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medical dermatology casey > Eczema, prurigo, LSC, PsO > Flashcards

Eczema, prurigo, LSC, PsO Flashcards

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USMLE® Step 1 flashcards Dermatology Board Prep flashcards
1
Q

List pathophys factors for AD

A 
Genetic - fillagrin (AD)
Genetic - immune dysfunction syndromes (PAWHANAH)
Immune dysregulation - Th2 cell mediated - IL13, IL4, IL31
Hygiene hypothesis
Atopic march 
Environmental - allergens/irritants
Microbiome, gut flora
Food allergy
Breastfeeding
Barrier dysfunction
Infection - staph, HSV
Pruritus, scratching induced skin dammage + inflammation (itch scratch cycle)
Climate
Stress
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2
Q

ATopic dermatitis associations

A

ASthma, hay fever, allergic rhinitis, food allergy, contact dermatitis
Autoimmune - vitiligo, AA, chronic urticaria, RA, IBD, coeliac, thyroid

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3
Q

Clinical features of AD

A

Fillagren mutation (hyperlinear palms, ichthyosis, KP)
ITCH is key for all + erythema, lichenification, oedema/induration, excoriation
Subdivide into age groups:
- infants - (<2 years) - initially on cheeks, then becomes extensor surfaces before flexural; sparing of napkin area (moisture)
- children - flexural pattern, atopic dirty neck (reticulate pigmentation)
- adults similar to late childhood - lichenification

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4
Q

What are the severity scores for AD

A

SCORAD, EASI, global score, DLQI

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5
Q

Explain EASI

A

Score H+N, UL, Trunk, LL

  • Erythema, Oedema, Lichenification, Excoriation (0-3)
  • x site factor (0.1, 0.2, 0.3, 0.4)
  • area % - 0, 1-9, 10-29, 30-49, 50-69, 70-89, 90-100
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6
Q

Explain SCORAD

A

A, B + C scores (A/5 + 7B/2 + C)
A = total % SA (rule of 9s)
B = 0-3 score for representative area (RO SOLD - Red, ooze, scratch, oedema, lichenification, dryness)
C= VAS for itch 0-10

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7
Q

Complications of AD

A
  • Psychological, poor sleep, poor concentration, depression, suicidality, poor self-esteem, social isolation
  • stunted growth
  • medication complications - steroid induced/ immunosuppression
  • infection (staph, strep, HSV, molluscum, warts)
  • non-cutaneous infections - strep throat, UTI, endocarditis, otitis
  • ocular - blepharitis, conjunctivitis, keratoconjunctivitis, keratoconus, cataracts, glaucoma
  • lymphoma
  • food allergy, contact dermatitis
  • AA, urticaria
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8
Q

Prognosis of AD including prognostic factors

A

-60% childhood cases resolve by adolescence
- 25% of cases will relapse though during adulthood
- In general:
– persistent (20%)
– intermittent (40%)
– remitting (40%)
Poor Prog Factors:
- early onset
- severe disease
- poorly controlled disease
- FHx atopy
- high IgE
- fillagrin mutation

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9
Q

What Ix in AD?

A 
Bx if unclear
Swabs/scrapings
IgE, RAST/specific IgE
Skin prick testing
Allergy patch testing
Pre-tx investigations
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10
Q

Any ways of minimising risk of AD in an infant?

A

No evidence for pregnancy diet, duration of breastfeeding etc
Just daily emollients from birth

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11
Q

General mx considerations in AD

A

Education
Photographs
Liaise w GP
Support psychology/ support groups
Modify triggers (heat, stress, allergy/irritant contact, infection, environment)
Address sleep + itch (antihistamines, behavioural)
General measures (soap avoidance, regular emollient)
Treat secondary infection, maintainance antimicrobial (nasal, bleach, condys)
Ocular
Skin topicals - TCS, tacrolimus, JAK, PDE4 (crisaborole)
Wet wrap
skin physical - ILCS, nbUVB, UVA-1
skin systemics - Pred, CsA, MMF, Mtx, Aza, dupilumab, omalizumab, ustekinumab, bunch of newbies
Follow up, monitor complications

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12
Q

Biologics in AD

A 
Dupilumab (4, 13)
Omalizumab (little evidence)
Ustekinumab (variable ev)
baricitinib (JAK)
nemolizumab (IL31)
lebrikizumab (IL13)
tralokinumab (IL13)
fezakinumab (IL22)
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13
Q

Diagnostic criteria for AD

A 
itchy skin + 3 or more of:
OCDAF
- onset < 2 years
- Crease involvement/cheeks
- dry skin
- atopy
- flexural dermatitis
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14
Q

Consider excluding immunodefiency in setting of eczema if:

A 
FETALL POO
failure to thrive
erythroderma
Thrombocytopenia
Alopecia
Lymphopenia
Large + multiple LNs
Parental cosanguinity
Onset in neonatal period
Opportunistic infection
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15
Q

What is the maximum EASI score?

A

72

PASI also 72 max score

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16
Q

Approach to pruritus in CKD patients - Mx

A 
general skin measures
parathyroidectomy if high PTH
phototherapy
reduce phosphate/ normalise Ca/Phosphate balance
topical capsaicin
topical tacrolimus
thalidomide
17
Q

Approach to pruritus in hepatobiliary disease

A 
Note that can be localised hands/feet
general measures
Phototherapy
cholestyramine, ursodeoxycholic acid
naltrexone
sertraline
18
Q

Features of itch associated w PCV

A

aquagenic (onset 15-60 mins exposure to water)

19
Q

Pruritic screen

A 
Skin bx + DIF  +/- culture
FBC
ELFTs
Iron studies
TFTs
IgE
anti-skin ab's
serum EPP, blood film
Strongyloides
Hep B/C
LDH
Glucose
Age-appropriate malignancy screen
Other - ANA, tryptase, PTH, calcium, coeliac abs, H pylori
20
Q

General measures for itchy patient

A 
Avoid triggers (dry skin, irritants, hot/spicy food, alcohol, stress)
Soap free wash
Lukewarm shower (not hot), not prolonged
soft permeable clothing
regular moisturiser
urea, menthol
wet/cool wraps
21
Q

Symptomatic tx for pruritic patients

A 
TCS, topical calcineurin
ILCS
Topical doxepin
Phototherapy
Antihistamines
Doxepin
Naltrexone
Thalidomide
22
Q

Mx prurigo nodularis

A 
General measures
TCS, calcinurin, calcipotriol
capsaicin 0.025%
phototherapy
systemic anti-itch/ psych
naltrexone
Thalidomide
gabapentin
SSRIs/ SNRIs
Immunomodulatory (CsA, mtx)
Nemolizumab (IL31)
Topical ketamine 5-10% + amitriptyline 5% + lidocaine 5%
23
Q

Epidemiology of chronic plaque psoriasis

A

Bimodal - 16-22 + 57-62

M=F though M more likely to have severe disease

24
Q

Genetics of Psoriasis

A

PSORS1-9 (majority PSORS1 on chromosome 6p)
HLA-C = major risk allele (MHC class I antigen)
CARD14 (clinical overlap PsO + PRP - CARD14-associated papulosquamous eruption)

25
Q

Pathophysiology of PsO

A

multifactorial

  • genetic (PSORS1-9)
  • infection - strep, hepatitis C, HIV
  • drugs - ALAN has a Big BIT of Psoraisis (ACEi, lithium, antimalarials, NSAIDs, B Blockers, Benzos, IFN-Y, TNFi, Pred withdrawal)
  • alcohol
  • obesity
  • smoking
  • psychological stress
  • UV (for 10%)
  • microbiome
  • trauma (Koebnerising)
  • immune dysregulation - Th2, IL17, IL23, IL12, TNF, IL22
26
Q

Associations w PsO

A
  • malignancy (solid organ + haematological)
  • autoimmune - LP, AA, thyroid, IBD, coeliac, RA, HS
  • metabolic syndrome - T2DM, HTN, hyperlipidemia, obesity, IHD, CVD
  • —– BSA > 10% have 60% increased risk of T2DM per year
  • PSYCH impact/ complications
27
Q

Clinical features

A

Symmetrical, majority somewhat itchy, well demarcated erythrosquamous plaques with silvery scale - Auspiz sign with removal of scale, Woronoff ring
Typical distribution - Scalp, extensor surfaces, lower leg, natal cleft
Scalp can show pityriasis amiantacea, may be sebopsoriasis
Geographical tongue
Eyes - blepharitis, conjunctivitis (uveitis)
Joints may show signs of PsA
Nails - pitting, crumbling, leukonychia red dots in lunulae, splinter haemorrhages, salmon oil drops, subungual hyperkeratosis, onycholysis, onychomadesis, nail dystrophy
Genitals occurs in 40% - Glans penis, Vulval involvement
Palmoplantar - sharp demarcation, no vesicles
Clinical variants

28
Q

What are the clinical variants of Psoriasis?

A 
Guttate
Small plaque
Large plaque
Flexural / inverse
Erythrodermic 
Pustular
Palmoplantar
Rupioid (limpet-like)
Ostraceous (oyster-shell like)
Linear/segmental
29
Q

What Ix will you perform in suspected PsO

A

To confirm the diagnosis/exclude DDx

  • usually clinical, consider PBx for histology if atypical
  • scraping for fungal m/c/s

To check for triggers
- throat swab m/c/s, ASOT/AntiDNAse B

To check for associations

  • HbA1c, OGTT, bp, lipids/triglyc, weight, urine Pr:Cr
  • ESR, CRP, RF, anti-CCP, xrays

Baseline pre-Ix
- FBC, ELFTs, Hep B/C/HIV, Strongyloides, MMR serology, varicella serology, B-HCG

30
Q

What are the histo changes in PsO

A
  • psoriasiform, regular acanthosis of the epi
  • thinning of the suprapapillar plates
  • can be scattered parakeratosis
  • neuts in the S corneum
  • Munro microabscesses
  • spongiform pustules of Kogij
  • tortuous + dilated papillary capillaries
31
Q

Maximum score of PASI

A

72

medical dermatology casey (13 decks)

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