Autoimmune Dermatology

Question 1

alopecia areata

Answer 1

*autoimmune attack on the hair follicle resulting in hair loss
*higher risk in patients with other autoimmune diseases
*common in children and young adults
*disease spectrum:
1. areata → patchy on scalp
2. totalis → all of scalp
3. universalis → all of scalp & body
*unpredictable course
*often does not affect de-pigmented hairs

Question 2

treatment of alopecia areata

Answer 2

*topical: steroids, anthralin
*injections of corticosteroids into patches
*oral: prednisone, methotrexate
*phototherapy: Xtrac laser (focused UVB), PUVA

Question 3

hidradenitis suppurativa

Answer 3

*“acne inversa”
*follicular and apocrine gland occlusion in intertriginous regions (skin folds)
*painful nodules, scarring, sinus tracts, draining lesions
*risk factors: female, obese, smoker
*treat with antibiotics, retinoids, adalimumab, surgery, laser hair removal

Question 4

psoriasis (overview)

Answer 4

*common chronic autoimmune disease
*inflammation of the skin leads to increase in cell turnover, skin doesn’t shed normally (TNFalpha, IL17, IL1 involved in pathogenesis)
*psoriasis can affect the joints in 1/3 of patients (psoriatic arthritis)
*associated with metabolic syndrome and increased CVD risk

Question 5

psoriasis - clinical variants

Answer 5

1. plaque type
2. guttate
3. inverse
4. pustular
5. erythrodermic
6. nail psoriasis
7. scalp psoriasis
8. sebopsoriasis

Question 6

plaque-type psoriasis

Answer 6

*well-demarcated erythematous silvery scaling plaques symmetrically distributed on extensor skin
*most common type of psoriasis

Question 7

guttate psoriasis

Answer 7

*very small scaly plaques appear abruptly, often after Streptococcal pharyngitis

Question 8

inverse psoriasis

Answer 8

*smooth and shiny plaques in skin folds (armpits, groin, buttocks, inframammary areas)

Question 9

pustular psoriasis

Answer 9

*sterile pustules (neutrophils) on an erythematous base, often on the hands and feet

Question 10

erythrodermic psoriasis

Answer 10

*red scaling skin eruption involving >90% of the skin surface

Question 11

nail psoriasis

Answer 11

*onycholysis, ridging, oil spots, pitting

Question 12

scalp psoriasis

Answer 12

*well defined scaly plaques often on occipital scalp, sometimes also affecting the ears

Question 13

sebopsoriasis

Answer 13

*scaling and greasy erythema of the scalp, face, upper chest in a “Seborrheic” distribution

Question 14

psoriasis - aggravators

Answer 14

*improves in summer (light responsive)
*stress can make psoriasis flare
*picking the scales off perpetuates the lesions
*certain meds can flare psoriasis: beta blockers, lithium, interferon, antimalarials
*has less bacterial colonization and risk of infection (compared to eczema)

Question 15

psoriasis - treatment

Answer 15

1. topical: salicylic acid, corticosteroids, vitamin D analogues, retinoids
2. phototherapy: UVB, psoralen + UVA, extrac laser
3. systemic therapy: methotrexate, cyclosporine, oral retinoids, apremilast, biologics (IL17 and IL23 blockers)

Question 16

atopic dermatitis (eczema) - overview

Answer 16

*common skin disease, more common in younger patients
*chronic, relapsing dermatitis associated with intense itching and subsequent changes in the skin
*associated with asthma and allergic rhinitis

Question 17

atopic dermatitis (eczema) - clinical presentation

Answer 17

*distribution and characteristics of lesions vary with age:
1. infantile: intense pruritus, erythema, oozing, crusting in a facial and extensor distribution
2. childhood: erythematous papules, plaques, scaling, excoriations, lichenification in plexural areas (antecubital fossa, popliteal fossa), neck, and wrists
3. adulthood: thickened, hyperkeratotic plaques with lichenification and prurigo nodules

Question 18

complications of atopic dermatitis (eczema)

Answer 18

*nearly 80% will develop allergic rhinitis or asthma
*pts more prone to cutaneous infections (bacterial or viral)
*susceptible to allergic and irritant contact dermatitis (sensitive skin)

Question 19

atopic dermatitis (eczema) - treatment

Answer 19

*barrier restoration
*inflammation control (topical corticosteroids and topical calcineurin inhibitors)
*itch control (oral anti-histamines)
*infection control
*systemic therapy

Question 20

lichen planus - overview

Answer 20

*chronic inflammatory condition with multiple subtypes
*T cell mediated autoimmune disease with unknown protein target
*can be stimulated by viral infections, skin injury, exposure to allergen
*clinical features: the 5 P’s = purple, polygonal, pruritic, papules, plaques
*Wickham striae = fine white lines overlying skin lesions, often in oral mucosa

Question 21

lichen planus - treatment

Answer 21

*localized disease: potent topical steroids, under occlusion, intralesional injections
*widespread disease: systemic immunosuppressive meds (methotrexate, azathioprine, dapsone, mycophenolate mofetil)
*UV therapy
*screen for Hep C
*ask pts about mucosal or vulvovaginal involvement