Systemic Therapy for Psoriasis — MCQs
What is the primary condition for which calcitriol is used as a treatment?
All these drugs are known to exacerbate psoriasis, except:
All of the following are used in systemic therapy of psoriasis except
Assertion: Vitamin D analogues are effective in psoriasis. Reason: They reduce keratinocyte proliferation
What is the mechanism of action of Bevacizumab?
The Drug of choice for a pregnant woman in 2nd trimester with pustular psoriasis is:
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:
Secukinumab is used in:
Systemic Therapy 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: All these drugs are known to exacerbate psoriasis, except:
- A. Beta blocker
- B. Hydroxychloroquine
- C. Ciclosporin (Correct Answer)
- D. Lithium
Explanation: ***Ciclosporin*** - **Ciclosporin** is an immunosuppressant often used to **treat severe psoriasis**, not exacerbate it. - It works by inhibiting the activation of T-cells, which are central to the pathogenesis of psoriasis. *Beta blocker* - **Beta-blockers**, particularly non-selective ones like **propranolol**, can worsen existing psoriasis or induce new lesions. - The mechanism is thought to involve effects on beta-adrenergic receptors in the skin, leading to inflammation. *Hydroxychloroquine* - **Hydroxychloroquine**, an antimalarial and immunosuppressant, can trigger or exacerbate psoriasis, especially **pustular psoriasis**. - It likely affects keratinocyte proliferation and immune responses in the skin. *Lithium* - **Lithium** is a mood stabilizer that is known to exacerbate or trigger various forms of psoriasis, including **plaque psoriasis** and **pustular psoriasis**. - The mechanism is believed to involve alterations in cyclic AMP metabolism and arachidonic acid pathways within keratinocytes.
Question 3: All of the following are used in systemic therapy of psoriasis except
- A. Methotrexate
- B. Cyclosporine
- C. Oral glucocorticoids (Correct Answer)
- D. Acitretin
Explanation: ***Oral glucocorticoids*** - **Oral glucocorticoids** are generally avoided in psoriasis because they can precipitate severe **rebound flares** upon discontinuation or during dose tapering. - While they can temporarily suppress inflammation, the risk of worsening psoriasis and other systemic side effects makes them unsuitable for long-term systemic therapy. *Methotrexate* - **Methotrexate** is a commonly used systemic agent for psoriasis due to its **immunosuppressive** and **anti-proliferative effects**, targeting rapidly dividing cells. - It works by inhibiting dihydrofolate reductase and is typically given once weekly for chronic plaque psoriasis. *Cyclosporine* - **Cyclosporine** is an effective systemic immunosuppressant used for severe, resistant psoriasis, particularly when rapid control is needed. - It primarily acts by inhibiting **T-cell activation** and proliferation, thereby reducing the inflammatory response in psoriasis. *Acitretin* - **Acitretin** is an oral retinoid derivative of vitamin A, used in severe forms of psoriasis, especially **pustular** and **erythrodermic** types. - It works by modulating **keratinocyte differentiation** and proliferation, helping to normalize skin cell growth.
Question 4: Assertion: Vitamin D analogues are effective in psoriasis. Reason: They reduce keratinocyte proliferation
- A. Both A & R true, R explains A (Correct Answer)
- B. A false R true
- C. Both A & R true, R doesn't explain A
- D. A true R false
Explanation: ***Both A & R true, R explains A*** - **Vitamin D analogues** (e.g., calcipotriol) are a cornerstone treatment for psoriasis because they effectively modulate **keratinocyte proliferation** and differentiation. - Psoriasis is characterized by the **rapid overgrowth of keratinocytes**, and the antiproliferative effects of vitamin D analogues directly address this pathological hallmark. *A false R true* - This option is incorrect because both the assertion (Vitamin D analogues are effective in psoriasis) and the reason (They reduce keratinocyte proliferation) are individually true. - The effectiveness of vitamin D analogues in treating psoriasis is well-established in dermatological practice. *Both A & R true, R doesn't explain A* - This option is incorrect because the reduction of keratinocyte proliferation is precisely *how* vitamin D analogues exert their therapeutic effect in psoriasis. - The mechanism of action described in the reason directly explains the efficacy mentioned in the assertion. *A true R false* - This option is incorrect because the reason ("They reduce keratinocyte proliferation") is a fundamental and well-understood mechanism by which vitamin D analogues work in psoriasis. - Vitamin D analogues bind to vitamin D receptors in keratinocytes, influencing gene expression to inhibit their excessive growth.
Question 5: What is the mechanism of action of Bevacizumab?
- A. Anti VEGF antibody (Correct Answer)
- B. Histone deacetylase inhibitor
- C. HER2 neu inhibitor
- D. Proteasome inhibitor
Explanation: ***Anti VEGF antibody*** - **Bevacizumab** is a **monoclonal antibody** that specifically targets and binds to vascular endothelial growth factor (VEGF). - By inhibiting VEGF, bevacizumab prevents the formation of new blood vessels (**angiogenesis**) that tumors need to grow and metastasize. *Histone deacetylase inhibitor* - **Histone deacetylase (HDAC) inhibitors** influence gene expression by modifying chromatin structure, leading to cell cycle arrest and apoptosis in cancer cells. - They are used in certain hematologic malignancies and solid tumors but do not directly interfere with angiogenesis. *Proteasome inhibitor* - **Proteasome inhibitors** like bortezomib block the action of proteasomes, leading to an accumulation of ubiquitinated proteins and induction of apoptosis in cancer cells. - This mechanism is distinct from blocking new blood vessel formation. *HER2 neu inhibitor* - **HER2 neu inhibitors** (e.g., trastuzumab) specifically target the HER2/neu receptor, which is overexpressed in certain breast and gastric cancers. - Their action primarily involves blocking growth signals transmitted through this receptor, not inhibiting VEGF or angiogenesis.
Question 6: The Drug of choice for a pregnant woman in 2nd trimester with pustular psoriasis is:
- A. Prednisolone (Correct Answer)
- B. Acitretin
- C. Methotrexate
- D. Dapsone
Explanation: ***Prednisolone*** - **Systemic corticosteroids** such as prednisolone are considered **safe and effective** for treating severe pustular psoriasis during pregnancy and represent the **best option among the choices provided**. - Pustular psoriasis is a severe systemic condition that can be associated with fever, malaise, and potential complications, necessitating **systemic therapy** rather than topical treatment alone. - While **cyclosporine** is often considered the preferred first-line agent for severe pustular psoriasis in pregnancy in current practice, it is not listed among the options here, making prednisolone the most appropriate choice. - Prednisolone **crosses the placenta minimally** (converted to less active prednisolone by placental 11β-HSD2 enzyme) and has a well-established safety profile in pregnancy. *Acitretin* - **Acitretin** is a systemic **retinoid** that is **highly teratogenic** and can cause severe birth defects including craniofacial, cardiac, thymic, and CNS abnormalities. - It is **absolutely contraindicated in pregnancy** (FDA Category X) and must be avoided for at least 2-3 years before conception due to its long half-life and storage in adipose tissue. *Methotrexate* - **Methotrexate** is an **antimetabolite** and **folate antagonist** that is a potent teratogen, particularly during the first trimester. - It can cause **aminopterin syndrome** (neural tube defects, craniofacial abnormalities, limb defects) and is **absolutely contraindicated in pregnancy** (FDA Category X). - Women on methotrexate must use effective contraception and discontinue the drug at least 3 months before attempting conception. *Dapsone* - **Dapsone** has anti-inflammatory properties and is used in some dermatological conditions, but it is **not indicated for pustular psoriasis**. - Risks in pregnancy include **hemolytic anemia** (particularly in G6PD-deficient individuals), methemoglobinemia in the newborn, and potential neonatal hyperbilirubinemia. - It is **not a first-line or appropriate treatment** for pustular psoriasis in pregnancy.
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: 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 9: 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."
Question 10: Secukinumab is used in:
- A. Psoriasis (Correct Answer)
- B. Colorectal carcinoma
- C. Breast cancer
- D. Rheumatoid arthritis
Explanation: ***Psoriasis*** - **Secukinumab** is a monoclonal antibody that targets **interleukin-17A (IL-17A)**, a cytokine crucial in the pathogenesis of psoriasis. - It is approved for the treatment of **moderate to severe plaque psoriasis**, psoriatic arthritis, and ankylosing spondylitis. *Colorectal carcinoma* - **Secukinumab** is not used in the treatment of colorectal carcinoma; different classes of drugs like **chemotherapy**, **targeted therapies**, and **immunotherapy** (e.g., PD-1 inhibitors for MSI-high status) are employed. - Colorectal cancer treatment focuses on blocking pathways specific to cancer cell growth and survival, not IL-17A. *Breast cancer* - **Secukinumab** has no role in the treatment of breast cancer, which is managed with therapies such as **hormonal therapy**, **chemotherapy**, **HER2-targeted therapy**, and PARP inhibitors. - Breast cancer involves distinct molecular pathways and immune responses unrelated to IL-17A. *Rheumatoid arthritis* - While **rheumatoid arthritis** is an inflammatory condition, **secukinumab** is not a primary or approved treatment for it; other biologics like **TNF inhibitors**, **IL-6 inhibitors**, or **JAK inhibitors** are commonly used. - The inflammatory cascade in rheumatoid arthritis involves different key cytokines and cellular processes compared to those targeted by secukinumab.
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