clinical Pearls for NEET-PG:** * **Histopathology:** Look for Munro’s microabscesses (neutrophils in the stratum corneum) and Kogoj’s pustules (neutrophils in the stratum spinosum). * **Grattage Test:** Scraping the lesion increases the visibility of silvery scales (candle grease sign) before revealing the Auspitz sign. * **Koebner Phenomenon:** Development of new lesions at the site of trauma (also seen in Vitiligo and Lichen Planus). * **Woronoff’s Ring:** A pale halo around a healing psoriatic plaque.

Q: Which of the following is true about the specified skin disease?

All of the above. ***All of the above*** - **Psoriasis** is a chronic inflammatory skin condition with multiple **systemic comorbidities** affecting cardiovascular, musculoskeletal, and dermatological systems. - The **chronic inflammation** associated with psoriasis increases risk for **premature coronary artery disease**, **psoriatic arthritis**, and can present with **pruritus** in affected skin areas. *Can cause premature coronary artery disease* - **Chronic systemic inflammation** in psoriasis increases **cardiovascular risk** through elevated **inflammatory markers** like TNF-α and IL-17. - Patients with moderate to severe psoriasis have **2-3 times higher risk** of myocardial infarction and stroke at younger ages. *Can cause arthritis* - **Psoriatic arthritis** develops in approximately **30%** of patients with psoriasis, often presenting as **asymmetric oligoarthritis**. - Commonly affects **distal interphalangeal joints**, **sacroiliac joints**, and can cause **dactylitis** (sausage digits) and **enthesitis**. *Itching can be present* - **Pruritus** occurs in **70-90%** of psoriasis patients, ranging from mild to severe intensity. - The itching is often **worse at night** and can significantly impact **quality of life** and sleep patterns.

Q: DITRA syndrome is associated with a mutation in which of the following?

IL-36. **Explanation:** **DITRA Syndrome** (Deficiency of Interleukin-36 Receptor Antagonist) is a rare, life-threatening autoinflammatory disorder characterized by recurrent episodes of generalized pustular psoriasis (GPP), 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)**. Under normal physiological conditions, IL-36Ra binds to the IL-36 receptor to inhibit pro-inflammatory signaling. In DITRA, the lack of this antagonist leads to uncontrolled, constitutive activation of the IL-36 pathway, resulting in massive cutaneous recruitment of neutrophils and the formation of sterile pustules. **2. Why the Other Options are Incorrect:** * **IL-46:** There is no well-characterized cytokine or clinical syndrome associated with "IL-46" in standard dermatological pathology. * **IL-10:** This is a potent anti-inflammatory cytokine. While its deficiency can lead to early-onset inflammatory bowel disease (IBD), it is not the primary driver of DITRA. * **IL-26:** This is a member of the IL-10 family involved in mucosal immunity and Th17 responses, but it is not linked to the specific genetic mutation found in DITRA. **Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Sudden onset of high fever, malaise, and widespread sterile pustules on an erythematous base (Lakes of pus). * **Genetics:** Autosomal recessive inheritance. * **Targeted Therapy:** **Spesolimab** is a novel monoclonal antibody that inhibits the IL-36 receptor, specifically approved for GPP flares. * **Differential:** While DITRA is genetic, GPP can also be triggered by pregnancy (Impetigo Herpetiformis) or rapid withdrawal of systemic steroids.

Q: Chloroquine can cause exacerbation of which of the following conditions?

Psoriasis. **Explanation:** **Chloroquine** and other antimalarials (like Hydroxychloroquine) are well-known triggers for the exacerbation of **Psoriasis**. The underlying mechanism involves the inhibition of the enzyme transglutaminase, which leads to increased epidermal proliferation and keratinocyte differentiation. Clinically, these drugs can provoke a flare-up of existing plaque psoriasis or induce a severe morphologic shift into **Erythrodermic** or **Pustular psoriasis**. **Analysis of Options:** * **A. Malaria:** Chloroquine is a primary treatment for sensitive strains of *Plasmodium vivax* and *falciparum*; it treats the condition rather than exacerbating it. * **C. Discoid Lupus Erythematosus (DLE):** Antimalarials are actually the **first-line systemic treatment** for DLE and Systemic Lupus Erythematosus (SLE) due to their anti-inflammatory and photoprotective properties. * **D. Photosensitivity:** Chloroquine is used therapeutically to manage various photodermatoses (e.g., Polymorphous Light Eruption) because it stabilizes lysosomal membranes and reduces UV-induced inflammation. **High-Yield Clinical Pearls for NEET-PG:** * **Drugs Exacerbating Psoriasis (Mnemonic: "BLANK"):** **B**eta-blockers, **L**ithium, **A**ntimalarials/ACE inhibitors, **N**SAIDs, **K**-sparing diuretics (and systemic steroids upon withdrawal). * **Chloroquine Side Effects:** The most feared side effect is **retinopathy** (bull’s eye maculopathy). * **Contraindication:** Chloroquine is contraindicated in patients with Psoriasis and Porphyria Cutanea Tarda (can cause hepatotoxicity).

Question 1

All of the following are used in the management of Psoriasis except?

Accepted Answer

Reslizumab

Answer

Secukinumab

Answer

Ixekizumab

Answer

Guselkumab

Question 2

What is the drug of choice for pustular psoriasis in pregnancy?

Accepted Answer

Systemic steroids

Answer

Methotrexate

Answer

Ciclosporin

Answer

Azathioprine

Question 3

The oil drop sign of the nail is seen in which condition?

Accepted Answer

Psoriasis

Answer

Lichen planus

Answer

Dermatophytes

Answer

Lupus vulgaris

Question 4

A 30-year-old male presents with silvery, scaling plaques on his elbows and knees. His mother has a history of the same condition. What is the most likely diagnosis?

Accepted Answer

Psoriasis vulgaris

Answer

Acne rosacea

Answer

Acne vulgaris

Answer

Pemphigus vulgaris

Question 5

Formation of multiple pinpoint bleeding spots on scratching the skin is characteristic of which condition?

Accepted Answer

Psoriasis

Answer

Pemphigus vulgaris

Answer

Lupus erythematosus

Answer

Herpangina

Question 6

Limpet-like cone-shaped lesions in psoriasis refer to which of the following conditions?

Accepted Answer

Rupioid psoriasis

Answer

Elephantine psoriasis

Answer

Ostraceous psoriasis

Answer

Inverse psoriasis

Question 7

All of the following are seen in psoriasis except?

Accepted Answer

It is a premalignant disease

Answer

Auspitz sign

Answer

10% of cases are associated with arthritis

Answer

Worsening of disease during winter

Question 8

Which of the following is true about the specified 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 9

DITRA syndrome is associated with a mutation in which of the following?

Accepted Answer

IL-36

Answer

IL-46

Answer

IL-10

Answer

IL-26

Question 10

Chloroquine can cause exacerbation of which of the following conditions?

Accepted Answer

Psoriasis

Answer

Malaria

Answer

Discoid lupus erythematosus (DLE)

Answer

Photosensitivity

Psoriasis — MCQs

Psoriasis — MCQs

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