28: Psoriasis Flashcards
What is the significance of HLA-Cw6 in the epidemiology of psoriasis?
HLA-Cw6 is associated with an earlier age of onset of psoriasis and is linked to a positive family history. It is particularly relevant in Type I psoriasis, which occurs in individuals with an age of onset <40 years.
What are the characteristics of Psoriasis vulgaris?
Psoriasis vulgaris is the most common form of psoriasis, affecting 90% of patients. It is characterized by red plaques with a white scaly surface and can exhibit the Auspitz sign.
What is the Koebner phenomenon in relation to psoriasis?
The Koebner phenomenon refers to the traumatic induction of psoriasis on nonlesional skin, typically occurring 7-14 days after injury.
What are the main features of erythrodermic psoriasis?
Erythrodermic psoriasis is characterized by erythema as the most prominent feature, with superficial scaling. It can lead to hypothermia and lower extremity edema.
What are the complications associated with generalized pustular psoriasis (von Zumbusch)?
Complications include fever, hypocalcemia, bacterial superinfection, sepsis, and dehydration.
What distinguishes inverse psoriasis from other types of psoriasis?
Inverse psoriasis is distinguished by its localization in major skin folds, where scaling is minimal or absent.
What is the typical age of onset for pustulosis palmaris et plantaris, and what are its associations?
Pustulosis palmaris et plantaris typically has an age of onset around 47 years and is more common in females. It is associated with psoriatic arthritis and smoking.
What are the characteristics of napkin psoriasis?
Napkin psoriasis typically appears in infants aged 3-6 months, manifesting as a confluent red area in the diaper region.
What is the clinical significance of the Woronoff ring in psoriasis?
The Woronoff ring is a hypopigmented ring that surrounds individual psoriatic lesions, indicating inhibition of prostaglandin synthesis.
A patient with a history of streptococcal throat infection develops small papules on their upper trunk. What type of psoriasis is most likely?
Guttate psoriasis, which is strongly associated with HLA-Cw6 and streptococcal throat infection.
A patient presents with thickly scaling, large plaques on their lower extremities. What subtype of psoriasis might this be?
Elephantine psoriasis, characterized by thickly scaling, large plaques on the lower extremities.
A pregnant woman in her third trimester develops pustules on a ring-like erythema. What condition might this indicate?
Impetigo herpetiformis, a form of pustular psoriasis associated with pregnancy.
A 47-year-old female smoker presents with pustules on her palms and soles. What type of psoriasis is this likely to be?
Pustulosis palmaris et plantaris, which is more common in females and associated with smoking.
A patient presents with erythematous plaques and greasy scales localized to seborrheic areas. What is the likely diagnosis?
Sebopsoriasis, characterized by erythematous plaques with greasy scales in seborrheic areas.
A 6-month-old infant presents with confluent red areas in the diaper region and small red papules on the trunk. What is the likely diagnosis?
Napkin psoriasis, which typically appears in the diaper area.
A patient with psoriasis is experiencing hypothermia and lower extremity edema. What type of psoriasis might this indicate?
Erythrodermic psoriasis, which can cause hypothermia and lower extremity edema.
A patient with psoriasis develops pustules that coalesce to form lakes of pus and experiences nail loss. What condition is this?
Acrodermatitis continua of Hallopeau, a form of pustular psoriasis.
What is the Koebner phenomenon, and how is it related to psoriasis?
The Koebner phenomenon is the traumatic induction of psoriasis on nonlesional skin, usually occurring 7-14 days after injury.
A patient with psoriasis is found to have hypocalcemia and bacterial superinfection. What type of psoriasis might this be?
Generalized pustular psoriasis (von Zumbusch), which can lead to hypocalcemia and bacterial superinfection.
What is the Woronoff ring, and in which condition is it observed?
The Woronoff ring is a hypopigmented ring surrounding psoriatic lesions.
A patient with psoriasis develops widespread pustules after a viral infection. What type of pustular psoriasis is this?
Exanthematic pustular psoriasis, which occurs after a viral infection.
What is the primary environmental factor that interacts with genetic predisposition in psoriasis?
UV light exposure is a major environmental factor interacting with genetic predisposition in psoriasis.
A patient with psoriasis has erythematous plaques localized to the axillae and genitocrural region. What type of psoriasis is this?
Inverse psoriasis, characterized by glossy, sharply demarcated erythema in major skin folds.
What is the difference between Type I and Type II psoriasis based on age of onset?
Type I psoriasis has an onset before 40 years and is HLA-associated, while Type II occurs after 40 years.
A patient with psoriasis develops annular pustular lesions. What is the characteristic appearance of these lesions?
Annular pustular psoriasis presents with pustules on a ring-like erythema resembling erythema annulare centrifugum.
What is the significance of HLA-Cw6 in psoriasis?
HLA-Cw6 is associated with an earlier age of onset and a positive family history of psoriasis.
A patient with psoriasis has erythema as the most prominent feature and superficial scaling. What type of psoriasis is this?
Erythrodermic psoriasis, characterized by prominent erythema and superficial scaling.
What are the common triggers for generalized pustular psoriasis (von Zumbusch)?
Triggers include infections, irritating topical treatments, and withdrawal of oral steroids.
A patient with psoriasis develops pustules on their palms and soles. What type of psoriasis is this?
Pustulosis palmaris et plantaris, which is more common in females and associated with smoking.
What are the common nail changes associated with psoriasis?
- Nail pitting: Defective keratinization in proximal nail matrix.
- Onychodystrophy: Stronger association with PsA than other changes.
- Oil spots & salmon patches: Translucent, yellow-red discolorations under the nail plate.
- Oil spotting: Nearly specific for psoriasis.
- Splinter hemorrhage: From capillary bleeding underneath the thin suprapapillary plate.
- Subungual hyperkeratosis: Hyperkeratosis of the nail bed.
- Onycholysis: Separation of the nail plate from the nail bed.
- Anonychia: Total loss of the nail plate.
What are the noncutaneous findings associated with psoriasis?
- Geographic tongue: Benign migratory glossitis with erythematous patches.
- Histology: Acanthosis, clubbing of the rete ridges, focal parakeratosis, neutrophilic infiltrate.
- Psoriatic arthritis: Seen in up to 40% of patients.
What complications are associated with psoriasis?
- Cardiovascular: Increased risk of myocardial infarction, metabolic syndrome, hypertension, hyperlipidemia.
- Increased risk for: Rheumatoid arthritis, Crohn’s disease, ulcerative colitis, Hodgkin’s lymphoma, CTCL.
- Psychological: Depression and suicidal ideation.
What are the key factors in the etiology of psoriasis?
- Polygenic predisposition combined with environmental triggers.
- Genetic signal: HLA-C*0602, which encodes HLA-Cw6 protein.
- Other risk factors: Obesity, smoking, infections.
- Medications that can exacerbate psoriasis include: Antimalarials, Beta blockers, Lithium, NSAIDs, IFN-a and -y, Imiquimod, ACE inhibitors, Gemfibrozil.
What is the role of IFN-γ in psoriatic lesions?
Psoriatic lesions are rich in IFN-γ, indicative of Th1 polarization of CD4 cells and Tc1 polarization of CD8 cells.
A patient presents with nail pitting and oil spots under the nail plate. What condition is this indicative of?
Psoriatic nail changes, specifically nail pitting and oil spots.
A patient with psoriasis develops erythematous patches on their tongue resembling a map. What is this condition called?
Geographic tongue (benign migratory glossitis), which is associated with psoriasis.
A patient with psoriasis is at increased risk for which cardiovascular complications?
Increased risk of myocardial infarction, metabolic syndrome, hypertension, and hyperlipidemia.
What genetic marker is strongly associated with psoriasis?
HLA-C*0602, which encodes the HLA-Cw6 protein.
Which medications are known to exacerbate psoriasis?
Antimalarials, beta blockers, lithium, NSAIDs, IFN-α and -γ, imiquimod, ACE inhibitors, and gemfibrozil.
A patient with psoriasis has translucent, yellow-red discolorations under their nail plate. What is this feature called?
Oil spots or salmon patches, caused by psoriasiform hyperplasia.
What are the systemic complications associated with psoriasis?
Cardiovascular risks, increased risk for RA, Crohn’s disease, ulcerative colitis, Hodgkin’s lymphoma, and CTCL.
A patient with psoriasis has erythematous patches on their tongue with serpiginous borders. What is the histological finding?
Histology shows acanthosis, clubbing of the rete ridges, focal parakeratosis, and neutrophilic infiltrate.
A patient with psoriasis is found to have splinter hemorrhages under their nails. What causes this feature?
Splinter hemorrhages result from capillary bleeding underneath the thin suprapapillary plate.
What are the psychological complications associated with psoriasis?
Psychological complications include depression and suicidal ideation.
What is the role of imiquimod in exacerbating psoriasis?
Imiquimod acts on plasmacytoid dendritic cells and stimulates IFN-α production.
What precautions should be taken when treating women of childbearing potential and during pregnancy for psoriasis?
Special caution is needed when treating women of childbearing potential and during pregnancy. Medications such as methotrexate and oral retinoids should be avoided.
A woman of childbearing potential with psoriasis is considering treatment. Why should methotrexate and oral retinoids be avoided?
Methotrexate is fetotoxic and an abortifacient, while retinoids are potent teratotoxins.
What is the first-line treatment for psoriasis during pregnancy?
Emollients and other topical agents, often in association with ultraviolet B phototherapy.
Which biologic agents are considered safe for use during pregnancy in psoriasis patients?
Several biologic agents are Pregnancy Category B and can be used during pregnancy.
What is the recommended treatment for psoriasis in pregnant women who require systemic therapy?
Cyclosporin A may be considered as it is Pregnancy Category C and nonteratogenic.
What are the dosing recommendations for Narrowband UVB (NB-UVB) therapy in psoriasis?
- Initial treatment at 50% of MED followed by three to five treatments weekly.
- Treatments 1-20: increase by 10% of initial MED.
- Treatments 21+: increase as ordered by physician.
How does the efficacy of Broad Band UVB (BB-UVB) compare to Narrowband UVB (NB-UVB)?
- BB-UVB shows a 47% improvement after 4 weeks.
- NB-UVB is more effective than BB-UVB, with >70% improvement.
What are the safety concerns associated with Psoralen and UVA Light (PUVA) therapy?
- Increased risk of skin aging, melanoma, and nonmelanoma skin cancers.
What are the contraindications for using Excimer Laser (308 NM) in psoriasis treatment?
- Absolute: light-sensitizing disorders, lactation, melanoma.
What are the remarks regarding the effectiveness of Narrowband UVB therapy?
- Effective as a monotherapy, but coal tar or systemic therapies may increase effectiveness in resistant cases.
Psoriatic arthritis occurs in _____% of patients; pustular and erythrodermic forms may be associated with fever.
10% to 25%
The prevalence of psoriasis is _____ in
Asians.
lower
Gender predilection of psoriasis?
Equally common in males and females.
Psoriasis may begin at any age, but it is uncommon before the age of ___ years. It is most likely to appear between the ages of _____ years.
10
15 and 30
Possession of certain human leukocyte antigen (HLA) class I antigens, particularly _____, is associated with an
earlier age of onset and with a positive family history.
HLA-Cw6
Henseler and Christophers propose that two different forms of psoriasis exist: type I, with age of onset before ___ years and HLA associated,
and type II, with older age of onset.
40
The classic lesion of psoriasis is a _____.
well-demarcated, raised, red plaque with a white scaly surface
Under the scale, the skin has a glossy homogeneous erythema, and bleeding points appear when the scale is removed, traumatizing the dilated capillaries below (the _____ sign).
Auspitz
The _____ phenomenon (also known as the _____ response) is the traumatic induction of psoriasis on nonlesional skin; it occurs more frequently during flares of disease and is an all-or-none phenomenon (ie, if psoriasis occurs at one site of injury, it will occur at all sites of injury). It usually occurs _____ after injury, and from _____% of patients may develop trauma-related Koebner phenomenon at some point during their disease.
Koebner
isomorphic
7 to 14 days
25% to 75%
Occasionally, there is partial cen-
tral clearing, resulting in ringlike lesions. This is called: _____. This is usually associated with lesional clearing and portends a good prognosis.
annular psoriasis
_____ is the most common form of psoriasis, seen in approximately 90% of patients.
Psoriasis vulgaris
Lesions may extend laterally and become circinate because of the confluence of several plaques. This is called: _____.
psoriasis gyrata
_____ refers to lesions in the shape of a cone or limpet.
Rupioid psoriasis
_____, an infrequently used term, refers to a ring-like, hyperkeratotic concave lesion, resembling an oyster shell.
Ostraceous psoriasis
_____ is an uncommon
form characterized by thickly scaling, large plaques, usually on the lower extremities.
Elephantine psoriasis
A hypopigmented ring called _____ surrounding individual psoriatic lesions may occasionally be seen and is usually associated with treatment, most commonly _____ or _____. The pathogenesis is not well understood but may result from inhibition of _____ synthesis.
Woronoff ring
UV radiation
topical corticosteroids
prostaglandin
_____ is characterized by eruption of small (0.5–1.5 cm in diameter) papules over the upper trunk and proximal extremities, typically manifesting at an early age, frequently in young adults.
Guttate psoriasis
This form of psoriasis has the strongest association to HLA-Cw6, and _____ frequently precedes or is concomitant with the onset or flare.
Guttate psoriasis
streptococcal throat infection
T or F: Antibiotic treatment has been shown to be beneficial or to shorten
the disease course of guttate psoriasis.
False. Antibiotic treatment has NOT been shown to be beneficial or to shorten the disease course.
_____ resembles guttate psoriasis clinically but can be distinguished by its onset in older patients, by its chronicity, and by having somewhat larger lesions (typically 1–2 cm) that are thicker and scalier than in guttate disease. It is said to be a common adult-onset presentation of psoriasis in ______.
Small plaque psoriasis
Korea and other Asian countries
_____ may be localized in the major skin folds, such as the axillae, the genitocrural region, and the neck. Scaling is usually minimal or absent, and the lesions show a glossy sharply demarcated erythema, which is often localized to areas of skin- to-skin contact. _____ is impaired in affected areas.
Inverse psoriasis
Sweating
In erythrodermic psoriasis, _____ is the most prominent feature. Patients lose excessive heat because of generalized vasodilatation, and this may cause hypothermia. Patients may shiver in an attempt to raise their body temperature. Psoriatic skin is often _____ because of occlusion of the sweat ducts, and there is
an attendant risk of hyperthermia in warm climates.
_____ is common secondary to vasodilation and loss of protein from the blood vessels into the tissues. _____ and impaired hepatic and renal function may also occur.
erythroderma
hypohidrotic
Lower extremity edema
High-output cardiac failure
What are the 2 types of erythrodermic psoriasis? Which is relatively responsive to therapy?
- worsening of chronic plaque type psoriasis (remain responsive to therapy)
- sudden, generalized erythroderma or generalized koebner reaction from non-tolerated external treatment
Clinical variants of pustular psoriasis (5)?
- generalized pustular psoriasis (von Zumbusch type)
- annular pustular psoriasis
- impetigo herpetiformis
two variants of localized pustular psoriasis—
4. pustulosis palmaris et plantaris
5. acrodermatitis continua of Hallopeau.
This is a distinctive acute variant of psoriasis that is usually preceded by other forms of the disease. Attacks are characterized by fever that lasts several days and a sudden generalized eruption of sterile pustules 2 to 3 mm in diameter. The pustules are disseminated over the trunk and extremities, including the nail beds, palms, and soles. With prolonged disease, the fingertips may become atrophic. The erythema that surrounds the pustules often spreads and becomes confluent, leading to erythroderma. Characteristically, the disease occurs in waves of fevers and pustules.
generalized pustular psoriasis (von Zumbusch type)
Provoking agents of GPP?
infections
irritating topical treatment (Koebner phenomenon) withdrawal of oral corticosteroids
Life threatening complications of GPP?
hypocalcemia
bacterial superinfection
sepsis
dehydration
_____ tends to occur after a viral infection and consists of widespread pustules with generalized plaque psoriasis. However, unlike the von Zumbusch pattern, there are no constitutional symptoms, and the disorder tends not to recur.
Exanthematic Pustular Psoriasis
There is an overlap between this form of pustular psoriasis and acute generalized exanthematous pustulosis, a type of drug eruption.
Exanthematic Pustular Psoriasis
_____ is a rare variant of pustular psoriasis. The characteristic features are pustules on a ringlike erythema that sometimes resembles _____. Identical lesions are found in patients with _____, an entity
defined by some as a variant of pustular psoriasis
occurring in pregnancy. Onset in pregnancy is usually
_____ and persists until delivery. It tends to develop earlier in subsequent pregnancies. Impetigo herpetiformis is often associated with _____. There is usually no personal or family history of psoriasis.
Annular pustular psoriasis
erythema annulare centrifugum
impetigo herpetiformis
early in the third trimester
hypocalcemia
_____ is a rare variant of pustular psoriasis that is localized to the palms and soles. It may coexist with chronic plaque psoriasis with approximately _____% of patients having concomitant chronic plaque psoriasis.
Palmoplantar pustular psoriasis (PPPP)
27%
Pustulosis palmaris et plantaris is
more common in _____ (about 78%) with a median
age of onset of _____ years.
females
47
_____ can be seen with pustulosis palmaris et plantaris, with a prevalence of 13% to 25%. _____ is strongly associated with pustulosis palmaris et plantaris, and about 80% of patients are _____ at the time of presentation.
Psoriatic arthritis (PsA)
Smoking
tobacco smokers
_____, also known as _____, is an extremely rare localized sterile pustular eruption of the fingers and toes. It typically involves the distal portions of the fingers and toes and may occur after minor trauma or infection.
Acrodermatitis continua of Hallopeau
dermatitis repens
Pustules in acrodermatitis continua of Hallopeau often coalesce to form lakes of pus and nail loss is common. Over time, _____ and _____ may occur. Similar to pustulosis palmaris et plantaris, it is more common in _____.
sclerosis of the underlying soft tissues
osteolysis of the distal phalanges
middle-aged women
T or F: Sebopsoriasis may represent a modification
of seborrheic dermatitis by the genetic background
of psoriasis and is relatively responsive to treatment.
It is relatively RESISTANT to treatment.
T or F: Although an etiologic role of Pityrosporum remains unproven, antifungal agents may be useful in sebopsoriasis.
True.
Napkin psoriasis usually begins between the ages of _____.
3 and 6 months
This kind of psoriasis first appears in the diaper
areas as a confluent red area with the appearance a few days later of small red papules on the trunk that may also involve the limbs. These papules have the typical white scales of psoriasis. The face may also be involved with red scaly eruption.
Napkin psoriasis
Napkin psoriasis responds readily to treatment and tends to disappear after the age of _____.
1 year
The existence of a linear form of psoriasis distinct from _____ is controversial.
ILVEN
Nail changes are frequent in psoriasis, being found in up to _____% of patients, and are rare in the absence of
skin disease elsewhere.
40%
_____ is one of the commonest features of psoriasis, involving the fingers more often than the toes, ranging from 0.5 to 2.0 mm in size and can be single or multiple.
Nail pitting
The _____ forms the dorsal (superficial) portion of the nail plate, and psoriatic involvement of this region results in pitting caused by defective keratinization.
proximal nail matrix
What clinical signs are seen if the PROXIMAL MATRIX is involved in nail psoriasis?
BOP
Beau’s lines
Onychorrhexis
Pitting
What clinical signs are seen if the INTERMEDIATE MATRIX is involved in nail psoriasis?
Leukonychia
What clinical signs are seen if the DISTAL MATRIX is involved in nail psoriasis?
FET
Focal onycholysis
Erythema of the lunula
Thinned nail plate
What clinical signs are seen if the NAIL BED is involved in nail psoriasis?
SOSO
Subungual hyperkeratosis
Onycholysis
Splinter hemorrhages
Oil drop sign / Salmon patch
What clinical signs are seen if the HYPONYCHIUM is involved in nail psoriasis?
SO
Subungual hyperkeratosis
Onycholysis
What clinical signs are seen if the NAIL PLATE is involved in nail psoriasis?
CD
Crumbling and Destruction + other changes
What clinical signs are seen if the PROXIMAL & LATERAL NAIL FOLDS are involved in nail psoriasis?
Cutaneous psoriasis
Nail change with stronger association with PsA?
Onychodystrophy
Nail changes nearly specific for psoriasis?
Oil spots / Salmon patches
_____ are translucent, yellow-red discolorations observed beneath the nail plate often extending distally toward the hyponychium caused by psoriasiform hyperplasia, parakeratosis, microvascular changes, and trapping of neutrophils in the nail bed.
Oil spots and salmon patches
_____, also known as _____ or _____, is an idiopathic
inflammatory disorder resulting in the local loss of filiform papillae. The condition usually presents as
asymptomatic erythematous patches with serpiginous
borders, resembling a map. These lesions characteristically have a migratory nature. It has been postulated to be an oral variant of psoriasis.
Geographic tongue
benign migratory glossitis
glossitis areata migrans
Arthritis is a common extracutaneous manifestation of
psoriasis seen in up to _____% of patients. It has a strong genetic component.
40%
Risk of _____ is particularly elevated in younger patients with severe psoriasis.
myocardial infarction
T or F: Vascular inflammation as detected by PET/CT correlates directly with the extent of cutaneous involvement.
True.
Patients with psoriasis have been shown to be at increased risk for (8)?
Metabolic syndrome
Hypertension
Hyperlipidemia
Rheumatoid arthritis
Crohn’s disease
Ulcerative colitis
Hodgkin’s lymphoma
Cutaneous T-cell lymphoma
Psychological disease associations of psoriasis (3)?
Depression
Anxiety
Suicidal ideation
In a fully developed lesion in psoriasis, neutrophils exit from the tips of a subset of dermal capillaries (the “_____”), leading to their accumulation in the
overlying parakeratotic stratum corneum (_____) and, less frequently, in the spinous layer (_____).
squirting papillae
Munro’s microabscesses
spongiform pustules of Kogoj
Epidermal T cells, particularly _____ cells, appear to have a critical role in development of psoriatic plaques as either blocking the entry of these cells into the epidermis or neutralization of these cells prevents development of psoriasis in a xenograft model.
CD8+
The cytokine profile of psoriatic lesions is rich in
_____, indicative of _____ polarization of CD4+ cells, and _____ polarization of CD8+ cells.
interferon (IFN)-γ
T helper 1 (Th1)
T cytotoxic 1 (Tc1)
Two other subsets of _____ cells, stimulated by interleukin _____ and characterized by production of _____ or _____, have been shown to play a major role in maintaining chronic inflammation in psoriasis.
CD4+ T
IL-23
IL-17 (Th17, ∼20% of T cells), IL-22 (Th22, ∼15% of T cells)
_____ suppress immune responses in an antigen-specific fashion and are responsible not only for downregulating successful responses to pathogens but also for the maintenance of immunologic tolerance. The best characterized one is the CD4+ CD25+ subset
Regulatory T cells (Tregs)
_____ have a role in both the priming of adaptive immune responses and the induction of self-tolerance.
Dendritic cells
_____ cytokines are strong activators of keratinocytes, leading to secretion of chemotactic proteins, particularly neutrophil chemokines, thereby amplifying and sustaining the inflammatory process.
IL-36
_____ are a major producer of proinflammatory cytokines, chemokines, and growth factors, as well
as other inflammatory mediators such as eicosanoids
and mediators of innate immunity such as cathelicidins,
defensins, and S100 proteins. They are engaged in an alternative pathway of keratinocyte differentiation called _____.
Keratinocytes
regenerative maturation
The major genetic signal for psoriasis in the MHC is
_____, which encodes HLA-Cw6 protein. HLA-Cw6 presents antigens to ______, which are
MHC class I restricted and comprise about _____% of the
T cells in the epidermis of psoriatic lesions
HLAC∗0602
CD8+ T cells
80%
CD8+ T cells selectively traffic to the epidermis
because they express _____, which binds to Type IV basement membrane collagen as well as _____, which binds to keratinocyte E-cadherin.
integrin α1β1
integrin αEβ7
This melanocyte antigen is of genetic interest because it is presented specifically by HLA-Cw6.
ADAMTSL5
_____ T cells predominate in the dermis of psoriasis lesions and are also clonally expanded in psoriasis.
CD4+
_____ signaling promotes the survival and expansion of _____ T-cells, which protect epithelia against microbial pathogens.
IL-23
IL-17–expressing
Ankylosing spondylitis (AS) is another HLA class I–associated autoimmune disorder that is clinically associated with inflammatory bowel disease and genetically associated with _____.
IL23R
PsA is genetically associated with ___, ___ and ___.
IL12B
IL23A
IL23R
_____ is associated with cutaneous psoriasis but not with PsA.
LCE3B/3C indel
Several genes implicated in the pathogenesis of _____ or _____ are primarily expressed in the epidermis, including IL36RN, AP1S3, and CARD14.
generalized or PPPP
T or F: Obese individuals are more likely to present with severe psoriasis. However, obesity does not appear to have a role in defining the onset of psoriasis.
True
Heavy smoking ( ___ cigarettes daily) has been associated with more than a twofold increased risk of severe psoriasis. Smoking appears to have a
role in the _____ of psoriasis.
> 20
onset
An association between _____ infection and guttate psoriasis has been repeatedly confirmed. It has also been demonstrated to exacerbate preexisting chronic plaque psoriasis, and _____ has been shown to lead to long-term improvement in psoriasis, particularly in _____ carriers.
streptococcal throat
tonsillectomy
HLA-Cw6
Severe exacerbation of psoriasis can be a manifestation of _____ infection. This infection is not a trigger for psoriasis but rather a modifying agent.
HIV
T or F: Psoriasis is increasingly more severe with progression of immunodeficiency but can remit in the terminal phase.
True. This paradoxical exacerbation of psoriasis may be caused by loss of Tregs and increased activity of the CD8 T-cell subset. Psoriasis exacerbation in HIV disease may be effectively treated with antiretroviral therapy.
Other than strep throat and HIV infection what other infection is associated with psoriasis?
Hepatitis C infection
Medications that exacerbate psoriasis?
- antimalarials
- β blockers (interfere with intracellular cyclic adenosine monophosphate)
- lithium (interfering with calcium release
within keratinocytes) - nonsteroidal antiinflammatory drugs (NSAIDs)
- IFNs-α and -γ
- imiquimod (stimulates IFN-α)
- angiotensin-converting enzyme inhibitors
- gemfibrozil
In _____, _____ , and _____, a negative nitrogen
balance can be detected, manifested by a decrease
of serum albumin.
severe psoriasis vulgaris
generalized pustular psoriasis
erythroderma
The serum _____ is elevated in up to 50% of patients and is mainly correlated with the extent of lesions and the activity of disease.
uric acid
There is an increased risk of developing gouty arthritis. Serum uric acid levels usually normalize after therapy.
Patients with psoriasis manifest altered _____, even at the onset of their skin disease.
lipid profiles
Increased serum immunoglobulin (Ig) A levels and IgA immune complexes, as well as secondary amyloidosis, have also been observed in psoriasis, and the latter carries a _____ prognosis.
poor
It is useful to determine the age at onset and the presence or absence of a family history of psoriasis
because a _____ age of onset and _____ family history have been associated with more widespread and recurrent disease.
younger
positive
T or F: The frequently relapsing patients tend to develop more severe disease with rapidly enlarging lesions covering significant portions of the body surface.
True
A history of onset of joint symptoms before the _____ decade or a history of warm, swollen joints should raise the suspicion of PsA.
fourth
Guttate psoriasis is often a self-limited disease, lasting from _____ without treatment. One third to two thirds of
these patients later develop the _____ plaque type of psoriasis, which is lifelong.
12 to 16 weeks
chronic
Spontaneous remissions, lasting for variable periods of time (1 year to several decades), may occur in the course of psoriasis in up to _____% of patients.
50%
_____ and _____ have a poorer prognosis, with the disease tending to be severe and persistent.
Erythrodermic
generalized pustular psoriasis
Mechanism of action of topical steroids?
Mechanism of action of vitamin D analogues?
Mechanism of action of tazarotene?
What topical medication?
Calcineurin inhibitors
Dosing of topical steroids?
Dosing of vit D analogues?
Dosing of tazarotene?
Dosing of calcineurin inhibitors?
What topical medication?
Calcineurin inhibitors
What topical medication?
Calcineurin inhibitors
What topical medication?
Vitamin D analogues
What topical medication?
Calcineurin inhibitors
What topical medication is contraindicated in pregnancy?
Tazarotene
T or F: Combination of steroid with tazarotene may reduce atrophy seen with superpotent topical steroids.
True.
T or F: If tazarotene is added during phototherapy, the UV doses should be reduced by _____.
one-third
Pregnancy category of topical medications for psoriasis?
All C excpet for tazarotene (X).
Psoriasis medications that are pregnancy category B?
Sulfasalazine
Biologics
Psoriasis medications that are pregnancy category C?
Mycophenolate mofetil
Cyclosporine
Fumaric acid esters
Psoriasis medications that are pregnancy category X?
Tazarotene
Methotrexate
Acitretin
Psoriasis medications that are pregnancy category D?
Hydroxyurea
6-Thioguanine
What systemic medication?
Cyclosporin A
What systemic medication?
Methotrexate
What systemic medication?
Acitretin
What systemic medication?
Fumaric acid esters
What systemic medication?
Hydroxyurea
What systemic medication?
6-thioguanine
What systemic medication?
Mycophenolate mofetil
What systemic medication?
Sulfasalazine
Absolute contraindication of acitretin?
Pregnancy during or within 3 years after termination of acitretin
Breastfeeding
When to do liver biopsy for methotrexate?
every 1.5 g (high risk)
every 3.5-4 g (low risk)
What systemic medication?
Cyclosporin A
What systemic medication?
Methotrexate
What systemic medication?
Acitretin
What systemic medication?
Fumaric acid esters
What systemic medication?
Hydroxyurea
What systemic medication?
6-thioguanine
What systemic medication?
Mycophenolate mofetil
What systemic medication?
Sulfasalazine
What biologic medication?
Aprimelast
What biologic medication?
Tofacitinib
What biologic medication?
Ustekinumab
What biologic medication?
Etanercept
What biologic medication?
Infliximab
What biologic medication?
Adalimumab
What biologic medication?
Secukinumab
What biologic medication?
Ixekizumab
Treatment considerations for women with childbearing potential / pregnant?
