Management plans for skin conditions

Question 1

Name the topical treatments commonly used for psoriasis.

Answer 1

• TCS
• Calcipotriene (vitamin D₃ analog)
• Tazarotene/”Tazorac” (topical retinoid)
• Topical pimecrolimus or tacrolimus (TCIs)

Question 2

Name the types of phototherapy used for moderate to severe psoriasis.

• What is most effective for guttate psoriasis?
• Name the (3) types of UVR phototherapy used.
• What laser can be used? Its wavelength?
• What is the wavelength range for UVB?

Answer 2

• NB-UVB (311 - 313 nm)
• BB-UVB (more effective than NB-UVB for guttate psoriasis)
• PUVA
• Excimer laser (308 nm; for localized disease)

Remember that UVB is 280 - 320 nm.

Question 3

Name the (5) notable systemic therapies used for moderate to severe psoriasis that are NOT biologics.

• What is best for erythrodermic or pustular psoriasis?
• What does each drug inhibit?

Answer 3

• Acitretin (especially for erythrodermic and pustular psoriasis)
• Apremilast (PDE-4 inhibitor)
• Cyclosporine (increased risk of SCCs)
• MTX
• Tofacinitib (JAK 1/3 inhibitor)

Question 4

Name the notable biologics used for moderate to severe psoriasis.

• Hint: most are monoclonal antibodies.
• What does each inhibit?

Answer 4

• Infliximab, etanercept and adalimumab (TNF-alpha inhibitors)
• Ustekinumab (IL-12 and IL-23 inhibitor)
• Secukinumab, brodalimumab, ixekizumab (IL-17 inhibitors)

Question 5

What is considered the treatment of choice for pustular (von Zumbusch) psoriasis?

Answer 5

Acitretin ( > cyclosporine, MTX or biologics)

Question 6

What is considered the treatment of choice for impetigo herpetiformis (pustular psoriasis arising in pregnancy)? (2)

Answer 6

• Early delivery, prednisone

Question 7

What is considered the treatment of choice for guttate psoriasis?

Answer 7

• BB-UVB at erythemogenic doses ( > NB-UVB)

Question 8

What is considered the treatment of choice for erythrodermic psoriasis? (3)

Answer 8

• Acitretin
• Cyclosporine
• Infliximab

Question 9

Aside from topical therapies, what are other treatments for moderate to severe atopic dermatitis?

• What types of light?
• What oral medications?
• What new biologic?

Answer 9

• Phototherapy (NB-UVB > BB-UVB, UVA1, PUVA)
• Oral steroids
• Cyclosporine
• Azathioprine
• Mycophenolate mofetil
• MTX
• Dupilumab

Question 10

How would you manage the following acne patients?

• Comedonal acne
• Mild inflammatory acne
• Moderate inflammatory acne
• Severe/nodulocystic acne in a male or female

Answer 10

Question 11

How would you manage the following bullous pemphigoid patients?

1. Mild disease
2. Someone with a BP flare
3. Recalcitrant BP
4. Mucosal predominant BP

Answer 11

1. Doxycycline plus nicotinamide
2. Systemic steroids plus a steroid-sparing agent (e.g., mycophenolate, azathioprine, methotrexate, cyclophosphamide)
3. Rituximab, IVIg or plasma exchange
4. Dapsone

Question 12

How would you treat a dermatophyte infection?

• Topicals?
• Orals?
• What orals are preferred for tinea pedis?
• What are orals are FDA approved for tinea capitis?
• What topical notably does NOT cover dermatophytes?

Answer 12

• Topical -azoles (Dr. Boull says only topical miconazole is effective though), topical terbinafine, topical ciclopirox
• Oral griseofulvin, itraconazole and fluconazole
• Oral itraconazole or fluconazole is preferred over griseofulvin for tinea pedis
• Oral griseofulvin and oral terbinafine are approved for tinea capitis
• Note that topical nystatin does NOT cover dermatophytes.