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PECT > Derm (Psoriasis) > Flashcards

Derm (Psoriasis) Flashcards

1
Q

Epidemiology of psoriasis

A
  • Incidence between 1-3%, with greater incidence in Europe and North America than East and South-East Asia
  • Estimated 40,000 people in Singapore with psoriasis
  • Same incidence in males as in females
  • Bimodal distribution-75% have onset before age of 40
  • Two peak ages of onset at 20 -30 and again at 50-60
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2
Q

Psychosocial burden of psoriasis

A
  • 33% experience depression and anxiety
  • 10% attempt suicide
  • 1 in 5 report being rejected due to their condition
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3
Q

Eiology of psoriasis

A
  • Fam Hx/genetic: TNFa
  • Infections: B-hemolytic streptococci, HIV -> 2wks after viral of streptococci infection
  • Hormonal: early age of onset in females
  • psychogenic: stress
  • drugs: lithium, b-blockers (timolol)
  • Koebner phenomenon -> psoriasis developing after tattoo
  • smoking, alcohol, obesity might be factors too
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4
Q

Comorbidities assoc with psoriasis

A
  • crohn disease
  • psoriatic arthritis
  • depression, alcoholism
  • metabolic syndrome: CVD risk, obesity, HTN etc
  • increases rate of mortality
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5
Q

Clinical presentations of psoriasis

A
  1. Lesions: ertythematous, red-violet colour, at least 0.5cm in diameter, well demarcated, typically covered by silver flaking scales
  2. Skin involvement: knees, elbows (extensor distribution) or generalised over a wide BSA.
    Mild: <=5% BSA
    Mod: PASI >=8
    Sev: PASI >=10 or BSA >= 10%.
  3. Pruritis: >50% will experience
  4. Plaques raides from skin

Inverse psoriasis: affects flexor surfaces, no scales
Nail psoriasis: pitting, complete nail distrophy

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6
Q

What is guttate psoriasis?

A
  • Gutta (Greek)-a droplet
  • Commonest in childhood
  • 2 weeks post streptococcal (haemolytic group A) pharyngitis or tonsillitis
  • Centripetal distribution (mainly on torso then spread to arm and leg)
  • In children usually self- limiting
  • Approx. 40% develop chronic plaque psoriasis
  • look like chicken pox
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7
Q

What is psoriatic arthritis (PsA)?

A
  • An inflammatory arthritis associated with psoriasis
  • Rheumatoid factor negative
  • Rheumatoid nodules absent
  • Develops after onset of psoriasis (~10yrs ltr) but can appear first in some pts
  • TNF-a and HLA-CW6 is linked to PsA and psoriasis -> use of MTX + NSAIDs
  • Swollen-like inflammation in joints, severe deformity in hand joints
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8
Q

What are the goals of tx of psoriasis?

A
  1. Minimizing or eliminating the signs of psoriasis, such as plaques
  2. Alleviating pruritus and minimizing excoriations
  3. Reducing the frequency of flare ups
  4. Ensuring appropriate management of co-morbid conditions
  5. Avoiding or minimising adverse effects
  6. Providing cost-effective therapy
  7. Guidance and counselling as needed
  8. Maintain or improving the patient’s quality of life
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9
Q

What to counsel to patients with psoriasis?

A
  • nature of disease (chronic skin disorder?)
  • no cure
  • treatment is suppressive, not curative
  • not contagious
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10
Q

What are the non-pharm management of psoriasis?

A
  • stress reduction
  • moisturisers
  • oatmeal baths
  • sunscreens
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11
Q

Overview of pharm management strategies for psoriasis (excluding biologics)

A

Mild (75%): TOP CS, TOP Vitamin D3 analogue, Tazarotene, Dithranol, Coal tar, Keratolytic (eg. salicylic acid), emollients

Mod: PUVA or UVB phototherapy

Severe: hydroxyurea, MTX, cyclosporin, aeitretin

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12
Q

Treatment algorithm for mild-mod psoriasis

A

first line: topical agents
if ineffective: topical agents + phototherapy.
If ineffective: topical agents + systemic agents

All of them shld add on moisturiser too.

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13
Q

What topical corticosteroids is used for psoriasis?

A

hydrocortisone 1% or 2.5%: cream, lotion, ointment

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14
Q

What is the use of vitamin D3 analogues in psoriasis?

A
  • First line monotherapy or in combination regimens
  • Effective as all but the most potent TCS
  • Calcipotriol, calcitriol, tacalcitol
  • Binding to vitamin D receptors which results on inhibition of keratinocyte proliferation and enhancement of keratinocyte differentiation
  • Inactivated by salicylic acid
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15
Q

What are the side effects of vitamin D3 analogues?

A
  • common: mild irritant contact dermatitis, burning, pruritis, edema, peeling, dryness, erythema
  • systemic: hyperCa, parathyroid hormone depression, impaired renal func, impaired Ca metabolism
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16
Q

What is the use of retinoids in psoriasis?

A
  • Tazarotene acts by normalising abnormal keratinocyte differentiation, diminishing keratinocyte hyperproliferation and clearing the inflammatory infiltrate in the psoriatic plaque
  • Tazarotene 0.1% gel has similar efficacy to Calcipotriol 0.05% cream but less effective than Clobetasol propionate 0.05% cream
  • Tazarotene may be combined with TCD to increase efficacy
  • Tazarotene-apply once a night and avoid sun exposure
  • Tazarotene is contraindicated in pregnancy unless effective contraception is used at the same time
17
Q

What are the side effects of tazarotene?

A
  • high incidence of irritation at site (can be reduced by using cream formulation or low conc)
  • burning
  • itching
  • erythema
18
Q

What is the use of coal tar in psoriasis?

A
  • keratolytic, anti-proliferative, may have anti-infl.
  • bethamethasone valroate more effective altho coal tar has similar efficacy to calcipotriol.
  • conc of 0.5% - 5% is considered safe
  • not well accepted due to black appearance, smell, staining of clothes
  • limited efficacy
  • SE: acne, local irritation, phototoxicity
19
Q

What is the use of salicylic acid in psoriasis?

A
  • keratolytic properties
  • use with combi of TCS as it helps enhance steroid penetration into skin, increasing efficacy
  • not used w UVB light phototherapy due to filtering effect of SA that reduces efficacy of phototherapy
  • Salicylic acid 2-3% is used for psoriasis

Note: 15-27% for viral warts and corns. 0.5% for acne as cleanser

20
Q

What is the use of phototherapy and photochemotherapy?

A
  • used w crude coal tar
  • treat psoriatic lesions
  • PUVA is more effective than UVB but risk of skin cancer is higher so is less used
21
Q

Treatment algorithm for mod-sev psoriasis

A

First line: systemic agent +/- TOP agent or phototherapy, consider BRM (costly) if comorb exists
If ineffective: more potent systemic agent
If ineffective: biological response modifier (BRM) +/- other agents

Moisturisers shld be used tgt for all.

22
Q

What systemic treatments are available?

A
  1. Acitretin
  2. MTX
  3. Biologics (eg. Infliximab, Tofacitinib)
23
Q

What is the use of acitretin and its SE in psoriasis

A
  • less effective than MTX when used as monotherapy but initial response may be more rapid for severe psoriasis
  • replaced with isotretinoin now due to SE
  • teratogenic unless birth control is used and 2yrs after discontinuing
  • alcohol shld be avoided and after 2months of discontinuation

SE: nail thinning, diffuse hair loss, dryness of eye, chapped lips, angular cheilitis, xerosis, burning. Less common: retinoid dermatitis, decreased colour vision, photosensitivity

24
Q

What is the use of MTX in psoriasis?

A
  • more efficacious than acitretin and similar efficacy to cyclosporine.
  • direct anti-infl effect due to effect on T-cell gene expression
  • slow down growth of skin cells to stop scales
  • inhibit folate biosynthesis

Other conditions which MTX is used to treat: atopic eczema, bullous pemphigoid, psoriasis

25
Q

What is the use of biologics for psoriasis?

A
  • esp if comorb exists
  • can be considered as 1st line in mod-sev psoriasis
  • infliximab is one of the more efficacious drug. clears in 10wks
  • tofacitinib dose: 5mg/day PO

PECT (17 decks)

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