2_Papulosquamous Disorders Flashcards
define: papulosquamous disorders
- inflammatory reactions characterized by a red/purple papule and/or plaques with scale
what are examples of papulosquamous lesions
- psoriasis,
- pityriasis rubra pilaris,
- pityriasis rosea,
- lichen planus
what disorder is a “red plaque with silvery scales”
psoriasis
psoriasis epidemiology facts:
- is a chronic multisystem disease
- doesn’t affect just skin – it’s inflammation of the whole body
- 10-30% will develop psoriatic arthritis,
- affects 2-3% of world’s population,
- affects 7 million Americans, costs $3 billion/year,
- most will miss 1-3 days/month from work,
- 48% are embarrassed
psoriasis: define
very common, dynamic, genetic, immunological multi-systemic disorder that manifests itself on the body’s surface as well as in the joints
compare type I and type II psoriasis
-
Type I early onset** – peak at **age 20-30**, **HLA-Cw6** definite, **refractory and severe
- 30% of patients have a 1st degree relative with disease
- Type II late onset** – peak at **age 50-60**, **rare genetic link**, **milder form
- Basically, a genetic predisposition coupled with environment (trauma, infections, medications) can trigger psoriasis
what are the 5 possible morphology classifications for PSORIASIS?
- Erythrodermic
- Inverse/ flexural
- Guttate
- Plaque
- Pustular
which psoriasis form:
scaly, erythematous patches, papules and plaques that are often pruritic
PLAQUE psoriasis
which psoriasis form:
“tear drop” lesions, 1-10mm salmon pink papules with fine scale
GUTTATE psoriasis
which psoriasis form:
palmoplantar version and generalized – w/ pustules present
PUSTULAR psoriasis
which psoriasis form:
located in skin folds (elbow, breast, under belly, groin)
INVERSE/FLEXURAL psoriasis
which psoriasis form:
generalized erythema covering most of the body with scaling
ERYTHRODERMIC psoriasis;
uncommon, aggressive, inflammatory form of psoriasis. Symptoms include a peeling rash across the entire surface of the body. The rash can itch or burn intensely, and it spreads quickly.
which morphologies are associated w/ PALMOPLANTAR PSORIASIS?
what can it be confused with?
- can be plaque or pustular, often disabling to patient
- Skin lesions of reactive (AKA Reiter’s) arthritis typically occur on palms and soles and are indistinguishable from this type of psoriasis
if pt has palmoplantar psoriasis, what should you evaluate the digits for?
- Look at digits for dactylitis and look at nails for signs of psoriatic nail disease – always think of psoriatic arthritis occurring
- Dactylitis: swelling of digit, sausage digit
define: enthesitis
ligament/tendon goes into bone and inflammation occurs there
describe the basic psoriatic histology:
- acanthosis with elongated rete ridges,
- parakeratosis,
- hyperkeratosis,
- dilated blood vessels (gives it red color),
- neutrophil aggregates in epidermis
define: acanthosis
epidermal hyperplasia
define parakeratosis, and hyperkeratosis
- Parakeratosis – retention of nuclei in epidermis
- Hyperkeratosis – thickening of corneum
define: Auspitz sign
- bleeding when scratching plaque
- assoc w/ psoriasis
how to determine severity of psoriasis?
- psoriasis surface area
- Mild psoriasis affects < 3% of body, 3-10% is moderate, > 10% is severe
- Palm of the hand = 1% of skin
- how much it affects quality of life
- psoriasis can have a serious impact even if it involves a small area (such as palms/soles)
what are some important questions to consider with a diagnosis of psoriasis?
- ask about meds, history of chickenpox, arthritis, which joints affected, first time occurrence or not, recent infections
- ASK! – can be triggered by infections, worse in HIV positive patients, increased BMI correlation, metabolic syndrome, systemic corticosteroid withdrawal, genetic predisposition, smokers, alcohol use/abuse
define: metabolic syndrome
low level inflammation in body that will affect all systems of body, can affect endocrine system/blood vessels/GI system
for a physical exam on this patient, where should you look?
- Scalp, ears, elbows, knees, umbilicus, gluteal cleft, nails, sites of recent trauma
- HANDS if also on FEET**! – **high probability of being psoriasis if present on soles and palms
which is the most common type of psoriasis?
CHRONIC PLAQUE PSORIASIS
(80-90% of cases)
what are the hallmark signs of chronic plaque psoriasis?
- plaque with white-silvery scale on red base,
- Auspitz sign on vigorous rubbing,
- extensor surfaces and often symmetrical and bilateral,
- Koebner phenomenon at sites of trauma,
- may or may not itch,
- may relapse spontaneously or remain stable
define: koebner phenomenon
- when you scratch it or undergoes trauma,it may get worse;
- appearance of skin lesions on lines of trauma
- may result from either a linear exposure or irritation.
describe the normal pathology of a MILD PSORIASIS presentation?
- hyperproliferative state with hyperkeratotic skin and excess scale,
- cytokines gone wild
- bilateral and symmetrical
what is included in the differential diagnosis for psoriasis?
- tinea corporis,
- nummular eczema,
- Seborrheic dermatitis,
- drug eruption
- Secondary syphilis
how would you treat a case of NEW ONSET PSORIASIS?
Topical steroids –
**NEVER give systemic steroids as it can worsen symptoms
why treat psoriasis?
a patient with metabolic syndrome is at increased risk for:
- obesity,
- smoking,
- DM2,
- HTN,
- CV disease,
- increased CV mortality,
- alcohol misuse,
- depression
T/F:
Moderate-severe psoriasis is a systemic disease
TRUE;
Moderate-severe** psoriasis is a **SYSTEMIC disease
what is this diagnosis? what is seen?
HYPERKERATOTIC PALMAR-PLANTAR PSORIASIS;
- fissure, scale, plaque
- nails are also affected
What is the 1st line tx for MILD-MODERATE psoriasis?
what is the assoc risk?
- 3 things: topical steroid, vitamin D analog, and moisturizer
- se of topical steroids over time can result in tachyphylaxis and other side effects – so educate patient
- tachyphylaxis– stops working over time
- can inject steroid intralesionally into itchy plaques
what should you NEVER use to treat psoriasis?
ORAL or SYSTEMIC STEROIDS
what are the drug names and dosage for VITAMIN D ANALOG for psoriasis?
-
Vitamin D analogs** (steroid-sparing agents) **(*KNOW DRUGS FOR EXAM)
- Calcipotriene (Dovonex)** lotion/ointment/cream – vitamin D analog that is **equivalent to a mid-potency steroid use**; also **Calcitriol (Vectical)
- Limit to max dosage of 100 grams/week
what is thought to be the function of VITAMIN D ANALOG?
what can you alternate it with?
- Believed to have an effect on gene regulation
- Can alternate with Ultravate (topical steroid) therapy on a daily basis or on a weekend
What is the combination medication and benefit of Taclonex suspension and Enstilar foam?
- combo of Dovonex and Ultravate
- purpose: doesn’t deactivate itself
what is a second line tx for MILD-MODERATE psoriasis that DECREASE EPIDERMAL PROLIFERATION?
- Tazarotene (Tazorac) - a topical retinoid
- Avail in gel or cream, qd or bid
- can be used for nail involvement
- Irritating, so good in combo with topical steroid
what are the four older but still useful treatments for psoriasis?
what are the use in psoriasis and associated side effects of :
- topical steroids
- vitamin D analogs
why might a patient present with psoriasis but no redness?
- might not see redness; because the patient has used a lot of drugs that reduce redness;
- bilateral and symmetrical
what can be used to supplement topical tx for MODERATE-SEVERE PSORIASIS?
- Oral treatments for psoriasis (esp mod-severe plaque, pustular, erythrodermic, nail)
- Acitrecin (Soriatane**) aka oral retinoid, **severely teratogenic
- Methotrexate**– good **liver function is important; avoid pregnancy
- Cyclosporine (Neoral**) – oral med that can be used to reduce inflammation, good **kidney function is important, can only be on this med for 1 year
what is PUVA?
- UVA therapy following ingestion/topical use of PSORALEN for psoriasis;
- an adjunct therapy; can be used full body or foot/hand unit
- 20-25 sessions until clear w/ long term remission
- 5-10 min 2-3x per week
what do UVB and Sunlight adjunct therapies do for psoriasis patients?
what is the associated risks?
- UVB – traditional Goeckerman regimen and in combo with other topicals
- Sunlight – psoriatics usually improve in the summer
- Risk – skin cancer in those subject to high doses of PUVA
when would you consider biologics for psoriasis?
what are the biologics you might use?
If topicals are ineffective, or if patient failed the treatment
why is Raptiva (Efalizumab) therapy now off the market?
Causes “John Cunningham (JC)” virus to come out –> PML is a rapidly progressive infection of the central nervous system caused by JC virus that leads to death or severe disability/ Lou Gherig symptoms
what type of psoriasis might be appropriate for STELARA therapy?
Patient with GUTTATE psoriasis rxn –> cutting through would cause Koebnor phenomenon / make it worse
what type of patient can we NEVER give a biologic to?
CAN NEVER GIVE A BIOLOGIC TO A PATIENT WITH HX OF CANCER --
BECAUSE IT CAN REACTIVATE CANCER
Remicade (Infliximab) therapy:
use, mechanism
- For psoriatic arthritis, plaque, and nail disease
- Helpful for dactylitis and enthesopathy
- Inhibits activity of TNF-alpha
describe dosing for:
Remicade (Infliximab) therapy
- Baseline TB test,
- Then infusion of 5mg/kg at 0, 2, 6, and then every 8 weeks thereafter
TAKE HOME POINTS FOR PSORIASIS:
- Topical treatment alone is used when psoriasis is localized
- Moderate-severe disease requires systemic treatment, but many factors must be considered
- ORAL steroids should NEVER be used
- NEVER debride psoriasis
- It is a lifelong disease that can affect all aspect of a patient’s quality of life
what percentage of patients w/ psoriatic arthritis have nail changes?
in which psoriasis subtypes can nail changes occur?
-
Up to 90% of patients with psoriatic arthritis may have nail changes
- (50% fingernails, 35% toenails),
- can occur in all subtypes, pitting/onycholysis/subungual hyperkeratosis/trachyonychia
define: trachyonychia
means “rough nails”;
a disorder of the nail unit that most commonly presents with rough, longitudinally ridged nails (opaque trachyonychia) or less frequently, uniform, opalescent nails with pits (shiny trachyonychia).
Psoriatic arthritis
what is it? examples?
- psoriatic arthritis: arthritis in the presence of psoriasis,
- Enthesitis at Achilles tendon insertion, plantar fascial insertion at calcaneus, sausage digits
- Worst case – arthritis mutilans (not seen as often due to biologics)
is psoriatic arthritis related to severity of psoriasis?
- Psoriatic arthritis** –is **NOT related to severity of psoriasis
what is the worst case scenario of psoriatic arthritis?
arthritis mutilans (not seen as often due to biologics);
characterized by resorption of bones and the consequent collapse of soft tissue. When this affects the hands, it can cause a phenomenon sometimes referred to as ‘telescoping fingers.
possible etiologies of guttate psoriasis?
- Path
- often following strep throat infection** **(*KNOW FOR BOARDS) in children and young adults,
- can follow rapid discontinuation of systemic meds (steroids, methotrexate, cyclosporine)
- pts w/ plaque psoriasis may have guttate flare occasionally
*
how to differentiate guttate psoriasis and shingles?
guttate psoriasis looks like shingles but
shingles is usually unilateral
what is the presentation of guttate psoriasis?
what is included in differential diagnosis?
- acute onset of raindrop sized lesions on trunk/extremities,
- papular and inflammatory
- Ddx: pityriasis rosea, shingles
tx for guttate psoriasis?
- phototherapy (UBV),
- short case of Methotrexate,
- PUVA,
- antibiotics if strep infection present
what is the presentation of pustular psoriasis?
- superficial sterile pustules with fine desquamation, eventually become brown scaly spots that peel off, infection can flare,
- IMAGE shows koebner phenomenon); purple/brown spots are dried pustules;
- pustules can also dry up and peel off
what is most common cause of PUSTULAR PSORIASIS?
often triggered by corticosteroid (systemic) withdrawal, less stable form can be debilitating
what are the 2 types of pustular psoriasis?
- Acute – generalized** (von Zumbusch), can be **life-threatening
- Chronic – involving palms/soles
what are the possible treatments for PUSTULAR PSORIASIS?
- Strong topical steroid + occlusion + Dovonex or Tazorac first, but usually topical therapy will fail
- Phototherapy in combo with orals and topicals
- (Soriatane, Hydroxyurea) may be added because quality of life becomes an issue
- New biologics
define: Inverse psoriasis
involves intertriginous (where 2 skin areas but rub/touch one another) areas rather than extensor surfaces,
may involve scalp/nails,
may not have scale due to moistness of area but are red plaques,
can be macerated and secondarily infected with Candida
what can inverse psoriasis be mistaken for?
how do you differentiate?
inverse psoriasis can be mistaken for yeast infection;
- inverse psoriasis can be macerated and secondarily infected with Candida
- a yeast infection will NOT have scale
treatment for Inverse Psoriasis?
- Use non-fluorinated topical steroids or topical immunomodulators or anti-Candida therapy if needed
which type of psoriasis is severe but rare, and involves almost entire skin surface?
-
Erythrodermic psoriasis –
- severe but rare form, involves almost entire skin surface,
- plaques merge to form erythroderma and exfoliative dermatitis
what is the pathogenesis, assoc sxs
of ERYTHRODERMIC PSORIASIS?
- path: follows infections, inappropriate systemic steroid usage, burns during phototherapy
- sxs: patients have malaise, fever, chills
what is the possible sequelae of untreated
ERYTHRODERMIC PSORIASIS?
- Can result in cardiac and renal failure, sudden death due to hypothermia
tx for ERYTHRODERMIC PSORIASIS?
- hospitalization, AND
- methotrexate
- soriatane
- topicals
- avoid phototherapy until inflammation under control
what might be included in the differential for
ERYTHRODERMIC PSORIASIS?
- atopic eczema,
- CTCL- (cutaneous T cell lymphoma)
- PRP - (Pityriasis rubra pilaris)
- drug reaction
what must you consider if patient has psoriasis?
- They are NOT contagious – and if they don’t know that already, they should be informed of that
- They will have it forever, but it can be controlled
- If they are embarrassed, respect their requests
- Understand that this is a multifactorial disease and you might be the only doc in town who can help
systemic therapy is NOT appropriate;
Topical steroid, vitamin D analog, moisturizer
ask if she sees a dermatologist,
check palms,
DO NOT schedule for surgery
how to diagnose red scaly skin rashes?
Pityriasis rubra pilaris (PRP)
presentation
- rare with reddish orange lesions involving hair follicles, mildly pruritic;
- Rubra = red; pilaris = around hair follicle
- Affects palms/soles with a yellowish scale – well demarcated “PRP sandal”
- Islands of sparing – even when most of the body is red (erythrodermic)
what is classic onset for PRP (pityriasis rbura pilaris)?
- Most common is classic adult onset which begins at scalp and moves caudally
Pityriasis rosea:
typical patient age
self-limiting in young adults and kids (ages 10-35)
Pityriasis rosea:
presentation and course
-
Herald patch (misdiagnosed as ringworm) – 2-10cm patch anywhere on body
- THEN… salmon colored lesions erupt on trunk/arms/thighs – may appear lilac or violaceous in color in darker skin types
- “Christmas tree” appearance on back
- Peripheral collarette on lesions is scale that peels from inside towards the edge
- Disappears in 6-8 weeks, mild steroids for any irritation
which might be misdiagnosed as Pityriasis rosea?
- secondary syphilis
- Comes weeks later after painless chancre**, **may resemble with papulosquamous lesion (palms/soles involved)
- Get sexual history, VDRL or RPR
- History – painless chancre, fevers, myalgias, lymphadenopathy
- Secondary syphilis very common on plantar foot in some patients with localized disease
*lichen planus:
presentation
- acute eruption of itchy papules, will usually settle in a few months, start on inside of arms/legs and go up
- Flat-topped, shiny, polygonal, violaceous (reddish purple) papules
- Wickham’s striae – fine lacy network of lines on top of papules
- Koebner’s phenomenon
what are the 7 Ps of lichen planus?
- plentiful
- pruritic
- polygonal
- polished
- purple
- papular
- planar
what is thought to be the etiology of LICHEN PLANUS?
- T-cell mediated attack on epidermis but still mysterious
- Other LP connections – occasionally SLE has been diagnosed in patients with LP, SLE lesions on extremities may resemble LP, clinical features of SLE will commonly be present, also graft vs host disease may produce a lichenoid eruption
treatment for lichen planus?
- must treat nail involvement (nails will permanently scar if left untreated),
- potent topical steroids to control pruritis,
- systemic steroids or Cyclosporine (*KNOW FOR EXAM) for severe cases
how are morphology and distribution clues to disease?
- Nails/mouth/distribution = lichen planus
- Islands of sparing = pityriasis rubra pilaris
REVIEW: how to approach a red scaly rash
- Take a good history and physical – look at morphology and distribution
- Is it tinea corporis? Can do a KOH to rule out fungal involvement
- If KOH negative, is it psoriasis?
- Could it be pityriasis rosea? (20’s, r/o syphilis)
