28. Inflammatory Disorders Flashcards
Most common psoriasis
Plaque (most common) • Extensor extremities most common; pink patches and plaques with overlying silvery scale
Inverse – Flexural psoriasis are located:
• Axillae, groin, perineum, chest
• Drop-like, 2-10mm, symmetric trunk/proximal extremities • Often triggered by Group A Strep What type of psoriasis is this?
Guttate
– Pustular psoriasis is usually located on:
• May be localized to palms and soles or be generalized
Generalized erythema; amount of scaling is variable, what kind of psoriasis is this?
– Erythrodermic
immune-mediated polygenic skin condition. Mutlifactoral triggers disease in predisposed individuals. lesions are well-demarcated erythematous papules and plaques,
ranging in size from pinpoint to < 20 cm in diameter, with overlying micaceous or silvery scale
Psoriasis
Other signs of psoriasis besides skin changes
Nail changes can also be seen with pitting
(pinpoint indentations in the nail plate), thickening, and yellow discoloration.
20-30% developing psoriatic arthritis have
increased risk of metabolic syndrome and atherosclerotic cardiovascular disease
When evaling a pt with psoriasis, what other things should we take into consideration?
recent infections
– may trigger flares, particularly Streptococcal
• risk factors for HIV
– HIV patients often have worse disease
• Ask about joint symptoms
– Up to 20% also have psoriatic arthtitis
• Evaluate body mass index (BMI)
– Correlation between obesity and prevalence and
severity of psoriasis
• Ask about CV risk factors– see increased risk for CV
Genetics and psoriasis
• Ask about other family members with
psoriasis
– Strong genetic predisposition for psoriasis
– Multiple psoriasis genes identified
– 1/3 with a positive family history
How can mediation be involved in pt presenting with psoriasis
can be triggered or exacerbated by
many medications, including:
– Systemic corticosteroid withdrawal
– Beta blockers (propranolol, metoprolol)
– Lithium
– Anti-malarials (chloroquine, hydroxychloroquine)
– Interferons
What is this… what types of pts may have this
Pencil in cup deformity seen in pts with psoriasis arthritis
Psoriasis arthritis seen in 20-30% pts
What joint issues should we keep in mind with psoriasis pts?
oligoarthritis (common in knee) and psoriasis arthritis. See sausage fingers, pencil in cup deformities, flexure deformities and bone destruction
What type of nail changes do we see with psoriasis?
Pitting, discoloration, onycholysis in 25-30% pts
In psoriasis we see development of skin lesions at site of injury… this is called:
Koebner phenomenon
Pt has psoriais:
– Localized (<5% BSA)
Tx recommendation?
topicals alone
Pt has psoriasis that can be chacterized as:
Generalized
Tx?
- systemic/phototherapy + topicals
• Refer to dermatologist for management
What are some aggravating factors
– Concurrent infection
– Medications
– Obesity
For localized or mild psoriasis, tx?
opical corticosteroids are first-line therapy. Other topical agents include retinoids, coal tar derivatives, and calcineurin inhibitors
used in psoriasis
to induce terminal differentiation and inhibit proliferation of keratinocytes, as well as modulating
the immune response.
Topical vitamin D analogues (e.g. calcipotriene, calcitriol)
Psoriasis: extensive disease or recalcitrance to topical
corticosteroids, treatment with what two things should we consider?
phototherapy or systemic medications may be indicated.
Systemic agents used in the treatment of psoriasis include
methotrexate, cyclosporine, acitretin,
and targeted immune modulators (“biologics”).
Biologic therapies target
T cells and cytokines
involved in the pathogenesis of psoriasis. TNF-α inhibitors used for psoriasis include etanercept,
infliximab, and adalimumab.
What should we avoid in pts with psoriasis?
Oral corticosteroids should be avoided in patients with psoriasis as withdrawal of the corticosteroids will provoke a flare of their disease, often pustular. C
TNF alpha blockers for psoriasis
Entanercept, Infliximab, Adalimumab
IL-12, IL23 blocker used for psoriasis tx
Ustekinumab
What UV is used for phototherpy of psoriasis
narrrowband UVB and sometimes UVA
psoriasis on face an groin, used what class of topical coritcosteroids?
Class V and VI
Psoriasis on the body… what class of corticosteoids should we use
Class III to IV
What class of coriticosteroids should we use for psoraisis on hands and feet
Class I and II, strongest
Inflammatory disease of skin, hair, nails and
mucous membranes
• Flat-topped (planar) polygonal pruritic pink or
violaceous (purple) papules or plaques
• Flexural lower legs, ankles, wrists, genitalia
most common
Lichen Planus
Describe this lichen planus
• Flat-topped (planar) polygonal pruritic pink or
violaceous (purple) papules or plaques
SUPER itchy
What exposures are associated with increased incidence of Lichen Planus?
– Viruses (Hepatitis C)
– Hepatitis B vaccine
– Drugs
• Beta-blockers
• ACE inhibitors
• Thiazide diuretics
• Antimalarials
• Gold and metals
• Penicillamine
– Thinning of nail plates
– Longitudinal ridging
– Pterygium formation (scarring)
–What does this pt have?
Nail Lichen Planus: 10% of LP patients have nail involvement
• Isolated nail LP may occur
Most common locations for mucosal lichen planus
Mucosal Lichen Planus
– Oral most common
– Genital
– Pharynx, esophagus, GI tract
What are the two types of Lichen planus?
– Reticulated: • Linear lace-like pattern of tiny white papules, Buccal mucosa most common, Typically asymptomatic
– Erosive, Gingiva or tongue, Typically painful
Topical Tx options for Lichen Planus
Topical corticosteroids
• Topical calcineurin inhibitors
• NBUVB phototherapy
Systemic Tx options for Lichen planus
– Oral corticosteroids
– Metronidazole, Griseofulvin
– Antimalarials
– Acitretin (retinoid)
– Mycophenolate mofetil
– Methotrexate
– Cyclosporine
4 week history of this facial eruption. Was treated with a 10 day course of cephalexin with no response Mother reports seeing him occasionally scratch at it, but otherwise not particularly bothered by this. Dx?
Atopic Dermatitis
most common chronic inflammatory skin disease. Onset in infancy is typical,
Atopic dermatitis (AD)
What do we tend to see in infants with atopic dermatitis?
– Facial involvement predominates early
– Tends to spare midface
– Oozing, crusting common
– Exacerbated by saliva, foods
– Extensor involvement late infancy
– Sparing of diaper area
What childhood disease would we expect this guy to have had?
Dennie-Morgan folds show evidence of atopic dermatitis
where else do we expect to see atopic dermatitis in childhood (NOT infants)
Flexural involvement: antecubital and popliteal fossa, wrists, ankles, neck and hands… less crusting
Kiddo presents with atopic dermatitis on the foot… has new tender lesions that is not typcial of her eczema according to mom.. What may be going on?
Secondary infection with Staph. Aurues or Staphylococcus
Infection with Herpes overlying eczema:
Eczema herpaticum
Treating a Flare of AD:
Topicals – Corticosteroids
• Ointments preferred
Immunomodulators :
Calcineurin inhibitors: Tacrolimus , Pimecrolimus
• Antihistamines for pruritus
• Treat/prevent secondary infections
– Bleach baths
Factors to consider when choosing topicals for AD
– DURATION of lesion; New lesion will often respond to weaker agents, Chronic lesion requires stronger treatment
– LOCATION of lesion; Thin skin (e.g. face, axilla, groin), Higher risk for side effects, should use lower strength med VS Thicker skin (e.g. palms, soles)
– Lower penetration/absorption, higher strength med often equired
Systemic Tx of AD
- Phototherapy – Narrowband UVB
- Systemic agents: Cyclosporine, Methotrexate, Mycophenolate mofetil, Azathioprine
Management of Atopic Dermatitis:
Maintenance
• Gentle skin care: Daily baths, Gentle cleansers , Thick moisturizer twice daily
• Petrolatum/Aquaphor > Cream > Lotion
– Avoidance of irritants (i.e. fragrance)
• Pathogenesis of AD
– Barrier-disrupted skin (abnormal barrier)
– Triggers : Allergens, Microbes (especially S. aureus)
and Scratching
Immune dysregulation of Atopic Dermatitis
• Acute:
• Chronic:
- Acute: Th2
- Chronic: Th1
DX?
Cradle cap or Seborrheic Dermatitis
Mom presents with child that has cradle cap… what can it progress to?
Seborrheic Dermitis
– Evolves to moist erythematous intertriginous
patches in
• Can be secondarily infected with Candida or
Streptococcus specis
– Dissemination with scaly papules, patches, and
plaques resembling atopic dermatitis/psoriasis
may occur as well
This 50 yo male presents
with complaints of itching
and flaking in the scalp for
as long as he can
remember.
Adult form of seborrheic Dermatitis
Seen as yellow-red papules, erythema and scaling
Mostly on the scalp–> aslo forehead, medial eyebrow, skin and ear or presternal
Tx for seborrheic dermatitis in infants
Low potentcy topical steroid, ketoconazol cream, mild shampoos, gentle skin care
Tx for Seborrheic derm in Adults
Azole cream or shampoo, Low potentcy topical steroid, Shampoos (tar, zinc, sulfide)
