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MyDermatology-Bolognia > Ch. 8 - Psoriasis > Flashcards

Ch. 8 - Psoriasis Flashcards

1
Q

Prevalence of psoriasis

A

2%

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2
Q

What % patients with psoriasis develop arthritis

A

5-30%

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3
Q

When does psoriasis occur?

A

Any time, peaks are 2nd and 5th decade

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4
Q

Which HLA is most strongly associated with psoriasis?

A

HLA-Cw6

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5
Q

How many times risk increased if HLA Cw6

A

15x

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6
Q

What are the genomic regions associated with psoriasis? What chromosome? Which is more important?

A

PSOR1-PSOR9 region on chromosome 6
PSOR1 strongest (contains Cw6 region)

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7
Q

Name 5 HLA haplotypes associated with psoriasis

A

HLA CW6
HLA B27–> sacrolitis and PsA
HLA DR7
HLA B13 + HLA B17 : erythrodermic and guttate
HLA-B8, Bw35, Cw7, and DR3: pustular

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8
Q

Which T Helper cells are increased in psoriasis?

A

Th1
Th17
Th22

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9
Q

What are the Th1 cytokines

A

IFN-gamma, TNF, IL-2, IL-6, IL-8, IL-12

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10
Q

What cytokines stimulates production of Th1 cells ?

A

IL-12/IFN-gamma

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11
Q

What are the Th17 cytokines

A

IL-17A/17F

IL-22

TNF-alpha,

IL-23receptor–> perpetuate th17

IL-21–>perpetuate th17

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12
Q

What cytokines stimulate Th17 cells

A

Il-6,TGF-Beta primarily

IL-23, IL-21 further self amplify

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13
Q

What is an antimicrobial peptide seen increased in psoriasis

A

Cathelicidin LL37

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14
Q

What cytokine to plasmacytoid dendritic cells release to trigger dermal dendritic cells to migrate to lymph nodes

A

INF

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15
Q

What is the general explanation of psoriasis pathophysiology

A

Triggering event (stress, trauma, etc.) –> release of antigen (e.g. cathelicidin LL37 complexes with DNA/RNA) –> TLR-9/7 activated and causes plasma DC’s secrete INTERFERON to activate dermal DC’s–> dDCs to lymph node and present neo-antigen to naive T-cells:
1) DC’s secrete IL-12/IFN–> Th1 –> IL-2, TNF, INF–> macrophages
2) DC’s secrete IL-12/23–> Th17 –> IL-17A, 17F, IL-22 –> Neutrophils, proliferate
3) Some degree IL-4–> Th2 activation–> Macrophage M2 cells–> vEGF/angiogenesis
4) CD8+ cytotoxic cells with some Th1 and Th17 properties, move to epidermis (hence why epidermis mostly CD8)

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16
Q

What is the main T-cell type in epidermis? Dermis?

A

Epidermis CD8
Dermis CD4 and CD8

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17
Q

What is the name of neutrophils in stratum corneum? Stratum spinsosum?

A

Munroe microabcesses (corneum)

Spongiform pustules of Kojog

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18
Q

List 6 clinical variants of Psoriasis

A
  • Plaque
  • Inverse
  • Pustular (multiple)
  • Guttate
  • Erythrodermic
  • Special sites: Palmoplantar, scalp, nails, genitals, oral mucosa
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19
Q

List 5 potential triggers for psoriasis

A

SICK NAILS

Stress
Smoking, Alcohol, Obesity/Pregnancy
Infection-strep
HypoCalcemia
CD4+ disease -HIV
Koebner

NSAIDS
AntiHTN: ACEi, BB
Anti-malarials
Imiquimod
INF
Inflixmab/TNFs
Lithium
Steroids/CsA withdrawal

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20
Q

Other than direct cutaneous trauma, name 3 other ways the koebner phenomenon may elicit psoriasis

A

Sunburn
Drug eruption
Viral eruption

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21
Q

Which 3 sites in a patient with psoriasis are highly associated with psoriatic arthritis?

A
  • Scalp
  • Nails
  • Gluteal cleft
    + psoriasis severity
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22
Q

List 10 histopathological features of psoriasis.

A
  • Regular acanthosis
  • Confluent parakeratosis
  • Munroe’s micro abscesses (stratum corneum)
  • Micro pustules of Kojog (stratum spinosum)
  • Squirting papillae (neutrophils discharge from papillary capillaries)
  • Thinning suprapapillary plates
  • Dilated and tortuous capillaries in dermal papillae
  • Elongation dermal papillae
  • Superficial perivascular infiltrate w/ lymphocytes and macrophages
  • Decreased or absent granular layer
  • Elongated and squared off rete ridges
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23
Q

What are 10 cytokines that are elevated in Psoriasis?

A

IL-2, IFN

IL-17, IL-22, IL-23

IL-15

IL-1, IL-6, TNF-alpha

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24
Q

What does PASI stand for? What are its 3 main components? What is the maximum and minimum PASI score?

A

Psoriasis Area and Severity Index

Erythema, scale, thickness/induration

Minimum: 0, Max: 72

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25
List 5 variants of Pustular Psoriasis.
1. Generalized pustular psoriasis of von Zombusch 2. Impetigo herpetiformis 3. Annular psoriasis of LaPierre Localized: 4. Acrodermatitis continua of Hallopeau 5. Acrodermatitis repens of Crocker 5. Linear pustular psoriasis 6. Pustular psoriasis of palms and soles
26
List 5 CLASSES of SYSTEMIC treatments for generalized psoriasis.
PDE-4 inhibitor (Apremilast) Retinoids (Acitretin) Immunosuppressants (MTX, Cyclosporine) Biologics (TNF, 12/23, 23, 17) JAK inhibitor (Tofacitinib)
27
Which cytokine elevation correlates with disease activity
IL-22
28
What is the auspitz sign
pinpoint bleeding when scale is removed
29
What is Woronoffs ring
psoriatic lesions are sometimes surrounded by a pale blanching ring
30
What are the main sites of psoriasis
Scalp Periumbilical Gluteal cleft/lumbosacral Elbows Knees Hands/feet
31
What % psoriasis patients have genital involvement
up to 45%
32
How to tell genital psoriasis vs. atopic dermatitis
Involves the folds vs AD spares diaper area
33
Name 4 possible triggers for generalized psoriasis
Steroids withdrawl Pregnancy HypoCalcemia Infections Topical irritants-localized
34
How does palmar-plantar psoriasis present?
sterile pustules admixed with brown and yellow macula's
35
What syndrome is palmar-plantar pustulosis associated with?
SAPHO synovitis, acne, pustulosis, hyperostosis and osteitis
36
How does acrodermatitis continua of hallopeau present? How does it differ from acrodermatitis repent of Crocker?
Pustules on distal fingers, may replace nail plate or partial shed of nail plate
37
How does acrodermatitis continua of hallopeau present? How does it differ from acrodermatitis repent of Crocker?
Pustules on distal fingers, may replace nail plate or partial shed of nail plate
38
What is annulus migrans of the tongue? What psoriasis variants are associated?
Resembles geographic tongue, migratory annular erythematous lesions with hydrated white scale Seen in arcodermatitis continua of hallopeau and generalized pustular psoriasis
39
Name 6 nail findings in psoriasis
Subungual hyperkeratosis Oil spots Onycholysis Irregular pitting Splinter hemorrhages Total dystrophy of the nail Leukonychia
40
What % patients with psoriasis have arthritis
5-30%
41
List 4 RF for more severe PsA course
initial presentation at an early age female gender polyarticular involvement genetic predisposition radiographic signs of the disease early on.
42
What are the 5 types of psoriatic arthritis
1. Mono and oligoarthritis 2. Spondylitis and sacroilitis 3. RA-like 4. Asymetric DIP 5. Arthritis mutilans
43
What are the 5 types of psoriatic arthritis
1. Mono and oligoarthritis 2. Spondylitis and sacroilitis 3. RA-like 4. Asymetric DIP 5. Arthritis mutilans
44
How does mono and oligarthritis PsA present?
DIP and PIP joints of the hands and feet Often spares MCP May have some larger joints Most common form
45
Name 3 disorders related but distinct to psoriasis
Reactive arthritis Sneddon-Wilkinson (subcorneal pustular dermatosis)-excellent response to dapsone and sub corneal > spongiform pustules Inflammatory linear verrucous epidermal nevus
46
Name 6 diseases patients with psoriasis are at an increased risk for?
CV disease Metabolic syndrome HTN Diabetes NASH IBD
47
What condition is associated with rupioid psoriasis
Hypothyroidism
48
Name 6 topical therapies for psoriasis
Topical steroids Vitamin D analogues Topical retinoids-Tazarotene Anthralin (dithranol) Topical tar/LCD Salicyclic acid -scalp Topical calcineurin inhbitors-face/flexures
49
Name 2 phototherapy options for psoriasis
nbUVB PUVA
50
What % patients reach PASI 75 on MTX by 12-16 weeks
24-60% (low-high dose)
51
What % patients reach PASI 75 on MTX by 12-16 weeks
24-60% (low-high dose)
52
What PASI reduction is expected with cyclosporine at 4 weeks
60–70%
53
Other than the side effects, what is one drawback of CsA
Not effective for PsA
54
What non-biologic systemic therapy can be used for both PsA and PsO
MTX
55
Name 4 oral systemic treatments for psoriasis
MTX Cyclosporine Apremilast Acitretin
56
Target dose for MTX?
25 mg po daily
57
Starting and target dose acitretin for plaque, erythrodermic and pustular?
Plaque-0.5mg/kg--> mild cheilitis Erythrodermic- 0.25 mg/kg Pustular- 1 mg/kg (max )
58
Which psoriasis variants is acitretin most effective for?
pustular erythrodermic
59
Starting and target dose for CsA
3 mg/kg/day in divided doses--> 5 mg/kg/day in divided doses after 2 weeks
60
What % patients on apremilast achieve PASI 75
33%
61
What is the starting and target dosage for apremilast
10 mg po BID 30 mg po BID
62
Name 5 other non biologic systemic therapies (other than MTX/CsA/Acitretin/Apremilast)
Hydroxyurea Fumarates MMF Oral calcitriol 6-Thioguanine
63
Name 5 other non biologic systemic therapies (other than MTX/CsA/Acitretin/Apremilast)
Hydroxyurea Fumarates MMF Oral calcitriol 6-Thioguanine
64
Compare and contrast: Calcitriol Calcipotriol Calcipotriene
Calcitriol=natural vitamin D Calcipotriol and calcipotriene are the same, both vitamin D derivatives
65
Compare and contrast: Calcitriol Calcipotriol Calcipotriene
Calcitriol=natural vitamin D Calcipotriol and calcipotriene are the same, both vitamin D derivatives
66
Name 3 Vitamin D products for psoriasis
Dovonex (calcipotriene) ointment or Dovobet (calcipotriol + betamethasone diprop) as an ointment Enstilar (calcipotriene and betamethasone diproprionate) as a foam
67
What is the most efficacious topical product for psoriasis
Vitamin D3 + steroid> High potency steroids> Vitamin D analogues alone
68
Name 4 combinations that are more efficacious together than alone
ultra potent TCS + calcipotriene CsA + calcipotriene Acitretin + calcipotriene PUVA + calcipotriene Etanercept weekly + acitretin
69
Name 3 combination therapies that should not be used
Acitretin (inhibits cyP450) + CsA = risk accumulation CsA CsA + PUVA = risk SCC Coal tar + PUVA = phototoxic Cautious with: -MTX+ CsA -MTX + Acitretin
70
What is systemic TOC in juvenile psoriasis
MTX
71
What is therapy of choice in juvenile psoriasis after MTX or CsA/acitretin
Etanercept
72
Systemic TOC in HIV+
Acitretin
73
Systemic TOC in liver disease
Biologic (Can't do CsA/MTX/acitretin)
74
Systemic TOC in Hep B or C infection +
Biologics Etanercept> adalimumab>ustekinumab>secukinumab
75
Systemic TOC in patient with history internal malignancy
Retinoids

MyDermatology-Bolognia (31 decks)

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