Chronic Inflammatory Dermatoses

Question 1

PSORIASIS

Answer 1

Population: ~4% with geographic and ethnic variance
Peaks: third and sixth decades
Genetics: presumed autosomal dominance with modifying features but also environmental triggers
Clinical Features: sharply demarcated erythema usually with thick micaceous scale, Auspitz Sign and Koebner phenomenon; Nail disease up to 50%; Rarely pustular

Question 2

psoriasis pathogenesis

Answer 2

T Cell Mediated Autoimmune Disorder
Environmental factor-T cell produce cytokines – Stimulate keratinocyte proliferation and production of antigenic adhesion molecules in the dermal blood vessels-adhesion molecules further stimulate T cells to produce cytokines…

Question 3

psoriasis risk factors

Answer 3

Genetic: 30% of patients have first degree relative with psoriasis
Psychological Stress
Medications
Infection
Chronic HIV

Question 4

psoriasis PRECIPITATING AGENTS

Answer 4

Infection
Trauma
Stress
ETOH
Systemic steroids-especially upon withdrawal
Beta blockers
Lithium
Antimalarials
Indomethacin

Question 5

psoriasis diagnosis

Answer 5

Differential Diagnosis: lichen simplex chronicus, nummular eczema, seborrheic dermatitis and tinea corporis
Punch Biopsy

Question 6

PSORIASIS: Chronic Plaque Type

Answer 6

Scalp
Extensor Surfaces: elbows, knees, presacral, nails
Palms and Soles: thick scale of the arch of the foot and the thenar and hypothenar palms

Question 7

PSORIASIS: Inverse Type

Answer 7

Intertriginous areas (Fold Areas): Gluteal fold, axillae, glans of the penis
Scale may not appear in these areas

Question 8

PSORIASIS: Guttate Type

Answer 8

Post streptococcal Infection
Usually Childhood, Young Adults
Eruptive Trunkal Dermatosis
Sudden onset of tear drip shaped 2 to 5 mm scaled spots of the trunk and proximal extremities
<2% of all psoriasis
Greater tendency toward spontaneous resolution

Question 9

PSORIASIS: Pustular Type

Answer 9

Generalized: Potentially life threating; Small pustules becoming generalized with fever
Localized: Hand and foot form involves the palms and soles. May be termed Pustular Psoriasis of Barber

Question 10

psoriasis treatment

Answer 10

topicals:
Steroid
Anthralin
Tar
Calciptriol
Retinoids
Tacrolimus

systemic:
Retinoids
Cyclosporin
PUVA/UVB/Narrow Band UVB
Methotrexate
Etanercept, Efalizumab, Alefacept

Question 11

psoriasis complications

Answer 11

Depression, anxiety, sexual dysfunction, poor, self-esteem, and suicidal thoughts may coexist from the cosmetic effects of the disease
Increased risk of non-melanoma skin cancers and lymphoma
Psoriatic Arthritis

Question 12

PSORIATIC ARTHRITIS

Answer 12

Inflammatory, seronegative arthritis with a variable course
Asymmetric and involves the fingers and toes
Prevalence: ~1/3 of patients with psoriasis

Question 13

LICHEN PLANUS

Answer 13

Chronic, inflammatory, autoimmune disease
Population: 0.1 to 4% general population
Gender: Females > Males; Perimenopausal women most often
Age: 30-60 years
Association with Hepatitis C (HCV)
Location: wrists, shins, mucous membranes, Wickham’s stria (lacy, reticular, white lines)
Diagnosed by Punch Biopsy

Question 14

Lichen Planus Histopathology

Answer 14

“Interface Dermatitis”: Dermatitis occurs at the junction of the epidermis with the dermis
Band of infiltration of dermis and perivascular areas with lymphocytes and histiocytes
Vascular degeneration at the D-E junction
Necrosis of keratinocytes
Saw Tooth Acanthosis
Immunofluorescence: shaggy deposits of IgM along the basement membrane zone (unlike lupus which would have IgG)

Question 15

LICHEN PLANUS (6 Ps)

Answer 15

Planar (flat topped)
Purple
Polygonal
Pruritic
Papules
Plaques

Question 16

LICHEN PLANUS: Linear (Classical)

Answer 16

Erythematous to violaceous polygonal papules especially on the flexor areas such as wrists and ankles
Genitalia frequently involved
Hallmark is development of Wickham’s Striae

Question 17

LICHEN PLANUS: Forms

Answer 17

Hypertrophic: very thick plaques of scale over the lichen planus especially over the extremities and extensor surfaces
Bullous: blisters that occur under the lichen planus due to the severe interface dermatitis
Scalp: Lichen Planopilaris-scarring alopecia of scalp due to lichenoid infiltrate

Oral: Can occur by itself or with classical LP but not common with drug induced; tender red patches especially buccal mucosa with a with surface (Wickham’s Striae) that does not wipe off like thrush

Question 18

SYSTEMIC LUPUS ERYTHEMATOSUS risk factors

Answer 18

More common in women
Most often diagnosed between ages 14-40
More common in African-Americans, Hispanics and Asians

labs:
CBC	
Sed Rate
Kidney/Liver tests
UA
ANA*

Question 19

SYSTEMIC LUPUS ERYTHEMATOSUS histopathology

Answer 19

Long term autoimmune disorder that may affect skin, joints, kidney, brain
Immunofluorencence: IgG at the basement membrane
Acute: Pauci-inflammatory interface dermatitis; prominent dermal edema and dermal mucin
Subacute: Prominent suprabasilar exocytosis of lymphocytes, prominent epidermal atrophy; lymphocytic infiltrate
Discoid: Very thick basement membrane, follicular plugging; Dense perivascular and peri-adenxal infiltrate

Question 20

ACUTE LUPUS ERYTHEMATOSUS

Answer 20

Photosensitive pattern of erythema
Butterfly rash across the nose and the cheeks
Red rash of the sun exposed upper chest and the extensor areas
May become bullous in these areas
May have non-specific features like digital infarcts, Raynaud’s Syndrome

Question 21

SUBACUTE CUTANEOUS LUPUS

Answer 21

Erythematous and usually scaling rash of upper trunk and extensor surfaces that is psoriasis plaque like form or annular polycyclic form
Due to SSA or SSB antibody

Question 22

CHRONIC CUTANEOUS LUPUS

Answer 22

Discoid Lupus: scarring lesions of skin (especially pinna)
Tumid Lupus: erythematous indurated plaques in sun exposed areas
Lupus Panniculitis: infiltration and destruction of adipose tissue, especially upper extremities, unlike erythema nodusum which is usually lower extremities
Verrucous Lupus: very thick hyperkeratotic discoid lupus like lesions that usually occur on the extensor sun exposed surfaces

Question 23

SLE

Answer 23

treatment:
NSAIDs
Antimalarials (Plaquenil)
Corticosteroids
Immunosuppressants-cyclophosphamide (Cytoxan), Azathaprine (Imuran)

triggers:
Sunlight
Medications (anti-seizure, antibiotics, BP Rx)

Question 24

NON-SPECIFIC SKIN LESIONS OF LUPUS

Answer 24

Vascular 50-70%: Telangiectasia, Vasculitis, Thrombophlebitis, Raynaud’s phenomenon, Livedo reticularis, ulcers, gangrene
Alopecia 40-60%: Frontal, Diffuse
Other: Urticaria, Mucous membrane, pigment changes