Psoriasis Practice Questions

Q: A 50-year-old patient presents with erythematous scaly plaques over the trunk and extremities for the last 10 years. The lesions are occasionally itchy, with a history of remission and relapse, and exacerbation during winters. What is the most likely diagnosis?

Psoriasis vulgaris. ### Explanation **Psoriasis vulgaris** is the most likely diagnosis based on the classic clinical presentation of chronic, well-demarcated erythematous scaly plaques. **Why Psoriasis is Correct:** * **Chronic Course:** A 10-year history of remission and relapse is characteristic of this autoimmune inflammatory condition. * **Morphology:** Erythematous plaques with silvery-white scales are the hallmark. * **Winter Exacerbation:** Psoriasis typically worsens in winter due to low humidity and reduced UV exposure (which normally inhibits T-cell activity in the skin). * **Distribution:** Involvement of the trunk and extremities (especially extensors) is typical. **Why Other Options are Incorrect:** * **Lichen Planus:** Presents with the "6 Ps" (Planar, Purple, Polygonal, Pruritic, Papules, and Plaques). It usually involves the flexor surfaces (wrists) and oral mucosa (Wickham striae), rather than showing winter exacerbation. * **Pityriasis Rosea:** An acute, self-limiting condition lasting 6–8 weeks. It starts with a "Herald patch" followed by a "Christmas tree" distribution. A 10-year history rules this out. * **Seborrheic Dermatitis:** Characterized by greasy, yellowish scales in "seborrheic areas" (scalp, nasolabial folds, chest). It lacks the thick, silvery scaling and chronic plaque formation seen here. **High-Yield Clinical Pearls for NEET-PG:** * **Auspitz Sign:** Pinpoint bleeding upon removal of scales (due to thinning of suprapapillary plate). * **Koebner Phenomenon:** Development of new lesions at sites of trauma (also seen in Lichen Planus and Vitiligo). * **Histopathology:** 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 Corticosteroids are first-line for localized disease.

Q: Which of the following is NOT a treatment option for psoriasis?

Oral corticosteroids. **Explanation:** In Psoriasis, **Oral Corticosteroids (Option D)** are generally contraindicated. While they provide rapid initial improvement due to their potent anti-inflammatory effects, their withdrawal—even with a slow taper—can trigger a life-threatening rebound flare-up. This often manifests as **Pustular Psoriasis (von Zumbusch type)** or **Erythrodermic Psoriasis**. Therefore, systemic steroids are reserved only for exceptional circumstances, such as persistent pregnancy-related psoriasis (Impetigo Herpetiformis) where other options are limited. **Analysis of other options:** * **Retinoids (Option A):** Oral retinoids like **Acitretin** are highly effective, especially in pustular and erythrodermic variants. They normalize keratinocyte proliferation and differentiation. * **Methotrexate (Option B):** A folate antagonist that inhibits dihydrofolate reductase. It is a gold-standard systemic therapy for extensive plaque psoriasis and psoriatic arthritis. * **Cyclosporine (Option C):** A calcineurin inhibitor that provides rapid induction of remission in severe, recalcitrant psoriasis by inhibiting T-cell activation. **High-Yield Clinical Pearls for NEET-PG:** * **First-line topical treatment:** Topical Corticosteroids + Vitamin D3 analogues (Calcipotriol). * **Drug of choice for Psoriatic Arthritis:** Methotrexate (or TNF-alpha inhibitors like Etanercept). * **Auspitz Sign:** Pinpoint bleeding on peeling a scale, characteristic of psoriasis. * **Woronoff Ring:** A pale halo around a healing psoriatic lesion. * **Guttate Psoriasis:** Often follows a Streptococcal sore throat; treated primarily with phototherapy (NBUVB).

Q: A child with a sore throat starts developing skin lesions as in the image below. Which of the following is the diagnosis?

Guttate psoriasis. ***Guttate psoriasis***- It characteristically appears 2–3 weeks following an infection, most commonly **Streptococcal pharyngitis**, making this post-sore throat presentation highly suggestive.- The rash consists of generalized, small (2–10 mm), discrete, **"tear-drop"**-shaped papules or plaques with fine scale, often covering the trunk and extremities.*Pustular psoriasis*- This form is characterized by the presence of numerous sterile **pustules** on erythematous skin, which is a different morphology than the papular rash described.- Generalized pustular psoriasis (**von Zumbusch type**) is a severe systemic illness that is distinct from the typical post-streptococcal rash seen in children.*Erythrodermic*- This represents a severe form of psoriasis involving widespread erythema and scaling affecting **>90% of the body surface area**.- It is often associated with systemic symptoms (fever, instability) and is a medical emergency, inconsistent with the presentation following a simple sore throat.*Inverse psoriasis*- This variant exclusively affects **intertriginous areas** (skin folds) like the axilla, groin, or under the breasts.- The lesions are typically smooth, shiny, and often lack the significant scaling found in guttate or plaque psoriasis due to the moist environment.

Q: A 26-year-old male presented with erythematous plaques covered with silvery scales over the extensor surfaces of both arms. Punctate pitting was noted on examining the nails. What is the most likely diagnosis?

Psoriasis. ***Psoriasis*** - The clinical presentation of **well-demarcated, erythematous plaques** covered with **silvery scales** on **extensor surfaces** is the hallmark of plaque psoriasis. - **Nail pitting**, as shown in the image, along with other nail changes like **onycholysis** (separation of the nail from the nail bed) and the **oil drop sign**, are highly characteristic findings in psoriasis. *Lichen planus* - Lichen planus is characterized by the "6 P's": **Pruritic, Purple, Polygonal, Planar Papules, and Plaques**, which differ significantly from the silvery-scaled lesions of psoriasis. - It commonly appears on **flexor surfaces**, such as the wrists, and is often associated with **Wickham's striae** (fine white lines on the lesions or oral mucosa). *Eczema* - Eczema (atopic dermatitis) typically presents with **poorly-demarcated, erythematous patches** with intense **pruritus**, leading to **lichenification** and **excoriations**, rather than well-defined plaques with silvery scales. - In adults, eczema classically involves the **flexor surfaces**, such as the antecubital and popliteal fossae, contrasting with the extensor distribution seen in this case. *Pityriasis rosea* - Pityriasis rosea typically begins with a solitary, larger lesion known as a **herald patch**, which is absent in this presentation. - This is followed by a generalized eruption of smaller, oval, pink papules with fine scale in a **"Christmas tree" distribution** on the trunk, which is inconsistent with the described findings.

Q: A 26-year-old male presents with greasy papules on face and chest that feel like sandpaper. Palms and soles have minute pits. Skin biopsy was performed. What is the diagnosis?

Darier's disease. ***Darier's disease*** - The presentation of **greasy papules** on the face and chest resembling "sandpaper," along with **minute pits on palms and soles**, is classic for Darier's disease. - Histologically, Darier's disease is characterized by **dyskeratosis** (premature keratinization of individual keratinocytes) and **acantholysis** (loss of cohesion between keratinocytes), which would be seen on a skin biopsy. *Hailey-Hailey disease* - This condition typically presents with **flaccid vesicles and bullae** in intertriginous areas (e.g., axillae, groin) that rupture to form erosions. - Histology shows **acantholysis** (loss of cell adhesion) creating a "dilapidated brick wall" appearance, but without the prominent dyskeratosis seen in Darier's. *Epidermolysis bullosa* - This is a group of genetic disorders characterized by **extreme skin fragility** and the formation of **blisters** (bullae) in response to minimal trauma. - The clinical presentation with greasy papules and pits is not consistent with the primary blistering nature of epidermolysis bullosa. *Incontinentia pigmenti* - This X-linked dominant disorder primarily affects females and presents with **skin lesions in distinct stages** (vesicular, verrucous, hyperpigmented, atrophic) following Blaschko's lines. - It does not typically involve greasy papules or palmoplantar pitting in the manner described.

Q: A 21-year-old college student presents with this clinical finding. All are true about the condition except:

Three genome copies per coccal unit. ***Three genome copies per coccal unit*** - The image depicts **urethral discharge**, characteristic of **gonococcal or chlamydial urethritis**. - *Neisseria gonorrhoeae* is a **Gram-negative diplococcus** that contains a **single bacterial genome** per cell, not "three genome copies per coccal unit." - This statement is **false**, making it the correct answer to this "EXCEPT" question. *In case of absence of laboratory facility, initial treatment regimens must incorporate azithromycin or doxycycline* - This statement is **true**. Empirical treatment for suspected urethritis includes **azithromycin (1g single dose)** or **doxycycline (100mg BD for 7 days)** to provide coverage for both *N. gonorrhoeae* and *Chlamydia trachomatis*. - Dual therapy with **ceftriaxone plus azithromycin** is recommended when gonococcal infection is suspected. *Most common complication is prostatitis* - This statement is **true**. In untreated or inadequately treated male urethritis, complications include **prostatitis, epididymitis, and epididymo-orchitis**. - In females, complications include **pelvic inflammatory disease (PID)**, which can lead to infertility and ectopic pregnancy. *Nucleic acid amplification is used with >90% sensitivity* - This statement is **true**. **Nucleic acid amplification tests (NAATs)** are the gold standard for diagnosing both gonorrhea and chlamydia. - NAATs demonstrate **sensitivity >90-95%** and high specificity, and can be performed on first-void urine, urethral swabs, or vaginal swabs.

Q: Choose the correct statement for the clinical sign shown in psoriasis: (Recent NEET Pattern 2016-17)

Punctate bleeding spots from elongated capillary loops. ***Punctate bleeding spots from elongated capillary loops*** - This describes **Auspitz sign**, a characteristic clinical finding in **psoriasis**, where removal of scales reveals pinpoint bleeding spots. - The bleeding occurs due to the presence of **elongated and dilated dermal capillary loops** that are close to the epidermal surface in psoriatic plaques. *Punctate bleeding spots from tortuous arterioles* - This statement is incorrect as the bleeding in Psoriasis comes specifically from the **capillary loops**, not arterioles. - Arterioles are precapillary vessels and are not typically the direct source of bleeding in Auspitz sign. *Punctate bleeding spots from venules* - This statement is incorrect. While venules are part of the microvasculature, the specific vessels responsible for Auspitz sign bleeding are the **elongated capillary loops**. - Venules are post-capillary vessels and do not typically exhibit the characteristic changes seen in psoriasis that lead to this sign. *All are correct* - This is incorrect because only the statement referring to "elongated capillary loops" accurately describes the source of punctate bleeding in the context of the Auspitz sign in psoriasis.

Q: A patient presents with the skin lesions shown in the image. All of the following are routinely indicated for the treatment of this condition EXCEPT:

Rituximab. ***Rituximab*** - The image displays **plaque psoriasis**, characterized by erythematous plaques with silvery scales. Rituximab, an anti-CD20 monoclonal antibody, targets B-cells and is primarily used in conditions like **lymphoma, leukemia, and rheumatoid arthritis**, not typically for psoriasis. - While some off-label uses or investigational studies might explore its role, it is **not routinely indicated** for the treatment of psoriasis. *Topical vitamin D* - **Topical vitamin D analogs** (e.g., calcipotriene, calcitriol) are a common first-line treatment for mild to moderate plaque psoriasis. They work by **inhibiting keratinocyte proliferation** and promoting their differentiation. - These agents are often used alone or in combination with topical corticosteroids to reduce inflammation and scaling. *Cyclosporine* - **Cyclosporine** is a calcineurin inhibitor used as a systemic treatment for severe psoriasis, especially in cases that are refractory to topical therapies or phototherapy. - It works by **suppressing the immune system**, thereby reducing the inflammation and rapid cell turnover seen in psoriasis. *Acitretin* - **Acitretin** is an oral retinoid indicated for severe psoriasis, particularly **pustular and erythrodermic psoriasis**, and in some cases of chronic plaque psoriasis. - It normalizes epidermal cell growth and differentiation, effective for extensive or difficult-to-treat forms of the disease.

Q: Which of the following layers is absent in psoriasis?

B. ***B*** - The layer labeled 'B' corresponds to the **stratum granulosum (granular layer)** of the epidermis, which is **absent or markedly thinned in areas of parakeratosis** in psoriatic lesions. - The loss/absence of the stratum granulosum in psoriasis is a characteristic histological feature, particularly in regions showing parakeratosis (retention of nuclei in the stratum corneum). - This is considered the classic answer for "which layer is absent in psoriasis" in medical examinations. *A* - The layer labeled 'A' is the **stratum corneum (horny layer)**, which is actually **thickened** in psoriasis (hyperkeratosis) and shows **parakeratosis** (retention of nuclei). - The stratum corneum is not absent but rather abnormal, showing retained nuclei and increased thickness with scaling. *C* - The layer labeled 'C' represents the **stratum spinosum (prickle cell layer)**, which is significantly **thickened (acanthosis)** in psoriasis due to increased keratinocyte proliferation. - Acanthosis (thickening of the spinous layer) is a hallmark feature of psoriasis, not absence of this layer. *D* - The layer labeled 'D' points to the **stratum basale (basal layer)**, which contains actively dividing keratinocytes and is always present in the epidermis. - In psoriasis, the basal keratinocytes show increased proliferation and shortened cell cycle, leading to epidermal hyperplasia, but the layer is never absent.

Question 1

A 50-year-old patient presents with erythematous scaly plaques over the trunk and extremities for the last 10 years. The lesions are occasionally itchy, with a history of remission and relapse, and exacerbation during winters. What is the most likely diagnosis?

Accepted Answer

Psoriasis vulgaris

Answer

Lichen planus

Answer

Pityriasis rosea

Answer

Seborrheic dermatitis

Question 2

Which of the following is NOT a treatment option for psoriasis?

Accepted Answer

Oral corticosteroids

Answer

Retinoids

Answer

Methotrexate

Answer

Cyclosporine

Question 3

A child with a sore throat starts developing skin lesions as in the image below. Which of the following is the diagnosis?

Accepted Answer

Guttate psoriasis

Answer

Pustular psoriasis

Answer

Inverse psoriasis

Answer

Erythrodermic

Question 4

A 26-year-old male presented with erythematous plaques covered with silvery scales over the extensor surfaces of both arms. Punctate pitting was noted on examining the nails. What is the most likely diagnosis?

Accepted Answer

Psoriasis

Answer

Eczema

Answer

Pityriasis rosea

Answer

Lichen planus

Question 5

A 26-year-old male presents with greasy papules on face and chest that feel like sandpaper. Palms and soles have minute pits. Skin biopsy was performed. What is the diagnosis?

Accepted Answer

Darier's disease

Answer

Hailey Hailey disease

Answer

Epidermolysis bullosa

Answer

Incontinentia pigmenti

Question 6

A 21-year-old college student presents with this clinical finding. All are true about the condition except:

Accepted Answer

Three genome copies per coccal unit

Answer

In case of absence of laboratory facility, initial treatment regimens must incorporate azithromycin or doxycycline

Answer

Most common complication is prostatitis

Answer

Nucleic acid amplification is used with >90% sensitivity

Question 7

All are correct about the condition shown except:

Accepted Answer

Pustular psoriasis follows streptococcal pharyngitis

Answer

Parakeratosis

Answer

Autosomal dominant with incomplete penetrance

Answer

Associated with formation of Munro micro-abscess formation

Question 8

Choose the correct statement for the clinical sign shown in psoriasis: (Recent NEET Pattern 2016-17)

Accepted Answer

Punctate bleeding spots from elongated capillary loops

Answer

Punctate bleeding spots from tortuous arterioles

Answer

Punctate bleeding spots from venules

Answer

All are correct

Question 9

A patient presents with the skin lesions shown in the image. All of the following are routinely indicated for the treatment of this condition EXCEPT:

Accepted Answer

Rituximab

Answer

Topical vitamin D

Answer

Cyclosporine

Answer

Acitretin

Question 10

Which of the following layers is absent in psoriasis?

Accepted Answer

B

Answer

A

Answer

C

Answer

D

Psoriasis — MCQs

Psoriasis — MCQs

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