Psoriasis Practice Questions

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: Munro's microabscesses are typically seen in which layer of the epidermis?

Stratum corneum. **Explanation:** **Munro’s microabscesses** are a pathognomonic histological feature of Psoriasis. They represent focal collections of **neutrophils** that have migrated from the dermal papillae through the epidermis to reach the **Stratum corneum**. This occurs due to the chemotactic effect of leukotriene B4 and IL-8. * **Why Stratum Corneum is correct:** In Psoriasis, the epidermal turnover time is significantly shortened. Neutrophils trapped within the parakeratotic scales (nucleated cells in the horny layer) of the **stratum corneum** form these microabscesses. * **Stratum granulosum:** This layer is typically **thinned or absent** (hypogranulosis) in Psoriasis, making it an incorrect site for these abscesses. * **Basal layer:** This layer shows increased mitotic activity (hyperplasia) in Psoriasis, but it is not the site of neutrophil accumulation. * **Papillary tips:** While dilated capillaries and edema are seen here, neutrophil collections specifically at the papillary tips are characteristic of **Dermatitis Herpetiformis** (forming "Kogoj-like" patterns or papillary microabscesses), not Munro’s microabscesses. **High-Yield Clinical Pearls for NEET-PG:** 1. **Kogoj’s Pustule:** If neutrophils collect in the **Stratum spinosum** (malpighian layer), they are called **Spongeiform pustules of Kogoj** (commonly seen in Pustular Psoriasis). 2. **Histology Mnemonic (P-S-O-R):** **P**arakeratosis, **S**tratum granulosum decrease, **O**longated rete ridges (regular), **R**educed suprapapillary plate thickness. 3. **Auspitz Sign:** Pinpoint bleeding on scraping a psoriatic plaque occurs due to the rupture of dilated capillaries in the dermal papillae covered by a thin suprapapillary plate.

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).

Q: Which of the following sites is least commonly involved in psoriasis?

CNS involvement. **Explanation:** Psoriasis is a chronic, systemic, immune-mediated inflammatory disorder primarily affecting the skin, nails, and joints. The correct answer is **CNS involvement** because psoriasis does not have any direct pathological manifestation within the Central Nervous System. While patients may experience psychological comorbidities (like depression), the disease process itself does not involve neural tissue. **Analysis of Options:** * **Scalp involvement (Option A):** This is one of the most common sites, affecting approximately 75–90% of patients. It often presents as well-demarcated erythematous plaques with silvery-white scales extending beyond the hairline. * **Nail involvement (Option B):** Seen in up to 50% of patients (and 80% of those with psoriatic arthritis). Characteristic findings include **pitting** (most common), oil spots, onycholysis, and subungual hyperkeratosis. * **Arthritis (Option D):** Psoriatic Arthritis (PsA) occurs in roughly 30% of patients. It is a seronegative spondyloarthropathy typically involving the distal interphalangeal (DIP) joints and the axial skeleton. **High-Yield Clinical Pearls for NEET-PG:** * **Auspitz Sign:** Pinpoint bleeding upon removal of a psoriasis scale due to thinning of the suprapapillary epidermis and dilated capillaries. * **Koebner Phenomenon:** Development of psoriatic lesions at sites of local trauma (also seen in Vitiligo and Lichen Planus). * **Histology:** Look for **Munro’s microabscesses** (neutrophils in the stratum corneum) and **Kogoj’s pustules** (neutrophils in the stratum spinosum). * **Treatment:** Topical Vitamin D analogues (Calcipotriol) and steroids are first-line; Methotrexate or Biologics (TNF-α inhibitors) are used for systemic disease.

Q: Ahritis mutilans is seen in which of the following conditions?

Psoriatic arthropathy. **Explanation:** **Arthritis Mutilans** is the most severe and destructive form of inflammatory arthritis, characterized by extensive bone resorption (osteolysis) leading to the collapse of joint surfaces. **1. Why Psoriatic Arthropathy is correct:** Arthritis mutilans is a classic, high-yield subtype of **Psoriatic Arthritis (PsA)**, occurring in about 5% of cases. The hallmark pathological process is "telescoping" of the fingers (Moll and Wright criteria), where the digits shorten due to bone loss. Radiologically, this presents as the **"Pencil-in-cup" deformity**, where the proximal bone is whittled down (pencil) and the distal bone surface is excavated (cup). **2. Why other options are incorrect:** * **Osteoarthritis:** A degenerative "wear and tear" disease characterized by joint space narrowing and osteophytes (Heberden’s/Bouchard’s nodes), not gross osteolysis. * **Rheumatoid Arthritis:** While RA causes joint destruction and deformities (Ulnar deviation, Swan neck), "mutilans" is specifically associated with the osteolytic pattern of PsA. (Note: Rarely, a mutilans-like variant exists in RA, but PsA is the primary association for exams). * **Reiter’s Syndrome (Reactive Arthritis):** Typically presents as an asymmetric oligoarthritis of the lower limbs and is associated with the triad of urethritis, conjunctivitis, and arthritis. **Clinical Pearls for NEET-PG:** * **Moll and Wright Classification:** PsA has 5 types: Asymmetric oligoarthritis (most common), Symmetric polyarthritis, DIP joint involvement, Spondylitis, and **Arthritis Mutilans** (most severe). * **Radiology Sign:** "Pencil-in-cup" appearance is pathognomonic for PsA. * **Clinical Sign:** "Opera glass hand" (La main en lorgnette) refers to the folding of skin over the shortened, telescoped joints. * **Nail Changes:** Pitting and onycholysis in a patient with joint pain strongly suggest Psoriatic Arthritis.

Q: Auspitz sign is seen in which of the following conditions?

Psoriasis. **Explanation:** **Auspitz Sign** is a classic clinical diagnostic feature of **Psoriasis**. It refers to the appearance of pinpoint bleeding points when the silvery-white scales of a psoriatic plaque are forcibly removed. **1. Why Psoriasis is correct:** The underlying pathophysiology involves two key changes: **parakeratosis** (retention of nuclei in the stratum corneum) and **suprapapillary thinning** (thinning of the epidermis over the dermal papillae). Additionally, the dermal papillae contain dilated, tortuous capillaries. When the scale is removed (Grattage test), these superficial capillaries are ruptured, leading to the characteristic pinpoint bleeding. **2. Why other options are incorrect:** * **Lichen Planus:** Characterized by **Wickham’s striae** (whitish reticular patterns) and the 6 P’s (Planar, Purple, Polygonal, Pruritic, Papules, Plaques). It does not show Auspitz sign. * **Alopecia Areata:** An autoimmune non-scarring hair loss condition characterized by **Exclamation mark hairs**. * **Lichen Sclerosus:** Typically presents as "parchment-like" or "cigarette paper" skin, often in the anogenital region. **Clinical Pearls for NEET-PG:** * **Grattage Test:** The clinical procedure used to elicit Auspitz sign by scraping the lesion with a glass slide. * **Candle Grease Sign:** As the scale is scraped, it becomes more silvery-white, resembling a scratch on a wax candle. * **Bulkeley’s Membrane:** The thin, moist, transparent membrane seen just before the pinpoint bleeding occurs. * **False Negatives:** Auspitz sign is usually absent in **Pustular Psoriasis**, **Inverse Psoriasis**, and **Erythrodermic Psoriasis**. * **Koebner Phenomenon:** Also seen in Psoriasis (and Lichen Planus), where new lesions appear at the site of trauma.

Q: "Microabscess of Munro" is seen in which of the following conditions?

Psoriasis. **Explanation:** **Munro’s Microabscesses** are a hallmark histopathological feature of **Psoriasis**. They consist of small collections of **neutrophils** within the **stratum corneum** (parakeratotic layer). This occurs due to the rapid turnover of keratinocytes and the chemotactic migration of neutrophils from the papillary dermis through the epidermis (Kogoj’s spongiform pustules) into the topmost layer. **Analysis of Options:** * **Psoriasis (Correct):** Characterized by the "Psoriasiform Triad": Regular elongation of rete ridges, Munro’s microabscesses, and thinning of the suprapapillary plate. * **Lichen Planus:** Histology shows "saw-tooth" rete ridges, basal cell degeneration (liquefaction necrosis), and **Wickham striae**, but not neutrophil collections. * **Pityriasis Rosea:** Features focal parakeratosis and "mound-like" edema in the dermis, but lacks the specific Munro’s microabscesses seen in psoriasis. * **Tuberous Sclerosis:** A neurocutaneous syndrome characterized by hamartomas (e.g., Angiofibromas, Ash-leaf spots, Shagreen patches). Histology shows collagenous proliferation, not epidermal neutrophilic abscesses. **High-Yield Clinical Pearls for NEET-PG:** * **Kogoj’s Spongiform Pustule:** Similar to Munro’s, but these are neutrophil collections in the **stratum spinosum** (seen in pustular psoriasis). * **Auspitz Sign:** Pinpoint bleeding when a psoriasis scale is removed due to thinning of the suprapapillary plate over dilated capillaries. * **Grattage Test:** Scraping a psoriatic lesion increases the visibility of silvery-white scales (candle grease sign). * **Koebner Phenomenon:** Development of new lesions at sites of trauma (also seen in Lichen Planus and Vitiligo).

Q: What is the appropriate treatment for an erythematous skin rash with multiple pus lakes in a pregnant woman?

Corticosteroids. **Explanation:** The clinical presentation of an erythematous skin rash with "multiple pus lakes" is characteristic of **Impetigo Herpetiformis**, which is a variant of **Pustular Psoriasis** specifically occurring during pregnancy (usually in the third trimester). **1. Why Corticosteroids are correct:** Systemic corticosteroids (e.g., Prednisolone) are the first-line treatment for Impetigo Herpetiformis. They are used to rapidly control systemic inflammation and prevent maternal-fetal complications. Since this condition can lead to placental insufficiency, electrolyte imbalances, and even fetal demise, aggressive management with steroids is essential and considered safe during pregnancy compared to other systemic antipsoriatic agents. **2. Why other options are incorrect:** * **Retinoids (B):** These are highly **teratogenic** (Category X). Acitretin, commonly used for pustular psoriasis, is strictly contraindicated in pregnancy and requires avoidance of pregnancy for 3 years after discontinuation. * **Methotrexate (C):** This is a folate antagonist and a potent **teratogen** and abortifacient. It is contraindicated in pregnancy. * **Psoralen with PUVA (D):** Psoralens are mutagenic and can cross the placenta; therefore, PUVA is generally avoided. While UVB therapy is considered safe, PUVA is not. **Clinical Pearls for NEET-PG:** * **Impetigo Herpetiformis:** Despite the name, it is *not* caused by the herpes virus or an infection; it is a form of Pustular Psoriasis. * **Key Lab Finding:** Hypocalcemia is frequently associated and must be monitored to prevent tetany. * **Delivery:** The condition usually resolves rapidly after delivery but may recur in subsequent pregnancies. * **Cyclosporine:** This can be used as a second-line agent if steroids fail, as it is relatively safe in pregnancy.

Question 1

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 2

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 3

Munro's microabscesses are typically seen in which layer of the epidermis?

Accepted Answer

Stratum corneum

Answer

Stratum granulosum

Answer

Basal layer

Answer

Papillary tips

Question 4

Chloroquine can cause exacerbation of which of the following conditions?

Accepted Answer

Psoriasis

Answer

Malaria

Answer

Discoid lupus erythematosus (DLE)

Answer

Photosensitivity

Question 5

Which of the following sites is least commonly involved in psoriasis?

Accepted Answer

CNS involvement

Answer

Scalp involvement

Answer

Nail involvement

Answer

Arthritis

Question 6

Which is the most malignant type of pustular psoriasis?

Accepted Answer

Von Zumbusch type

Answer

Palmo-plantar pustulosis

Answer

Acrodermatitis continua

Answer

Pustular bacterids

Question 7

Ahritis mutilans is seen in which of the following conditions?

Accepted Answer

Psoriatic arthropathy

Answer

Osteoarthritis

Answer

Rheumatoid arthritis

Answer

Reiter's syndrome

Question 8

Auspitz sign is seen in which of the following conditions?

Accepted Answer

Psoriasis

Answer

Lichen Planus

Answer

Alopecia Areata

Answer

Lichen Sclerosus

Question 9

"Microabscess of Munro" is seen in which of the following conditions?

Accepted Answer

Psoriasis

Answer

Lichen planus

Answer

Pityriasis rosea

Answer

Tuberous sclerosis

Question 10

What is the appropriate treatment for an erythematous skin rash with multiple pus lakes in a pregnant woman?

Accepted Answer

Corticosteroids

Answer

Retinoids

Answer

Methotrexate

Answer

Psoralen with PUVA

Psoriasis — MCQs

Psoriasis — MCQs

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