Dermatology II

Question 1

What is psoriasis?

Answer 1

Dermecated, scaly, erythematous plaques on skin
- Scalp, elbows, knees (nails, hands, feet, trunk)
- Chronic disorder —> polygenic and environmental
triggers
—> associated psoriatic arthritis
(nail involvement indicative)

Question 2

What are the clinical features of psoriasis?

Answer 2

• Red/pink skin patches
• White/silver scaly skin
• Itchy
• Sore

1. Plaque —> patches
2. Guttate —> dots
3. Pustular —> pussy bumps
4. Inverse —> rash in skin folds
5. Nail —> thick
6. Psoriatic erythroderma —> widespread red
7. Psoriatic arthritis

Question 3

What is the pathophysiology of psoriasis? (2)

Answer 3

1. Stressed keratinocytes —> release DNA/RNA
2. dDCs migrate to lymph nodes —> keratinocyte
   proliferation —> psoriatic plaque

Question 4

What are the 7 types of psoriasis?

Answer 4

1. Plaque —> patches
2. Guttate —> dots
3. Pustular —> pussy bumps
4. Inverse —> rash in skin folds
5. Nail —> thick
6. Psoriatic erythroderma —> widespread red
7. Psoriatic arthritis

Question 5

How is psoriasis managed via lifestyle?

Answer 5

1. Stop smoking
2. Stop alcohol
3. Controlling co-morbidities

Question 6

What is the therapeutic ladder for psoriasis treatment? (5)

Answer 6

1. Topical
   
   • Vit D analogues
   • Corticosteroids
   • Retinoids
   • Tacrolimus/pimecrolimus
2. Phototherapy
   
   • Narrowband UVB
   • PUVA (Psoralen + UVA)
3. Acitretin
4. Systemic Immunosuppression
   
   • Methotrexate
   • Ciclosporin
5. Advanced
   -PDE4 inhibitors —> apremilast
   
   • Biologics (anti-TNF-α, IL-17, -IL-23)

Question 7

What are the 4 topical therapies for psoriasis?

Answer 7

1. Vit D analogues
2. Corticosteroids
3. Retinoids
4. Tacrolimus/pimecrolimus

Question 8

What are the 2 phototherapies for psoriasis?

Answer 8

1. Narrowband UVB
2. PUVA

Question 9

What are the 2 systemic immunosuppressant therapies for psoriasis?

Answer 9

1. Methotrexate
2. Ciclosporin

Question 10

What are the 2 advanced therapies for psoriasis?

Answer 10

1. PDE4 inhibitors —> apremilast
2. Biologics
   
   • anti-TNF-α
   • anti-IL-17
   • anti-IL-23

Question 11

What is atopic eczema?

Answer 11

Pruritic (itchy), dry, cracked skin
- Chronic inflammatory condition —> complex genetic
- Starts —> infancy/early childhood

Question 12

What are the clinical features of eczema?

Answer 12

Itchy, dry, cracked, sore skin
- Infants —> acute inflammation (cheeks, scalp,
extensors)
Children/adults —> flexural inflammation
—> lichenification
- Fissuring —> skin cracks (fingers)
- Impetiginisation —> gold crust
- secondary staph. a infection
- Eczema herpeticum —> facial red dots
- HSV infection —> emergency
- Erythroderma —> widespread red (skin failure)

Question 13

What are the 6 types eczema?

Answer 13

1. Atopic eczema —> dark patches
2. Seborrhoiec dermatitis —> scalp (hair)
3. Venous stasis eczema —> varicose veins
4. Allergic contact dermatitis —> shaped red
5. Irritant contact dermatitis —> shaped crusting

Question 14

What is the pathophysiology of eczema? (2)

Answer 14

1. Barrier defect —> filaggrin binds keratin and
   filaments in corneocytes —> dec lipids + ceramides,
   inc TEWL
2. Immune dysregulation —> inc Th2, dec Th0

Question 15

How does atopic eczema present in infants?

Answer 15

Erythromatous oedematous papulaes and plaques
(possible vesiculation)

Question 16

When is atopic eczema a medical emergency?

Answer 16

Develops into eczema herpeticum (HSV infection)

Question 17

How is eczema treated via lifestyle?

Answer 17

1. Emollients (moisturisers)
2. No soap
3. Teaching —> topical application, habit reversal
4. Patch testing + biopsy
5. Controlling co-morbidities

Question 18

What is the therapeutic ladder for eczema treatment? (4)

Answer 18

1. Topical
   
   • Corticosteroids —> adjust potency to site:
     hydrocortisone - least
     clobetasone (eumovate)
     betamethasone (betnovate)
     mometasone (elocon)
     clobetasol (dermovate)
   • Tacrolimus/pimecrolimus
2. Phototherapy
   
   • Narrowband UVB
   • PUVA
3. Systemic Immunosuppression
   
   • Methotrexate
   • Ciclosporin
   • Azathioprine
4. Advanced
   
   • Biologics (anti-IL-4α, -IL-13)
   • JAK inhibitors

Question 19

What is the topical steroid ladder? (5)

Answer 19

1. Hydrocortisone
2. Clobetasone (eumovate)
3. Betamethasone (betnovate)
4. Mometasone (elocon)
5. Clobetasol (dermovate)

Question 20

What are the adverse effects of topical corticosteroids and how are they prevented?

Answer 20

Rare: skin atrophy, folliculitis, acne, rosacea, infection
V. rare: perioral dermatitis, tachyphylaxis, allergy
V.v. rare: hormonal issue (HPA axis), hirsuitism

1. Use topical calcineurin inhibitors —> no atrophy
2. Counselling —> prevent over/underuse
   - use FTU

Question 21

What are the 2 topical therapies for eczema?

Answer 21

1. Corticosteroids —> adjust potency to site:
   hydrocortisone - least
   clobetasone (eumovate)
   betamethasone (betnovate)
   mometasone (elocon)
   clobetasol (dermovate)
2. Tacrolimus/pimecrolimus

Question 22

What are the 2 phototherapies for eczema?

Answer 22

1. Narrowband UVB
2. PUVA

Question 23

What are the 3 systemic immunosuppressant therapies for eczema?

Answer 23

1. Methotrexate
2. Ciclosporin
3. Azathioprine

Question 24

What are the 2 advanced therapies for eczema?

Answer 24

1. JAK inhibitors
2. Biologics
   
   • anti-IL-4α (dupilumab)
   • anti-IL-13