Ch. 8 - Psoriasis Flashcards
Prevalence of psoriasis
2%
What % patients with psoriasis develop arthritis
5-30%
When does psoriasis occur?
Any time, peaks are 2nd and 5th decade
Which HLA is most strongly associated with psoriasis?
HLA-Cw6
How many times risk increased if HLA Cw6
15x
What are the genomic regions associated with psoriasis? What chromosome? Which is more important?
PSOR1-PSOR9 region on chromosome 6
PSOR1 strongest (contains Cw6 region)
Name 5 HLA haplotypes associated with psoriasis
HLA CW6
HLA B27–> sacrolitis and PsA
HLA DR7
HLA B13 + HLA B17 : erythrodermic and guttate
HLA-B8, Bw35, Cw7, and DR3: pustular
Which T Helper cells are increased in psoriasis?
Th1
Th17
Th22
What are the Th1 cytokines
IFN-gamma, TNF, IL-2, IL-6, IL-8, IL-12
What cytokines stimulates production of Th1 cells ?
IL-12/IFN-gamma
What are the Th17 cytokines
IL-17A/17F
IL-22
TNF-alpha,
IL-23receptor–> perpetuate th17
IL-21–>perpetuate th17
What cytokines stimulate Th17 cells
Il-6,TGF-Beta primarily
IL-23, IL-21 further self amplify
What is an antimicrobial peptide seen increased in psoriasis
Cathelicidin LL37
What cytokine to plasmacytoid dendritic cells release to trigger dermal dendritic cells to migrate to lymph nodes
INF
What is the general explanation of psoriasis pathophysiology
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)
What is the main T-cell type in epidermis? Dermis?
Epidermis CD8
Dermis CD4 and CD8
What is the name of neutrophils in stratum corneum? Stratum spinsosum?
Munroe microabcesses (corneum)
Spongiform pustules of Kojog
List 6 clinical variants of Psoriasis
- Plaque
- Inverse
- Pustular (multiple)
- Guttate
- Erythrodermic
- Special sites: Palmoplantar, scalp, nails, genitals, oral mucosa
List 5 potential triggers for psoriasis
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
Other than direct cutaneous trauma, name 3 other ways the koebner phenomenon may elicit psoriasis
Sunburn
Drug eruption
Viral eruption
Which 3 sites in a patient with psoriasis are highly associated with psoriatic arthritis?
- Scalp
- Nails
- Gluteal cleft
+ psoriasis severity
List 10 histopathological features of psoriasis.
- 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
What are 10 cytokines that are elevated in Psoriasis?
IL-2, IFN
IL-17, IL-22, IL-23
IL-15
IL-1, IL-6, TNF-alpha
What does PASI stand for? What are its 3 main components? What is the maximum and minimum PASI score?
Psoriasis Area and Severity Index
Erythema, scale, thickness/induration
Minimum: 0, Max: 72
List 5 variants of Pustular Psoriasis.
- Generalized pustular psoriasis of von Zombusch
- Impetigo herpetiformis
- Annular psoriasis of LaPierre
Localized:
- Acrodermatitis continua of Hallopeau
- Acrodermatitis repens of Crocker
- Linear pustular psoriasis
- Pustular psoriasis of palms and soles
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)
Which cytokine elevation correlates with disease activity
IL-22
What is the auspitz sign
pinpoint bleeding when scale is removed
What is Woronoffs ring
psoriatic lesions are sometimes surrounded by a pale blanching ring
What are the main sites of psoriasis
Scalp
Periumbilical
Gluteal cleft/lumbosacral
Elbows
Knees
Hands/feet