Psoriasis Practice Questions

Q: In psoriasis, the following are seen except:

CNS involvement. ***CNS involvement*** - Psoriasis is primarily a **skin disorder** with systemic manifestations but typically does **not directly involve the central nervous system**. - While patients with psoriasis may experience symptoms like depression or anxiety, these are generally considered **comorbid conditions** rather than direct manifestations of psoriatic pathology in the CNS. *Skin involvement* - **Plaque psoriasis**, the most common form, is characterized by well-demarcated, erythematous plaques with silvery scales. - Psoriasis directly affects the skin, leading to rapid **keratinocyte proliferation** and inflammation. *Nail changes* - **Onycholysis (separation of the nail from the nail bed)**, **pitting**, and **oil spots** (yellow-brown discolorations under the nail) are common in psoriasis. - These nail changes can occur with or without concurrent skin involvement. *Arthritis* - **Psoriatic arthritis (PsA)** is a chronic inflammatory arthritis associated with psoriasis, affecting up to 30% of patients. - It can involve peripheral joints, the **axial skeleton**, and entheses, often presenting with symptoms like stiffness and pain.

Q: In Erythrodermic psoriasis, _____ or more of body surface area is involved

90%. ***90%*** - Erythrodermic psoriasis is defined by the involvement of **90% or more of the total body surface area** with erythema and scaling. - This extensive skin involvement leads to significant systemic symptoms and is considered a **medical emergency**. - It represents the most severe form of psoriasis with near-complete body involvement. *85%* - While representing extensive involvement, **85%** does not meet the diagnostic threshold for erythrodermic psoriasis. - The definition specifically requires **≥90%** body surface area involvement. *95%* - Although **95%** body surface area involvement would certainly qualify as erythrodermic psoriasis, it exceeds the minimum diagnostic threshold. - The defining cutoff is **90% or more**, not 95%. *80%* - Involvement of **80%** of the body surface area, while extensive, does not meet the criteria for erythrodermic psoriasis. - This would typically be classified as **severe plaque psoriasis** rather than erythrodermic form.

Q: Auspitz sign is seen in?

Psoriasis. ***Psoriasis*** - Auspitz sign refers to the appearance of **pinpoint bleeding** after the removal of psoriatic scales. - This phenomenon is caused by the thinning of the **epidermis** over the dermal papillae, making the superficial blood vessels more prone to rupture. *Vitiligo* - Vitiligo is characterized by **patches of depigmentation** due to the destruction of melanocytes. - It does not involve scaling or bleeding upon scratching. *Contact dermatitis* - Contact dermatitis is an **inflammatory skin reaction** caused by contact with an allergen or irritant, presenting as redness, itching, and sometimes vesicles. - While scratching can cause bleeding, it does not typically produce the specific **pinpoint bleeding** pattern seen with Auspitz sign. *Lichen Planus* - Lichen planus is an **inflammatory condition** affecting the skin, hair, nails, and mucous membranes, characterized by **pruritic, polygonal, purple papules**. - It does not present with scaling that reveals pinpoint bleeding when removed.

Q: A 30-year-old male presented with silvery scales on elbow and knee, that bleed on removal. The probable diagnosis is:

Psoriasis. ***Psoriasis*** - The presence of **silvery scales** on the elbows and knees, which **bleed upon removal** (Auspitz sign), is a classic presentation of **plaque psoriasis**. - Psoriasis is a chronic inflammatory skin condition characterized by **accelerated epidermal turnover**. *Secondary syphilis* - Secondary syphilis typically presents with a **generalized maculopapular rash**, which can affect the palms and soles, but it does not usually feature silvery scales or the Auspitz sign. - Other common symptoms of secondary syphilis include **fever, lymphadenopathy, and condyloma lata**. *Pityriasis* - **Pityriasis rosea** is characterized by an oval, fawn-colored, scaly rash, often preceded by a **herald patch**, and usually resolves spontaneously. It does not typically present with silvery scales or bleeding on removal. - **Pityriasis versicolor** is caused by yeast and presents as hypopigmented or hyperpigmented macules with fine scales, commonly on the trunk, not silvery scales on elbows and knees. *Seborrhoeic dermatitis* - Seborrhoeic dermatitis involves greasy, yellowish scales on red skin, typically affecting areas rich in sebaceous glands like the scalp, face (nasolabial folds, eyebrows), and chest. - It does not present with silvery scales or the Auspitz sign, which are specific to psoriasis.

Q: Psoriasis is exacerbated by -

All of the options. ***All of the above*** - **Beta-blockers**, **lithium**, and **antimalarial drugs** are well-established medications that can exacerbate or trigger psoriasis flares. - Patients with psoriasis require careful monitoring when these medications are prescribed, with consideration of alternative treatments when feasible. ***Beta-blockers*** - **Non-selective beta-blockers** (particularly propranolol) can worsen existing psoriasis or induce new-onset disease. - The mechanism likely involves alterations in **T-cell function** and **epidermal proliferation**. - Risk is higher with non-selective agents compared to cardioselective beta-blockers. ***Lithium*** - **Lithium**, used for bipolar disorder, is a frequent and well-documented psoriasis trigger. - Can induce or worsen various forms including **plaque psoriasis**, **pustular psoriasis**, and **erythrodermic psoriasis**. - Exacerbations typically occur within weeks to months of initiation. ***Antimalarials*** - **Chloroquine** and **hydroxychloroquine** can precipitate severe psoriasis flares. - Particularly associated with **erythrodermic** and **generalized pustular psoriasis**. - Mechanism involves **immune cell activation** and amplification of inflammatory pathways.

Q: Koebner's phenomenon is characteristic of –

Psoriasis. ***Psoriasis*** - **Koebner's phenomenon**, or isomorphic response, refers to the development of new lesions at sites of **skin trauma** (e.g., cuts, scratches, burns, or friction). - This phenomenon is **most characteristically associated with psoriasis** and is considered a distinctive clinical feature that helps in diagnosis. - While Koebner's phenomenon can occur in other dermatological conditions (such as lichen planus, vitiligo, and rarely pemphigus), **psoriasis remains the classic and most frequent example** in clinical practice and medical education. *Lupus vulgaris* - This is a chronic and progressive form of **cutaneous tuberculosis**, characterized by reddish-brown plaques with an "apple jelly" appearance on diascopy. - While skin trauma can sometimes trigger or worsen infections, **Koebner's phenomenon is not a characteristic feature** of lupus vulgaris. *Pemphigus vulgaris* - Pemphigus vulgaris is an **autoimmune blistering disease** affecting the skin and mucous membranes. - It is **primarily characterized** by flaccid blisters that rupture easily and a positive **Nikolsky's sign** (epidermis detaches with slight lateral pressure). - While Koebner's phenomenon has been rarely reported in pemphigus, **Nikolsky's sign is the pathognomonic feature**, not Koebner's phenomenon. *Pityriasis rosea* - This is a common, acute, self-limiting skin eruption that typically begins with a **herald patch** followed by smaller, oval, fine-scaling patches in a **'Christmas tree' pattern** on the trunk. - Its etiology is thought to be viral, and it **does not exhibit Koebner's phenomenon**.

Q: A patient with chronic plaque psoriasis develops an adverse response to therapy. Which response indicates treatment with hydroxychloroquine?

Sudden generalized flare. ***Sudden generalized flare*** - Hydroxychloroquine, while sometimes used for **psoriatic arthritis**, is notorious for exacerbating cutaneous psoriasis, typically causing a **sudden generalized flare** of the disease. - This adverse effect is particularly significant in patients with plaque psoriasis, making hydroxychloroquine a **relative contraindication** in many cases. - This is the **most characteristic** adverse response to antimalarial therapy in psoriasis patients. *Localized plaque thickening* - This is a common feature of chronic plaque psoriasis itself and does not specifically indicate a response to hydroxychloroquine. - Plaque thickening can occur with disease progression or insufficient treatment but is not a recognized side effect of hydroxychloroquine. *Palmoplantar involvement* - **Palmoplantar psoriasis** is a specific morphological variant of the disease and is not a direct response to hydroxychloroquine treatment. - While it can be severe and difficult to treat, its presence does not signify a drug-induced phenomenon related to hydroxychloroquine. *Development of pustules* - While hydroxychloroquine can rarely trigger transformation to **pustular psoriasis**, this is less common than the typical presentation of acute generalized plaque exacerbation. - **Sudden generalized flare** of plaque psoriasis remains the most characteristic adverse response to hydroxychloroquine, making it the best answer among the options provided.

Q: A 50-year-old man with severe plaque psoriasis presents with worsening erythroderma and pustules despite recently starting cyclosporine. Labs show leukocytosis and elevated CRP. Most appropriate next step is:

Hospitalize for systemic therapy. ***Hospitalize for systemic therapy*** - The presentation of **erythroderma** and **pustules** with **leukocytosis** and **elevated CRP** in a patient with severe psoriasis suggests **generalized pustular psoriasis** (von Zumbusch) or **erythrodermic psoriasis**, both life-threatening emergencies. - This requires **immediate hospitalization** for close monitoring, fluid and electrolyte management, temperature regulation, infection surveillance, and aggressive systemic therapy (often including biologics, systemic steroids, or combination therapy). - The severity with systemic inflammation mandates inpatient care rather than outpatient management. *Switch to methotrexate* - While **methotrexate** is effective for severe psoriasis, this patient is hemodynamically unstable with systemic inflammation requiring immediate inpatient monitoring and rapid intervention. - Methotrexate has a **slow onset of action** (weeks) and would not provide the urgent control needed for this acute emergency. - Outpatient drug switching is inappropriate for an unstable patient with erythroderma. *Start oral retinoids* - **Acitretin** is used for pustular psoriasis, but has **delayed onset** (2-3 months for full effect) and would be insufficient as monotherapy for this acute, life-threatening presentation. - The patient requires immediate hospitalization and faster-acting therapies, possibly including biologics or short-term systemic corticosteroids. *Continue cyclosporine and add topical steroids* - The disease is clearly not controlled on cyclosporine alone, and **topical steroids are inadequate** for managing widespread erythroderma with systemic inflammation. - This severe presentation requires **escalation to inpatient systemic therapy**, not continuation of an inadequate outpatient regimen.

Q: Which of the following statements about biologics in psoriasis is FALSE?

IL-23 inhibitors require most frequent dosing. ***IL-23 inhibitors require most frequent dosing*** - **IL-23 inhibitors** generally have some of the **least frequent dosing schedules** among biologics for psoriasis, often administered every 8-12 weeks after an initial loading phase. - This statement is false because their less frequent dosing contributes to better patient adherence and convenience. *TNF inhibitors increase risk of TB reactivation* - **TNF inhibitors** (e.g., infliximab, adalimumab) modulate the immune system by blocking tumor necrosis factor-alpha, which is crucial for granuloma formation to contain **tuberculosis**. - This mechanism significantly **increases the risk of reactivation of latent TB**, making TB screening essential before and during treatment. *All require baseline TB screening* - Due to the immunosuppressive nature and mechanisms of action of most biologics in psoriasis, **screening for latent or active tuberculosis (TB)** is a mandatory baseline requirement for all classes. - This precaution helps prevent the reactivation of TB, which can be life-threatening in immunocompromised patients. *IL-17 inhibitors may exacerbate IBD* - **IL-17 inhibitors** (e.g., secukinumab, ixekizumab) act by blocking interleukin-17, a cytokine involved in both psoriasis and the pathogenesis of **inflammatory bowel disease (IBD)**. - While generally effective for psoriasis, there have been reports of new-onset or exacerbation of IBD in some patients treated with IL-17 inhibitors, making this a relevant clinical consideration.

Q: Assertion: Vitamin D analogues are effective in psoriasis. Reason: They reduce keratinocyte proliferation

Both A & R true, R explains A. ***Both A & R true, R explains A*** - **Vitamin D analogues** (e.g., calcipotriol) are a cornerstone treatment for psoriasis because they effectively modulate **keratinocyte proliferation** and differentiation. - Psoriasis is characterized by the **rapid overgrowth of keratinocytes**, and the antiproliferative effects of vitamin D analogues directly address this pathological hallmark. *A false R true* - This option is incorrect because both the assertion (Vitamin D analogues are effective in psoriasis) and the reason (They reduce keratinocyte proliferation) are individually true. - The effectiveness of vitamin D analogues in treating psoriasis is well-established in dermatological practice. *Both A & R true, R doesn't explain A* - This option is incorrect because the reduction of keratinocyte proliferation is precisely *how* vitamin D analogues exert their therapeutic effect in psoriasis. - The mechanism of action described in the reason directly explains the efficacy mentioned in the assertion. *A true R false* - This option is incorrect because the reason ("They reduce keratinocyte proliferation") is a fundamental and well-understood mechanism by which vitamin D analogues work in psoriasis. - Vitamin D analogues bind to vitamin D receptors in keratinocytes, influencing gene expression to inhibit their excessive growth.

Question 1

In psoriasis, the following are seen except:

Accepted Answer

CNS involvement

Answer

Skin involvement

Answer

Nail changes

Answer

Arthritis

Question 2

In Erythrodermic psoriasis, _____ or more of body surface area is involved

Accepted Answer

90%

Answer

85%

Answer

95%

Answer

80%

Question 3

Auspitz sign is seen in?

Accepted Answer

Psoriasis

Answer

Vitiligo

Answer

Contact dermatitis

Answer

Lichen Planus

Question 4

A 30-year-old male presented with silvery scales on elbow and knee, that bleed on removal. The probable diagnosis is:

Accepted Answer

Psoriasis

Answer

Secondary syphilis

Answer

Pityriasis

Answer

Seborrhoeic dermatitis

Question 5

Psoriasis is exacerbated by -

Accepted Answer

All of the options

Answer

Beta-blockers

Answer

Lithium

Answer

Antimalarials

Question 6

Koebner's phenomenon is characteristic of –

Accepted Answer

Psoriasis

Answer

Lupus vulgaris

Answer

Pemphigus vulgaris

Answer

Pityriasis rosea

Question 7

A patient with chronic plaque psoriasis develops an adverse response to therapy. Which response indicates treatment with hydroxychloroquine?

Accepted Answer

Sudden generalized flare

Answer

Localized plaque thickening

Answer

Palmoplantar involvement

Answer

Development of pustules

Question 8

A 50-year-old man with severe plaque psoriasis presents with worsening erythroderma and pustules despite recently starting cyclosporine. Labs show leukocytosis and elevated CRP. Most appropriate next step is:

Accepted Answer

Hospitalize for systemic therapy

Answer

Switch to methotrexate

Answer

Start oral retinoids

Answer

Continue cyclosporine and add topical steroids

Question 9

Which of the following statements about biologics in psoriasis is FALSE?

Accepted Answer

IL-23 inhibitors require most frequent dosing

Answer

TNF inhibitors increase risk of TB reactivation

Answer

All require baseline TB screening

Answer

IL-17 inhibitors may exacerbate IBD

Question 10

Assertion: Vitamin D analogues are effective in psoriasis. Reason: They reduce keratinocyte proliferation

Accepted Answer

Both A & R true, R explains A

Answer

A false R true

Answer

Both A & R true, R doesn't explain A

Answer

A true R false

Psoriasis — MCQs

Psoriasis — MCQs

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