Eczema & Psoriasis Flashcards
1
Q
In what proportion of children does eczema occur?
A
15-20%
2
Q
At what age does eczema typically present in children?
A
typically before 6 months
3
Q
When does the majority of childhood eczema clear?
A
clears in 50% of children by age 5
clears in 75% of children by age 10
4
Q
In younger children and infants what are 3 areas typically affected by eczema?
A
- Face
- Trunk
- Extensor surfaces
5
Q
What areas of the body are affected by eczema in older children?
A
more typical distribution: flexor surfaces and creases of face and neck
6
Q
What are 4 steps of the management of eczema in children?
A
- Avoid irritants
- Simple emollients: large quantities should be prescribed
- Topical steroids
- In severe cases: wet wraps and oral ciclosporin
7
Q
What is an example of the amount of emollient which may be prescribed for children?
A
250g/ week with ratio to steroid 10:1
8
Q
What is the guidance on which steroid cream to use for eczema?
A
use the weakest steroid cream which controls patients’ symptoms
9
Q
What are the 4 strenghts of topical steroids and examples of each?
A
- Mild: hydrocortisone (0.5-2.5%)
- Moderate: eumovate + betnovate RD
- Potent: betnovate + cutivate
- Very potent: dermovate
10
Q
What is the mild topical steroid that is used for eczema?
A
hydrocortisone 0.5-2.5%
11
Q
What are 2 types of moderate topical steroid used for eczema?
A
- Betamethasone valerate 0.025% (Betnovate RD)
- Clobetasone butyrate 0.05% (Eumovate)
12
Q
What are 2 types of potent steroid cream used for eczema?
A
- Fluticasone propionate 0.05% (Cutivate)
- Betamethasone valerate 0.1% (Betnovate)
13
Q
What is a very potent topical steroid used for eczema?
A
Clobetasol propionate 0.05% (Dermovate)
14
Q
What is a finger tip unit?
A
= 0.5g = sufficient to treat a skin area about twice that of the flat of an adult hand
15
Q
What finger tip units can be used for the hand and fingers (front and back)?
A
1
16
Q
What finger tip units can be used for the adult foot (all over)?
A
2.0
17
Q
What finger tip units of steroid cream can be used for the adult front of check and abdomen?
A
7.0
18
Q
What finger tip units of steroid cream can be used for the adult back and buttock?
A
7.0
19
Q
What finger tip units of steroid cream can be used for the adult face and neck?
A
2.5
20
Q
What finger tip units of steroid cream can be used for the adult entire arm and hand?
A
4.0
21
Q
What finger tip units of steroid cream can be used for the adult leg (entire) and foot?
A
8.0
22
Q
What does the BNF is the recommended quantity of topical steroids that should be prescribed for an adult for single daily application to the face and neck for 2 weeks?
A
15-30g
23
Q
What does the BNF is the recommended quantity of topical steroids that should be prescribed for an adult for single daily application to both hands for 2 weeks?
A
15-30g
24
Q
What does the BNF is the recommended quantity of topical steroids that should be prescribed for an adult for single daily application to the scalp for 2 weeks?
A
15-30g
25
What does the BNF is the recommended quantity of topical steroids that should be prescribed for an adult for single daily application to both arms for 2 weeks?
30-60g
26
What does the BNF is the recommended quantity of topical steroids that should be prescribed for an adult for single daily application to both legs for 2 weeks?
100g
27
What does the BNF is the recommended quantity of topical steroids that should be prescribed for an adult for single daily application to the trunk for 2 weeks?
100g
28
What does the BNF is the recommended quantity of topical steroids that should be prescribed for an adult for single daily application to the groin and genitalia for 2 weeks?
15-30g
29
What are 5 prognostic markers for severe eczema?
1. Onset at age 3-6 months
2. Severe disease in childhood
3. Associated asthma or hay fever
4. Small family size
5. High IgE serum levels
30
What are 4 aspects of the management of eczema in adults?
1. Emollients
2. Topical steroids
3. UV radiation
4. Immunosuppressants e.g. ciclosporin, antihistamines and azathioprine
31
What are 3 types of immunosuppressants that can be used for the management of adult eczema?
1. Ciclosporin
2. Antihistamines
3. Azathioprine
32
What is eczema herpeticum?
severe primary infection of the skin by herpes simplex virus 1 or 2
33
In what patient group is eczema herpeticum more commonly seen?
children with atopic eczema
34
How does eczema herpeticum often present?
rapidly progressing painful rash
35
What is usually seen on examination of eczema herpeticum?
monomorphic punched-out erosions (circular, depressed, ulcerated lesions) usually 1-3 mm in diameter
36
What is the management of eczema hepeticum?
admit for IV aciclovir (life-threatening)
37
What is the prevalence of psoriasis?
2%
38
What 2 things are patients with psoriasis at increased risk of?
arthritis and cardiovascular disease
39
What are 3 things involved in the multifactorial pathophysiology of psoriasis?
1. Genetic
2. Immunological
3. Environmental
40
What are 3 genes associated with psoriasis?
1. HLA-B13
2. HLA-B17
3. HLA-Cw6
41
What is the role of immunology in the pathophysiology of psoriasis?
* abnormal T cell activity stimulated keratinocyte proliferation
* increasing evidence this is mediated by group of T helper cells, Th17, producing IL-17
* third effector cell subset in addition to Th1 and Th2
42
What are 4 environmental factors that can influence psoriasis?
1. Skin trauma
2. Stress
3. Streptococcal infection (can trigger)
4. Sunlight (can improve)
43
What are the 4 recognised subtypes of psoriasis?
1. Plaque psoriasis
2. Flexural psoriasis
3. Guttate psoriasis
4. Pustular psoriasis
44
What is the most common subtype of psoriasis?
plaque psoriasis
45
What is the presentation of plaque psoriasis?
well-demarcated red, scaly patches affecting the extensor surfaes, sacrum and scalp
46
What is the appearance of flexural psoriasis?
in contrast to plaque psoriasis, the skin is smooth
47
What is the appearance of guttate psoriasis?
multiple red, teardrop lesions appear on body - trunk and limbs
48
What is the cause of guttate psoriasis?
it is a transient rash frequently triggered by a **streptococcal infection** 2-4 weeks prior to lesions
49
Where does pustular psoriasis affect?
commonly occurs on the palms and soles
50
What are 2 features commonly also seen with psoriasis?
1. Nail signs: pitting, onycholysis
2. Arthritis
51
What are 5 complications of psoriasis?
1. Psoriatic arthropathy (around 10%)
2. Increased incidence of metabolic syndrome
3. Increased incidence of cardiovascular disease
4. Increased incidence of venous thromboembolism
5. Psychological distress
52
What are 4 things that can exacerbate psoriasis?
1. Trauma
2. Alcohol
3. Drugs: beta blockers, lithium, antimalarians, NSAIDs, ACEis, infliximab
4. Withdrawal of systemic steroids
53
What are 6 drugs which can exacerbate psoriasis?
1. Beta blockers
2. Lithium
3. Antimalarials (chloroquine and hydroxychloroquine)
4. NSAIDs
5. ACE inhibitors
6. Infliximab
54
What are 4 steps to the management of **chronic plaque psoriasis?**
1. **First line:** potent *corticosteroid* once daily plus *vitamin D* *analogue* applied once daily
2. **Second line:** if no improvement after 8 weeks, offer *vitamin D analogue twice daily*
3. **Third line:** if no improvement after 8-12 weeks offer either: *potent corticosteroid applied twice daily* for up to 4 weeks or *coal tar preparation* applied once or twice daily
4. Short-acting **dithranol**
55
What is the first line management of psoriasis?
* **potent** **corticosteroid** once daily plus **vitamin** **D analogue** applied once daily
* apply separately, once in morning and other in the evening
* for up to 4 weeks
56
How long should the first line treatment for psoriasis be applied?
up to 4 weeks
57
What is the second-line management for psoriasis?
if no improvement after 8 weeks then offer a **vitamin D analogue twice daily**
58
What are 2 options for third line management of psoriasis?
if no improvement after 12 weeks offer either:
1. potent corticosteroid applied twice daily up to 4 weeks
2. coal tar preparation applied once or twice daily
59
What are 3 examples of topical vitamin D analogues?
1. Calcipotriol (Dovonex)
2. Tacalcitol
3. Calcitriol
60
What are 4 possible negative effects of using steroids in psoriasis?
1. skin atrophy
2. striae
3. rebound symptoms
4. systemic side effects when potent on large areas (\>10% of body surface area)
61
What are 2 recommendations from NICE about using topical steroids in psoriasis?
1. aim for 4 week break before starting another course of topical corticosteroids
2. recommend using **potent** coricosteriods for no longer than **8 weeks** at a time and **very potent** corticosteroids for no longer than **4 weeks** at a time
62
How do vitamin D analogues work to treat psoriasis?
reduce cell division and differentiation
63
How common are adverse effects with vitamin D analogues?
uncommon
64
What are is an advantage of vitamin D analogues over corticosteroids?
can be used long term
65
What is an advantage of vitamin D analogues over coal tar and dithranol?
do not smell or stain
66
viWhat is the action of vitamin D analogues in psoriasis?
reduce scale and thickness of plaques but not erythema
67
When should vitamin D analogues be avoided?
pregnancy
68
What is the maximum weekly amount of vitamin D analogues for adults?
100g
69
What are 2 areas of psoriasis tha tsteroids are useful to treat?
flexural psoriasis and facial psoriasis (mild steroids)
70
If steroids are ineffective for psoriasis what are 2 things that should be used second line?
1. vitamin D analogues or
2. tacrolimus ointment
71
What are 3 places that the skin is particularly prone to steroid atrophy?
1. Scalp
2. Face
3. Flexures
72
How long should topical steroids be used on the face, scalp and flexures?
no more than 1-2 weeks/ month
73
What are 2 things recommended by NICE for scalp psoriasis?
1. potent topical corticosteroids once daily for 4 weeks
2. if no improvement: either different formulation of potent corticosteroid (e.g. shampoo or mousse) and/or topical agent to remove adherent scale (e.g. containing salicylic acid, emollients and oils) before application of potent corticosteroid
74
What do NICE recommd fo the management of face, flexural and genital psoriasis?
mild or moderate potency corticosteroid, once or twice daily for maximum 2 weeks
75
What are 7 aspects of secondary care management of psoriasis?
1. Phototherapy - UV B light
2. Photochemotherapy - psoralen + UVA (PUVA)
3. Oral methotrexate
4. Ciclosporin
5. Systemic retinoids
6. Biological angets: infliximab, etanercept, adalimumab
7. Ustekinumab (IL-2 and IL-23 blocker) - ni trials
76
What is the first line type of phototherapy which can be used for psoriasis in secondary care?
ultraviolet B light 3x a week
77
What are 2 adverse effects of phototherapy for psoriasis?
1. Skin ageing
2. Squamous cell cancer (_not_ melanoma)
78
What is the first line systemic therapy provided in secondary care for psoriasis?
oral methotrexate
79
What is a situation when oral methotrexate is particularly useful to treat psoriasis?
if associated joint disease
80
What is the mechanism of action of coal tar to treat psoriasis?
inhibits DNA synthesis
81
What is the mechanism of action of calcipotriol to treat psoriasis?
reduces epidermal proliferation and restores a normal horny layer
82
What is the mechanism of action of dithranol?
inhibits DNA synthesis, wash off after 30 mins
83
What are 2 side effects of dithranol?
burning
staining
84
What age group is guttate psoriasis common in?
children and adolescents
85
What are 5 aspects of the management of guttate psoriasis?
1. Most cases resolve spontaneously in 2-3 months
2. no firm evidence to support use of antibiotics to eradicate strep infection
3. topical agents as per psoriasis
4. UVB phototherapy
5. tonsillectomy if recurrent episodes
86
pitWhat is the typical appearance of pityriasis rosea?
herald patch followed 1-2 weeks later by multiple ertyehmatous slightly raised oval lesions with fine scale confined to outer aspects of the lesions
may follow distribution with longitudinal diameters of oval lesions running parallel to line of Laner - fir tree appearance
87
What sometimes precedes pityriasis rosea?
recent respiratory tract infections
88
What is the typical course of pityriasis rosea?
usually disappears after 6-12 weeks, self-limiting
89
Where is the herald patch for pityriasis rosea usually located?
on trunk
90
What infective agent is thought to maybe play a role in pityriasis rosea?
herpes hominis virus 7 (HHV-7)
91
Which age group is typically affected by pityriasis rosea?
young adults
