28 - Psoriasis Flashcards by dvojnd rivera

Types of psoriasis based on age of onset

Type I - onset before 40 years and HLA associated

Type II - age after 40 years

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Also known as isomorphic response

Koebner phenomenon

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Koebner reaction usually occurs

7-14 days after injury

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Psoriasis vulgaris is seen approximately in _____% of patients

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Type of psoriasis: lesions may extend laterally and become circinate because of the confluence of several plaques

Psoriasis gyrata

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Type of psoriasis: partial central clearing resulting in ringlike lesions

Annular psoriasis

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Type of psoriasis: usually associated with lesional clearing and portends a good prognosis

Annular psoriasis

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Type of psoriasis: lesions in the shape of a cone or limpet

Rupioid psoriasis

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Type of psoriasis: ringlike, hyperkeratotic concave lesion, resembling an oyster shell

Ostraceous psoriasis

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Type of psoriasis: thickly scaling, large plaques, usually on the lower extremities

Elephantine psoriasis

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Hypopigmented ring surrounding individual psoriatic lesions usually associated with treatment, most commonly UV radiation or topical steroids

Woronoff ring

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Pathogenesis of Woronoff ring

Not well understood but may result from inhibition of prostaglandin synthesis

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Guttate psoriasis has the strongest association to

HLA-Cw6

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Frequently precedes or is concomitant with the onset or flare of guttate psoraisis

Streptococcal throat infection

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Common adult presentation of psoriasis in Korea and other Asian countries

Small plaque psoriasis

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Characterized by fever that lasts several days and a sudden generalized eruption of sterile pustules; waves of fever and pustules

Generalized pustular psoriasis (von Zumbusch)

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Tends to occur after a viral infection and consists of widespread pustules with generalized plaque psoriasis

Exanthematic pustular psoriasis

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Exanthematic pustular psoriasis vs von Zumbusch

Exanthematic pustular psoriasis - no constitutional symptoms and tends not to recur

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Characterized by pustules on a ringlike erythema that sometimes resembles erythema annulare centrifugum

Annular pustular psoriasis

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Variant of pustular psoriasis occuring in pregnancy

Impetigo herpetiformis

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Impetigo herpetiformis onset

Early in the third trimester and persists until delivery

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Y/N: Impetigo herpetiformis tends to develop earlier in subsequent pregnancies.

Yes

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Impetigo herpetiformis is often associated with

Hypocalcemia

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Rare variant of pustular psoriasis that is localized to the palms and soles

Palmoplantar pustular psoriasis or

Pustulosis palmaris et plantaris

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Palmoplantar pustular psoriasis vs palmoplantar pustulosis

Palmoplantar pustular psoriasis - chronic plaque psoriasis is present

Y/N: Pustulosis palmaris et plantaris has a sex predilection

Yes - more common in females

Strongly associated with pustulosis palmaris et plantaris

Smoking

Also knows as dermatitis repens

Acrodermatitis continua of Hallopeau

Napkin psoriasis usually between the ages of

3 and 6 months

Napkin psoriasis prognosis

Disappear after the age of 1 year

May be an underlying nevus, possibly an inflammatory linear verrucous epidermal nevus

Linear psoriasis

Nail changes are found in up to _____% of patients

Nail finding that is considered to be nearly specific for psoriasis

Oil spotting

Nail segment involved: pitting

Proximal matrix

Nail segment involved: onychorrhexis

Proximal matrix

Nail segment involved: Beau’s lines

Proximal matrix

Nail segment involved: leukonychia

Intermediate matrix

Nail segment involved: focal onycholisis

Distal matrix

Nail segment involved: thinned nail plate

Distal matrix

Nail segment involved: erythema of the lunula

Distal matrix

Nail segment involved: “oil drop” sign or “salmon patch”

Nail bed

Nail segment involved: onycholysis

Nail bed | Hyponychium

Nail segment involved: subungual hyperkeratosis

Nail bed | Hyponychium

Nail segment involved: crumbling and destruction plus other changes secondary to the specific site

Nail plate

Nail segment involved: cutaneous psoriasis

Proximal and lateral nail folds

Y/N: Alopecia is a common observation is scalp psoriasis

No - not a common observation

Present as asymptomatic erythematous patches with serpiginous borders; idiopathic inflammatory disorder resulting in the local loss of filiform papillae

Geographic tongue or Benign migratory glossitis or Glossitis areata migrans

Y/N: Geographic tongue is seen in many nonpsoriatic individuals

Yes

Psoriatic arthritis is seen in up to _____% of patients

About _____% of basal keratinocytes are cycling in normal skin, but this value rises to _____% in lesional psoriatic skin

10 | 100

Neutrophils exit from the tips of a subset of dermal capillaries

Squirting papillae

Accumulation of neutrophils in the overlying parakeratotic stratum corneum

Munro’s micrabscesses

Accumulation of neutrophils in the spinous layer

Spongiform pustules of Kogoj

CD8+ T cells are predominantly located in the

Epidermis

CD8+ T cells are predominantly located in the

Upper dermis

______ are prominent in developing psoriatic lesions, with _____ appearing somewhat later

Macrophages | Neutrophils

Are likely to play a major role in pustular psoriasis

Neutrophils

Psoriatic keratinocytes are engaged in an alternative pathway of keratinocyte differentiation called

Regenerative maturation

Major genetic signal for psoriasis in the MHC

HLAC*0602 - encodes HLA-Cw6 protein

Medications that exacerbate psoriasis

``` Antimalarials Beta blockers Lithium NSAIDs IFN- alphas and gammas Imiquimod ACE inhibitors Gemfibrozil ```

Elevated in up to 50% of patients and is mainly correlated with the extent of lesions and the activity of disease

Serum uric acid

Y/N: Serum uric acid is persistently elevated in patients with psoriasis.

No - usually normalize after therapy

Guttate psoriasis prognosis

Self-limited, lasting from 12-16 weeks without treatment

_____ of patients with guttate psoriasis patients later develop the chronic plaque type

One-third to two thirds

First-line therapy in mild to moderate psoriasis and in sites such as the flexures and genitalia, where other topical treatments can induce irritation

Corticosteroids

Only major concern with the use of topical vitamin D preparations

Hypercalcemia

Recommended weekly dose of vitamin D3 analogues

100 g

Naturally occurring substance found in the bark of the araroba tree in South America

Anthralin (dithranol)

Anthralin combined with UVB phototherapy

Ingram regimen

Most common side effects of anthralin

ICD | Staining of clothing, skin, hair, and nails

Nail segment involved: splinter hemorrhages

Nail bed

To prevent auto-oxidation of anthralin, ______ should be added

Salicylic acid

Main active ingredient in a tar

Carbazole

Coal tar adverse effects

Folliculitis Unwelcome smell and appearance Staining of clothing Carcinogenesis

Significant proportions of patients on tazarotene develop

Local irritation

UV doses should be (decreased/increased) by at least one third if tazarotene is added to phototherapy

Decreased

Macrolide antibiotic derived from the the bacteria Streptomyces tsukubaensis

Tacrolimus

Main side effect of topical calcineurin inhibitors

Burning sensation

Carry a US FDA “black box warning” due to anecdotal reports of lymph node or skin malignancy

Tacrolimus

MOA: reduction of keratinocyte adhesion and lowering the pH of the stratum corneum, which results in reduced scaling and softening of the plaques, thereby enhancing absorption of other agents

Salicylic acid

Topical salicylic acid (decreases/increases) the efficacy of UVB phototherapy

Decreases

Peak UVB erythema appears within

24 hours of exposure

Objective in UVB phototherapy for psorisis

Minimally perceptible erythema

Excimer laser is commonly used for patients with

Stable recalcitrant plaques, particularly of the elbows and knees

Climactic therapy in psoriasis

Going to a sunny climate can improve psoriasis

MOA of methotrexate

Inhibition of AICAR (enzyme involved in purine metabolism) which leads to accumulation of extracellular adenosine

Therapeutic effects of methotrexate usually require _____ to become evident

4-8 weeks

Liver biopsy in low risk patients

Cumulative MTX dose of 3.5-4 g

Liver biopsy in patients with one or more risk factors

Baseline either before treatment or after 2-6 months of treatment Cumulative MTX dose of 1-1.5 g

Risk factors for liver injury

Current or past alcohol consumption Persistent abnormalities of liver function enzymes Personal or family history of liver disease Exposure to hepatotoxic drugs or chemicals Diabetes mellitus Hyperlipidemia Obesity

Only antidote for the hematologic toxicity of MTX

Leucovorin calcium (folinic acid)

Folinic acid administration

Immediate dose of 20 mg parenterally or orally then every 6 hours

Clinical forms most responsive to etretinate or acitretin as monotherapy

Generalized pustular psoriasis | Erythrodermic psoriasis

Dose of acitretin

Initial dose of 25 mg/day, with a maintenance dose of 20-50 mg/day

Inhibitor of PDE-4 which degrades cAMP intracellularly

Apremilast

Apremilast adverse effects

``` GI symptoms (diarrhea, nausea, headaches) Worsening of depression ```

Oral Janus kinase inhibitor that has a role in downstream signaling of multiple proinflammatory cytokines

Tofacitinib

Tofacitinib is only approved for

Rheumatoid arthritis

Tofacitinib adverse effects

Changes in hemoglobin Leukopenias Lipid abnormalities Increased incidences of viral infections, particularly herpes zoster

Neutral cyclic undecapeptide derived from the fungus Tolypocladium inflatum gams

Cyclosporin A

Y/N: Nephrotoxic effects of cyclosporine A are largely irreversible.

Yes

Most common adverse effects in patients using cylosporin A for short periods of time

Neurologic - tremors, headache, paresthesia, hyperesthesia

Y/N: Fumaric acid is poorly absorbed after oral intake.

Yes - Esters are used for treatment are almost completely absorbed in the small intestines

Systemic steroids may have a role in the management of

Persistent, otherwise uncontrollable, erythroderma and fulminant generalized pustular psoriasis if other drugs are ineffective

Inhibitor of inosine-5’-monophosphate dehydrogenase

Mycophenelate mofetil

Purine analog that has been highly effective for psoriasis

6-thioguanine

Antimetabolite that has been shown to be effective as monotherapy for psoriasis

Hydroxyurea

Most troublesome cutaneous reaction to hydroxyurea

Leg ulcers

Three types of biologics for psoriasis

1. Recombinant human cytokines 2. Fusion proteins 3. Monoclonal autoantibodies- fully humanized, humanized or chimeric

TNF-alpha antagonists

``` Infliximab Etanercept Adalimumab Golimumab Certolizumab pegol ```

Chimeric monoclonal antibody that has high specificity, affinity, and avidity for TNF-alpha

Infliximab

Human recombinant, soluble, TNF-alpha receptor-Fc IgG fusion protein

Etanercept

Fully human recombinant IgG1 monoclonal antibodies and specifically targets TNF-alpha

Adalimumab | Golimumab

Polyethylene glycol Fab’ fragment of a humanized TNF inhibitor monoclonal antibody

Certolizumab pegol

Human monoclonal antibody that binds the shared p40 subunit of IL-12 and IL-23

Ustekinumab

Interleukin-17A antagonists

Secukinumab Ixekizumab Brodalumab

Fully human antibody that binds and neutralizes IL-17A

Secukinumab

Humanized antibody that binds and neutralizes IL-17A

Ixekizumab

Fully human antibody targeting the IL-17 receptor alpha chain

Brodalumab