Pustular Psoriasis — MCQs
All are nail changes seen in cases of psoriasis except:
All are true about psoriasis except:
PUVA therapy is used in:
A patient with psoriasis was started on systemic steroids. After stopping the treatment, the patient developed generalized pustules all over the body. The cause is most likely to be -
A 26-year-old girl at 31 weeks' gestation complains of a 4-week history of a pustular eruption that initially developed on the periumbilical skin and subsequently spread to involve the breasts, back, flexures, and proximal limbs, accompanied by cutaneous pain, fever, and malaise. On examination, the lesions were found to be pustules arranged in concentric rings, while on the breasts, there was coalescence of pustules forming lakes of pus. What is the treatment of choice in this case?
What diagnosis is suggested by the finding on the sole of this patient's foot?
In which of the following conditions is the Koebner phenomenon most commonly observed?
Treatment of choice for Pustular psoriasis is:
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:
Which statement about systemic steroids in psoriasis is correct:
Pustular Psoriasis Indian Medical PG Practice Questions and MCQs
Question 1: All are nail changes seen in cases of psoriasis except:
- A. Subungual hyperkeratosis
- B. Oil drop sign
- C. Mees lines (Correct Answer)
- D. Pitting
Explanation: ***Mees lines*** - **Mees lines** (or Aldrich-Mees lines) are **transverse white bands** that appear in the nail plate. - They are typically associated with **heavy metal poisoning** (e.g., arsenic), chemotherapy, or systemic illnesses, not psoriasis. *Subungual hyperkeratosis* - This is a common finding in **psoriasis**, characterized by the **thickening of the nail bed** due to excessive keratin production. - It leads to lifting of the nail plate from the nail bed. *Oil drop sign* - The **oil drop sign** (or salmon patch) is a classic psoriatic nail change, presenting as a **translucent, yellowish-red discoloration** under the nail plate. - It is due to psoriasis of the nail bed. *Pitting* - **Nail pitting** refers to the presence of **small depressions or pits** on the nail surface. - It results from defective keratinization of the nail matrix and is a characteristic sign of nail psoriasis.
Question 2: All are true about psoriasis except:
- A. Parakeratosis & acanthosis
- B. Pitting of nails
- C. Very pruritic (Correct Answer)
- D. Joint involvement in 5–30%
Explanation: ***Very pruritic*** - While psoriasis can be itchy, it is generally not characterized as "very pruritic" compared to other dermatological conditions like **eczema** or **scabies**. - **Pruritus** in psoriasis tends to be mild to moderate, and it is not a defining characteristic that differentiates it from other skin disorders. *Parakeratosis & acanthosis* - **Parakeratosis** (retention of nuclei in the stratum corneum) and **acanthosis** (epidermal hyperplasia) are classic histopathological hallmarks of psoriasis. - These features reflect the rapid epidermal turnover characteristic of the condition. *Pitting of nails* - **Nail pitting**, onycholysis, and subungual hyperkeratosis are common and characteristic manifestations of psoriasis, affecting up to 50% of patients. - These nail changes are highly indicative of **psoriatic involvement**. *Joint involvement in 5–10%* - **Psoriatic arthritis**, involving inflammation of the joints, affects approximately 5-30% of individuals with psoriasis. - This statistic makes joint involvement a significant comorbidity of psoriasis.
Question 3: PUVA therapy is used in:
- A. Melasma
- B. Lichen planus
- C. Psoriasis (Correct Answer)
- D. Freckles
Explanation: ***Psoriasis*** - **PUVA (Psoralen plus ultraviolet A)** therapy is a well-established and effective treatment for **moderate-to-severe psoriasis**. - Psoralen is a photosensitizing agent that, when activated by UVA light, inhibits **DNA synthesis** and reduces cell proliferation in the affected skin. - PUVA is considered a **gold standard phototherapy** for psoriasis, particularly for extensive plaque psoriasis and generalized disease. *Melasma* - Melasma is a **hyperpigmentary disorder** characterized by dark patches on the face. - While some light-based therapies are used, **topical agents** like hydroquinone and chemical peels are the primary treatments, and PUVA is not typically indicated due to the risk of worsening hyperpigmentation. *Lichen planus* - Lichen planus is an **inflammatory skin condition** that can be treated with phototherapy including **PUVA**, particularly for oral lichen planus and widespread cutaneous disease. - However, **narrowband UVB** is generally preferred as first-line phototherapy due to fewer side effects. - While PUVA has a role in lichen planus, psoriasis remains the **primary and most established indication** for this therapy. *Freckles* - Freckles are **benign pigmented macules** and do not require medical treatment. - Protection from **UV exposure** and cosmetic treatments like laser therapy for aesthetic reasons are sometimes used, but PUVA is entirely inappropriate and would cause harm.
Question 4: A patient with psoriasis was started on systemic steroids. After stopping the treatment, the patient developed generalized pustules all over the body. The cause is most likely to be -
- A. Pustular psoriasis (Correct Answer)
- B. Erythrodermic Psoriasis
- C. Bacterial infection
- D. Drug induced reaction
Explanation: ***Pustular psoriasis*** - **Generalized pustules** developing after the abrupt cessation of systemic steroids in a patient with a history of psoriasis is highly indicative of **pustular psoriasis**. - This form of psoriasis is characterized by the sudden appearance of widespread, sterile pustules on an erythematous base and can be triggered by various factors, including **steroid withdrawal**. *Erythrodermic Psoriasis* - This form presents as widespread **redness and scaling** affecting more than 90% of the body surface. - While it can be severe and may be triggered by systemic steroid withdrawal, it does not typically manifest with **generalized pustules** as the primary feature. *Bacterial infection* - A bacterial infection might cause pustules, but they are usually associated with signs of infection such as **fever, pain, and localized inflammation**, and the pustules would likely be non-sterile and rupture. - The context of a pre-existing psoriasis diagnosis and **steroid withdrawal** points away from a primary bacterial etiology for such widespread, generalized pustules. *Drug induced reaction* - While drug reactions can cause skin eruptions, the specific presentation of **generalized pustules** in a known psoriasis patient, directly following **steroid withdrawal**, strongly suggests a flare of their underlying condition. - **Drug-induced reactions** typically have a broader range of presentations and would not be as specifically linked to pustular morphology in this context.
Question 5: A 26-year-old girl at 31 weeks' gestation complains of a 4-week history of a pustular eruption that initially developed on the periumbilical skin and subsequently spread to involve the breasts, back, flexures, and proximal limbs, accompanied by cutaneous pain, fever, and malaise. On examination, the lesions were found to be pustules arranged in concentric rings, while on the breasts, there was coalescence of pustules forming lakes of pus. What is the treatment of choice in this case?
- A. Corticosteroids (Correct Answer)
- B. Methotrexate
- C. Topical itraconazole
- D. Third generation cephalosporins
Explanation: ***Corticosteroids*** - The constellation of **pustular eruption** with **concentric rings**, especially in pregnancy, along with systemic symptoms like fever and malaise, is highly suggestive of **Pustular Psoriasis of Pregnancy (PPP)**, also known as **Impetigo Herpetiformis**. - **Systemic corticosteroids** (prednisolone) are the **first-line treatment** for this rare but severe dermatosis in pregnancy, aimed at controlling inflammation and preventing maternal and fetal complications. *Methotrexate* - **Methotrexate** is an **anti-metabolite** and **immunosuppressant** that is **teratogenic** and absolutely **contraindicated in pregnancy** due to its potential to cause severe birth defects and miscarriages. - While it can be used for severe psoriasis in non-pregnant individuals, its use in this pregnant patient is inappropriate and dangerous. *Topical itraconazole* - **Itraconazole** is an **antifungal medication** used to treat fungal infections. While typically used systemically, topical formulations exist for localized fungal infections. - The clinical presentation of widespread pustules arranged in **concentric rings** with systemic symptoms and **"lakes of pus"** in a pregnant woman is pathognomonic for **Impetigo Herpetiformis**, not a fungal infection, making this treatment inappropriate. *Third generation cephalosporins* - **Third-generation cephalosporins** are **antibiotics** primarily used to treat bacterial infections. - The distinctive pattern of **pustules in concentric rings**, the periumbilical onset, and progression to form **lakes of pus** in a pregnant woman represents an **inflammatory dermatosis** (Impetigo Herpetiformis), not a primary bacterial infection requiring antibiotics.
Question 6: What diagnosis is suggested by the finding on the sole of this patient's foot?
- A. Chemical burn
- B. Pemphigus
- C. Plantar wart (Correct Answer)
- D. Radiation dermatitis
Explanation: ***Plantar wart (Verruca plantaris)*** - The image shows a **hyperkeratotic lesion with central black dots** on the sole of the foot, which is pathognomonic for a **plantar wart** - Plantar warts are caused by **human papillomavirus (HPV)** infection, most commonly types 1, 2, and 4 - The characteristic **black dots represent thrombosed capillaries**, not necrosis - Key diagnostic features include **interruption of skin lines** across the lesion and **tenderness on lateral compression** (pinch test) - They occur on **pressure-bearing areas** of the foot and can be solitary or multiple (mosaic warts) *Chemical burn* - Chemical burns present with **erythema, blistering, or ulceration** with more diffuse or irregular borders - History of **chemical exposure** would be present, and the lesion lacks the characteristic black dots seen in plantar warts - The pattern and location don't fit typical chemical injury *Pemphigus* - Pemphigus is an **autoimmune blistering disease** presenting with **flaccid bullae** that rupture easily - It primarily affects **mucous membranes and flexural areas**, rarely presenting as a solitary hyperkeratotic lesion on the sole - The clinical presentation is completely different from the hyperkeratotic lesion with black dots shown *Radiation dermatitis* - Radiation dermatitis occurs after **therapeutic or accidental radiation exposure** - Presents with **erythema, desquamation, hyperpigmentation, or fibrosis** in the radiation field - Would not present as a discrete hyperkeratotic lesion with black dots, and the sole of the foot is an unusual site for radiation therapy
Question 7: 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 8: 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 9: 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.
Question 10: Which statement about systemic steroids in psoriasis is correct:
- A. No definitive indication exists (Correct Answer)
- B. Only as bridge therapy in rare cases
- C. Emergency situations under specialist supervision only
- D. Systemic steroids are contraindicated in all forms of psoriasis
Explanation: ***No definitive indication exists*** - Systemic steroids have **no established therapeutic role** in psoriasis management and are **strongly avoided** in clinical practice. - They can cause severe **rebound flares** upon withdrawal and may precipitate life-threatening **pustular psoriasis** or **erythrodermic psoriasis**. - While not absolutely contraindicated in every conceivable scenario, they provide **no long-term benefit** and actively worsen disease control by masking symptoms and creating dependency. - This statement most accurately reflects the medical consensus: systemic steroids lack definitive indications and should be avoided. *Systemic steroids are contraindicated in all forms of psoriasis* - While systemic steroids are strongly discouraged, the absolute term "contraindicated in **all forms**" is **too extreme**. - There may be rare emergency situations where short-term use under specialist care is considered when safer alternatives are unavailable. - The statement overstates the position; "no definitive indication" is more medically accurate. *Only as bridge therapy in rare cases* - Bridge therapy with systemic steroids is **not recommended** in psoriasis due to high risk of disease exacerbation. - Unlike other inflammatory conditions, psoriasis responds poorly to steroid withdrawal, making bridge therapy particularly dangerous. *Emergency situations under specialist supervision only* - This suggests systemic steroids have a defined role in emergencies, which is **misleading**. - Even in urgent situations, alternative treatments like **cyclosporine**, **methotrexate**, or **biologics** are strongly preferred. - The rare exceptions don't constitute a "definitive indication."
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
Start For Free