Psoriasis Practice Questions

Q: Multiple psoriatic lesions on hands. Treatment of choice is?

Topical steroids with salicylic acid. ***Topical steroids with salicylic acid*** - For **localized psoriasis**, such as lesions primarily on the hands, **topical corticosteroids** are the first-line treatment due to their anti-inflammatory effects. - **Salicylic acid** helps with **keratolysis**, reducing the scaling associated with psoriatic plaques, thereby improving penetration of the steroid. *NBUVB* - **Narrowband UVB (NBUVB)** therapy is more suitable for **widespread plaque psoriasis** rather than localized lesions on the hands. - It requires frequent clinic visits and may not be practical or cost-effective for small, confined areas. *Systemic methotrexate* - **Systemic methotrexate** is reserved for **moderate to severe psoriasis** or psoriatic arthritis that is unresponsive to topical treatments or phototherapy. - Its use carries risks of **hepatotoxicity** and **bone marrow suppression**, making it inappropriate for localized disease. *Systemic steroids* - **Systemic corticosteroids** are generally avoided in psoriasis due to the risk of **rebound flares** or exacerbation of the disease upon withdrawal. - They are typically reserved for severe, acute flares and used with extreme caution, often as a bridge therapy.

Q: What is the treatment of choice for erythrodermic psoriasis?

Methotrexate. ***Methotrexate*** - **Methotrexate** is considered the first-line systemic treatment for erythrodermic psoriasis in most standard guidelines and medical textbooks. - It is an immunosuppressant that works by inhibiting folate metabolism, thereby reducing keratinocyte hyperproliferation and inflammatory processes. - It has an established efficacy profile, relatively rapid onset of action (4-8 weeks), and is cost-effective and widely accessible. *Prednisone* - While systemic corticosteroids like **prednisone** can acutely suppress inflammation, they are **contraindicated** in erythrodermic psoriasis due to high risk of **rebound flares** and potential worsening upon withdrawal. - Long-term systemic corticosteroid use carries significant side effects including osteoporosis, hypertension, and diabetes. *Acitretin* - **Acitretin** is an oral retinoid that can be effective for erythrodermic psoriasis, but has a **slower onset of action** (2-3 months) compared to methotrexate. - It carries significant **teratogenic risks** requiring strict contraception for 2-3 years after discontinuation in women of childbearing potential. - Side effects include mucocutaneous dryness, hyperlipidemia, and hepatotoxicity. *Biologics* - **Biologics** (anti-TNF, anti-IL-17, anti-IL-23 agents) are highly effective for severe psoriasis including erythrodermic forms. - They are typically considered **second-line** agents due to higher cost, limited availability in resource-constrained settings, need for parenteral administration, and potential for serious infections. - While increasingly used in modern practice, **methotrexate** remains the standard first-line systemic agent in most treatment protocols.

Q: HLA-Cw6 is associated with

Psoriasis vulgaris. ***Psoriasis vulgaris*** - **HLA-Cw6** is the **strongest genetic risk factor** associated with an increased susceptibility to psoriasis vulgaris, particularly early-onset forms. - Its presence is linked to a more severe and widespread presentation of the disease. *Myasthenia gravis* - This autoimmune disorder is primarily associated with **HLA-DR3** and **HLA-B8**, and autoantibodies against the acetylcholine receptor. - While other HLA alleles may be involved, **HLA-Cw6** is not a primary or strong genetic association for myasthenia gravis. *Behcet's disease* - **HLA-B51** is the most significant genetic association with Behcet's disease, particularly in populations of Middle Eastern and East Asian descent. - Symptoms include **recurrent oral and genital ulcers**, **uveitis**, and skin lesions. *Pemphigus vulgaris* - This autoimmune blistering disease is strongly associated with **HLA-DR4** and **HLA-DRw6**, especially in individuals of Jewish descent. - It involves autoantibodies targeting **desmoglein 1 and 3**, leading to acantholysis within the epidermis.

Q: The Grattage test is used to diagnose which of the following conditions?

Psoriasis. ***Psoriasis*** - The **Grattage test** (candle grease sign) involves **scraping the psoriatic lesion** to reveal characteristic features - First reveals **fine, silvery-white scales** resembling candle wax - Further scraping exposes **pinpoint bleeding points** (**Auspitz sign**) due to exposure of dilated capillaries in dermal papillae - This combination is **pathognomonic for psoriasis** and helps differentiate it from other scaly dermatoses *Tinea capitis* - A **fungal infection of the scalp** caused by dermatophytes - Diagnosed by **KOH mount** (showing fungal hyphae), **fungal culture**, and sometimes **Wood's lamp examination** - The Grattage test is not used for diagnosing fungal infections *Lichen planus* - Characterized by **purplish, polygonal, flat-topped, pruritic papules and plaques** - Surface shows **Wickham's striae** (fine white lines) - Diagnosis is **clinical**, supported by **skin biopsy** showing band-like lymphocytic infiltrate and sawtooth rete ridges - The Grattage test is not applicable *Pemphigus vulgaris* - A severe **autoimmune blistering disorder** with **suprabasal acantholysis** - Presents with **flaccid bullae** that rupture easily, leaving erosions - Diagnosed by **skin biopsy**, **direct immunofluorescence** (intercellular IgG and C3 deposits), and **Nikolsky's sign** (positive) - The Grattage test is not used for bullous disorders

Q: In which of the following conditions is the Koebner phenomenon most commonly observed?

Psoriasis. ***Correct: Psoriasis*** - **Psoriasis** is the **most classic and commonly cited example** of the Koebner phenomenon (isomorphic response) - New psoriatic plaques characteristically develop at sites of cutaneous trauma, scratches, or surgical incisions in 25-50% of psoriasis patients - This is a **pathognomonic feature** frequently tested in competitive exams and considered the prototype condition for demonstrating this phenomenon - The mechanism involves inflammatory cascades triggered by trauma in genetically predisposed skin *Incorrect: Lichen planus* - While lichen planus does exhibit the Koebner phenomenon with purplish polygonal papules appearing along scratch lines, it is **less commonly observed** compared to psoriasis - Seen in approximately 10-25% of lichen planus cases - Not considered the primary example when teaching about Koebner phenomenon *Incorrect: Viral warts* - Viral warts can demonstrate **pseudo-Koebner phenomenon** where new warts form along trauma lines due to viral inoculation - This is more accurately described as **autoinoculation** rather than true isomorphic response - Less commonly discussed in the context of classic Koebner phenomenon compared to psoriasis *Incorrect: All of the options* - While all three conditions can show Koebner-like responses, the question asks for "**most commonly observed**" - Psoriasis remains the **gold standard** and most frequently encountered example in clinical practice and medical literature

Q: A 26-year-old girl at 31 weeks' gestation complains of a 4-week history of a pustular eruption that initially developed on the periumbilical skin and subsequently spread to involve the breasts, back, flexures, and proximal limbs, accompanied by cutaneous pain, fever, and malaise. On examination, the lesions were found to be pustules arranged in concentric rings, while on the breasts, there was coalescence of pustules forming lakes of pus. What is the treatment of choice in this case?

Corticosteroids. ***Corticosteroids*** - The constellation of **pustular eruption** with **concentric rings**, especially in pregnancy, along with systemic symptoms like fever and malaise, is highly suggestive of **Pustular Psoriasis of Pregnancy (PPP)**, also known as **Impetigo Herpetiformis**. - **Systemic corticosteroids** (prednisolone) are the **first-line treatment** for this rare but severe dermatosis in pregnancy, aimed at controlling inflammation and preventing maternal and fetal complications. *Methotrexate* - **Methotrexate** is an **anti-metabolite** and **immunosuppressant** that is **teratogenic** and absolutely **contraindicated in pregnancy** due to its potential to cause severe birth defects and miscarriages. - While it can be used for severe psoriasis in non-pregnant individuals, its use in this pregnant patient is inappropriate and dangerous. *Topical itraconazole* - **Itraconazole** is an **antifungal medication** used to treat fungal infections. While typically used systemically, topical formulations exist for localized fungal infections. - The clinical presentation of widespread pustules arranged in **concentric rings** with systemic symptoms and **"lakes of pus"** in a pregnant woman is pathognomonic for **Impetigo Herpetiformis**, not a fungal infection, making this treatment inappropriate. *Third generation cephalosporins* - **Third-generation cephalosporins** are **antibiotics** primarily used to treat bacterial infections. - The distinctive pattern of **pustules in concentric rings**, the periumbilical onset, and progression to form **lakes of pus** in a pregnant woman represents an **inflammatory dermatosis** (Impetigo Herpetiformis), not a primary bacterial infection requiring antibiotics.

Q: Which HLA allele is most strongly associated with psoriasis?

HLA CW6. ***HLA CW6*** - **HLA-Cw6** is the most strongly associated **HLA allele** with **psoriasis**, particularly with Type I (early-onset) psoriasis. - Its presence is linked to a more severe and widespread form of the disease. *HLA B27* - **HLA-B27** is strongly associated with **spondyloarthropathies** like **ankylosing spondylitis** and **reactive arthritis**, not directly with psoriasis itself, although it can be present in psoriatic arthritis. - Its primary role is in conditions affecting the **axial skeleton** and **entheses**. *HLA DR4* - **HLA-DR4** is a significant genetic marker for **rheumatoid arthritis** and **Type 1 diabetes**. - It is not directly associated with the pathogenesis of psoriasis. *HLA B8* - **HLA-B8** is associated with various autoimmune diseases such as **celiac disease**, **myasthenia gravis**, and **lupus erythematosus**. - It does not have a direct or strong association with psoriasis.

Q: Which of the following features is characteristic of psoriasis?

Micro-Munro's abscess. ***Micro-Munro's abscess*** - These are small collections of **neutrophils in the stratum corneum** and represent a **specific histological hallmark of psoriasis**. - Also known as **Munro microabscesses**, they are formed due to neutrophil migration into the upper epidermis in response to inflammatory signals. - This is a **characteristic and diagnostic feature** that helps differentiate psoriasis from other papulosquamous disorders. *Hyperkeratosis* - While hyperkeratosis (thickening of stratum corneum) is present in psoriasis and causes the silvery scales, it is **not specific** to psoriasis. - Hyperkeratosis occurs in many dermatological conditions including **eczema, lichen planus, ichthyosis**, and other keratinization disorders. - It is a general finding rather than a characteristic diagnostic feature. *Grenz zone* - The **Grenz zone** is a clear, narrow band of unaffected dermis between the epidermis and underlying dermal infiltrate. - This feature is characteristic of conditions like **granulomatous diseases** and **mycosis fungoides**, not psoriasis. - In psoriasis, the dermal infiltrate typically extends to the dermoepidermal junction without a clear zone. *Pautrier's microabscess* - These are **intraepidermal collections of atypical lymphocytes** and are a diagnostic feature of early-stage **mycosis fungoides** (cutaneous T-cell lymphoma). - They are not seen in psoriasis; psoriasis involves **neutrophils** (Munro microabscesses), not lymphocytic collections.

Q: Auspitz's sign is characteristically seen in

Plaque Psoriasis. ***Plaque Psoriasis*** - **Auspitz's sign** is the appearance of pinpoint bleeding after the removal of scales from a psoriatic plaque, a classic finding in **plaque psoriasis**. - This phenomenon is due to the thinning of the epidermis over elongated and dilated dermal papillae, making the superficial capillaries prone to rupture. *Pustular Psoriasis* - This form of psoriasis is characterized by the presence of sterile **pustules** on erythematous skin, either localized or generalized. - While it is a type of psoriasis, Auspitz's sign is not its characteristic feature; rather, the presence of pustules defines this variant. *Inverse Psoriasis* - Inverse psoriasis typically affects **skin folds** (e.g., axillae, groin, inframammary regions) and presents as smooth, erythematous patches without the characteristic scaling seen in plaque psoriasis. - Due to the absence of thick scales, Auspitz's sign is generally not observed in inverse psoriasis. *Lichen Planus (flat-topped, purple papules)* - Lichen planus is an inflammatory condition characterized by **pruritic, polygonal, planar, purple papules** and plaques, often with **Wickham's striae**. - It does not involve the epidermal scaling and capillary changes that lead to Auspitz's sign.

Q: Which type of psoriasis is commonly seen in children and may follow a streptococcal sore throat?

Guttate psoriasis. ***Guttate psoriasis*** - This form of psoriasis is characterized by **small, drop-like lesions** that often appear suddenly over the trunk and extremities. - It is frequently precipitated by an **upper respiratory infection**, most commonly a **streptococcal sore throat**, particularly in children and young adults. *Pustular psoriasis* - This is a rare, severe form characterized by widespread **sterile pustules** on red, inflamed skin. - It is not typically associated with streptococcal infections or common in children as an initial presentation. *Stable plaque psoriasis* - This is the most common form, presenting with **well-demarcated, erythematous plaques** covered with silvery scales. - It usually has a **chronic course** and is not typically triggered by acute infections like strep throat. *Arthropathic psoriasis* - This is a form of **psoriatic arthritis** where psoriasis is accompanied by inflammation of the joints. - While it can occur in children, its hallmark is joint involvement, and it is not primarily associated with preceding streptococcal infections.

Question 1

Multiple psoriatic lesions on hands. Treatment of choice is?

Accepted Answer

Topical steroids with salicylic acid

Answer

NBUVB

Answer

Systemic methotrexate

Answer

Systemic steroids

Question 2

What is the treatment of choice for erythrodermic psoriasis?

Accepted Answer

Methotrexate

Answer

Acitretin

Answer

Prednisone

Answer

Biologics

Question 3

HLA-Cw6 is associated with

Accepted Answer

Psoriasis vulgaris

Answer

Behcet's disease

Answer

Pemphigus vulgaris

Answer

Myasthenia gravis

Question 4

The Grattage test is used to diagnose which of the following conditions?

Accepted Answer

Psoriasis

Answer

Tinea capitis

Answer

Lichen planus

Answer

Pemphigus vulgaris

Question 5

In which of the following conditions is the Koebner phenomenon most commonly observed?

Accepted Answer

Psoriasis

Answer

Lichen planus

Answer

All of the options

Answer

Viral warts

Question 6

A 26-year-old girl at 31 weeks' gestation complains of a 4-week history of a pustular eruption that initially developed on the periumbilical skin and subsequently spread to involve the breasts, back, flexures, and proximal limbs, accompanied by cutaneous pain, fever, and malaise. On examination, the lesions were found to be pustules arranged in concentric rings, while on the breasts, there was coalescence of pustules forming lakes of pus. What is the treatment of choice in this case?

Accepted Answer

Corticosteroids

Answer

Methotrexate

Answer

Topical itraconazole

Answer

Third generation cephalosporins

Question 7

Which HLA allele is most strongly associated with psoriasis?

Accepted Answer

HLA CW6

Answer

HLA B27

Answer

HLA DR4

Answer

HLA B8

Question 8

Which of the following features is characteristic of psoriasis?

Accepted Answer

Micro-Munro's abscess

Answer

Grenz zone

Answer

Hyperkeratosis

Answer

Pautrier's microabscess

Question 9

Auspitz's sign is characteristically seen in

Accepted Answer

Plaque Psoriasis

Answer

Inverse Psoriasis

Answer

Pustular Psoriasis

Answer

Lichen Planus (flat-topped, purple papules)

Question 10

Which type of psoriasis is commonly seen in children and may follow a streptococcal sore throat?

Accepted Answer

Guttate psoriasis

Answer

Pustular psoriasis

Answer

Stable plaque psoriasis

Answer

Arthropathic psoriasis

Psoriasis — MCQs

Psoriasis — MCQs

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