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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
Q

List 5 variants of Pustular Psoriasis.

A
  1. Generalized pustular psoriasis of von Zombusch
  2. Impetigo herpetiformis
  3. Annular psoriasis of LaPierre

Localized:

  1. Acrodermatitis continua of Hallopeau
  2. Acrodermatitis repens of Crocker
  3. Linear pustular psoriasis
  4. Pustular psoriasis of palms and soles
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26
Q

List 5 CLASSES of SYSTEMIC treatments for generalized psoriasis.

A

PDE-4 inhibitor (Apremilast)

Retinoids (Acitretin)

Immunosuppressants (MTX, Cyclosporine)

Biologics (TNF, 12/23, 23, 17)

JAK inhibitor (Tofacitinib)

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27
Q

Which cytokine elevation correlates with disease activity

A

IL-22

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28
Q

What is the auspitz sign

A

pinpoint bleeding when scale is removed

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29
Q

What is Woronoffs ring

A

psoriatic lesions are sometimes surrounded by a pale blanching ring

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30
Q

What are the main sites of psoriasis

A

Scalp
Periumbilical
Gluteal cleft/lumbosacral
Elbows
Knees
Hands/feet

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31
Q

What % psoriasis patients have genital involvement

A

up to 45%

32
Q

How to tell genital psoriasis vs. atopic dermatitis

A

Involves the folds vs AD spares diaper area

33
Q

Name 4 possible triggers for generalized psoriasis

A

Steroids withdrawl
Pregnancy
HypoCalcemia
Infections
Topical irritants-localized

34
Q

How does palmar-plantar psoriasis present?

A

sterile pustules admixed with brown and yellow macula’s

35
Q

What syndrome is palmar-plantar pustulosis associated with?

A

SAPHO

synovitis, acne, pustulosis, hyperostosis and osteitis

36
Q

How does acrodermatitis continua of hallopeau present? How does it differ from acrodermatitis repent of Crocker?

A

Pustules on distal fingers, may replace nail plate or partial shed of nail plate

37
Q

How does acrodermatitis continua of hallopeau present? How does it differ from acrodermatitis repent of Crocker?

A

Pustules on distal fingers, may replace nail plate or partial shed of nail plate

38
Q

What is annulus migrans of the tongue? What psoriasis variants are associated?

A

Resembles geographic tongue, migratory annular erythematous lesions with hydrated white scale

Seen in arcodermatitis continua of hallopeau and generalized pustular psoriasis

39
Q

Name 6 nail findings in psoriasis

A

Subungual hyperkeratosis
Oil spots
Onycholysis
Irregular pitting
Splinter hemorrhages
Total dystrophy of the nail
Leukonychia

40
Q

What % patients with psoriasis have arthritis

A

5-30%

41
Q

List 4 RF for more severe PsA course

A

initial presentation at an early age

female gender

polyarticular involvement

genetic predisposition

radiographic signs of the disease early on.

42
Q

What are the 5 types of psoriatic arthritis

A
  1. Mono and oligoarthritis
  2. Spondylitis and sacroilitis
  3. RA-like
  4. Asymetric DIP
  5. Arthritis mutilans
43
Q

What are the 5 types of psoriatic arthritis

A
  1. Mono and oligoarthritis
  2. Spondylitis and sacroilitis
  3. RA-like
  4. Asymetric DIP
  5. Arthritis mutilans
44
Q

How does mono and oligarthritis PsA present?

A

DIP and PIP joints of the hands and feet

Often spares MCP

May have some larger joints

Most common form

45
Q

Name 3 disorders related but distinct to psoriasis

A

Reactive arthritis

Sneddon-Wilkinson (subcorneal pustular dermatosis)-excellent response to dapsone and sub corneal > spongiform pustules

Inflammatory linear verrucous epidermal nevus

46
Q

Name 6 diseases patients with psoriasis are at an increased risk for?

A

CV disease
Metabolic syndrome
HTN
Diabetes
NASH
IBD

47
Q

What condition is associated with rupioid psoriasis

A

Hypothyroidism

48
Q

Name 6 topical therapies for psoriasis

A

Topical steroids
Vitamin D analogues
Topical retinoids-Tazarotene
Anthralin (dithranol)
Topical tar/LCD
Salicyclic acid -scalp
Topical calcineurin inhbitors-face/flexures

49
Q

Name 2 phototherapy options for psoriasis

A

nbUVB
PUVA

50
Q

What % patients reach PASI 75 on MTX by 12-16 weeks

A

24-60% (low-high dose)

51
Q

What % patients reach PASI 75 on MTX by 12-16 weeks

A

24-60% (low-high dose)

52
Q

What PASI reduction is expected with cyclosporine at 4 weeks

A

60–70%

53
Q

Other than the side effects, what is one drawback of CsA

A

Not effective for PsA

54
Q

What non-biologic systemic therapy can be used for both PsA and PsO

A

MTX

55
Q

Name 4 oral systemic treatments for psoriasis

A

MTX

Cyclosporine

Apremilast

Acitretin

56
Q

Target dose for MTX?

A

25 mg po daily

57
Q

Starting and target dose acitretin for plaque, erythrodermic and pustular?

A

Plaque-0.5mg/kg–> mild cheilitis
Erythrodermic- 0.25 mg/kg
Pustular- 1 mg/kg (max )

58
Q

Which psoriasis variants is acitretin most effective for?

A

pustular
erythrodermic

59
Q

Starting and target dose for CsA

A

3 mg/kg/day in divided doses–> 5 mg/kg/day in divided doses after 2 weeks

60
Q

What % patients on apremilast achieve PASI 75

A

33%

61
Q

What is the starting and target dosage for apremilast

A

10 mg po BID

30 mg po BID

62
Q

Name 5 other non biologic systemic therapies (other than MTX/CsA/Acitretin/Apremilast)

A

Hydroxyurea
Fumarates
MMF
Oral calcitriol
6-Thioguanine

63
Q

Name 5 other non biologic systemic therapies (other than MTX/CsA/Acitretin/Apremilast)

A

Hydroxyurea
Fumarates
MMF
Oral calcitriol
6-Thioguanine

64
Q

Compare and contrast:
Calcitriol
Calcipotriol
Calcipotriene

A

Calcitriol=natural vitamin D
Calcipotriol and calcipotriene are the same, both vitamin D derivatives

65
Q

Compare and contrast:
Calcitriol
Calcipotriol
Calcipotriene

A

Calcitriol=natural vitamin D
Calcipotriol and calcipotriene are the same, both vitamin D derivatives

66
Q

Name 3 Vitamin D products for psoriasis

A

Dovonex (calcipotriene) ointment or

Dovobet (calcipotriol + betamethasone diprop) as an ointment

Enstilar (calcipotriene and betamethasone diproprionate) as a foam

67
Q

What is the most efficacious topical product for psoriasis

A

Vitamin D3 + steroid>
High potency steroids>
Vitamin D analogues alone

68
Q

Name 4 combinations that are more efficacious together than alone

A

ultra potent TCS + calcipotriene

CsA + calcipotriene

Acitretin + calcipotriene

PUVA + calcipotriene

Etanercept weekly + acitretin

69
Q

Name 3 combination therapies that should not be used

A

Acitretin (inhibits cyP450) + CsA = risk accumulation CsA

CsA + PUVA = risk SCC

Coal tar + PUVA = phototoxic

Cautious with:
-MTX+ CsA
-MTX + Acitretin

70
Q

What is systemic TOC in juvenile psoriasis

A

MTX

71
Q

What is therapy of choice in juvenile psoriasis after MTX or CsA/acitretin

A

Etanercept

72
Q

Systemic TOC in HIV+

A

Acitretin

73
Q

Systemic TOC in liver disease

A

Biologic
(Can’t do CsA/MTX/acitretin)

74
Q

Systemic TOC in Hep B or C infection +

A

Biologics
Etanercept> adalimumab>ustekinumab>secukinumab

75
Q

Systemic TOC in patient with history internal malignancy

A

Retinoids

MyDermatology-Bolognia (31 decks)

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