Chapter 8: Psoriasis and Other Papulosquamous Diseases Flashcards
What are papulosquamous diseases?
A group of disorders characterized by scaly papules and plaques.
What percentage of the population is affected by psoriasis.
1 to 3%
What is psoriasis?
A genetic disease of dysregulated inflammation.
In immune-mediated skin and/or joint inflammatory disease in which inflammation primes basal stem keratinocytes to hyperproliferate.
What are the clinical manifestations of psoriasis?
Begin as red scaling papules that coalesce to form round to oval plaques, which can easily be distinguished from the surrounding normal skin.
The scale is adherent and silvery white, and reveals bleeding points when removed.
What is Auspitz sign?
Bleeding that occurs when scales are removed in psoriatic patients.
What is koebener phenomenon?
Psoriasis can develop at the site of physical trauma (scratching, sunburn, or surgery), the so-called isomorphic phenomenon
What four drugs or associated with precipitating or exacerbating psoriasis?
- Lithium
- Beta blocking agents.
- Antimalarial agents
- Systemic steroids
What medical comorbidities are associated with Development of psoriasis?
Autoimmune diseases cardiovascular disease metabolic disease lymphoma or nonmelanoma skin cancer depression/suicide smoking alcohol obesity
What comorbidities are associated with psoriasis?
Higher risk for arthritis heart disease diabetes cancer hypertension
- comorbidities Tend to increase with age
What is thought to trigger guttate psoriasis?
Streptococcal pharyngitis or a viral upper respiratory tract infection may proceed the eruption by one or two weeks.
more than 30% of psoriatic patients have their first episode before the age of 20.
What is generalized pustular psoriasis?
A rare form of psoriasis
Also called Von Zumbusch’s psoriasis.
A serious and sometimes fatal disease.
What is von Zumbusch’s psoriasis?
Generalized pustular psoriasis
What is the treatment for generalized pustular psoriasis?
Topical medications such as tar and anthralin may precipitate episodes in patients with unstable or labile psoriasis.
Systemic therapy may be necessary for severe cases. Acitretin yields rapid control.
Methotrexate and cyclosporine are also effective.
What is erythrodermic psoriasis?
A severe, unstable, highly labile disease that may appear as the initial manifestation of psoriasis but usually occurs in patients with previous chronic disease.
What is treatment erythrodermic psoriasis
Bedrest, initial avoidance of all UV light, Burroughs solution compresses, colloidal ointment baths, the liberal use of emollients, increase protein and fluid intake, anti-histamines for pruritus, avoidance of potent topical steroids and, in severe cases, hospitalization.
Does psoriasis cause hair loss of the scalp?
Even in the most severe cases, the hair is not permanently lost.
What is pustular psoriasis of the palms and soles?
Deep pustules first appear on the middle portion of the palms and in steps of the soles; they either remain localized or spread
Pustules do not rupture but turn dark brown and scaly as they reach the surface..
Considerably higher prevalence of smoking in these patients.
Where do plaques typically develop an scalp psoriasis
Hair margin
What physical exam finding may help differentiate psoriasis of the fingertips from an eczematous eruption?
Rich red hue is typical of psoriasis
What is Keratoderma Blennorrhagicum?
Reiter syndrome
Appears to be a reactive immune response that is usually triggered in a genetically susceptible individual (HLA – B 27+) By any of several different infections, especially those that cause dysentery or urethritis, such as Yersinia enterocolitica and Y. pseudo-tuberculosis
What are the distinctive lesions of keratoderma Blennorrhagicum?
Typically appear on the souls and extend onto the toes but also occur on the legs, scalp, and hands.
Psoriaform skin lesions develop in patients usually one to two months after the onset of arthritis; conjunctivitis occurs in 25% of patients.
What is the treatment for Reiter syndrome
Skin and joint symptoms have responded to methotrexate, acitretin, and ketoconazole
What is acrodermatitis continua?
Pustular psoriasis of the digits
A severe localized variant of psoriasis, may remain localized to one finger for years. Vesicles rupture, resulting in a tender, diffusely eroded, and fissured surface that continually exudes serum
What is psoriasis inversus?
The gluteal fold, axillary, growing, submammary folds, retroauricular folds, and the glands of the uncircumcised penis may be affected.
What do pustules beyond the Plaque border suggest?
Secondary yeast infection
Can psoriasis be the first or one of the first signs of acquired immunodeficiency syndrome?
Yes
The disease is difficult to treat. PUVA, Ultraviolet light B, and topical steroids are immunosuppressive and SHOULD BE AVOIDED
What is the treatment for HIV induced psoriasis?
Acitretin is the drug of choice for severe disease.
Zidovudine is effective and cleared and acitretin-resistant case
What are the nail changes associated with psoriasis?
Onycholysis Subungal debris pitting Oil spot lesion nail deformity
What is onycholysis?
Psoriasis of the nail bed causes separation of the nail from the nail bed. The nail detaches an irregular manner
What is Subungal debris associated with psoriasis?
Analogous to fungal infection; the nail bed scale is retained, forcing the distal nail to separate from the nail bed
What is nail pitting?
Nail pitting is the best-known and possibly the most frequent psoriatic nail abnormality
Nail plate cells are shed in such the same way as psoriatic scale is shed, leaving a variable number of tiny, punched – out depressions on the nail plate surface. they emerge from under the cuticle and grow out with the nail.
What diseases are associated with nail pitting?
Psoriasis
eczema
fungal infections
alopecia areata
Or it may occur as an isolated finding as a normal variation
What is an oil spot lesion?
Psoriasis of the nail bed may cause localized separation of the nail plate. Cellular debris and serum accumulate in the space.
The brown-yellow color observed to the nail plate looks like a spot of oil
What is psoriatic arthritis?
A chronic inflammatory arthropathy of the peripheral joints, spine, and enthesis; it is associated with psoriasis in which rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP) measurements are usually negative.
What is the age of onset for psoriatic arthritis?
Between ages 20 and 40
Men and women are equally affected.
How to psoriatic arthritis and rheumatoid arthritis differentiated by joints affected?
Unlike in rheumatoid arthritis, the distal interphalangeal joints are regularly involved
What percentage of patients have symptoms of arthritis before the onset of psoriasis?
15%
What percentage of patients with psoriatic arthritis have nail involvement?
80%
What percentage of patients With uncomplicated psoriasis have nail involvement?
30%
Does the presence of nail disease have predictive value in determining if a patient is at risk for psoriatic arthritis?
No
What is enthesitis?
Inflammation at the site of ligamentamentous and tendinous insertion.
Characteristic of all HLA–B27 associated spondyloarthropathies.
What are the Moll and Wright clinical subtypes of psoriatic arthritis?
- Oligoarticular
- Polyarticular
- Distal interphalangeal joint predominant
- Destructive polyarthritis
- Ankylosing spondylitis and sacroiliitis
How can you differentiate psoriatic arthritis from rheumatoid arthritis
– Rheumatoid arthritis affects women more commonly
– rheumatoid arthritis affects metacarpophalangeal and proximal interphalangeal joints while psoriatic arthritis affects the D IP joints and at least 50% of patients.
– Rheumatoid arthritis tends to have asymmetric distribution
What is the treatment for psoriatic arthritis?
Similar to that of other chronic inflammatory joint diseases. NSAIDs are the mainstay of therapy in usually provide adequate control, but they do not induce remission.
Methotrexate may be used for advanced disease, As well as anti-tumor necrosis factor-alpha
Is methotrexate a primary or secondary line of therapy for psoriatic arthritis?
Secondary
Is used as the primary DMARD; pain and function improved dramatically 2 to 6 weeks after starting methotrexate therapy with 5 mg every 12 hours in three consecutive doses once a week.
What is the dosage of cyclosporine for the treatment of psoriatic arthritis?
Daily doses usually ranging from 1.5 to 5 mg/kg provides impressive relief from arthralgias and improvement of joint function.
How is the length of treatment determined for psoriasis?
The plaque is effectively treated when induration has disappeared.
If the plaque cannot be felt by drawing the finger over the skin surface, treatment may be stopped.
When should topical agents be considered for the treatment of psoriasis?
Less than 20% of the body is covered
What are the topical agents use for psoriasis, or psoriasis is less than 20% of the body?
Topical steroids Calcipotriol (Dovonex) Tazorotene (Tazorac) Anthralin Tar UVB and lubricating agents of tar tape or occlusive dressing intralesional steroids
What other treatment options for persons with psoriasis of more than 20% of the body?
UVB in narrowband ultraviolet B light PUVA acitretin (Soriatane) cyclosporine biologic therapies
What is the mechanism of calcipotriene
A vitamin D3 analog inhibits epidermal cell proliferation and enhances cell differentiation
Dovonex- 0.005% vitamin D3
What is the dosing of dovonex
Up to 100 grams/week
Does tachyphylaxis occur with calcipotriene
No
How is calcipotriene and steroids combined for the treatment of psoriasis
Calcipotriene is applied in the morning and the class I steroid is applied at night for two weeks before transitioning to maintenance treatment.
Maintenance:
Calcipotriene BID weekdays
Steroid BID weekend
60-70% effective for plaque type at 6-8 weeks
What are the topical approaches to psoriasis
Calcipotriene Retinoids Topical steroids Tazorac Anthrallin Tar UVB Tape/occlusive dressing Intralesional steroid
How are retinoids used in the treatment of psoriasis
Tazarotene (0.05%, 0.1%) gel or cream is typically combined with a steroid or UVB
What can happen when class I steroids are used under occlusion
Rapid appearance of atrophy and telangectasia
How should intralesional steroids be used for the treatment of psoriasis
Kenalong 5 or 10 can be injected for patients with a few small chronic plaques on the scalp or body
What is anthralin
Need to figure it out
How is anthralin used in the treatment of psoriasis
Medication s applied and left for a 20 minute contact time up to 1 hour before being washed off.
What is the most effective topical approach to psoriasis
UVB in combination with lubricating agents, tar, or tazarotene.
What is the probability of benefit from UVB for the treatment of psoriasis
Sunlight nonresponders have a 70% chance of failure
Sunlight responders have an 80% chance that clearance treatment will succeed.
What treatment protocol is needed for UVB for the treatment of psoriasis
6 treatments per month
What is PUVA
psoralen + UVA
How is PUVA used in the treatment of psoriasis.
PUVA is most appropriate for for severe plaque psoriasis in patients over the age of 50
Not approved for pediatrics
Patients ingest a prescribed dose of methoxsalen 2 hours before being exposed to a carefully measured amount of UVA.
After the clearance phase, patients require 30 treatments per year on average.
What are the side effects of PUVA
Promotes skin aging, AK’s and SK’s, SCC
Increased risk of melanoma after 15 years of first treatment, greater in patients with more than 250 treatments
