5

CHAPTER

Papulosquamous
Disorders
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„„ This group includes disorders presenting with papules/plaques having scales (term “papulo” means papules and
“squamous” means scaling.)

Pityriasis also means scaling, so all disorders prefixed with term “pityriasis” are also included here.
All disorders starting with term pityriasis (like P. alba, P. versicolor, P. rosea, P. rubra pilaris etc.) have scaly lesions

Disorders included in papulosquamous disorders are:

„„ Psoriasis, parapsoriasis, pityriasis lichenoides chronica (PLC), Pityriasis rosea, Pityriasis rubra pilaris
„„ Seborrheic dermatitis, Secondary syphilis,
„„ Reiter’s disease
„„ Lichen planus.
„„ Neoplasm: Mycosis fungoides cutaneous t-cell lymphoma (CTCL), squamous cell carcinoma
„„ Drug induced.
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“ReD Li’PS”

ReD Lips

Common causes Less common

• Li = Lichen planus • Re = Reiter’s disease

• P = Psoriasis, pityriasis lichenoides chronica, • D = Drugs
pityriasis rosea, Pityriasis rubra pilaris
• S = Seborrheic dermatitis, secondary syphilis

PSORIASIS
Definition (Fig. 1)
It is a chronic, multifactorial, inflammatory and proliferative condition with multiple genetic (PSORS 1-8 genes) and
environmental (trauma, infection drugs) factors having a critical role (Fig. 1).

Etiology
TABLE 1:  Genetic and environmental factors of psoriasis

Genetic factors Environmental factors

• HLA association
ƒƒ HLA CW6Q → Juvenile
(early onset) psoriasis
ƒƒ HLA B27 → psoriatic
arthritis and pustular
psoriasis.
• Psoriasis genes: 8 genes,
located on different
chromosomes – PSORS1
to 8
• Trauma: Associations with koebner’s/
isomorphic phenomenon.Q
• Infections
ƒƒ Beta hemolytic streptococcal
infectionQ (triggers guttate psoriasis)Q
ƒƒ HIV infection.
• Drugs: Antimalarial (chloroquine), Beta
blockers, NSAID’s, Lithium.Q
Withdrawal of “Corticosteroids” may Fig. 1:  Psoriasis lesion with silvery white
precipitate pustular psoriasis.Q scaling
 Papulosquamous Disorders  5 Chapter 103

� QHLAB27 association is common “Reiter’s disease > Psoriasis”

 Koebner’s/isomorphic phenomenon (iso = similar, morphic = form or morphology) this phenomenon is indicative
of active disease, where new lesions start developing at the site of trauma (scratch, injury or surgical site).
� Psoriasis tends to aggravate with alcohol, smoking, stress and cold environment (winters) while improves during
pregnancy.

Pathogenesis
„„ Basically disease of “T-cells”
zz Epidermal → CD8 + T-cells
Th 17 cells
zz Dermal → CD4+ T-cells subsets → → Stimulate IL 23 → respectively produce IL17 and IL22
Th 22 cells
which mediate dermal inflammation and epidermal hyperplasia.

„„ Up regulation of Th1 cytokines → IFN-γ, IL-2

„„ Reduction of anti-inflammatory cytokine- IL-10.
„„ Keratinocytes–increased proliferation (transit time reduced)
zz They also express STAT-3 transcription factor (pathogenic)

Biochemical Changes n e mo n

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Levels of
„„ Calmodulin↑, cGMP↑ (But cAMP↓)
„„ Arachidonic acid↑
„„ Proteinases and polyamines↑ CAP↑ increases

Sites Commonly Involved in Psoriasis (Figs 2A and B)

A B

Figs 2A and B:  Sites commonly involved in psoriasis. A. Posterior; B. Anterior

 104 New SARP Series Skin

Types
Psoriasis Vulgaris (Figs 4 to 9)
„„ Psoriasis vulgaris (chronic plaque psoriasis) (Fig. 3) → Most common type.

Points to Remember
“Vulgaris” means “commonest”Q

Clinical features
Well demarcated, erythematous, indurated plaque with silvery white (mica like)
scalingQ over scalp, extensors (elbows, knees, knuckles and lower back)Q, palm,
sole (also flexures). Fig. 3:  Psoriasis vulgaris with
erythematous plaque having silvery
Points to Remember white scaling over extensor (Back)

Scaling in psoriasis is detachable, lamellar, silvery white (micaceous) which

� Accentuates on grating
� Minimal in early lesions
� Absent in lesions over flexures and glans (of an uncircumcised male)
� Adherent and profuse in rupioid psoriasis
Silvery white scaling is seen due to presence of air trapped in between scales.

Fig. 4:  Periumbilical lesion of inverse psoriasis Fig. 5:  Psoriasis vulgaris with Fig. 6:  Psoriasis vulgaris with
extensive involvement extensor and scalp involvement

Variant’s based on site

„„ Inverse psoriasis (Fig. 4) → involvement of flexures
„„ Scalp psoriasis (Fig. 7) → involvement of scalp
„„ Penile psoriasis → involvement of penis
„„ Palmoplantar psoriasis (Fig. 9) → involvement of palm and sole.
 Papulosquamous Disorders  5 Chapter 105

Fig. 7:  Scalp psoriasis Fig. 8:  Rupoid psoriasis with Fig. 9:  Palmoplantar psoriasis
heaped up scales

Rupioid Psoriasis (Figs 8 and 10)

„„ Firmly adherent, limpet like, heaped up scales (so appear conical).

Memory Aid
Limpet is a conical shell fish, very adherent to rocks

„„ Such lesions are also seen in Reiter’s syndrome/reactive arthritis.

„„ Term ‘pityriasis’ means ‘scaling’ and ‘amiantacea’ means ‘asbestos
like’.

 Pityriasis amiantacea (Fig. 11) is an inflammatory

condition of the scalp in which thick tenaciously adherent scale Fig. 10:  Rupoid psoriasis with adherent
infiltrates and surrounds the base of a group of scalp hairs. heaped up scales
It does not result in scarring or alopecia. It is observed as a
sequel or complication of psoriasisQ, staphylococcal infection,
seborrheic dermatitis, atopic dermatitis and tinea capitis.
 In psoriasis: Lesions may spill on to forehead
 In seborrheic dermatitis: Lesions do not spill on to forehead
 Sebopsoriasis → Psoriasis in seborrheic area (like: scalp, retro
auricular area, face, upper trunk ). Not associated with alopecia.

Guttate Psoriasis (Term “Guttate” Means

“Dew Drop/Rain Drop”) (Fig. 12)
„„ Multiple small guttate (rain drop like) lesions, erythematous to salmon
pink papules with fine scales, usually precipitated by streptococcalQ
tonsillitis/sore throat. Common in childrenQ.
Fig. 11:  Pityriasis amiantacea with thick
„„ Most common site: Trunk
tenaciously adherent scales
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Treatment
„„ Self-resolving in weeks to months.
„„ Topical corticosteroids and phototherapy also useful (Role of antistreptococcal
antibiotics is controversial).

Nail Changes Seen in Psoriasis (Fig. 13)

10–55% of all patients with psoriasis have nail involvement and in <5% of patients
with no cutaneous findings of psoriasis.

Nail changes due to defect in nail matrix

„„ Nail pitting → Most commonQ nail change, random, irregular, deep
(thimbleQ) pits (Fig. 20)
Nail changes due to defect in nail bed Fig. 12:  Guttate psoriasis
„„ Oil drop sign/salmon patch → pathognomonic, specific , yellowish discoloration in nail bed, as if drop of oil
Q

beneath the nail plate.

„„ Onycholysis: Separation of nail plate from nail bed
„„ Leukonychia: White nails
„„ Subungual hyperkeratosis: Excessive deposit of keratin in nail bed
„„ Splinter hemorrhages
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Nail POLISH

P = PITTING, O = OIL DROP SIGN and ONYCHOLYSIS, L = LEUKONYCHIA,

I = Irregular pits S = Subungual hyperkeratosis, H = Hemorrhages
(Splinter)
Fig. 13:  Nail changes in psoriasis

Complications/Severe Types of Psoriasis

Erythrodermic Psoriasis (Figs 14A to C)
„„ Generalized (>90% of skin becomes erythematous), extremely itchy with fine scaling. Lesions lose their margins,
become ill defined and merge to become uniformly red (Fig. 14A to C).

A B C

Figs 14A to C:  Erythrodermic psoriasis

 Papulosquamous Disorders  5 Chapter 107
Precipitating factors
Withdrawal of steroidsQ or application of irritant topical therapy.

Treatment
MethotrexateQ (DOC), cyclosporine (for rapid control), acitretin.

Pustular Psoriasis (Figs 15 to 19)

Localized: Acrodermatitis continua (of hallopean)-pustules on distal fingers and nail bed (Figs 18A and B).
Generalized: Von Zumbusch’s pustular psoriasis - it is a severe acute form, associated with fever, chills, tachypnea.
Generalized, sudden appearance of fiery red erythema followed by waves of tiny superficial pustules (lakes of pus/sheets
of pus)Q
Von Zumbusch’s in pregnancy [Also known as Impetigo herpetiformisQ (Fig. 16)] occurs in last trimester of
pregnancy, which resolves after delivery.

Fig. 15:  Pustular psoriasis Fig. 16:  Impetigo herpetiformis

A Fig. 19:  Pustulosis of palms

Fig. 17:  Pustular psoriasis Figs 18A and B: Acropustulosis Fig. 20:  Nail involvement with
onycholysis and pitting
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Precipitating factors
Withdrawal of steroidsQ or application of irritant topical therapy.

Treatment
„„ AcitretinQ (DOC), methotrexate, cyclosporine.
„„ In impetigo herpetiformisQ: systemic steroidsQ >cyclosporineQ

Both, erythrodermic and pustular psoriasis develops after the application of irritant topical therapy or
withdrawal of systemic steroids. So, systemic steroids are avoided in psoriasis, except for Impetigo herpetiformisQ
where both acitretin, methotrexate can not be used (as they are teratogenic). So systemic steroidsQ >cyclosporineQ
is used. (Systemic Steroid are pregnancy category ‘B’ while cyclosporine is pregnancy category ‘C’ drug).

Psoriatic Arthritis
„„ Seronegative arthritis, seen in <40% all psoriasis patients.
„„ Associated with HLA B27.
„„ Diagnostic criteria used for psoriatic arthritis is CASPAR- [Classification criteria for (P = Psoriatic, AR = ARthritis)]
„„ Wright and moll criteria is used for classifying psoriatic arthritis.

There are five types of psoriatic arthritis

„„ Asymmetrical oligoarthritis → Most CommonQ (70%) –
inflammation of both distal (DIP) and proximal (PIP) of hands and
feet (in contrast to rheumatoid arthritis, the metacarpophalangeal
joint is an uncommon site)
„„ Symmetrical polyarthritis (RA like) (15%)
„„ Distal interphalangeal (DIP) arthritis (classic) (5%)- only DIP
involvement.
„„ Arthritis mutilans (5%) (Fig. 21)
„„ Axial arthritis → spondylitis and sacroiliitis- mainly with HLA
B27 positive cases.
Fig. 21:  Arthritis mutilans
Radiology
Pencil in a cup deformityQ on X-ray due to cupping of proximal end of phalanges.

Treatment
Methotrexate (DOC)Q, NSAID’s, Sulfasalazine, Leflunomide, Biological (TNF-alpha inhibitors).

� Most common type of psoriatic arthritis—Asymmetrical oligoarthritisQ

� Most common type of joint involved in psoriatic arthritis—Distal interphalangeal (DIP) jointQ

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Types of psoriatic arthritis

O.P. DAS: O = Oligoarthritis, P = Polyarthritis, D = Distal interphalangeal arthritis, A = Arthritis mutilans, S = Spondylitis
and sacroiliitis

MC 2nd MC
 Papulosquamous Disorders  5 Chapter 109
Clinical Sign
On scratching the lesions of psoriasis
„„ Grattage test → Accentuation of scales
„„ Candle Grease sign → Coming off scales attached together like onion-peels
„„ Auspitz’s signQ → Pin point bleeding spots (Fig. 22)

Important facts related to Auspitz’s signQ Fig. 22:  Auspitz’s sign

� Scratching (garattge) of the lesion of psoriasis with a clean glass slide leads to pin
point bleeding as the end result known as Auspitz’s sign.
� It is clinical reflection of elongated (dilated and tortuous) dermal vessels
together with suprapapillary thinning of epidermis.
� It is not seen in pustular psoriasis.

� On removing the scales, a glistening white adherent membrane known as Berkley’s membraneQ
appears, which when removed produce pin point bleeding spots.
� Psoriatic plaque is often surrounded by hypopigmented margin due to prostaglandin E2 (PGE2)Q known as Wornoff
ringQ.

Investigations
On Histology (Fig. 23)
Epidermal changes
„„ ParakeratosisQ—retention of nuclei in stratum corneum
„„ Acanthosis—thickening of stratum spinosum
„„ Absence of stratum granulosumQ
„„ Munro’s micro abscessQ—collection of neutrophils in stratum corneum
„„ Spongioform pustules of KOGOJQ—collection of neutrophils in stratum spinosum (also stratum granulosum)
„„ Elongated rete ridges—broad at the base, giving “camel foot” appearance.
„„ Suprapapillary thinningQ—thinning of epidermis above dermal papilla.

Fig. 23:  Histology of psoriasis

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„„ Dermal papillae enlarged
„„ Lymphocytic infiltration
„„ Dilated and tortuous dermal vesselsQ
P = Parakeratosis
S = Suprapapillary thinning
O = Loops(dermal capillary)
Scoring System in Psoriasis
R = Regular acanthosis
 PASI → for psoriasis (Psoriasis area severity index) I = Infiltration of CD 4 T cells in dermis
 NAPSI → for nail psoriasis (Nail Psoriasis Severity A = Abscess (munro’s microabscess)
Index) S = Spongioform pustules of kogoj and
 CASPAR → Diagnostic criteria for psoriatic arthritis I = Infiltration of CD8 T cells in epidermis
 Due to high risk of metabolic syndrome is psoriasis S = Stratum granulosum absent
many cardiovascular diseases (eg. Myocardial
infarction, pulmonary emboli, CVA) are associated.

Treatment
„„ Topical [preferred in localized disease i.e. <10% body surface area (BSA) involvement]

Drug Mechanism of action (MOA)

Coal tar (+salicylic acid) Coal tar is antimitotic, inhibits chemotaxis.
Salicylic acid is keratolytic agentQ
Dithranol Inhibits DNA synthesis
Steroids (+salicylic acid) Anti-inflammatory
Vit. D analogs (Calcipotriol) Reduces epidermal proliferation
Emollients Moisturizing agents
Tazarotene (Retinoid) Keratoplastics and keratolytic
„„ Phototherapy (Preferred in moderate disease, i.e. 10-30% BSA involvement).
Mode of action (MOA) → Inhibition of cell proliferation and apoptosis of T-cells.
Narrow band UVB (311 nm)Q: Treatment of choice in chronic plaque psoriasis with BSA >10% especially in:
zz Pregnancy
zz Renal/hepatic dysfunction
zz Immunocompromised patients
„„ Photochemotherapy: MOA →Inhibits DNA synthesis and epidermal turn over

PUVA: (Psoralen + UVA)

Wait for
8-methoxypsoralen 2 hours Exposure to UVA (chamber)Q
(0.6–0.8 mg/kg) (Initial exposure depending on
alternate day MPD-minimal phototoxic dose)

MPD is determined by exposing the patient to increasing dose of UVA, 2 hrs after ingestion of psoralens
and finding minimum dose of UVA which produces erythema at 72 hrs
 Papulosquamous Disorders  5 Chapter 111
Variant of PUVA
 PUVA sol → Sunlight (SOLar) instead of UVA chamber
 Topical PUVA → topical psoralen wait for½ hour UVA exposure
 Bath PUVA → Soak in psoralen water wait for½ hour UVA exposure

Laser used in psoriasis

Excimer laser (308 nm)Q is FDA approved for treatment of psoriasis.
„„ Systemic (preferred in extensive disease >30% BSA involvement)

Drugs Mechanism of action Side effects

Methotrexate • Folic acid antagonist
• Inhibits DNA synthesis in “S”
phase
• Anti- inflammatory
(suppresses lymphocytes)
Cyclosporine • Inhibits cell-mediated
immunity as it inhibits the
release of lymphokines and
lymphocyte mitosis
• Antiproliferative
Acitretin • Regulate growth and
terminal differentiation of
keratinocytes
• Anti-inflammatory
• HepatotoxicQ
• Bone marrow suppression
• TeratogenicQ
 (Advice contraception
 1 month→ females
 3 months → males)
• HypertensionQ
 (If develops treated with Amlodipine/ACE inhibitors)
 Avoid diuretics →Worsens renal function
 Avoid β-blocker → Worsens psoriasis
• NephrotoxicQ, Hypertrichosis, Hypertriglyceridemia in
females
• TeratogenicQ
 Avoid contraception for 3 years after stopping drug.
• Hypertriglyceridemia
• Hepatotoxic
• DISH (Disseminate interstitial skeleton hyperostosisQ:
ossification of paraspinal ligament

Biologicals
„„ Not used as 1st line therapy
„„ Preferred in moderate to severe disease with following:
zz Not responding to conventional therapy
zz Drug intolerance/toxicity
zz Erythrodermic/pustular/psoriatic arthritis

Drug Mechanism of action (MOA) Route of administration (ROA)

Infliximab IntravenousQ (IV)
Adalimumab TNF-a inhibitorQ Subcutaneous (S/C)
Etanercept Subcutaneous (S/C)
Alefacept CD-2 Intramuscular (I/M)
Efalizumab CD-11 T cell inhibitors Subcutaneous (S/C)
Itolizumab CD-6 Intravenous (IV)
Apremilast PDE-4 inhibitor Oral
Secukinumab Anti-IL-17A Subcutaneous (S/C)
UstekinumabQ Anti-IL-12/23Q Subcutaneous (S/C)
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Efalizumab → Withdrawn from market due to leukoencephalopathyQ.

Side effects of cyclosporine →
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‘3H’

 Hypertension
 Hypertriglyceridemia
 Hypertrichosis

Types of psoriasis Drug of choice/Treatment of choice (DOC/TOC)

Chronic plaque psoriasis
BSA: <10% Coal tar (3-6%) + Salicylic acid (3%)
BSA:10–30% Narrow band UVB
BSA: >30% Systemic Methotrexate.
Psoriatic arthritis MethotrexateQ
Erythrodermic psoriasis MethotrexateQ >Acitretin
Pustular psoriasis AcitretinQ> Methotrexate
Pustula psoriasis in pregnancy (Impetigo Systemic steroidQ > cyclosporineQ
herpetiformis) Both Acitretin and Methotrexate are contraindicated (teratogenic)
Psoriatic erythroderma in pregnancy Systemic steroidQ >cyclosporine
Psoriasis in HIV Acitretin
Arthritis mutilans TNA-∝ inhibitors

LICHEN PLANUS (FIGS 24 TO 27)

Term lichen planus is derived from “lichen=tree moss” (which are purple in color)
and “planus=flat”, thus purple and flat lesions (Fig. 24).

Etiology
Autoimmune.Q It is a cell-mediated immune response of unknown antigen.

Clinical Features
„„ It is an autoimmune inflammatory disease involving skin, mucosa, nail and
hair. Lesions are pruriticQ and have flexural predispositionQ.
„„ 5 Ps →Plane (flat), purple (violaceous), polygonal, pruritic, papules
„„ Surface of lesions have white streaks called wickham’s striaeQ, (Fig. 28) becomes
prominent if thin layer of oil is applied over the lesions Fig. 24:  Hypertrophic Lichen
„„ Sites → FlexorsQ (wrists), ankles, chin and lower back. planus
 Papulosquamous Disorders  5 Chapter 113

Fig. 25:  Ulcerative lichen planus Fig. 26:  Lichen planus of the buccal mucosa reticular form

Fig. 27:  Oral lichen planus Fig. 28:  Wickham’s striae

Associations
„„ Mucosa (50% patients with cutaneous lichen planus (LP) have mucosal involvement): Asymptomatic or may be
associated with burning and pain (on consuming spicy food).
Dental amalgamQ (dental filling having mercury ) may be causative.
Oral mucosa may present with →
zz Reticulate (lacy) patternQ (commonest type), The buccal mucosa, tongue, and gingiva are the common sites
which tend to be bilateral and symmetrical.
zz Erosive/ulcerative type- rare but have premalignant potential (may give rise to Squamous cell carcinomaQ)
Genital mucosa presents with → annular lesions
The following were identified as Risk of malignant Comments
potentially malignant disorders by the conversions in 10 years
WHO’s working group on oral cancer
• Erythroplakia Very high risk (70–85%) A fiery red patch or bright red velvety
plaques that cannot be characterized
clinically or pathologically as any other
definable disease.

Contd…
 114 New SARP Series Skin

• Leukoplakia
• Oral submucous fibrosis (SMF)
• Oral lichen planus (Fig. 29)
High risk (10–30%)- non
homogenous
Low risk (1–5%) –
homogenous
High risk (10–30%)
Low risk (below 1%)
A keratotic white patch or plaque that
cannot be scraped off and cannot be
characterized clinically or pathologically
as any other disease. Most common pre
malignant lesion in the oral cavityQ.
Particularly associated with areca nutQ
chewing, the main component of betel quid
Erosive/ulcerative type

A B C

Fig. 29:  Oral lichen planus Figs 30A to C:  Lichen planus nail (Arrow indicates wing shaped
projection pterygium)
Abbreviations:  NP, Nail plate, PNF, Proximal nail fold

„„ NAILS (10% of patients with cutaneous LP have nail involvement) →

zz PterygiumQ (dorsal) (Fig. 31) → Diagnostic
(Nail fold prolongs on to nail bed and splitting nail plate)
zz Thinning of nail plateQ → Most common
zz Longitudinal ridging and splitting (Onychorrhexis) (Fig. 30)
zz Tenting/Pup-tent signQ (Nail bed involvement leads to elevated nail plate like a tent)
zz Twenty nail dystrophyQ
zz Trachyonychia: rough, sandpaper nails

Fig. 31: Pterygium Fig. 32:  lichen plano pilaris

 Papulosquamous Disorders  5 Chapter 115

Causes of ventral pterygium:

 Scleroderma
 Causalgia of median nerve
Causes of twenty nail dystrophy:
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“PALE”

P = Psoriasis
A = Alopecia areata
L = Lichen planus
  E = Eczema

„„ SCALP → Follicular eruptions on scalp with cicatricial or scarring alopeciaQ (Lichen plano pilaris)Q (Fig. 32)
„„ Palm and sole → Yellowish, Keratotic grouped papules or plaques may be seen in case of palm and sole involvement.

Other Findings
„„ Koebner’s phenomenonQ
„„ Association with HCV, HBV (Hepatitis C and B virus infection) and primary biliary cirrhosisQ
„„ Lesions heal with hyperpigmentationQ (disease is self-limitingQ within 1–2 years)

Types of lichen Clinical features Site

planus
Actinic (term “actinic” Annual with perilesional Sun exposed (Face)
means “sun”) hypopigmented halo
Annular (Fig. 33) Hyperpigmented with Face, glans
elevated periphery
Bullous Bulla (rare type) Extensors
Follicular (Lichen plano Perifollicular (involve hair Scalp
pilaris) follicles)
Hypertrophic Thick, verrucous Legs
Linear Linear lesions Extensors
Lichen planus Flat, hyperpigmented Sun exposed areas
Fig. 33:  Annular lichen planus
pigmentosus macules (face, neck and
flexure)

Lichenoid eruptions
Lichen planus like eczematous eruptions with prominent scaling and absent Wickham’s striae develop over sun-
exposed area commonly triggered by drugsQ like:
 ACE inhibitors, Antimalarials
 β-blockers
 Penicillamines
 116 New SARP Series Skin

Lichenoid drug eruptions can look same as lichen planus, but can be differentiated with help of following
features:
� Extensive rash distributed symmetrically over the trunk and limbs
� Photodistribution.
� Rash may be scaly resembling eczema or psoriasis
� Wickham striae are usually absent
� Nail and mucosa involvement is uncommon
� More likely to resolve leaving marked pigmentation
� On histology: Parakeratosis with eosinophils

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“ABP”

A = ACE inhibitors, Antimalarials

B = β-blockers
  P = Penicillamines

Histology of Lichen Planus (Fig. 34)

„„ Basal cell degenerationQ → earliest
Liquefaction of the basal layer/vacuolization of basal layer
„„ CivatteQ/Colloid/Cytoid bodies → Classical
Apoptotic/Necrotic Keratinocytes
„„ Melanin (pigment) incontinence Q→ Due to destruction of basal layer, melanocytes fall down into dermis.
„„ Melanophages: Melanin containing macrophages
„„ Max-Joseph spaces (due to basal cell degeneration)
„„ Saw toothed appearance (pointed rete ridges)
„„ HypergranulosisQ (wedge shaped) → thickening of stratum granulosum. Responsible for Wickham’s striae seen
clinically in lesions of L.P.
„„ Band like lymphocytic infiltrate → in Dermo –Epidermal Junction and upper dermis
„„ Interface dermatitis → Band of lymphocytes + Basal cell vacuolization.
„„ Irregular acanthosis → irregular thickening of stratum spinosum

Interface dermatitis is also seen in n e mo n

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� Erythema multiformae and epidermal Necrolysis (SJS/TEN)

ic

� Connective tissue disorders (Dermatomyositis and Lupus erythematosus)

� Graft versus host disease.

ECG
 Papulosquamous Disorders  5 Chapter 117

Fig. 34:  Histology of lichen planus

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Mnemonic for remembering histological findings of lichen planus

“In MBBS and PG College”

I = Irregular acanthosis
In = interface dermatitis
M=Melanophages, Max-Joseph spaces
B= Basal cell degeneration
B= Band like lymphocytic infiltrate
S= Saw toothed appearance
P= Pigment incontinence
G= Granulosis (Hyper)
Coll= Colloid/Civatte/Cytoid bodies

Treatment
Localized → Topical steroids
Widespread → PUVA
Steroids (oral mini pulse)
Azathioprine
Acitretin
Hypertropic LP → Steroids + salicylic acid (applied under occlusion for better penetration)
Mucosal LP → Steroids + Dapsone
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PITYRIASIS ROSEA (FIGS 35 TO 38)

Pityriasis Rosea
↓   ↓ Pityriasis rosea: “HER trunk, curtain and Cigarette on
Scaling Pink (Rose like) fire”
Term ‘pityriasis’ means ‘scaling’ and ‘Rosea’ means ‘Rose HER = HER > HIS, herald patch, herpes (HHV 6,7)
like’ (pink) TRUNK = Mc Site
CURTAIN = Hanging curtain sign
Etiology CIGARETTE = Cigarette paper scaling
ON = Self limiting (heals on itself)
Unknown, some cases associated with HHV 7 > HHV 6Q FIRE = Fir tree appearance
and rarely drug induced (Captopril, Imatinib)
 118 New SARP Series Skin

A B

Figs 35A to B:  Herald patch Fig. 36:  Pityriasis rosea

Clinical Features
Age: 10-35 years; FemalesQ >Males
„„ Initial appearance of 1st lesion known as HeraldQ/mother
patch (Figs 35A and B). Annular lesion with salmon
pink color, cigarette paper like scales at the periphery
(collarette of scale)Q.
„„ Scales are attached at edges and free toward the center.
When lesion is stretched along long axis, scales fold across
the lines of stretch, called “Hanging Curtain” signQ.
„„ Initial lesions are followed by appearance of multiple similar
appearing smaller, less scaly, less erythematous lesions
along the lines of the ribs giving fir-tree/Christmas tree
appearanceQ (Fig. 37).
„„ Lesions of pityriasis rosea may mimic lesions of secondary
syphilisQ. They can be differentiated by past history of
Fig. 37:  Fir-tree/Christmas tree appearance
chancre, positive VDRL and involvement of palms and soles
in secondary syphilis.
„„ Most Common site—TrunkQ (Fig. 36).
„„ Self-limitingQ disease usually in 6–10 weeks.

Fig. 38:  Pityriasis rosea Flowchart 1:  Clinical course followed by pityriasis rosea
 Papulosquamous Disorders  5 Chapter 119
Treatment
Asymptomatic → Reassurance
Symptomatic
„„ Itchy → Antihistamine
Calamine
Topical steroid
„„ Severe/Erythematous/Scaly → Coal tar
Topical steroids
„„ Recalcitrant → Phototherapy
PUVA/PUVASOL
NBUVB

PITYRIASIS RUBRA PILARIS (PRP) (FIGS 39 TO 41)

Term ‘pityriasis’ means ‘scaling’, ‘Rosea’ means ‘Red’ and ‘pilaris’ means ‘follicular’

Pityriasis Rubra Pilaris (PRP)

↓ ↓ ↓
Scaling Red Follicular

Age of Onset
„„ Juvenile variant = 5–10 years
„„ Adult variant = 40–60 years

Clinical Features
Scaly (pityriasis), orange to red (Rubra), follicular (pilaris) papules,
coalesce to form large plaques, with islands of normal skinQ in
between. Sometimes >90% body surface involved (ErythrodermaQ)
(Figs 41A and B).
Most common site: Trunk (lesions evolve in cephalocaudal direction)
(Fig. 39). Fig. 39:  Distribution of pityriasis rubra pilaris

Other Sites
„„ Digits →follicular lesions (Nutmeg grater)
„„ Palm and sole → Keratoderma (thicking) of palm and sole (Keratodermic sandals) Fig. 42.
„„ Nails → Yellowish discoloration with thickened nail plate
Griffith’s classification → 6 types
1. Classic adult type
2. Atypical adult type
3. Classic Juvenile type
4. Atypical juvenile type
5. Circumscribed juvenile type
6. HIV associated
 120 New SARP Series Skin
New SARP Series Skin

A B

Figs 40A and B:  Pityriaisis rubra pilaris

Figs 41A and B:  Pityriasis rubra pilaris with islands of Fig. 42:  Keratodermic sandals
normal skin

Treatment
„„ Topical → Corticosteroids
Salicylic acid
„„ Systemic → Acitretin
Methotrexate
 Papulosquamous Disorders  5 Chapter 121
PARAPSORIASIS
Parapsoriasis describes a group of cutaneous diseases that can be characterized by scaly papules and/or plaques dispersed
on the trunk or proximal extremities that have a resemblance to psoriasis. Because of the variation in clinical presentation
and a lack of a specific diagnostic finding on histopathology, an uniformly accepted definition of parapsoriasis is lacking.
Brocq described 3 major entities that fit the description:
„„ Pityriasis lichenoides (Acuta and chronica)
„„ Small plaque parapsoriasis
„„ Large plaque parapsoriasis (Parapsoriasis en plaque)
zz Pityriasis lichenoides (Acuta and chronica)
Pityriasis lichenoides variants is scaly dermatoses with necrotic papules that are clinically and histologically
different from parapsoriasis. These diseases generally are benign and undergo spontaneous resolution.
zz Difference between small plaque parapsoriasis and large plaque parapsoriasis

Small plaque Large plaque

• Course Benign Premalignant/premycotic (as
may develop into mycosis
fungoides)
• Clinical Small (<5 cm), Large (>5 cm), asymmetrical
n e mo n

 M

ic
features asymmetrical, erythematous, scaly plaques
Mnemonic to remember
erythematous + with presence of
features of Poikiloderma = ATP
scaly plaques • Induration and
• Poikiloderma (atrophy, A = Atrophy
pigmentation, telangiectasia) T = Telangiectasia
• Treatment Not aggressive Aggressively treated P = Pigmentation

REITER’S DISEASE/REACTIVE ARTHRITIS

Classical triad of (Fig. 43)
„„ Arthritis
„„ Conjunctivitis
„„ Urethritis
Skin also gets involved: Cutaneous features are:
“Keratoderma BlennorrhagicaQ”→ Crusted, exudative (oozing
pus) plaques over palm and sole.
Circinate BalanitisQ → Lesions over glans penis with ring like
border
Eye involvement: Conjunctivitis, anterior uveitis/iritis. Fig. 43:  Triad of reiter’s disease
Joint involvement: Asymmetrical arthritis of large weight-bearing
joints. Enthesitis of achilles tendon and plantar fascia are characteristic.
HLA B27 association present. n e mo n
 M

Conjunctivitis
ic

„„
„„ Urethritis
„„ Balanitis Circinata → Lesions over glans penis with ring like border (circinate)
„„ Iridocyclitis and infections →
zz Sexually acquired (STI) → Chlamydia trachomatisQ CUBIKA
zz Enteric acquired (infection) → Shigella, Salmonella
„„ Keratoderma blenorrhagica → Crusted, exudated plaques over palm and sole
„„ Arthritis → Acute, Asymmetrical, Arthritis of lower Limb with sacroilitis.
 122 New SARP Series Skin
n e mo n
 M

ic Another mnemonic

CU KABIR on 27th
C = Conjunctivitis
U = Urethritis
K = Keratoderma blennorrhagicum
A = Arthritis
B = Balanitis circinata
I = Iridocyclitis
R = Rupioid psoriasis
27 = HLA B27

High Yield Info

Erythroderma (Exfoliative Dermatitis)
 Exfoliative dermatitis is characterized by generalized erythema and scaling involving 90% or more of the skin’s
surface and often obscures the primary lesions that are important clues to understanding the evolution of the
disease. Following diseases/conditions can present with erythroderma.
n e mo n
 M

ic

Mnemonic to remember the causes of erythroderma

“ID-SCALP”
 Idiopathic → MC (30%)
 DRUG (Anti-epileptics, carbamazepine), Ca2+Ch-blockers, Antibiotics (penicillin)
 Seborrheic dermatitis, Sezary syndrome
 Contact dermatitis
 Atopic dermatitis, airborne contact dermatitis
 Lymphoma and Leukemia
 Psoriasis, pityriasis rubra pilaris and pemphigus foliaceus

LICHEN NITIDUS
„„ Multiple discrete, tiny, pinheadQ sized skin colored papules common in children over forearms, dorsumQ of hand,
penis, chest, abdomen and buttock (Fig. 44).
„„ Koebner phenomenon present
Histology: “Claw and ball” appearance
„„ Elongated rete ridges with focal dense lymphohistiocytic infiltrate in upper dermis
„„ Elongated rete ridges resembles ‘claw’ and lymphohistiocytic infiltrate appears like a ‘ball’.
 Papulosquamous Disorders  5 Chapter 123

A B C

Figs 44A to C:  Lichen nitidus

Treatments

Topical • Corticosteroids
• Calcineurin inhibitors
Phototherapy
Systemic • Corticosteroides
• Cyclosporin
• Acitretin
 124 New SARP Series Skin

ONE LINERS
„„ Pityriasis amiantacea→Seen in psoriasis, atopic dermatitis, seborrheic dermatitis, Tinea capitis
↓ ↓
scaling asbestos like
It may be complicated by secondary staphylococcal infection.
n e mo n
 M

ic

Mnemonic to remember the causes of pityriasis amiantacea

PAST
P = psoriasis
A = atopic dermatitis
S = seborrheic dermatitis, staphylococcal infection
T = Tinea capitis

„„ Due to thickness of stratum corneum, lesions of psoriasis have less obvious erythema on palm and sole.
„„ Seborrheic dermatitis → Lesions do not spill onto forehead and nape of neck from scalp.
„„ Yellow greasy scales on seborrheic areas, severe in HIVQ: seborrheic dermatitis.
„„ Greasy scales over scalp of infant: cradle capQ (seborrheic dermatitis)
„„ Pityriasis capitis is commonly known as dandruff (no inflammation), inflammation is present in seborrheic
dermatitis.
„„ Psoriasis → Lesions may spill onto forehead and nape of neck.
„„ Dactytitis→ Digits become sausage shaped due to inflammation of tendons, joint and soft tissue
„„ Enthesitis→ Inflammation of entheses
„„ Dactytitis and enthesitis is typical manifestations of psoriatic arthritis
„„ Post sexual (chlamydia) and post enteric (shigella, salmonella) are infective causes of Reiter’s disease/reactive arthritis.

Points to remember in psoriasis:

P = Plaque/pinpoint bleeding (Auspitz’s sign)
S = Silvery white (mica like) scaling
O = Oil drop sign is pathognomonic/onycholysis
R = Red spot on nail (salmon patch)
I = Irregular pitting is most common nail change
A = Abscess (munro’s micro abscess)/acanthosis (thickening of stratum spinosum)
S = Stratum granulosum is absent/stratum corneum with nucleus (parakeratosis)
I = Infiltration of lymphocytes
S = Suprapapillary thinning

PS-clinical features
ORI-nail changes
ASIS- Histological findings
„„ Dental filling (amalgam)/MercuryQ → can cause oral lichen planus.
„„ Ulcerative/erosive oral L.P. → rare but premalignant.
„„ Civette bodiesQ are seen in lichen planus.
„„ Griffith’s classification is used for pityriasis rubra pilaris
„„ Wornoff ring seen in psoriasis is due to prostaglandinsQ
„„ Following clinical history/clues in the questions are suggestive of:
zz Scaly (pityriasis), orange to red (Rubra), follicular (pilaris) papules, coalesce to form large plaques: pityriasis
rubra pilaris
 Papulosquamous Disorders  5 Chapter 125
zz Keratotic sandalsQ (thickening of palm and sole), with islands of normal skinQ in between: pityriasis rubra
pilaris
zz Classic triad of arthritis, urethritis and conjunctivitis. Reactive arthritis/reiter’s disease.
zz “Lake of pus “ or “sheet of pus”Q in MCQ indicates: Impetigo herpetiformis/pustular psoriasis/von
zumbusch disease.

Diagnostic Box
„„ Understanding biological therapies used in psoriasis
„„ Basic interplay between T-cells, antigen presenting cell (APC) and cytokines is well established in psoriasis
 126 New SARP Series Skin

Recent Advances
„„ Psoriasis Genes: PSORS 1-8 genes (PSORiasis susceptibility)
„„ PSORS 1→ Located in MHC (chromosome 6p21.3)
Most replicated psoriasis susceptibility locus
PSORS 2 → 2nd most replicated psoriasis susceptibility locus
PSORS 5 → Linked to psoriasis in Swedish families
PSORS 8 → Susceptibility gene for Crohn’s disease and also implicated in psoriatic arthritis.
„„ Multiple HLA alleles associated with psoriasis
HLA CW6 →psoriatic arthritis and early onset psoriasis
HLA B27
B38 Also associated with psoriatic arthritis
B39
HLA B27 → Strongly associated with the axial variant of psoriatic arthritis.

Recent Biologicals
„„ Ixekizumab (phase III completed) anti IL-17A
„„ Brodalumab (phase II completed) bind to IL-17 receptor A
„„ Tofacitinib Janus kinase (JAK) Inhibitors → prevent cytokine receptor signaling → receptors
„„ Baricitinib for IL 2, 6, 22, 23, IFN-y, TNF-α
„„ Golimumab
TNF α inhibitor
„„ Certolizumab pegol
„„ Briakinumab
„„ Tildrakizumab IL-23
„„ Guselkumab
„„ Voclosporin Calcineurin inhibitor (similar to cyclosporine)
 Papulosquamous Disorders  5 Chapter
MULTIPLE CHOICE QUESTIONS
1. Which of the following is/are not a subtype of
lichen planus:  (PGI May 2018)
a. Ulcerative lichen planus
b. Lichen nitidus
c. Hypertrophic lichen planus
d. Lichen scrofulosorum
e. Lichen planus pigmentosus
2. Nail changes in psoriasis is/are:  (PGI May 2018)
a. Onycholysis
b. Oil drop discolouration
c. Subungual hyperkeratosis
d. Nail pitting
e. Pterygium formation
3. A lady with bilateral buccal reticulate white
streaks. Pain increases on intake of spicy food and
patient gives no H/O tobacco but show amalgam
on 3rd molar. Diagnosis? (AIIMS Nov 2015)
a. Leukoplakia b. Lichen planus
c. Aphthous stomatitis d. Candidiasis
4. Pityriasis rosea true:
a. Self-limiting
b. Chronic relapsing
c. Life threatening infection (autoimmune disease)
d. Caused by dermatophytes
5. Least common site involvement in psoriasis is:
a. Scalp involvement b. Nail involvement
c. CNS involvement d. Arthritis
6. 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. Pustular psoriasis
c. Bacterial infections d. Septicemia
7. The only indication of giving corticosteroids in
pustular psoriasis is:
a. Psoriatic erythroderma with pregnancy
b. Psoriasis in a patient with alchoholic cirrhosis
c. Moderate arthritis
d. Extensive lesions
127
8. Regarding Lichen Planus all are true, except:
a. Hypopigmentation in most residual disease
b. Lymphocytic infiltration in supradermal layer
c. Itchy polygonal purple papules
d. Skin, hair and oral mucosae are normal
9. Sawtooth rete ridges are seen in:
a. Erythroderma b. Psoriasis
c. Darier’s disease d. Lichen planus
10. A young lady presents with lacy lesions in oral
cavity and genitals, and her proximal nail fold
has extended onto the nail bed. What is the likely
diagnosis:
a. Psoriasis b. Geographic tongue
c. Lichen planus d. Candidiasis
11. Vitamin D analogue calcitriol is useful in the
treatment of:
a. Lichen planus b. Psoriasis
c. Pemphigus d. Leprosy
12. Complication of chronic Lichen planus:
a. Dermatofibroma
b. Malignant melanoma
c. Basal cell carcinoma
d. Squamous cell carcinoma
13. Nappes claires is seen in:
a. Pityriasis versicolor b. P. alba
c. P. rubra pilaris d. P. rosea
14. A 35-year-lady presents with bilateral buccal
reticulate white streaks as shown in, pain and
burning sensation on eating spicy food. There
is no history of tobacco chewing but shows
amalgamated 3rd molar tooth is present. What is
most likely cause?
a. Candida b. Aphthous stomatitis
c. Lichen planus d. Leukoplakia
 128 New SARP Series Skin
15. A 7 months pregnant lady with diabetes comes
with lesions all over the body, mainly trunk as
in the picture below. Which of these drugs is the
appropriate treatment?
a. Cyclosporine b. Azathioprine
c. Methotrexate d. Retinoids
16. In which of the following, Koebner phenomenon is
NOT seen: (PGMEE 2015)
a. Erythema multiforme
b. Lichen sclerosis
c. Lichen simplex chronicus
d. Lichen planus
17. A Hanging Curtain Sign is seen in:
a. Hordeolum externum b. Psoriasis
c. Lichen Planus d. Pityriasis Rosea
18. First topical retinoid approved by us FDA for
psoriasis: (PGMEE 2016-17)
a. Isotretinoin b. Tazaroten
c. Acitretin d. Calcipotrine
19. Tiny bleeding spots after removal of deep scales in
Plaque Psoriasis is Known as: (PGMEE 2015-16)
a. Koebner’s Sign b. Burkley’s Sign
c. Candle Wax Sign d. Auspitz Sign
20. 45-year-old male presents with scaly lesions over
back. Most likely diagnosis is: (PGMEE 2016-17)
a. Lichen planus
b. Pustular psoriasis
c. Erythrodermic psoriasis c. Pigment incontinence
d. Psoriasis vulgaris
21. This type of psoriasis is commonly seen in children
and may follow a streptococcal sore throat:
 (PGMEE 2014)
a. Pustular b. Stable plaque
c. Arthropathic d. Guttate
22. Goekarman regimen used in for treatment of
psoriasis is: (PGMEE 2015)
a. Coal tar plus anthralin
b. UVB plus coal tar
c. UVB plus anthralin
d. UVB plus methotrexate
23. Among various types of psoriatic arthritis, which
variety is most common: (PGMEE 2015)
a. Classic b. Spondylitis
c. Rheumatoid d. Oligoarticular
24. The treatment of choice for erythrodermic
psoriasis is: (PGMEE 2014)
a. Topical corticosteroids
b. Corticosteroids
c. Coaltar topically
d. Methotrexate
25. A primigravida female presented with
erythematous skin changes and lesions with
multiple pus lakes. Which of the following should
be the most appropriate: (PGMEE 2010)
a. Psorolen + PUVA b. PUVA
c. Atretin d. Corticosteroids
26. Psoriasis is exacerbated by: (PGMEE 2015)
a. Antimalarials b. Lithium
c. β-blockers d. All of the above
27. The most common association with coarse pitting
of nails and onycholysis is: (PGMEE 2014)
a. Cicatricial alopecia
b. Well defined scaly plaques
c. Polygonal papule
d. Violaceous papules
28. A young female presented with lacy linear lesions
on tongue since a month with elongation of nail
fold beyond the nail bed. What is the diagnosis:
a. Lichen planus (PGMEE 2010)
b. Psoriasis
c. Candidiasis
d. Geographic tongue
29. Characteristic bodies in Lichen planus:
a. Civatte bodies (PGMEE 2016-17)
b. HP bodies
c. Warthin Fiekendly Bodies
d. Negri bodies
30. Not a histological feature of lichen planus is:
a. Neutrophils in stratum (PGMEE 2014)
b. Hyperkeratosis
d. Acanthosis
 Papulosquamous Disorders  5 Chapter 129
31. The most characteristic finding in lichen planus
is: (PGMEE 2013)
a. Violaceous lesions
b. Civatte bodies
c. Thinning of nail plate
d. Basal cell degeneration
32. Cicatrising alopecia with perifollicular blue-gray
patches is most commonly associated with:
a. Pitting of nails (PGMEE 2011)
b. Discoid plaques in the face
c. Arthrtis
d. Whitish lesions in the buccal mucosa
33. A young boy presented to OPD with multiple shiny
a Lichen nitidus b. Lichen planus
pinhead size white papules over dorsum of head,
c. Scabies d. Phrynoderma
forearm and penis. What would be the diagnosis?
40. A 7 month pregnant lady comes with the following
a. Lichen planus (PGMEE 2014)
lesions all over the body. Picture shows multiple
b. Lichen nitidus
small pustules over skin. Which of these drugs is
c. Scabies
an appropriate treatment?
d. MC
34. Case with curtain like sign and Christmas tree
Pattern along the ribs: (PGMEE 2016-17)
a. Pityriasis rosea
b. Pityriasis versicular
c. Pityriasis lichenoides chronica
d. Pityriasis rubra pilaris
35. Multiple erythematous annular lesions with
peripheral collarette of scales arranged
predominantly on trunk are seen in:
a. Pityriasis vesicular (PGMEE 2012)
b. Pityriasis rubra pilaris a. Cyclosporine b. Azathioprime
c. Pityriasis rosea c. Methotrexate d. Retinoids
d. Pityriasis lichennoides chronica 41. Black follicular prominences seen over scalp,
36. Annular herald patch is seen in: (PGMEE 2013) leading to scarring alopecia along with nail
a. Psoriasis b. Nocardiasis dystrophy leading to anonychia. Diagnosis:
c. P.alba d. P. rosea
37. Keratodermic sandal is a feature of: (PGMEE 2013)
a. Psoriasis
b. Lichen planus
c. Pityriasis rubra pilaris
d. Pityriasis rosacea
38. All of the following are primary cutaneous
disorder except: (PGMEE 2012)
a. Icthiosis
b. Reiter’s disease
c. Lichen planus
d. Psoriasis a. Scalp psoriasis with nail changes
39. A child came with similar lesions over dorsum of b. Black dot tinea capitis with onychomycosis
hand, shaft of penis and forearm. Picture shows c. Lichen planus
Pinhead discrete but grouped papules. Diagnosis. d. Alopecia areata
130 New SARP Series Skin
ANSWERS WITH EXPLANATIONS
1. Ans. a.  Ulcerative lichen planus, d. Lichen
scrofulosorum
The clinical presentation of lichen planus has several
forms: actinic (in sun-exposed areas), annular,
atrophic, erosive/ulcerative, follicular, hypertrophic,
linear, pigmented, and vesicular/bullous.
Lichen scrofulosorum is a type of tuberculid which
occurs due to mycobacterial hypersensitivity.
Lichen nitidus is a rare skin condition that usually
appears as tiny, skin-colored, glistening bumps on
the surface of your skin. Lichen nitidus results from
abnormal inflammatory activity in skin cells, but the
cause of inflammation is unknown.
2. Ans. a.  Onycholysis, b. Oil drop discolouration,
c. Subungual hyperkeratosis, d. Nail pitting
Pterygium (Proximal nail fold extends onto and fuses
with nail bed) formation is seen in lichen planus.
•• Dorsal pterygium is seen in lichen planusQ
•• Ventral pterygium is seen in:-
ƒƒ Scleroderma with Raynaud’s phenomenon
ƒƒ Causalgia of median nerve
ƒƒ Trauma
3. Ans. b.  Lichen planus
White reticulate pattern is commonly seen associated
with lichen planus. History of amalgam filling in
teeth is also suggestive of lichen planus.
4. Ans. a.  Self-limiting
Pityriasis Rosea
It is an acute, self-limiting disease, probably
infective in origin, affecting mainly children and
young adults, characterized by a distinctive skin
eruption and minimal constitutional symptoms.
Etiology
Most common: Human herpes virus HHV 7 and HHV 6
Drugs: Arsenic, bismuth, lithium, metronidazole,
barbiturates, captopril, ketotifen.
Vaccination: Hep B / BCG
Mother/herald patch–Solitary annular plaque
which heralds the disease [site trunk, arm].
Followed by multiple oval shaped symmetrically
arranged collarette scaly plaques along the lines of
cleavage [Christmas tree pattern] involving bathing
trunk area.
Variants of P.R: Papular, vesicular, pustular,
hemorrhagic, purpuric, inverse, EMF like, giant,
urticarial without herald patch.
Treatment
•• Essentially symptomatic [antihistamine, calamine
lotion]
5. Ans. c.  CNS involvement
[Ref: 8th edition chapter 20]
Scalp is a common site of involvement in psoriasis.
Corona psoriatica is a band of psoriasis, projecting
beyond hairline on forehead.
Nail changes in psoriasis are pitting, onycholysis,
subungual hyperkeratosis, splinter hemorrhages,
uneven surface.
6. Ans. b.  Pustular psoriasis
[Ref: IADVL 4th edition page no: 1030]
Pustular Psoriasis
•• Acute widespread lakes of pus
•• Precipitated by steroid withdrawal.
•• Von Zumbusch reaction is a very severe
generalized pustular psoriasis
•• Pustular psoriasis is also aggravated by local
infections, hypocalcemia, topical application of
anthralin
•• Pustular psoriasis in pregnancy is called impetigo
herpetiformis
7. Ans. a.  Psoriatic erythroderma with pregnancy
8. Ans: a.  Hypopigmentation in most residual disease
Post-residual Hyperpigmentation is seen most
commonly in residual disease
9. Ans. d.  Lichen planus
HPE of Lichen Planus
•• Hyperkeratosis
•• Hypergranulosis
•• Acanthosis
•• Basal cell degeneration producing Civatte bodies
•• Max-Joseph Space
•• Band like infiltration of Lymphocytes at dermo-
epidermal junction.
•• Saw toothing of Rete – Ridges
 Papulosquamous Disorders  5 Chapter
10. Ans. c.  Lichen planus
[Ref: 8th edition chapter 41.1]
Lichen Planus
•• It is an idiopathic, chronic, inflammatory disease
that affects the skin, mucous membranes and
appendages
•• 5’p’s of LP – pruritus, plane (flat) topped,
polygonal, purple (violaceous), papules and
plaques.
•• Sites: Flexer aspect of wrist, forearm extensor
surface of lower legs, lumbosacral area.
•• Lesions heal with hyperpigmentation
•• Oral cavity: White streaks in lacy pattern in
posterior buccal mucosa seen.
•• Nails: Pterygium: Thinning, splitting, ridging.
•• Kobner’s phenomenon is positive
•• Wickham striae: Dedicate white lines seen over
lesions better viewed with oil application.
11. Ans. b.  Psoriasis
12. Ans. d.  Squamous cell carcinoma
13. Ans. c.  P. rubra pilaris
The islands of sparing in PRP is known as Nappes
claire’s
14. Ans. (c)  Lichen planus
[Ref: Rook dermatology 8th ed page 41.1]
Clues in the Question are
•• Bilateral reticulate white streaks is very characterstic
of wickham’sstriae seen in lichen planus.
•• Dental amalgams are known to predispose to
lichen planus symptoms of burning on intake of
spicy food can occur in all the mentioned options,
so let’s rule out the options.
Option (A) Oral Candida
The characteristic sign of this condition is a sharply
defined patch of creamy, crumbly, curd-like white
pseudomembrane, which, when removed, leaves
an underlying erythematous base. This membrane
consists of desquamated epithelial cells, fibrin,
leukocytes and fungal mycelium that attaches it to
the inflamed epithelium. Present in preterm babies,
immunocompromised conditions such as AIDS.
Option (B) Recurrent Aphthous Stomatitis (RAS)
It is characterized by recurring episodes of ulcers,
typically from childhood or adolescence, each lasting
131
from 1 to about 4 weeks before healing. Aphthae
typically are multiple round or ovoid ulcers with a
circumscribed margin, erythematous halo and a
yellow or grey floor.
Option (D) Leukoplakia
The World Health Organization defines leukoplakia
as a white patch or plaque on the mucosa that cannot
be rubbed off and that is not recognized as a specific
disease entity, which implies a diagnosis of exclusion
(e.g. of LP, candidiasis). The term is also used
irrespective of the presence or absence of epithelial
dysplasia, although there is a small malignant
potential to some keratoses.
15. Ans. a.  Cyclosporine
[Ref: Bolognia 3rd Ed page 2242, IADVL 2nd Ed page
1054, Roxburgh’s 18th ed page 148-150, Fizpatrick 7th
ed page 959-960]
The clinical picture is consistent with Pustular
Psoriasis of Pregnancy AKA Impetigo Herpitiformis.
Systemic steroids followed by impetigo
herpetiformis Cyclosporine is the drug of choice
in impetigo herpetiformis. As retinoids, PUVA
and Methotrexate are contraindicated in pregnancy,
cyclosporine and/or steroid is used. Localized
disease is treated by topical steroid while generalized
disease is treated by systemic steroid. Systemic
steroid should be avoided in routine care of Psoriasis,
because the disease requires progressively higher
dose and withdrawal of steroid is associated with
relapse into more severe forms.
16. Ans. c.  Lichen simplex chronicus
[Ref: IADVL Textbook of Dermatology 4th edition vol
1 pg 131]
Lichen simplex chronicus also known as
neurodermatitis occurs due to excessive scratching
at particular site and is not associated koebner’s
phenomenon
17. Ans. d.  Pityriasis Rosea
[Ref: Andrew’s Diseases of the Skin: Clinical
Dermatology 12th/e pg. 199; Multiple References]
Hanging certain sign, collarette of scales, cigarette
paper scales all are seen pityriasis rosea
18. Ans. b.  Tazaroten
[Ref: IADVL Textbook of Dermatology 4th edition vol
1 pg 1051]
132 New SARP Series Skin
•• Tazaroter: is topical retinoid used in psoriasis
•• Acitretin: is systemic retinoid used in psoriasis
19. Ans. d.  Auspitz Sign
[Ref: Harrison 19th/e pg. 347]
Auspitz sign is associated with pin point bleeding
spots
20. Ans. c.  Erythrodermic psoriasis
[Ref: IADVL Textbook of Dermatology 4th edition vol
1 pg 1027]
Erythro = red; Derma = skin
In this severe type of psoriasis whole skin may
become erythematous/Red
21. Ans. d.  Guttate
[Ref: IADVL Textbook of Dermatology 4th edition vol
1 pg 1028]
Guttate psoriasis occurs after beta-Haemolytic
streptococcal upper respiratory tract infection
(URTI)
22. Ans. b.  UVB plus coal tar
[Ref: IADVL Textbook of Dermatology 4th edition vol
1 pg 1051]
These are two phototherapy regimen used in psoriasis
•• Ingram regimen: Dithranol followed by light
exposure
•• Goeckerman regimen: Coal tar followed by light
exposure
23. Ans. d.  Oligoarticular
[Ref: IADVL Textbook of Dermatology 4th edition vol
1 pg 1037]
Asymmetrical oligoarticular type of psoriatic
arthritis is most common
•• Most common joint involved in psoriatic arthritis
is DIP (Distal interphalangeal joint)
Following findings are also associated with psoriatic
arthropathy
•• Sausage digit inflammation of entire digit
•• Pencil in cup deformity (on plain radiograph)
•• Opera glass deformity (telescoping fingers)
24. Ans. d.  Methotrexate
[Ref: IADVL Textbook of Dermatology 4th edition vol
1 pg 1057]
•• DOC for erythrodermic psoriasis: Methotrexate
•• DOC for pustular psoriasis: Acitretin
25. Ans. d.  Corticosteroids
[Ref: IADVL Textbook of Dermatology 4th edition vol
1 pg 1071]
•• Clinical history suggestive of pustular psoriasis in
pregnancy or impetigo herpetiformis
•• DOC: Systemic corticosteroid > cyclosporine
•• (Acitretin and methotrexate both are teratogenic,
so are contra indicated)
26. Ans. d.  All of the above
[Ref: IADVL Textbook of Dermatology 4th edition vol
1 pg 1025]
All can exacerbate psoriasis
27. Ans. b.  Well defined scaly plaques
[Ref: IADVL Textbook of Dermatology 4th edition vol
1 pg 1034]
Polygonal violaceous (purple) papules and cicatricial
alopecia is seen in lichen planus
28. Ans. a.  Lichen planus
[Ref: IADVL Textbook of Dermatology 4th edition vol
1 pg 1098]
Elongation of nail fold is known as pterygium
29. Ans. a.  Civatte bodies
[Ref: IADVL Textbook of Dermatology 4th edition vol
1 pg 1101]
Civatte or colloid bodies are apoptotic (degenerating)
basal keratinocytes
30. Ans. a.  Neutrophils in stratum
[Ref: IADVL Textbook of Dermatology 4th edition vol
1 pg 1101]
Neutrophilic collection in epidermis are seen in psoria-
sis known as munro’s Microabscess and Kogoj pustules
31. Ans. d.  Basal cell degeneration
[Ref: Rook’s Textbook of Dermatology 9th edition
pg37.14]
Most characteristic histological finding is basal cell
degeneration.
Most characteristic nail finding is pterygium
32. Ans. d.  Whitish lesions in the buccal mucosa
[Ref: IADVL Textbook of Dermatology 4th edition vol
1 pg 1099]
It’s a case of lichen planus
 Papulosquamous Disorders  5 Chapter 133
33. Ans. b.  Lichen nitidus Lichen nitidus

[Ref: IADVL Textbook of Dermatology 4th edition vol

1 pg 1107]
Lichen nitidus on histology shows claw clutching
appearance

34. Ans. a.  Pityriasisrosea

[Ref: Andrew’s Diseases of the Skin 12th edition pg
199]

35. Ans. c.  Pityriasisrosea

[Ref: Andrew’s Diseases of the Skin 12th edition pg 199] Scabies

36. Ans. d.  P.rosea

[Ref: Andrew’s Diseases of the Skin 12th edition pg 199]
Herald patch is first patch seen over trunk in
pityriasis rosea

37. Ans. c.  Pityriasis rubra pilaris

[Ref: IADVL Textbook of Dermatology 4th edition vol
1 pg 421]
Hypertrophic lichen planus over shin
Keratoderma over palm and sole appears like sandal

38. Ans. b.  Reiter’s disease

[Ref: Andrew’s Diseases of the Skin 12th edition pg
195]

39. Ans.  a. Lichen nitidus

Disorder Distribution
Lichen Trunk, dorsum of hand, shaft of penis and
nitidus forearm (flexors of upper extremities).
Lichen Extremities (flexors of wrists, ankles and
planus shin) and lower back.
Variants: Phrynoderma
Annular –face and glans
Actinic – face
Linear –extrimities
Follicular – scalp
Hypertrophic- shin
Pigmentosus – photoexposed and flexures
Scabies Web spaces, wrists, ulnar aspect of forearm,
groin. Face, palm and sole spared in adults
and involved in infants.
Phryno- Elbows, knees
derma
 134 New SARP Series Skin

40. Ans.  a. Cyclosporine Nail pterygium

„„ It’s a case of pustular psoriasis in pregnancy also
known as impetigo herpetiformis, where the
DOC is corticosteroides which is not mentioned
in the options.
„„ Methotrexate and acitretin are also used in
psoriasis but both are teratogenic(preg cat. X) so
can not be used in pregnancy.
„„ Azathioprine is not as effective as cyclosporine
in psoriasis, so answer here is cyclosporine.

41. Ans.  c.  Lichen planus

Oral lichen planus Follicular lesions of LP on scalp leads to scarring
„„
alopecia.
„„ Oral mucosal involvement is common in LP.
„„ Nail changes of LP are as follows:
zz Nail thinning
zz Trachyonychia
zz Tenting of nail plate
zz Pterygium
Anonychia