Erythrodermic Psoriasis — MCQs

10 questions

Skin biopsy shows psoriasiform hyperplasia with neutrophilic microabscesses in stratum corneum. Most likely diagnosis?

A patient with psoriasis was started on systemic steroids. After stopping the treatment, the patient developed universally red scaly skin with plaques losing their margins all over his body. The most likely cause is –

What percentage of skin involvement is characteristic of erythroderma?

Treatment of choice for Pustular psoriasis is:

Treatment of choice for Nodulocystic Acne is:

A patient with psoriasis who was started on systemic steroids develops generalized pustules all over the body after stopping treatment. What is the most likely cause?

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

The following is an important feature of psoriasis:

Q10

A patient with psoriasis was started on systemic steroids. After stopping treatment, the patient developed generalized pustules all over the body. The cause is most likely to be:

Erythrodermic Psoriasis Indian Medical PG Practice Questions and MCQs

Question 1: Skin biopsy shows psoriasiform hyperplasia with neutrophilic microabscesses in stratum corneum. Most likely diagnosis?

A. Psoriasis (Correct Answer)
B. Seborrheic dermatitis
C. Pityriasis rosea
D. Lichen planus

Explanation: ***Psoriasis*** - **Psoriasiform hyperplasia**, characterized by regular epidermal acanthosis and elongated rete ridges, is a classic histological feature of psoriasis. - The presence of **neutrophilic microabscesses (Munro microabscesses)** in the stratum corneum is a pathognomonic finding for psoriasis. *Seborrheic dermatitis* - Histologically, seborrheic dermatitis typically shows **irregular acanthosis** with parakeratosis and a **perivascular lymphocytic infiltrate**, but not regular psoriasiform hyperplasia or Munro microabscesses. - There may be *spongiosis* and neutrophils in the stratum corneum, but not the distinct microabscesses seen in psoriasis. *Pityriasis rosea* - Pityriasis rosea histology often reveals **focal parakeratosis**, **spongiosis**, and a **perivascular lymphocytic infiltrate** with extravasated red blood cells. - It does not demonstrate the characteristic regular psoriasiform hyperplasia or neutrophilic microabscesses of psoriasis. *Lichen planus* - Lichen planus is characterized by a **"sawtooth" rete ridge pattern**, a **band-like lymphocytic infiltrate** at the dermo-epidermal junction, and **colloid bodies (Civatte bodies)**. - It does not exhibit psoriasiform hyperplasia or neutrophilic microabscesses in the stratum corneum.

Question 2: A patient with psoriasis was started on systemic steroids. After stopping the treatment, the patient developed universally red scaly skin with plaques losing their margins all over his body. The most likely cause is –

A. Pustular psoriasis
B. Erythrodermic psoriasis (Correct Answer)
C. Drug induced reaction
D. Bacterial infection

Explanation: ***Erythrodermic Psoriasis*** - This condition is characterized by **widespread erythema** and scaling affecting over 90% of the body surface, often with a loss of distinct plaque margins. - The sudden withdrawal of **systemic corticosteroids** in patients with psoriasis is a well-known trigger for erythrodermic psoriasis. *Pustular psoriasis* - This form presents with widespread or localized pustules, often on an erythrematous base, and may be accompanied by fever and systemic symptoms. - While it can be severe, the primary described feature here is **universal redness and scaling with plaque confluence**, not predominant pustule formation. *Drug induced reaction* - While drugs can induce or exacerbate psoriasis, the specific trigger described (withdrawal of systemic steroids) points more directly to a rebound phenomenon of the underlying psoriasis. - A drug-induced reaction would typically be an *initial* eruption or a different morphology, not a flare of pre-existing psoriasis due to *cessation* of treatment. *Bacterial infection* - A bacterial infection might cause redness, scaling, and inflammation, but it would typically be accompanied by signs of infection like fever, purulence, or pus. - The described condition is a direct rebound phenomenon after steroid withdrawal, not primarily an infective process.

Question 3: What percentage of skin involvement is characteristic of erythroderma?

A. More than 90% (Correct Answer)
B. Less than 30%
C. 30% to 60%
D. 60% to 70%

Explanation: ***More than 90%*** - Erythroderma, also known as **exfoliative dermatitis**, is defined by diffuse redness and scaling involving **more than 90% of the body surface area**. - This extensive involvement leads to significant physiological disturbances due to impaired skin barrier function. *Less than 30%* - Skin involvement less than 30% does not meet the criteria for erythroderma and would be considered more localized dermatological conditions. - This percentage of involvement would typically indicate a benign rash or localized eczema, not a widespread inflammatory process. *30% to 60%* - While significant, 30% to 60% skin involvement is still insufficient to classify a condition as erythroderma. - This range might be seen in severe but still localized forms of conditions like psoriasis or eczema. *60% to 70%* - 60% to 70% involvement is extensive but falls short of the critical threshold for erythroderma. - Although indicating widespread disease, it does not constitute the near-total body erythema and scaling characteristic of erythroderma.

Question 4: Treatment of choice for Pustular psoriasis is:

A. Methotrexate (Correct Answer)
B. Psoralen - UV therapy
C. Systemic steroid
D. Estrogen

Explanation: ***Methotrexate*** - **Methotrexate** is a systemic immunosuppressant often considered the first-line treatment for severe forms of **pustular psoriasis** due to its efficacy in reducing inflammation and hyperproliferation of skin cells. - It works by inhibiting **dihydrofolate reductase**, thereby interfering with DNA synthesis and cell division, which is crucial in rapidly dividing cells like those found in psoriasis. *Psoralen - UV therapy* - **Psoralen and ultraviolet A (PUVA)** therapy can be used for chronic plaque psoriasis, but it is generally **contraindicated or used with extreme caution** in pustular psoriasis due to the risk of exacerbating the disease or causing irritation. - **UV light therapy** can sometimes trigger or worsen pustular flares, especially in acute generalized pustular psoriasis. *Systemic steroid* - While systemic steroids can provide temporary relief by addressing inflammation, their use in pustular psoriasis is generally **not recommended for long-term management** due to the high risk of severe rebound flares upon withdrawal. - Withdrawal of **systemic corticosteroids** can precipitate or worsen generalized pustular psoriasis, making them a less desirable long-term treatment option. *Estrogen* - **Estrogen** has no direct role in the treatment of psoriasis. Psoriasis is an inflammatory skin condition, and its pathophysiology is not directly influenced by estrogen levels. - Hormonal therapies are not indicated for the management of psoriasis, including its pustular forms.

Question 5: Treatment of choice for Nodulocystic Acne is:

A. Isotretinoin (Correct Answer)
B. Erythromycin
C. PUVA
D. Tetracycline

Explanation: ***Isotretinoin*** - **Isotretinoin** is a systemic retinoid that targets all four major pathogenic factors of acne: **sebum production**, **follicular hyperkeratinization**, **Propionibacterium acnes growth**, and **inflammation**. - It is considered the most effective medication for **severe, nodulocystic acne**, often leading to long-term remission. *Erythromycin* - **Erythromycin** is a topical or oral antibiotic primarily used for its antibacterial and anti-inflammatory properties against *P. acnes*. - While useful for milder inflammatory acne, it is generally **insufficient for severe nodulocystic acne** and carries risks of **antibiotic resistance**. *PUVA* - **PUVA (Psoralen plus ultraviolet A)** therapy is a form of photochemotherapy primarily used for severe **psoriasis**, **eczema**, and **cutaneous T-cell lymphoma**. - It is **not a treatment for acne** and has significant side effects, including increased risk of **skin cancer**. *Tetracycline* - **Tetracycline** is an oral antibiotic often used to treat moderate to severe inflammatory acne due to its anti-inflammatory effects and reduction of *P. acnes*. - While effective for some inflammatory acne, it is typically **less potent than isotretinoin** for severe, **nodulocystic acne** and may not provide a permanent cure.

Question 6: A patient with psoriasis who was started on systemic steroids develops generalized pustules all over the body after stopping treatment. What is the most likely cause?

A. Bacterial infection
B. Septicemia
C. Pustular psoriasis due to steroid withdrawal (Correct Answer)
D. Drug-induced pustular psoriasis

Explanation: ***Pustular psoriasis due to steroid withdrawal*** - **Systemic steroid withdrawal** can precipitate a severe flare of psoriasis, often leading to generalized **pustular psoriasis**. - This is a well-known phenomenon where the suppression of the immune system by steroids is abruptly removed, causing a rebound inflammatory response. *Drug-induced pustular psoriasis* - While certain drugs can induce pustular psoriasis, the scenario specifically highlights the **cessation of systemic steroids** as the trigger. - This option doesn't pinpoint the direct causal effect of stopping the medication. *Bacterial infection* - Although pustules can be associated with bacterial infections, the **generalized nature** and history of **steroid withdrawal** in a patient with psoriasis make an infectious cause less likely as the primary trigger. - A bacterial infection would typically present with signs of local infection (e.g., warmth, tenderness, fever) alongside the pustules, which are not exclusively mentioned here. *Septicemia* - **Septicemia** is a severe bloodstream infection and would present with systemic signs of illness such as high fever, chills, hypotension, and organ dysfunction, which are not described. - While pustules can sometimes occur in severe infections, the clinical context strongly points to a dermatological reaction to medication changes, not a systemic infection.

Question 7: Match the following scale types with their lesions. | Scales | Lesions | | :-- | :-- | | 1. Collarette scales | a. Pityriasis versicolour | | 2. Silvery scales | b. Pityriasis rosea | | 3. Mica-like scales | c. Psoriasis | | 4. Branny scales | d. Pityriasis lichenoides |

A. 1-d, 2-c, 3-a, 4-b
B. 1-c, 2-b, 3-d, 4-a
C. 1-a, 2-b, 3-d, 4-c
D. 1-b, 2-c, 3-d, 4-a (Correct Answer)

Explanation: ***1-b, 2-c, 3-d, 4-a*** - **Collarette scales** are pathognomonic of **Pityriasis rosea**, appearing as fine, trailing scales around the periphery of oval lesions in a "Christmas tree" distribution. - **Silvery scales** are the classic hallmark of **Psoriasis**, presenting as thick, adherent, silvery-white scales overlying well-demarcated erythematous plaques. - **Mica-like scales** are characteristic of **Pityriasis lichenoides**, appearing as thick, shiny, adherent scales that can be peeled off like mica sheets. - **Branny scales** are typical of **Pityriasis versicolor**, presenting as fine, powdery scales caused by **Malassezia** yeast overgrowth. *1-d, 2-c, 3-a, 4-b* - Incorrectly matches **collarette scales with Pityriasis lichenoides**, which typically presents with mica-like scales, not collarette scales. - Misassociates **mica-like scales with Pityriasis versicolor**, which characteristically has branny (fine, powdery) scales. *1-c, 2-b, 3-d, 4-a* - Wrongly pairs **collarette scales with Psoriasis**, which is known for thick silvery scales, not peripheral collarette scales. - Incorrectly matches **silvery scales with Pityriasis rosea**, which has collarette scales at lesion periphery, not silvery scales. *1-a, 2-b, 3-d, 4-c* - Falsely associates **collarette scales with Pityriasis versicolor**, which has branny scales from yeast infection, not collarette scales. - Mismatches **branny scales with Psoriasis**, which has characteristic thick silvery scales, not fine powdery scales.

Question 8: In which of the following conditions is the Koebner phenomenon most commonly observed?

A. Psoriasis (Correct Answer)
B. Lichen planus
C. All of the options
D. Viral warts

Explanation: ***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

Question 9: The following is an important feature of psoriasis:

A. Erythematous macules
B. Crusting
C. Silvery Scaling (Correct Answer)
D. Coarse bleeding

Explanation: ***Silvery Scaling*** - **Silvery scaling** is a hallmark clinical feature of **psoriasis**, resulting from the rapid turnover of skin cells. - These scales often appear on **erythematous plaques** and can be easily scraped off, sometimes revealing pinpoint bleeding underneath (**Auspitz sign**). *Erythematous macules* - While psoriasis does involve **erythema** (redness), the primary lesions are typically **plaques**, not macules (flat, discolored spots). - Macules are seen in other dermatological conditions such as drug eruptions or early viral exanthems, but not as the definitive feature of psoriasis. *Crusting* - **Crusting** is a feature of conditions involving exudation and drying of serum, blood, or pus, such as **impetigo** or **eczema** with secondary infection. - It is not a characteristic primary lesion of psoriasis, although secondary infection of psoriatic plaques could theoretically lead to crusting. *Coarse bleeding* - **Coarse bleeding** is not a primary feature of psoriasis; however, when psoriatic scales are removed, pinpoint bleeding known as the **Auspitz sign** can occur. - This is distinct from frank, coarse bleeding and is a diagnostic clue rather than a characteristic lesion in itself.

Question 10: A patient with psoriasis was started on systemic steroids. After stopping treatment, the patient developed generalized pustules all over the body. The cause is most likely to be:

A. Drug induced reaction
B. Septicemia
C. Pustular psoriasis (Correct Answer)
D. Bacterial infections

Explanation: ***Pustular psoriasis*** - The sudden withdrawal of **systemic corticosteroids** in a patient with psoriasis can trigger a severe flare-up, specifically **generalized pustular psoriasis** (GPP), characterized by widespread sterile pustules. - GPP is a distinct, severe form of psoriasis that can be precipitated by various factors, including drug withdrawal. *Drug induced reaction* - While steroids themselves can have side effects, the development of **generalized pustules** shortly after stopping treatment in a known psoriasis patient points more specifically to a paradoxical worsening of their underlying disease rather than a general drug reaction. - Drug-induced reactions are typically directly related to the drug's properties or an allergic response, whereas this scenario describes an exacerbation of the existing condition due to treatment cessation. *Septicemia* - Septicemia, or **sepsis**, would present with signs of systemic infection such as **fever, chills, hypotension, and organ dysfunction**, which are not explicitly mentioned as the primary cause of the pustules. - While severe GPP can lead to systemic symptoms and potentially secondary infections, the initial development of pustules post-steroid withdrawal is a primary dermatological event, not directly caused by septicemia. *Bacterial infections* - **Bacterial infections** would typically manifest with purulent pustules, often with signs of inflammation, pain, and potentially fever. These pustules would contain bacteria upon Gram stain and culture. - The pustules in **pustular psoriasis** are typically sterile, meaning they do not contain bacteria, and their appearance is a manifestation of the underlying autoimmune inflammatory process exacerbated by steroid withdrawal.

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