Phototherapy and Biologics for Psoriasis — MCQs
What is the primary condition for which calcitriol is used as a treatment?
Which one of these should not be used in severe widespread psoriasis?
PUVA therapy is used in all except:
A 45 year old female presents with the complaint of pain in the metacarpophalangeal, proximal interphalangeal and metatarsophalangeal joints of both right and left hands. Serology showed positive anti-CCP antibodies. She was placed on infliximab for control. Which of the following need to tested before starting treatment?
In which of the following conditions are Anti-TNF agents contraindicated?
A 40-year-old male presents with fever and abdominal pain and is diagnosed with HIV and TB. What is the most appropriate sequence of treatment?
Treatment of choice for Pustular psoriasis is:
The following lesion appears on the leg of a patient of ulcerative colitis. All are useful in management except:
An 8-year-old girl has extreme photosensitivity since birth. She has recently been diagnosed with skin cancer. What is the diagnosis?
A 16-year-old boy presented with asymptomatic, multiple erythematous annular lesions with a collarette of scales at the periphery of the lesions present on the trunk. What is the most likely diagnosis?
Phototherapy and Biologics for Psoriasis Indian Medical PG Practice Questions and MCQs
Question 1: What is the primary condition for which calcitriol is used as a treatment?
- A. Pemphigus
- B. Secondary hyperparathyroidism (Correct Answer)
- C. Lichen planus
- D. Leprosy
Explanation: Secondary hyperparathyroidism - Calcitriol is the active form of vitamin D (1,25-dihydroxyvitamin D₃), and it is crucial for regulating calcium and phosphate levels in the body [1]. - In secondary hyperparathyroidism, often seen in chronic kidney disease (CKD), the kidneys cannot convert vitamin D to its active form, leading to hypocalcemia and increased PTH secretion [1], [2]. - Calcitriol supplementation helps to increase calcium absorption from the gut and suppress the release of parathyroid hormone (PTH), thereby treating the underlying cause of secondary hyperparathyroidism [1], [2]. - This is the primary therapeutic indication for calcitriol in clinical practice. Lichen planus - This is a chronic inflammatory condition affecting the skin, hair, nails, and mucous membranes - Typically treated with corticosteroids or other immunosuppressants - Calcitriol has no primary role in the treatment of lichen planus; its therapeutic applications are predominantly related to calcium and bone metabolism Pemphigus - Pemphigus is a group of rare autoimmune blistering diseases that affect the skin and mucous membranes - Primary treatment involves immunosuppressants like corticosteroids, often in high doses - Calcitriol is not indicated for the treatment of pemphigus, as its mechanism of action is unrelated to the autoimmune processes characteristic of this disease Leprosy - Leprosy is a chronic infectious disease caused by the bacterium Mycobacterium leprae - Treated with multi-drug therapy (MDT), which includes antibiotics like rifampicin, dapsone, and clofazimine - Calcitriol is not an antibiotic and therefore has no role in treating the bacterial infection responsible for leprosy
Question 2: Which one of these should not be used in severe widespread psoriasis?
- A. Methotrexate
- B. Oral retinoids
- C. Cyclosporin
- D. Oral glucocorticoids (Correct Answer)
Explanation: ***Oral glucocorticoids*** - While they may provide temporary relief, **oral glucocorticoids** can exacerbate psoriasis upon withdrawal, leading to a severe flare-up or **pustular psoriasis**. - Their long-term use is associated with numerous side effects, making them unsuitable for widespread, chronic conditions like severe psoriasis. *Methotrexate* - **Methotrexate** is a systemic agent commonly used for severe psoriasis due to its immune-modulating and anti-proliferative effects. - It is effective in reducing inflammation and slowing down epidermal cell turnover. *Oral retinoids* - **Oral retinoids** like acitretin are effective systemic treatments for severe widespread psoriasis, especially **pustular** and **erythrodermic** forms. - They work by normalizing keratinocyte proliferation and differentiation. *Cyclosporin* - **Cyclosporin** is a potent immunosuppressant widely used for severe psoriasis, particularly when rapid disease control is needed. - It works by inhibiting T-cell activation and is highly effective in clearing psoriatic lesions.
Question 3: PUVA therapy is used in all except:
- A. Psoriasis
- B. Vitiligo
- C. Mycosis fungoides
- D. Melasma (Correct Answer)
Explanation: ***Melasma*** - **PUVA (Psoralen plus UVA) therapy** is contraindicated in melasma due to its potential to worsen hyperpigmentation and cause paradoxical darkening. - Melasma is best managed with topical agents like **hydroquinone**, **tretinoin**, and chemical peels, along with strict **sun protection**. *Psoriasis* - **PUVA therapy** is a well-established and effective treatment for moderate to severe psoriasis, especially for patients with widespread plaques. - It works by inhibiting DNA synthesis and cell proliferation in rapidly dividing keratinocytes, leading to a reduction in psoriatic lesions. *Vitiligo* - **PUVA therapy** is a common treatment for vitiligo, stimulating melanocyte activity and promoting repigmentation in affected areas. - Psoralen sensitizes melanocytes to UVA light, which then encourages melanin production. *Mycosis fungoides* - In its early stages, **mycosis fungoides**, a cutaneous T-cell lymphoma, can be effectively treated with **PUVA therapy**. - PUVA induces apoptosis of malignant T-cells in the skin, leading to remission of skin lesions.
Question 4: A 45 year old female presents with the complaint of pain in the metacarpophalangeal, proximal interphalangeal and metatarsophalangeal joints of both right and left hands. Serology showed positive anti-CCP antibodies. She was placed on infliximab for control. Which of the following need to tested before starting treatment?
- A. G6PD
- B. PPD skin test (Correct Answer)
- C. Uric acid
- D. Complete blood count
Explanation: ***PPD skin test*** - **Infliximab** is a **TNF-alpha inhibitor**, which can **reactivate latent tuberculosis** (TB) by suppressing the immune response critical for containing the infection. [1] - A **PPD skin test** (or interferon-gamma release assay like Quantiferon) is essential to screen for latent TB before initiating treatment with biologics like infliximab to prevent severe active infection. [1] *G6PD* - **Glucose-6-phosphate dehydrogenase (G6PD) deficiency** is primarily relevant when prescribing drugs that can cause **hemolysis**, such as certain antimalarials or sulfonamides. - It does not have a direct interaction or contraindication with infliximab, and screening is not standard practice before starting TNF-alpha inhibitors. *Uric acid* - **Uric acid levels** are primarily monitored in conditions like **gout** or when using medications that affect uric acid metabolism. - They are not a standard pre-treatment screening test for patients starting infliximab for rheumatoid arthritis. *Complete blood count* - A **complete blood count (CBC)** is generally part of routine workup for many conditions and can help assess baseline blood cell counts before starting any significant medication. [1] - While useful for monitoring during treatment, it is not the critical specific test required to prevent a severe infectious complication, like a PPD test, before starting infliximab. [1]
Question 5: In which of the following conditions are Anti-TNF agents contraindicated?
- A. RA with Hepatitis B (Correct Answer)
- B. RA with HCV
- C. RA with pulmonary fibrosis
- D. RA with HIV
Explanation: ***RA with Hepatitis B*** - **Anti-TNF agents** can cause reactivation of **latent Hepatitis B virus (HBV)** infection, leading to severe hepatitis and liver failure [1]. Therefore, screening for HBV is crucial before initiating these medications [1]. - Patients with active or chronic HBV infection often require **antiviral therapy** before or concurrently with anti-TNF treatment to prevent reactivation. *RA with HIV* - While caution is advised, **anti-TNF agents** can be used in patients with **well-controlled HIV infection** on antiretroviral therapy, often with close monitoring for infections. - The risk of opportunistic infections is carefully balanced against the benefits of controlling rheumatoid arthritis and preventing joint damage [1]. *RA with HCV* - **Anti-TNF agents** are generally considered safe for patients with **Hepatitis C virus (HCV)** infection, especially if the HCV is stable or being treated. - There is no strong evidence to suggest that anti-TNF therapy commonly causes HCV reactivation or worsening of liver disease. *RA with pulmonary fibrosis* - The use of **anti-TNF agents** in patients with established **pulmonary fibrosis** is generally not contraindicated, though careful monitoring for worsening respiratory symptoms is important. - Some anti-TNF agents have been associated with **interstitial lung disease**, but this is typically a new onset condition rather than exacerbation of pre-existing fibrosis.
Question 6: A 40-year-old male presents with fever and abdominal pain and is diagnosed with HIV and TB. What is the most appropriate sequence of treatment?
- A. First ATT and then ART
- B. ATT only
- C. First ART and then ATT
- D. ATT followed by ART within 2-8 weeks (Correct Answer)
Explanation: ***ATT followed by ART within 2-8 weeks*** - This sequence is crucial for patients with co-infection of **HIV and TB**. Initiating **anti-tuberculous treatment (ATT)** first is vital to control the active TB infection, which can be rapidly fatal [2]. - Subsequently, starting **antiretroviral therapy (ART)** within 2-8 weeks (typically 2-4 weeks after ATT in patients without CNS TB) helps to restore the immune system and prevent other opportunistic infections, but delaying it slightly reduces the risk of **IRIS (Immune Reconstitution Inflammatory Syndrome)** [1]. *First ATT and then ART* - While starting ATT first is correct, this option is too vague regarding the timing of ART initiation. - The specific window of 2-8 weeks (or 2-4 weeks without CNS TB) is important to balance TB treatment efficacy and mitigate **IRIS risk** [1]. *ATT only* - This approach is incorrect as it fails to address the underlying HIV infection, which would lead to continued immune decline and increased morbidity and mortality. - ART is essential for improving prognosis and reducing viral load in HIV-infected individuals. *First ART and then ATT* - Initiating ART before ATT in co-infected patients with active TB can worsen the TB condition due to **IRIS**, which can be severe and life-threatening [1]. - ART can cause a rapid immune reconstitution and paradoxical worsening of symptoms or presentation of subclinical TB [1].
Question 7: 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 8: The following lesion appears on the leg of a patient of ulcerative colitis. All are useful in management except:
- A. Steroids
- B. Sulfapyridine (Correct Answer)
- C. Procto-colectomy
- D. Infliximab
Explanation: ***Sulfapyridine*** - The image shows **pyoderma gangrenosum**, a painful ulcerative skin condition often associated with inflammatory bowel disease like ulcerative colitis. Among the given options, **sulfapyridine** has the **least established role** in pyoderma gangrenosum management. - **Sulfapyridine** is an inactive component of **sulfasalazine** and primarily acts as an **antibacterial agent**. While sulfasalazine has been reported in some PG cases, sulfapyridine alone is not a recognized treatment for the inflammatory, non-infectious nature of pyoderma gangrenosum. - Unlike the other options which have well-established roles, sulfapyridine lacks strong evidence for efficacy in PG. *Steroids* - **Corticosteroids** (oral or topical) are the **first-line treatment** for pyoderma gangrenosum due to their potent anti-inflammatory and immunosuppressive effects. - They help to reduce the inflammation and promote healing of the painful ulcers. *Procto-colectomy* - In cases of severe, refractory pyoderma gangrenosum associated with ulcerative colitis, **colectomy** can be a **definitive treatment** as it removes the underlying inflammatory trigger. - This surgical intervention is considered when medical therapies are unsuccessful or when the colonic disease itself necessitates surgery. *Infliximab* - **Infliximab**, a **TNF-alpha inhibitor**, is a biologic agent effective in treating both ulcerative colitis and pyoderma gangrenosum. - It is used in cases that are refractory to steroids or when patients cannot tolerate steroid therapy.
Question 9: An 8-year-old girl has extreme photosensitivity since birth. She has recently been diagnosed with skin cancer. What is the diagnosis?
- A. Xeroderma Pigmentosum (Correct Answer)
- B. Bloom syndrome
- C. Griscelli syndrome
- D. Chediak Higashi syndrome
Explanation: ***Xeroderma Pigmentosum*** - This condition is characterized by an extreme sensitivity to **ultraviolet (UV) light** from birth due to defects in **DNA repair mechanisms**, leading to severe sunburns, pigmentary changes (freckles, hypopigmented macules), and a high risk of developing **skin cancers** at a young age. - The history of extreme photosensitivity since birth and the diagnosis of skin cancer in an 8-year-old girl is highly indicative of Xeroderma Pigmentosum. *Bloom syndrome* - Bloom syndrome is an inherited disorder characterized by **stunted growth**, a **photosensitive facial rash (telangiectatic erythema)**, and a predisposition to **various cancers**, including leukemia and lymphomas. - While photosensitivity and cancer risk are present, the extreme skin damage and early onset of specific skin cancers (as opposed to leukemias/lymphomas often seen in Bloom) make Xeroderma Pigmentosum a more fitting diagnosis. *Griscelli syndrome* - Griscelli syndrome is a rare autosomal recessive disorder characterized by **partial albinism**, immunodeficiency, and neurological impairment. - While it involves pigmentary abnormalities, it does not typically present with the extreme photosensitivity or the very early skin cancer development described in the patient. *Chediak Higashi syndrome* - Chediak-Higashi syndrome is an autosomal recessive disorder characterized by **partial albinism**, recurrent pyogenic infections, and neurological abnormalities, due to defective lysosomal trafficking. - This syndrome is not primarily associated with extreme photosensitivity leading to early skin cancers but rather with immunodeficiency and neurological issues.
Question 10: A 16-year-old boy presented with asymptomatic, multiple erythematous annular lesions with a collarette of scales at the periphery of the lesions present on the trunk. What is the most likely diagnosis?
- A. Pityriasis versicolor
- B. Pityriasis alba
- C. Pityriasis rosea (Correct Answer)
- D. Pityriasis rubra pilaris
Explanation: ### Explanation The clinical presentation of multiple erythematous annular lesions with a characteristic **collarette of scales** at the periphery on the trunk is a classic description of **Pityriasis Rosea (PR)**. **Why Pityriasis Rosea is correct:** PR is an acute, self-limiting inflammatory dermatosis, often associated with Human Herpesvirus 6 or 7 (HHV-6/7). It typically begins with a single, large **"Herald Patch"** followed by a generalized eruption of smaller oval lesions. The scales in PR are unique; they are attached at the periphery and free in the center, forming a **"collarette"** appearance. On the back, these lesions follow the lines of cleavage, creating a **"Christmas Tree"** or "Fir Tree" distribution. **Why the other options are incorrect:** * **Pityriasis versicolor:** Presents as hypo- or hyperpigmented macules with fine, branny (furfuraceous) scaling. It is caused by *Malassezia* and does not typically show a peripheral collarette of scales. * **Pityriasis alba:** Commonly seen in children with atopy, presenting as ill-defined hypopigmented patches with fine scaling, usually on the face. It lacks the annular, erythematous nature of PR. * **Pityriasis rubra pilaris (PRP):** Characterized by follicular papules on an erythematous base, "islands of sparing," and orange-red palmoplantar keratoderma. It does not present with a collarette of scales. **High-Yield Clinical Pearls for NEET-PG:** * **Herald Patch:** The initial lesion (seen in 80% of cases), usually larger and more scaly than subsequent lesions. * **Hanging Curtain Sign:** When the skin is stretched across the long axis of the lesion, the scales tend to fold inwards (characteristic of PR). * **Treatment:** Usually conservative (reassurance); antihistamines for pruritus. * **Differential Diagnosis:** Secondary syphilis (always rule this out if lesions involve palms and soles; PR typically spares them).
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