Lecture 5 - Dermatology 2 Flashcards
tell tale sign of psoriasis
erythematous papule and plaques with silver scale
Psoriasis risk factors
Genetic predisposition
Environmental Triggers, infection, stress
Medications
Smoking
Obesity & higher BMI in adults and children
Vitamin D deficiency
exacerbating factors for psoriasis
Drugs = BB< lithium, antimalarial meds, ACEi, NSAIDs
Infections, bacterial and viral
Alcohol abuse
Exacerbating comorbidities for psoriasis
CVD
Malignancy
Diabetes
HTN
Metabolic syndrome
IBD
Patients with psoriasis are at increased risk for…..
CV events
Clinical presentation of plaque psoriasis
symmetrically distributed plaques
*sharply defined margins raised above surrounding normal skin
Tick, silvery scale is usually present
Auspit’z sign
1-10cm in diameter
typically asymptomatic, may have itching
Nail psoriasis
most often noted after onset of disease
involvement of nail Matrix or nail bed
nail pitting
Leukonychia
typically req system therapy or sublingual injections
How is severity of psoriasis assessed?
Based on %% of body surface area
Desired outcomes of psoriasis?
minimize or eliminate signs of psoriasis
Alleviate pruritus if present
Reduce frequency & flare ups
Avoid/minimize ADE
cost effective therapy
approve QOL
Non-pharm psoriasis therapy
Stress reduction
Using moisturizers
Oatmeal baths
sunscreen 30+ SPF
Avoidance of irritants
Avoidance of offending agents
Psoriasis: topical corticosteroid therapy
Mainstay of therapy
Location, age, plaque thickness taken into consideration
usually BID
Lower potency Topical steroid used for….
infants and lesions on the face, intertriginous areas (rub together) and area with thin skin
ex. Hydrocortisone 0.5-2.5% cream
Mid-high potency topical steroid used for….
most areas generally recommended
ex. Betamethasone valerate 0.12% ointment
Ultra-High potency topical steroid use for….
very thick plaques or recalcitrant disease
ex. Clobetasol 0.05% cream
Treatment of choice for mild-mod psoriasis…..
Topical corticosteroids
less ADR, QD-BID
Topical Vit D analogs info
inhibit keratinocyte proliferation and enhancement of keratinocyte differentiation
immunosuppressive properties
comparable to group 3 steroids, but more $$ & irritating
Calcitriol < Calcipotriene irritation
Vitamin D analog Safety
Photosensitivity and inc risk of UV-induced skin tumors
Acute psoriatic eruption of scalp can occur
topical solution and foam are flammable
Safe in peds
Vitamin D analog tolerability
Hypercalcemia is concern w/ higher doses (>100g/week)
can worsen psoriasis, cause skin irritation
Topical Vitamin D analog efficacy
Calcipotriene as effective as TCS but more ADR
Greatest efficacy when combo w/ betamethasone
Vitamin D analog clinical pearls
used in combo w/ TCS
inactivated by UVA, apply after not before exposure
BID application, not more than 30% BSA
Tazarotene info
Retinoid
limited absorption, but irritation is major issue and limits use
irritation is dose dependent
therapeutic benefit can persist up to 12weeks after stopping
Tazarotene safety
Preg X
Photosensitivity
Tazarotene Tolerability
Inc sensitivity to environmental factors
Skin burning, stinging, irritation
Tazarotene efficacy
50% improvement in symptoms at 12 weeks in 50% of treated pts
Tazarotene clinical pearls
used with TCS for inc efficacy and tolerability
use lower strength cream and combo with moisturizer
alternate days to reduce irritation
used QD
Other treatment options for psoriasis
Anthralin = V irritating, have to do short contact regimen
Coal Tar = stain and small, used at night
Salicylic Acid = avoid combo w/ calcipqotriol, phototherapy, > 20% BSA, renal impairment, children
Using topical calcineurin inhibi for psoriasis
not FDA approved
Not as effective so not really used
Excimer Laser
Faster responses
Can cause tanned spots on skin
high doses of UVA light to certain spots
Biologic agents used in which psoriasis patients
moderate to severe plaque type
good short/long term
Enbrel (Etanercept)
Approved for PsA and moderate to severe psoriasis
Give 50mg SQ BIW for 1st 12weeks, then 25/50mg QW
efficacious children 4-17 dosed 0.8mg/kg (50mg max) QW
Humira (Adalimmab)
rapid and efficacious control of psoriasis and PsA, can see improvement in 1st week
dose: 80mg SQ once, then 40mg SQ QOW
effective alternative for pts who fail to respond to Enbrel
Remicade (Infliximab)
more efficacious than Entanercept
Given Iv infusion over 6 weeks, then every 8 weeks
Rapid response
Rare but serious ADE = highest risk for TB, Bacterial/viral/invasive fungal infection, Fatal cases of hepatosplenic T-cell lymphomas
Cimzia (Certolizumab Pegol)
Dosed QOW
Mild ADR = nasopharyngitis & URI
$$$
relatively safe in pregnancy
TNF Alpha-inhibitors efficacy
Adalimumab = dec after 12 weeks
Etanercept = going from BIW -> QIW = less therapeutic effect
Infiximab = greatest dec symptoms shortest time
TNF-alpha inhibitor clinical pearls
combo w/ methotrexate = lower likelihood of resistnace
$$$$$
Dont sue w/ live vaccines as immune response can be compromised
Otezla (Apremilast)
PDE-4 inhibitor, inhibit TNF-a production
ADR mental = depression, suicidial ideation, mood changes = probs dont use
Titrate up to 30mg BID, reduce dose if CrCl < 30
Otezla (Apremilast) Efficacy & Peals
appears to be less effective than TNF-a inhibitor
Oral admin w/ minimal DI and ADR GI concern
IL-17 inhibitors
Cosentyx (Secukinumab)
Taltz (Ixekizumab)
Siliq (Brodalumab)
IL-12/23 inhibitors
Stelara (Ustekinumab)
Tremfya (Guselkumab)
Illumya (Tildrakizumab)
Skyrizi (Risankizumab)
Cosentyx (Secukinumab) info
Possible anaphylaxis and inc in infection rate
Greater efficacy for mod/severe plaque psoriasis than ustekinumab
Less long-term efficacy than guselkumab
Dosed: QW for 4 weeks, then Q monthly
Taltz (Ixekizumab) info
Dosed Q2 wks for 12 wks, then Q4wks
SE: neutropenia
More efficacy than etanercept
Siliq (Brodalumab)
Dosed: QWkly X 3, then Q2weeks
REMS for suicidal ideation & Box warning**
higher likelihood of complete remission than ustekinumab
SE: arthralgia, suicidal ideation, cryptococcal meningitis, candida infections
Stelara (ustekinumab) info
efficacy persistent over time
May worsen PsA for some pts
More major CV events reported**
Tremfya (Guselkumab)
SE: tinea, HSV infection
effective pts who had inadequate responses to ustekinumab
Alumna (Tildrakizumab)
Dosed: week 0/4 nd then every 12
superior to etanercept
antibody development w/ minimal impact on efficacy
Skyrizi (Risankizumab)
Dosed week 0/4 and then every 12
greater efficacy than ustekinumab and adalimumab
higher likelihood of antibody development effecting efficacy
IL inhibitor general info
All shown efficacy over etanercept but $$
Acitretin info
oral retinoid
utilized for sever psoriasis
can be used with UVB or PUVA therapy or topical calcipqotriol
Less effective used alone
Efficacy dose dependent, 50mg optimal
Bunch of ADRs, BW
Acitretin pregnancy info
Category X
pregnancy contraindicated for 3 years after D/c
No blood donations from men/women for atleast 3 years after
Acitretin in females of child-bearing age
two negative preg test
repeat test monthly during therapy, Q3 months 3yrs after therapy
2 forms of Birth control starting 1 month before and 3 years after therapy
cant drink during therapy and 2 months after D/c
Acitretin in females of child-bearing age
two negative preg test
repeat test monthly during therapy, Q3 months 3yrs after therapy
2 forms of Birth control starting 1 month before and 3 years after therapy
cant drink during therapy and 2 months after D/cMethotrexate info
Methotrexate info
Should be given with folic acid sup daily**
more effective than acitretin, similar to cyclosporine w/ less ADR
given Weekly
BW, Preg X, and 6 months females and 3 months before conception…both have to use contraception
CI in Breastfeeding too
Mild-moderate psoriasis treatment algorithm
- Mild to mod TCS
- trial of topical Vit D analog or retinoid alone or w/ TCS..combo recommended
- Trial of phototherapy or oral systemic agent
- consider moderate-severe disease therapy
Step down therapy to lowest therapy that maintains control of symptoms
Moderate to severe psoriasis treatment algorithm
- high-V high potency TCS + vitamin D analog/retinoid
- Add systemic agent ( IL/TNF-a I) to topical therapy or consider trial of phototherapy
- inc systemic agent potency or use 2 systemic agents in addition to topical therapy
- use BRM an other agents as needed
Step down therapy to lowest therapy that maintains control of symptoms
Exampels of BRM
Biologic Response modifiers
Acitretin, Methotrexate, Cyclosporine
Two main fungi that cause human disease
Dermatophytes
Candida albicans
Risk factors to mycotic infections of skin, hair and nails
prolonged exposure to sweat
maceration
intertriginous folds
sharing personal belongings
occlusion of the skin
close living quarters
immunodeficiency and suppresion
diabetes
obesity
poor hygiene
trauma
warm or humid climate
Tinea pedis
Athletes foot
usually 3/4 or 4/5th toes
usually seen in 1 foot and respond to topical therapy
Treatment for mild/acute cases of tines pedis
cream generally
Terbinafine better than azaleas
Treat for 1-6 weeks
avoid nystatin**
oral treatment of tinea pedis
oral treatments
terbinafine 250 QD for 2 weeks
Itraconazole 200mg BID X 1 week
fluconazole 150mg weekly for 2-6 weeks
Tinea unguium
aka onychomycosis
fungal infection of nail, more common toe nails
Risk factors for Tinea Unguium
> 40yrs old
Family history
Immunodeficiency
Psoriasis
Diabetes
PVD
Tinea pedis
Sporting activities
Distal sublingual onychomycosis (DSO)
most common
T.rubum common cause
nail plate, bed and maybe matrix effected
white, yellowish or brown discoloration
White superficial onychomycosis (WSO)
t.metagrophytes most common cause
localized to surface of nail place
Proximal sublingual onychomycosis (PSO)
invades nail through proximal nail fold and spreads to nail plate and matrix
uncommon in general pop, mostly immunocompromised patients
Topical medications approved for onychomycosis
Jublia
Kerydan
Penlac
Penlac (Ciclopirox 8%)
mild-moderate onychomycosis
Early stages of DSO
Treatment for 1yr
only superficial
Limited to 3-4 nails
used if Systemic therapy is CI
systemic treatment of onychomycosis
Terbinafine or itraconazole
generally 3 months
12 weeks for toenails or 6 weeks for fingernails
Tinea cruris
jock itch
scaly, erythematous margin
more common males
source of infection is almost always patients feet
Tinea cruris txm
topical therapy is recommended for 1-2 weeks after system resolution
severe/resistn require oral therapy
relief of itching/burning can be facilitated by using short-term topical steroids
Tinea corporis
ringworm of the body
commonly in obese, adults in warmer climates, day care kids
Tinea corporis appearance
small, circular, erythematous scaly areas
may have pustules
may be itchy
Tinea corporis treatments
topical agents usually
systemic for severely immunocompromised, griseofulvin preferred in children (has penicillin so if allergic cant use)
Tinea capitis
Typically occurs in childhood
one or more patches of partial hair loss
more common in black females
Tinea Capitis therapy
depends on causative organism
PO therapy for 4-12 wks depending on agent used
If Tinea Capitis Microsporum Canis confirmed or unknown
1st = Griseofulvin (6-12weeks)
2nd = Terbinafine, itraconazole, fluconazole
If Tinea Capitis Trichophyton tonsurans confirmed
1st = Terbinafine (2-4wks), 6 weeks if granule formation
2nd = Griseofulvin, itraconazole, fluconazole
Family members maybe asymptomatic = use antifungal shampoo for at least 5 min, 3 times per week
Pityriasis Versicolor
Also called tines versicolor
more common in adults and those in tropical temps
Pityriasis Versicolor therapy
1st line = Ketoconazole or selenium sulfide
Topical Terbinafine maybe used
Hypopigmented areas take longer to regiment
Pityriasis Versicolor therapy duration
Usually 2-3 weeks
Ketoconazole = QD 2-3weeks, let sit for 5min then wash off
Selenium sulfide = apply 10min, wash off for 7 days
systemic treatment of Pityriasis Versicolor
itraconazole and fluconazole are effective and preferred
keto works but dont want to work
terbinafine and griseofulvin not effective
Goals of therapy for fungal infections
Reduce and or relieve symptoms
Eradicate fungus
Prevent future infections
Prevent spreading of infections
Counseling points for fungal infections
reduce moisture to affected area
avoid tight fitting clothing
keep areas clean
dry areas completely
wash infected clothing separately
avoid walking barefoot in communal areas
keep nails short and clean
avoid sharing personal items
use separate towels to dry off affected area
Exclusions for self care
Tinea unguium or Capitis
uncealer etiology
signs of 2ndary infection
involvement of face, genitalia, or mucous membranes
if topical doesn’t work
diabetes, systemic infection or immunodeficiency
When to choose cream
better coverage because rubbed into skin
product needs to be dried before putting socks on
When to choose powder
good for excessive wetness
good for skin folds where moisture accumulates
When to choose solution
better coverage of affected areas like creams
dries more rapidly but more expensive
When to choose spray
easy to apply, especially hard to reach
Not as effective due to no rubbing
