CHAPTER 14 Psoriasis Flashcards
what are the triggers of psoriasis ?
Triggering factors, both external (directly interacting with the skin) and systemic, can elicit psoriasis in genetically predisposed individuals.
there is external and internal triggering factors
what is the external triggering factor for psoriasis ? % of patients suffering psoriasis that can experience this ?
The Koebner or isomorphic phenomenon, i.e. the elicitation of psoriatic lesions by injury to the skin, is observed in ~25% of patients with psoriasis.
Do patients that are KOEBNER - become KOEBNER + ?
YES! particular patient may be “Koebner-negative” at one point in time and later become “Koebner-positive”. The Koebner phenomenon suggests that psoriasis is a generalized skin disease that can be triggered locally
is Koebner induced by trauma only? or can it be produced by other triggers? if yes - please mention some ?
Psoriatic lesions can also be induced by other forms of cutaneous injury, e.g. sunburn, morbilliform drug eruption, viral exanthem.
what is the lag time for koebner ? ( from trauma to appearance of skin lesions)
The lag time between the trauma and the appearance of skin lesions is usually 2–6 weeks.
what are the Systemic triggering factors for psoriasis ? mention them and give examples
- Infections (particularly bacterial infections, may induce or aggravate psoriasis. Provoking infections have been observed in up to 45% of psoriatic patients. Streptococcal infections, especially pharyngitis -Streptococci can also be isolated from other sites of infection, e.g. dental abscesses, perianal cellulitis, impetigo.
- ENDOCRINE Hypocalcemia :
triggeers generalized pustular psoriasis,
active vitamin D3:
analogues improve psoriasis, abnormal vitamin D 3 levels have not been shown to induce psoriasis.
pregnancy : 50 % experience improvement, but there are some that experience pustular psoriasis - associated with hypocalcemia ( impetigo herpetiformis - sterile pustules )
-HIV
- PSYCHOGENIC STRESS
DRUGS ( see another slide)
what are the drugs that illicit psoriasis ?
can you explain how is it possible for one of these agents to cause psoriasis aggravation ?
IFN
LITHIUM
ANTI PD1 ( anti programmed death 1)
BB
Plaquinil
The association with immune checkpoint inhibitors may be related to increased levels of IL-6 and thus illicit psoriasis
can steroids illict psoriasis ?
steroids combined with vitamin d derivatives are therapeutic but it is important to know that SYSTEMIC STEROIDS if they are tapered rapidally this can trigger psoriasis
a patient walks into your clinic - he was treated with dupixent for atopic dermatitis. on your examination you notice new psoriasiform lesions what is this called ?
DUPILUMAB is IL4a blocker.
In addition, patients with atopic dermatitis who receive dupilumab can develop psoriasiform lesions, presumably due to a phenotypic shift from predominantly Th2-mediated inflammation to a Th1 immune response.
what are the other behavioral factors that could trigger psoriasis ?
Obesity, increased alcohol consumption, and smoking have all been associated with psoriasis.
However, other studies have suggested that weight gain often precedes the development of psoriasis
halting smoking could cause revertion of the lesions
common features to all psoriatic lesions?
erythema, thickening, and scale.
what is type 1 psoriasis associated with ?
- HLA-Cw6+
- early onset
- more widespread
- frequent recurrences.
compared to those with type II psoriasis.
what is the woronoff ring?
psoriatic lesions are sometimes surrounded by a pale blanching ring, which is referred to as Woronoff’s ring.
Psoriasis is characterized by erythema , thickening and scale. what are the histological findings that correlate to these clinical lesions
ERYTHEMA –> elongated dilated capillaries
THICKENING —> Epidermal acanthosis and cellular infiltrate
Scale —-> Abnormal keratinization
what is the Auspitz sign?
If the superficial silvery white (micaceous) scales are removed, then a wet surface is seen with characteristic pinpoint bleeding. This finding, called Auspitz sign, is the clinical reflection of elongated vessels in the dermal papillae together with thinning of the suprapapillary epidermis.
what could indicate an unstable phase of the disease in a psoriatic patient?
Pinpoint papules surrounding existing psoriatic plaques indicate that the patient is in an unstable phase of the disease.
how do the expanding psoriatic lesions look like ?
expanding psoriatic lesions are characterized by an active edge with a more intense erythema.
Unstable psoriasis ?
Unstable psoriasis represents an exacerbation of psoriatic disease and initially mimics guttate forms, presenting with diffuse small droplet-like papules. These lesions progress within days to weeks to enlarge or coalesce into larger plaques or evolve into pustular lesions or erythroderma.
differentiation of pustular psoriasis from pustules formed due to unstable psoriasis can be a challenge
what is PASI and why was it developed ?
Due to the fact that the the percentage of body surface area involved does not reflect the severity of the individual lesions with respect to erythema, induration, and scaling, the Psoriasis Area and Severity Index (PASI) was formulated
What are the Scoring systems used for psoriasis
- PASI
- Palmoplantar Psoriasis Physician Global Assessment
- Psoriasis Scalp Severity Index
- Nail Psoriasis Severity Index
- Static Physician Global Assessment of Genitalia
What is Guttate psoriasis ? which population does it affect the most ?
More commonly seen in children and adolescents
Usually there is URTI prior to the appearance of the lesion
- in over half of the patients there is Antistreptolysin O posiitvity or Anti DNase B, Streptozyme + (indicating recent infection)
what do you know about Erythrodermic Psoriasis?
- characterized by generalized erythema and scaling, and its onset can be gradual or acute.
Although there are many causes of erythroderma , clues to the diagnosis of psoriatic erythroderma include PREVIOUS PLAQUES in classic locations, characteristic NAIL CHANGES and FACIAL SPARING
CARD14-associated papulosquamous eruption, what is special about this eruption ?
this eruption happens due to CARD14 mutation. the patient looks erythrodermic with alot of scale
here there is features of both psoriasis and pityriasis rubra pilaris (PRP).
the features of this eruption include :
- family history of psoriasis or PRP
- lack of response to topical and systemic therapy for psoriasis
- it appears at an early stage and involves face ears and cheeks, chin and ears.
- surprising response to improvement with ustekinumab
what does the CARD14-associated papulosquamous eruption respond to (in regards to therapy )?
it doesnt respond to the topical and systemic therapy of psoriasis —> but surprisingly responds to USTEKINUMAB.
usually NF-κB is upregulated in the skin of those with this disorder and CARD14 mutations—–> Resulting in increase in IL-8 and CCL20 —-> recruit and activate inflammatory cells —>The latter leads to production of IL-23 by dendritic cells and IL-17 and IL-22 by T cells
this explains why stelara ( Il23 blocker) results in improvement of this eruption
what is the other name for pustular psoriasis in pregnancy ?
Impetigo herpetiformis
what is the histologic finding of Pustular psoriasis?
infiltration of neutrophils dominates the histologic picture . this explains the bright erythema and sterile pustules
List the possible causes to trigger pustular psoriasis ?
generalized:
- Pregnancy
- rapid tapering of Systemic steroids or other therapies
- hypocalcemia
- infection
localized patterns : local irritants can induce local pustular psoriasis
what is DIRA?
Deficency of IL1 receptor antagonist : results in phenotype similar to psoriasis
what is DITRA?
deficiency of IL-36 receptor antagonist
results in phenotype similar to psoriasis
Pustular psoriasis has four distinct phenotypic patterns, explain them:
1) von Zumbusch pattern: this is a generalized eruption starting
abruptly with erythema and pustulation.
HERE THE PATIENT WOULD POSSIBLE TELL YOU THAT HIS LESIONS ARE PAINFUL ! HE FEELS ILL AND MAY HAVE FEVER .
ובקיצור החולה פה יראה רע אך לאחר כמה ימים הפוסטולות יעלמו - יחד איתם יכולים גם להיעלם הרבדים הפסוריטים ומקומים יחליף קשקש
2) Annular pattern: annular lesions, consisting of erythema and scaling with pustulation at the advancing edge
The lesions enlarge by centrifugal expansion over a period of hours to days, while healing occurs centrally.
3) Exanthematic type: acute eruption of small pustules, abruptly appearing and disappearing over a few days.
- acute eruption of small pustules, abruptly appearing and disappearing over a few days.
- usually no systemic symptoms
- There is overlap between this form of pustular psoriasis and pustular drug eruptions, also referred to as acute generalized exanthematous pustulosis (AGEP)
4) “Localized” pattern: pustules appear within or at the edge of existing psoriatic plaques. This can be seen during the unstable phase of chronic plaque psoriasis and following the appli- cation of irritants, e.g. tars, anthralin.
what is sapho ?
sapho is commonly associated with palmoplantar pustulosis
sapho stands for synovitis, acne, pustulosis, hyperostosis, and osteitis
what is acrodermatitis continua of hallopeau?
Acrodermatitis continua of Hallopeau
- rare manifestation of psoriasis
- pustules seen in the distal portion of the fingers.
- occasionally on the toes also
- pustules may form in the nail beds and shedding of the nail plate
- can transit into other forms of psoriasis
- may be accompanied by annulus migrans of the tongue
Special location of psoriasis
- scalp :
is one of the most common sites for psoriasis.
it is not possible to distinguish seborrheic dermatitis from psoriasis, and the two disorders may coexist.
lesions of psoriasis often advance onto the periphery of the face, the retroauricular areas and the posterior upper neck
scales sometimes have an asbestos- like appearance and can adhere to hair shafts in clumps (pityriasis amiantacea)
when do you see pityriasis amiantacea?
most commonly seen in psoriasis
can also be seen in :
atopic that is superinfected
seborrhea
tinea capitis
also note that patients with dermatomyositis may have scalp involvement that may rese,ble psoriasis
which drugs can result in alopecia within psoriatic lesion ?
Alopecia occasionally develops within involved areas, including in the setting of TNF inhibitor- induced psoriasis
features of Flexural psoriasis (Special location) ?
- characterized by shiny, pink to red, sharply demar- cated thin plaques
- much less scale ( than in untreated )
- central fissure is often seen
- most common sites of involvement are the retroauricular fold, intergluteal cleft, inguinal crease, axilla, and inframammary region ( if only the flexural surfaces are involved its called INVERSA)
- Localized dermatophyte, candidal, or bacterial infec- tions can be a trigger for flexural psoriasis.
mainfestation of psoriasis in oral mucosa?
Migratory annular erythematous lesions with hydrated white scale (annulus migrans) have been observed in patients with acroderma- titis continua of Hallopeau and generalized pustular psoriasis
also known as GEOGRAPHIC TONGUE.
Occasionally, lesions are observed on the buccal mucosa.
where does psoriasis manifest more commonly ? nails or fingernails ?
- The fingernails are more often affected than the toenails .
- Nail involvement has been reported in 10%–80% of psoriatic patients.
- Patients with nail involvement appear to have an increased incidence of psoriatic arthritis.
- Psoriasis affects the nail matrix, nail bed, and hyponychium.
Psoriatic arthritis ? what percentage of the patients suffer from this ?
5% - 30% of the patients with psoriasis will experience psoriatic arthritis (probably underestimated)
In a minority of patients (10%–15%), the symptoms of psoriatic arthritis appear before involvement of the skin.
what are the risk factors for severe psoriatic arthritis?
Risk factors for a more severe course of the arthritis include:
-initial presentation at an early age.
- female sex.
- polyarticular involvement.
- genetic predisposition.
- radiographic signs of the disease early on
juxta-articular manifestation of psoriasis?
Patients with psoriatic arthritis can have involvement of juxta-articular tendons (tendonitis)
and the sites where they insert into bone (enthesitis)- occurs in 20%
as well as swelling of the fingers (dactylitis). occurs in 15-30%
how often do you see psoriatic arthritis in patients with cutaneous Pso?
5-30%
is there any. serological test that you can do that helps with the diagnosis of psoriasis?
Currently, there are no specific serologic tests for establishing the diagnosis of psoriatic arthritis, but an important hallmark is erosive change radiographically, which may occur years after the presenting peri-articular inflammation
who is more prone to have psoriatic arthritis ?
Psoriatic arthritis is more prevalent among patients with relatively severe psoriasis.
what are the risk factors for a more severe course of psoriatic arthritis?
Risk factors for a more severe course of the arthritis include: initial presentation at an early age, female sex, polyarticular involvement, genetic predisposition, and radiographic signs of the disease early on.
what are the types of psoriasis ?
Risk factors for a more severe course of the arthritis include:
- initial presentation at an early age.
- female sex
- polyarticular involvement
genetic predisposition.
- radiographic signs of the disease early on.
what is the most common manifestation of psoriatic arthritis?
mono and asymmetric oligo-arthritis
FIVE MAJOR TYPES OF PSORIATIC ARTHRITIS?
mono and asymmetric oligo-arthritis
Arthritis of the distal interphalangeal joints
Rheumatoid arthritis- like presentation (difficult to distinguish
from RA clinically*)
Arthritis mutilans† (least common type)
Spondylitis and sacroiliitis
(also have peripheral joint involvement)
WHAT IS ILVEN?
Inflammatory linear verrucous epidermal nevus - ENTITY RELATED TO PSORIASIS
ILVEN is characterized by linear psoriasiform lesions (i.e. scaling and erythematous plaques) that follow the lines of Blaschko
bur resistant to therapy and chronic thus thought to be a seperate entity
Reactive arthritis ? what does it include? which population does it affect?
urethritis
arthritis
ocular findings
oral ulcers
+ psoriasiform skin lesions.
this condition is uncommon in children and more common among men
urethritis can range from mild to severe (accompanied by complications such as cystitis, cervicitis, and salpingitis).
what is the most common trigger for reactive arthritis ?
chlamydia trachomatis
but other triggers can be shigellosis.
what is the most common eye finding in reactive arthritis
Conjunctivitis is a common eye finding in affected patients, although iritis, uveitis with glaucoma, and keratitis may also occur.
Most common joint manifestation of reactive arthritis?
Polyarthritis and sacroiliitis are the most frequent joint manifestations.
cutaneous manifestation of reactive arthritis?
Cutaneous lesions occur in ~5% of reactive arthritis patients, with a predilection for the soles, extensor surfaces of the legs, penis, dorsal aspects of the hands, fingers, nails, and scalp
The lesions on the plantar surface usually have thick yellow scale and are often pustular (keratoderma blennorrhagicum).
how do you call psoriatic plaques on the penis?
balanitis circinata.
does Reactive arthritis has association with HLA? how is the course of this disease?
Reactive arthritis has a strong association with HLA-B27.
the course is often self-limited, lasting weeks to months, some patients have disease that is chronic and disabling. Of note, HIV-infected patients can also develop this disorder and it may be severe.
features of sneddon wilkinson ?
Sneddon–Wilkinson disease (subcorneal pustular
dermatosis)
- characterized by annular or polycyclic lesions, usually commencing in the flexures.
- Very superficial (subcorneal) sterile pustules are the hallmark of Sneddon–Wilkinson disease
gravity-induced demar- cation in some vesiculopustules
how is the course of sneddon wilkinson ? what is the differential? with what it may be associated
- disease has a cyclic course ( as the pustules resolve they are replaced by superficial scaling and then new pustules form again.)
- may be associated with IgA paraprotienemia
- its DD is IgA pemphigus , thus DIF is needed
how is sneddon Wilkinson different from pustular psoriasis?
Its response to dapsone, combined with subcorneal pustules (in the absence of spongiform pustules), provide support for this condition being a disease entity distinct from pustular psoriasis.
association between psoriasis and other diseases?
regarding SKIN conditions:
patients with psoriasis less frequently experience atopic dermatitis, asthma, urticaria, and allergic contact dermatitis have been found to be lower in psoriatic patients .
immunologic difference between these two conditions, with a predominantly Th1 and Th17 response in psoriasis and a predominantly Th2 response in atopic dermatitis
