Psoriasis Practice Questions

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 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).

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: 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.

Question 1

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 2

Which condition is characterized by arthritis mutilans?

Accepted Answer

Psoriasis

Answer

Lichen planus

Answer

Staphylococcal scalded skin syndrome

Answer

Eczema

Question 3

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

Accepted Answer

Psoriasis.

Answer

Reiter's syndrome.

Answer

Geographic tongue.

Answer

OSMF.

Question 4

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 5

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 6

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

Accepted Answer

Pterygium formation

Answer

Pitting

Answer

Onycholysis

Answer

Subungual hyperkeratosis

Question 7

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

Accepted Answer

Reslizumab

Answer

Secukinumab

Answer

Ixekizumab

Answer

Guselkumab

Question 8

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

Accepted Answer

Systemic steroids

Answer

Methotrexate

Answer

Ciclosporin

Answer

Azathioprine

Question 9

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

Accepted Answer

Psoriasis

Answer

Lichen planus

Answer

Dermatophytes

Answer

Lupus vulgaris

Question 10

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

Psoriasis — MCQs

Psoriasis — MCQs

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