Topical Therapy for Psoriasis — MCQs

10 questions

All are true about psoriasis except:

A 19-year-old woman presents to the dermatology clinic for a follow-up of worsening acne. She has previously tried topical tretinoin as well as topical and oral antibiotics with no improvement. She recently moved to the area for college and says the acne has caused significant emotional distress when it comes to making new friends. She has no significant past medical or surgical history. Family and social history are also noncontributory. The patient’s blood pressure is 118/77 mm Hg, the pulse is 76/min, the respiratory rate is 17/min, and the temperature is 36.6°C (97.9°F). Physical examination reveals erythematous skin lesions including both open and closed comedones with inflammatory lesions overlying her face, neck, and upper back. The patient asks about oral isotretinoin. Which of the following is the most important step in counseling this patient prior to prescribing oral isotretinoin?

Which of the following statements about hypercalcemia in sarcoidosis is false?

Which statement about systemic steroids in psoriasis is correct:

All of the following are used in systemic therapy of psoriasis except

The most potent topical corticosteroid is

What is the naturally occurring form of vitamin D synthesized in the human skin?

Topical steroids are most effective in:

Treatment of choice for Pustular psoriasis is:

Q10

Secukinumab is used in:

Topical Therapy for Psoriasis Indian Medical PG Practice Questions and MCQs

Question 1: 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 2: A 19-year-old woman presents to the dermatology clinic for a follow-up of worsening acne. She has previously tried topical tretinoin as well as topical and oral antibiotics with no improvement. She recently moved to the area for college and says the acne has caused significant emotional distress when it comes to making new friends. She has no significant past medical or surgical history. Family and social history are also noncontributory. The patient’s blood pressure is 118/77 mm Hg, the pulse is 76/min, the respiratory rate is 17/min, and the temperature is 36.6°C (97.9°F). Physical examination reveals erythematous skin lesions including both open and closed comedones with inflammatory lesions overlying her face, neck, and upper back. The patient asks about oral isotretinoin. Which of the following is the most important step in counseling this patient prior to prescribing oral isotretinoin?

A. Wear a wide-brimmed hat outdoors
B. Apply topical retinoids in the evening before bed
C. Document 2 negative urine or blood pregnancy tests before beginning oral isotretinoin (Correct Answer)
D. Use non-comedogenic sunscreen daily with SPF of at least 45
E. Avoid direct sunlight, from 10am to 2pm

Explanation: ***Document 2 negative urine or blood pregnancy tests before beginning oral isotretinoin*** - **Oral isotretinoin** is a potent **teratogen**, meaning it can cause severe congenital disabilities if taken during pregnancy. Therefore, ensuring the patient is not pregnant is a critical safety measure. - Due to its high teratogenic risk, female patients of childbearing potential must be enrolled in the **iPLEDGE program**, which requires two negative pregnancy tests prior to starting isotretinoin and monthly negative pregnancy tests during treatment. *Wear a wide-brimmed hat outdoors* - While sun protection is important during isotretinoin treatment due to increased photosensitivity, wearing a wide-brimmed hat alone is not the *most important* counseling step, especially when considering the significant teratogenic risk. - This is a general recommendation for sun protection but does not address the primary safety concern associated with isotretinoin. *Apply topical retinoids in the evening before bed* - The patient has already tried **topical tretinoin** (a topical retinoid) with no improvement, indicating a need for a different treatment approach. - Combining oral isotretinoin with topical retinoids can increase skin irritation and dryness, and it's generally not recommended to use both simultaneously. *Use non-comedogenic sunscreen daily with SPF of at least 45* - Using **sunscreen** is important with isotretinoin due to **photosensitivity**. However, ensuring the patient is not pregnant is a more critical safety step given the severe risks of birth defects. - Sunscreen use is part of general skin care advice for isotretinoin but secondary to pregnancy prevention. *Avoid direct sunlight, from 10am to 2pm* - Avoiding direct sunlight is a good practice for anyone, and especially for those on isotretinoin due to increased **photosensitivity**. However, this is a lifestyle recommendation and not the most crucial safety prerequisite for starting the medication. - The primary concern before initiating treatment is addressing the **teratogenic** potential of the drug.

Question 3: Which of the following statements about hypercalcemia in sarcoidosis is false?

A. PTHrP level is increased
B. Parathormone level is increased (Correct Answer)
C. Oral steroids are useful
D. Calcitriol level is increased

Explanation: ***Parathormone level is increased*** - In **sarcoidosis-associated hypercalcemia**, the parathormone (PTH) level is typically **low or suppressed**. [1] - This is because the hypercalcemia is due to **extra-renal 1-$\alpha$ hydroxylation** of 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D (calcitriol) by macrophages in granulomas, not primary hyperparathyroidism. [1] *PTHrP level is increased* - This statement is **false** for sarcoidosis. Elevated **parathyroid hormone-related peptide (PTHrP)** is a common cause of hypercalcemia in **malignancy**, particularly squamous cell carcinomas, but not in sarcoidosis. - Hypercalcemia in sarcoidosis is **PTH-independent** and not mediated by PTHrP. [1] *Oral steroids are useful* - This statement is **true**. **Corticosteroids** (like oral prednisone) are effective in treating hypercalcemia in sarcoidosis. - They work by **inhibiting the activity of 1-$\alpha$ hydroxylase** in alveolar macrophages and reducing intestinal calcium absorption. *Calcitriol level is increased* - This statement is **true**. In sarcoidosis, activated **macrophages within granulomas** aberrantly express **1-$\alpha$ hydroxylase**. [1] - This leads to the **extra-renal synthesis of calcitriol** (1,25-dihydroxyvitamin D), which increases intestinal calcium absorption and bone resorption, causing hypercalcemia. [1]

Question 4: 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 5: 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 6: The most potent topical corticosteroid is

A. Clobetasol propionate (Correct Answer)
B. Betamethasone valerate
C. Hydrocortisone acetate
D. Triamcinolone acetonide

Explanation: ***Clobetasol propionate*** ✓ - **Clobetasol propionate** (usually 0.05%) is classified as a Class I **super high-potency topical corticosteroid**, making it the **most potent** topical corticosteroid available. - Due to its high potency, it's used for **severe inflammatory dermatoses** (e.g., psoriasis, lichen planus) and for **short durations** (typically 2 weeks maximum) to minimize side effects like skin atrophy and adrenal suppression. *Betamethasone valerate* - **Betamethasone valerate** is a **medium-potency (Class III-IV) topical corticosteroid**, significantly less potent than clobetasol propionate. - It is typically used for less severe conditions or in areas where a strong effect is not desirable. *Hydrocortisone acetate* - **Hydrocortisone acetate** is a **low-potency (Class VI-VII) topical corticosteroid**, the weakest among all options. - Primarily used for mild inflammatory skin conditions or for sensitive areas like the face and intertriginous zones. *Triamcinolone acetonide* - **Triamcinolone acetonide** falls into the **medium-to-high potency (Class III-IV)** range, depending on the concentration and formulation. - While stronger than hydrocortisone, it is considerably less potent than clobetasol propionate.

Question 7: What is the naturally occurring form of vitamin D synthesized in the human skin?

A. 25 hydroxy cholecalciferol
B. 1,25 dihydroxy cholecalciferol
C. 7-dehydrocholesterol
D. Cholecalciferol (Vitamin D3) (Correct Answer)

Explanation: ***Cholecalciferol (Vitamin D3)*** - This is the form of vitamin D synthesized in the skin when exposed to **ultraviolet B (UVB) radiation**. - **7-dehydrocholesterol** in the skin is converted to cholecalciferol by UVB light. *7-dehydrocholesterol* - This is the **precursor** molecule in the skin that is converted into vitamin D3 upon exposure to UVB light. - It is not the final naturally occurring form of vitamin D, but rather the **substrate** for its synthesis. *25 hydroxy cholecalciferol* - This is the **storage form** of vitamin D, also known as **calcidiol**, produced in the liver from cholecalciferol. - It circulates in the blood and is used to assess an individual's vitamin D status. *1,25 dihydroxy cholecalciferol* - This is the **active form** of vitamin D, also known as **calcitriol**, primarily synthesized in the kidneys from 25-hydroxycholecalciferol. - It plays a crucial role in **calcium and phosphate homeostasis** by acting as a hormone.

Question 8: Topical steroids are most effective in:

A. Bullous lesions due to HSV
B. Herpes Zoster
C. Dermal atrophy
D. Eczematous dermatitis (Correct Answer)

Explanation: ***Eczematous dermatitis*** - Topical steroids are the **first-line treatment** for eczematous dermatitis due to their potent **anti-inflammatory** and **immunosuppressive** properties. - They effectively reduce **itching**, **redness**, and **inflammation** associated with eczema. *Bullous lesions due to HSV* - **Topical steroids are contraindicated** in herpes simplex virus (HSV) infections as they can exacerbate viral replication and worsen the lesions, potentially leading to widespread infection. - **Antiviral medications** like acyclovir are the appropriate treatment for HSV infections. *Herpes Zoster* - Similar to HSV, herpes zoster is a **viral infection** (reactivation of varicella-zoster virus), and topical steroids can worsen the condition by suppressing the immune response. - **Antiviral drugs** (e.g., valacyclovir, famciclovir) are the primary treatment for herpes zoster. *Dermal atrophy* - Dermal atrophy is a **side effect** of prolonged or potent topical steroid use, not a condition treated by them. - It involves **thinning of the skin**, **telangiectasias**, and **striae**, indicating skin damage from steroid exposure.

Question 9: 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 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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