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Miscellanous Skin Conditions Flashcards

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1
Q

Psoriasis:

  1. Most common gender?
  2. Familial?
A
  1. Equal incidence in males and females

2. Hereditary – up to 40% of patients have a first degree relative with psoriasis or psoriatic arthritis

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2
Q

Psoriasis PP
1. Normal cell turnover in the epidermis takes about ___ days

  1. Cell turnover in psoriasis is reduced to about __ days
  2. What three events contribute to the PP of psoriasis?
  3. Keratinocytes have a shortened cell cycle time of ____days vs. normal of about ___ days
  4. Autoimmune component? 2
  5. What kind of treatments are very effective?
A
  1. 27
  2. 4
    • Massive increase in the number of cells produced and
    • normal cell keratinization does not take place
    • Subdermal blood vessel dilation also seen (contributes to erythema)
  4. 1.5, 13
    • T lymphocytes and dendritic cells
    • Multiple T cells are present in psoriatic lesions
  6. Therapies that suppress T cells are very effective
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3
Q

Psoriasis Risk Factors

7

A
  1. Family history
  2. Strep infection can trigger guttate psoriasis
  3. Medications
  4. Smoking,
  5. obesity and
  6. alcohol are associated
  7. Vitamin D deficiency?
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4
Q

Which medications could trigger psoriasis?

3

A
  1. Beta blockers,
  2. lithium,
  3. anti-malaria
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5
Q

Presentation of psoriasis
1. Bimodal age distribution: Describe this?

  1. ONset?
  2. What symptom is common?
  3. Hx of improvement with what?
  4. How is it different from eczema? 3
A
    • Early 30-39 years
    • Late 50-69 years
    • Can also occur in children but less common than in adults
  2. May be gradual in onset or sudden
  3. Pruritus is common
  4. History of improvement with sun exposure
  5. Psoriasis is more on the tops of knees back of elbows, less itchy, and more scaly (a little bledding underneath the scale when removed)
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6
Q

Associated Conditions: Psoriasis

13

A
  1. Psoriatic arthritis
  2. CV disease,
  3. malignancy,
    4 DM,
  4. metabolic syndrome,
  5. HTN,
  6. inflammatory bowel disease,
  7. serious infections
  8. Ocular involvement
  9. Swollen lids,
  10. conjunctivitis,
  11. xerosis,
  12. uveitis
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7
Q

Types of psoriasis

6

A
  1. Plaque
  2. Inverse
  3. Guttate
  4. Erythrodermic
  5. Pustular
  6. Nails
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8
Q

What is the most common type of psoriasis?

A

Plaque psoriasis

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9
Q

Plaque psoriasis

  1. Onset?
  2. Course?
  3. Describe the shape of the lesions?
  4. Typically appears where? 5
A
  1. Slow-forming
  2. Stable
  3. Usually well defined and symmetrical
  4. Typically appears on the
    - knees,
    - scalp,
    - elbows,
    - lower back and
    - can affect the nails
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10
Q

Plaque psoriasis presentation

4

A
  1. Salmon pink papules and plaques, sharply marginated with marked silvery-white scaling
  2. Scales are loose and easily removed by scratching
  3. Removal of scales results in small blood droplets (Auspitz sign)
  4. Plaques at sites of former skin injury (Koebner’s phenomenon)
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11
Q
  1. Koebner’s phenomenon
    occurs when after the injury?
  2. May occur from what? 5
A
  1. Occurs 1-2 weeks after injury
  2. May occur from
    - bug bites
    - bruises and scrapes
    - poison ivy or poison oak
    - burns, including chemical burns and sunburn
    - constant pressure and rubbing, medical processes such as injections or vaccinations; skin blemishes from acne, herpes or chickenpox; or from acupuncture or tattoo needles
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12
Q

Distribution of Psoriatic Lesions

  1. Symmetrical or Asymmetrical?
  2. Favors what areas? 3
  3. Uncommon where?
  4. Distributed how? (many lesions vs single lesion?)
A
  1. Often symmetrical
  2. Favors
    - elbows,
    - knees and
    - intertriginous areas
  3. Uncommon on the face
  4. Single lesions or lesions localized to one area or can be over the entire body
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13
Q

Inverse psoriasis

  1. Describe the margins?
  2. Found in what area? 7
  3. What makes it different from plaque psoraisis?
  4. More common in who?
  5. What is this difficult to distinguish from?
A
  1. Sharply demarcated plaques
  2. Found in
    - axilla,
    - groin,
    - naval,
    - submammary region,
    - palms,
    - scalp,
    - soles
  3. No scales like plaque psoriasis
  4. More common in overweight persons
  5. Difficult to distinguish from candidiasis without biopsy
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14
Q

Guttate psoriasis

  1. AKA?
  2. Characteristically occurs in who?
  3. Strong association with what?
  4. What do the lesions look like?
  5. Distribution looks like what?
  6. Prognosis?
A
  1. Also known as eruptive psoriasis
    - abrupt onset
  2. Characteristically occurs in young adults and children
  3. strong association between recent streptococcal infection (usually pharyngitis) in the preceeding 2-3 weeks
  4. Multiple small teardrop shaped erythematous papules
  5. Scattered diffusely on the proximal extremities and trunk
  6. Usually self limiting in a few weeks to months
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15
Q

Erythrodermic psoriasis

  1. Most generalized. What does this mean?
  2. What does it look like?
  3. Cause?
  4. How common is this?
  5. Symptoms? 2
  6. High risk of what? 2
  7. Treatment?
A
  1. Often affects most or all of the body’s surface
  2. Erythema and scaling from head to toe
  3. Inflammatory
  4. Least common
    • Severe itching and
    • pain as skin reddens and sheds
  6. High risk of
    - systemic infection and
    - electrolyte imbalances
  7. Inpatient management

HOWLER MONKEY

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16
Q

Pustular psoriasis

  1. What is it?
  2. Prognosis?
  3. Can be associated with what? 5
  4. There is a milder form that just affects what?
A
  1. Acute onset of widespread erythema, scaling, and sheets of superficial pustules with erosions characterizes the most severe variant
  2. Severe form of psoriasis with life-threatening complications
  3. Can be associated with
    - malaise,
    - fever,
    - diarrhea,
    - leukocytosis, and
    - hypocalcemia
  4. A milder form may just affect the fingers

HOWLER MONKEY

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17
Q

Erythrodermic and pustular psoriasis
1. The most common precipitating factors for erythrodermic and pustular psoriasis is what?

  1. Can occur in those with what?
A
  1. acute withdrawal of systemic corticosteroids

2. other forms of psoriasis

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18
Q

Nail Psoriasis

  1. More closely associated with what?
  2. May appear before the onset of what?
A
  1. More closely associated with psoriatic arthritis

2. May appear before the onset of cutaneous psoriasis

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19
Q

Treatment of plaque psoriasis

3

A
  1. Exacerbating factors
  2. Topical therapy
  3. Systemic therapy
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20
Q

Psoriasis
1. Some drugs that may exacerbate include? 5

  1. Combination therapy for treatment is the trend to do what?
A
  1. -Beta-blockers,
    -NSAIDs,
    -lithium,
    -ACEI,
    -digoxin
    Consider switching med if possible
  2. minimize side effects
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21
Q

Topical therapy for plaque psoriasis

7

A
  1. Emollients
  2. Steroids
  3. Vitamin D analogues
  4. Topical retinoids
  5. Calcineurin inhibitors
  6. Coal tar preparations
  7. Phototherapy
    - UVA, UVB
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22
Q

What is first line therapy for psoriasis?

A

Topical steroids

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23
Q

Topical therapy - Emollients

  1. Useful in what?
  2. What does it do? 3
  3. What are some of the available agents? 3
  4. Applied when?
A
  1. Useful in ALL cases as an adjunct
    • Hydrate stratum corneum
    • Decrease water evaporation
    • Soften the scales of the plaques
  3. Some available agents
    - Eucerin
    - Lubriderm
    - Moisturel
  4. Lubricating creams are applied twice daily after bathing, while the skin is still damp.
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24
Q

Topical therapy - steroids

  1. Can be continued as long as the pt has what?
  2. Once the psoriasis is under control what should we do?
  3. For thick plaques on extensor surfaces what should we do? (two choices)
  4. These are often used in conjunction with what? 3
A
  1. Can be continued as long as pt has thick active lesions
  2. Back off on frequency and strength once under better control (skin can have problems with withdrawl if on it too long)
  3. potent preparations (eg, betamethasone 0.05% or clobetasol propionate 0.05%) *
  4. Often used in conjunction with a
    - topical vitamin D analoge,
    - topical retinoid or
    - UVB therapy
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25
Q

Topical therapy – vitamin D analogues

  1. What is the medication called?
  2. MOA?
  3. Used in what type and degree of psoriasis?
  4. SE? 2
  5. Too irritating for what areas? 2
  6. Can be used how?
A
  1. Calcipotriol (Dovonex)
  2. Causes immune modulation
  3. Used in mild to moderate plaque psoriasis
  4. Side effects include
    - hypercalcemia and
    - hypercalciuria when topical doses exceed 100g/wk
  5. Too irritating for use on face or groin
  6. Can be used as monotherapy with steroids for breakthrough or just a few days a week
26
Q

Topical therapy – vitamin A derivatives (Retinoids)

  1. What is the drug called?
  2. MOA?
  3. May cause what SE?
  4. Advanatge?
A
  1. Tazarotene (Tazorac)
  2. modulates differentiation and proliferation of epithelial tissue and exerts some degree of anti-inflammatory and immunological activity
  3. May cause skin irritation
  4. Effective with little systemic absorption
27
Q

Topical therapy – Calcineurin inhibitors

  1. What are the two drugs?
  2. MOA?
  3. Good to use where? 2
  4. Generally not used how?
A
    • Tacrolimus (Protopic)
    • Pimecrolimus (Elidel)
  2. Inhibits T-lymphocyte activation) by binding to an intracellular protein, FKBP-12 and complexes with calcineurin dependent proteins to inhibit calcineurin phosphatase activity
  3. Good to use on
    - intertriginous areas and the
    - face where steroid use should be limited
  4. Not generally used as monotherapy as steroids are most effective
28
Q

Topical therapy – coal tar

  1. When used alone it is effective as what?
  2. Primarily used as what?
  3. Also tends to enchance what?
  4. Tar shampoos are used for what and with what?
  5. Use is limited by what?

OTC

A
  1. When used alone only as effective as mild to midpotency topical steroids
  2. Primarily used as add-on therapy
  3. Also tends to enhance the effects of UVB therapy
  4. Tar shampoos beneficial for scalp lesions in combination with topical steroid solutions
  5. Use is limited by staining of clothes and odor

OTC

29
Q

Phototherapy

  1. MOA?
  2. UV radiation will accelerate photodamage and risk of what?
  3. What are the types? 2
A
  1. Has antiproliferative effects by slowing keratinization and anti-inflammatory effects by inducing apoptosis of pathogenic T-cells
  2. skin cancer
    • UVB
    • PUVA
30
Q

What is PUVA?

A

UVA radiation administered with psoralen bath or oral dose (photosensitizing drug)

31
Q

Systemic therapy for psoriasis

  1. Reserved for what?
  2. What are the medications for this? 6
A
  1. Systemic therapy is for severe cases resistant to topical treatment
  2. -Methotrexate
    -Acetretin (systemic retinoid) or Psoriatane
    -Systemic calcineurin inhibitior (Cyclosporine)
    -Biologic agents
    (Infliximab (Remicade))

Other immune suppressants

  • Hydroxyurea,
  • azathiprine
32
Q

Urticaria

  1. aka?
  2. What is it?
  3. ___ mediated?
A
  1. Hives
  2. Immune mediated skin eruption of well-circumscribed wheals on an erythematous base
  3. IgE mediated
33
Q

Angioedema

  1. What is it?
  2. Swelling of the what? 5
  3. Half the time it is associated with what?
A

1, Hypersensitivity reaction involving the deep layers of the skin

  1. Swelling of the
    - lips,
    - eyelids,
    - palms,
    - soles,
    - genitalia
  2. Urticaria + angioedema
34
Q
  1. __% urticaria alone

2. ___% angioedema alone

A
  1. 40

2. 10

35
Q

Urticaria and Angioedema

PP? 4 steps

A
  1. Allergen →
  2. IgE antibody attached to mast cell →
  3. sudden release of immunologic mediators →
  4. inflammation
36
Q
  1. Idiopathic chronic urticaria thought to be caused by what?
  2. Principle mediator released by mast cells is what?
A
  1. autoimmune process

2. histamine

37
Q
  1. Urticaria presentation
  2. Size?
  3. What kind of borders?
  4. Lesions may persist for how long but usually resolve when?
A
  1. Characteristic edematous, erythematous, well-circumscribed blanching wheals
  2. Can range from a few millimeters to several centimeters in diameter
  3. Serpiginous borders
  4. Lesions may persist for 12-24 hours but most resolve sooner than this
38
Q 
Urticaria specific presentations
Food and Drug induced:
1. Attacks tend to be on what time line?
2. Usually do not cause what?
3. May be accompianed by what?
A
  1. Attacks tend to be brief
  2. Usually do NOT cause chronic urticaria
  3. May be accompanied by angioedema
39
Q

Urticaria specific presentations: Physical Urticarias. Describe the following:

  1. Dermatographism?
  2. Pressure urticaria?
  3. Cold urticaria?
  4. Cholinergic urticaria?
  5. Aquagenic urticaria?
  6. Solar urticaria?
A
  1. gentle stroking of the skin produces immediate wheal and flare response
  2. pressure to skin at right angle results in red swelling after latent period of up to 4 hours
  3. eruptions within minutes following application of cold
  4. punctate hives triggered by exercise or hot shower
  5. hives after contact with water
  6. hives develop following exposure to UV light
40
Q

Urticaria and angioedema
1. Key to evaluation is a what?

  1. What is the goal?
A
  1. Key to the evaluation is a thorough history (much more important than the physical)
  2. Goal is to identify a specific cause or precipitant
41
Q

Urticaria and angioedema
Management?
2

A
  1. Avoidance of etiologic agent(s) if identified

2. Avoidance of substances that may aggravate

42
Q

What substances/drugs may cause urticaria and angioedema?

4

A
  1. ASA,
  2. NSAIDs,
  3. ETOH,
  4. ACEI (especially angioedema)
43
Q

Urticaria and angioedema treatment:
1. For Empiric measures for symptomatic relief we would use? 3
(which drug class and which drugs?)

  1. For refractory cases? 2
A
  1. Antihistamines
    - Sedating and/or nonsedating H1-blockers (e.g. Diphenhydramine, Fexofenadine)
  2. Steroids
  3. Sub Q Epi for severe attacks
  4. Refractory cases:
    - H2-blockers (e.g. Ranitidine)(15% of the receptors in the cutaneous vasculature are H2 receptors)

-Doxepin (Sinequan) is a TCA with some H1 and H2 blocking activity

44
Q

Chronic Urticaria can be frustrating
Education on this?
2

A
  1. Be careful with steroids (the adverse effects can be more serious than the disease)
    Education, education, education
  2. Inform patients that oftentimes a precipitating cause is not found
45
Q

Urticaria and angioedema
1. Always consider investigating what? 2

  1. Epipen for who?
  2. Referral to?
A
  1. Always consider investigating
    - thyroid and/or for
    - H. Pylori in the patient who’s history and physical suggest associated disease
  2. Epipen prescription for anyone who has had a severe bout of angioedema or anaphylaxis
  3. Referral to allergist recommended
46
Q

Vitiligo

  1. Onset?
  2. Lesions occur primarily where? 8
  3. What could happen to the hair?
A
  1. Onset usually early in life (age 20-30)
  2. Lesions occur primarily on the
    - face,
    - upper trunk,
    - finger tips,
    - hands,
    - arm pits,
    - genitalia,
    - bony prominences and
    - perioral region
  3. Hair may be white in involved areas
47
Q

Pathophysiology of vitiligo
1. PP?

  1. Often occurs in the context of other autoimmune conditions such as what?
A
  1. Autoimmune mechanism with formation of antibodies to melanocytes
    • pernicious anemia and
    • Hashiomoto’s thyroiditis
48
Q

Vitiligo treatment

5

A

Repigmentation can be achieved to variable degrees with

  1. Topical steroids
  2. Tacrolimus
  3. Psoralens
  4. UVA, UVB
  5. Surgical skin grafting
49
Q

Pemphigus

  1. What is it?
  2. PP?
  3. Mortality rate?
A
  1. Rare, chronic, potentially fatal disease of the mucous membranes and skin
  2. Intraepidermal blistering secondary to an autoimmune process
  3. Mortality rate as high as 5%

HOWLER MONKEY

50
Q

Pemphigus

  1. What do the lesions look like?
  2. Where do the lesions start and where do they progress to? 5
  3. Bullae are what? 2
  4. What sign is associated with this?
  5. Whats required for dx?
A
  1. Flaccid bullae that
  2. often begin in the oropharynx and then may spread to involve the
    - scalp,
    - face,
    - chest,
    - axillae and
    - groin
  3. Bullae are tender and painful
  4. Nikolsky sign
  5. Skin biopsy required for diagnosis

HOWLER MONKEY

51
Q

Pemphigus Treatment ?

3 (two meds)

A
  1. Recognize and refer
  2. May require hospital admission for severe disease
  3. Treat with systemic
    - corticosteroids and
    - immunosuppressives
52
Q

Bullous Pemphigoid

  1. What is it?
  2. May be triggered by what? 2
  3. Almost exclusively in what population?
  4. _____ as common as what?
  5. What is the most common presentation?
  6. What is the difference in the lesions compared to Pemphigus?
A
  1. Chronic, subepidermal blistering autoimmune disease
  2. May possibly be triggered by a drug reaction or infection
  3. Almost exclusively in the elderly population (>60)
  4. Twice as common as pemphigus
  5. Most common presentation is a widespread blistering eruption
  6. Pemphigus- more flaccid. This one has tenser lesions.

Increased mortality

53
Q

Bullous Pemphigoid

  1. Associated with what?
  2. Describe the blisters?
  3. Dx?
  4. Treatment?3
A
  1. Associated urticarial plaques
  2. Blisters are tense and fluid filled
  3. Skin biopsy required
  4. Treatment
    - Recognize and refer
    - 1st line topical high dose (preferred) or oral steroids
    - May require immunosuppressants
54
Q

Epidermoid Cyst

  1. AKA? 3
  2. Derived from where? 2
  3. Formed by what?
  4. Becomes filled with what?
  5. Rupture is common and may result in what?
  6. May become what?
A
  1. Synonyms include:
    - Sebaceous cyst,
    - infundibular cyst,
    - epidermal cyst
  2. Derived from epidermis or epithelium of hair follicle
  3. Formed by cystic enclosure of epithelium
  4. Becomes filled with keratin and lipid-rich debris
  5. Rupture is common, may result in painful inflammatory mass
  6. May become secondarily infected, communicates with skin
55
Q

Dermatofibroma

  1. What are they?
  2. Lesion may feel what?
  3. Prognosis?
A
  1. Very common, button-like dermal nodule
  2. Lesion may be tender
  3. Benign but can be confused with dangerous lesions
56
Q

Lipoma

  1. What is it?
  2. How does the lipoma feel and look?
  3. Composed of what?
  4. Some individuals have Familial Lipoma Syndrome which is what?
A
  1. Benign subcutaneous tumors
  2. Soft, rounded, and movable against the overlying skin!
  3. Composed of fat cells that have the same morphology as normal fat cells
  4. Some individuals have Familial Lipoma Syndrome, an autosomal dominant trait appearing in early adulthood where an individual may have hundreds of lipomas
57
Q
  1. Plaques with silver scaling?
  2. ______ psoriasis is by far the most common type, is generally easily recognized, and the mild to moderate form can often be handled by the primary care provider in most cases
  3. Atypical forms of psoriasis are more difficult to identify. If you’re not sure what’s going on, do what? 2
A
  1. Psoriasis almost every time!
  2. Plaque
  3. biopsy or refer
58
Q
  1. Think of anaphylaxis, angioedema, and urticaria as being on a what?
  2. Generally, when someone uses the term “anaphylaxis,” they are indicating what?
  3. How commonly will you see urticaria with or without angioedema and vice versa?
A
  1. spectrum.
  2. the potentially life-threatening form where someone is struggling to breathe.
  3. You will commonly see urticaria without angioedema. You will rarely see angioedema without urticaria.
59
Q

Chronic “idiopathic” urticaria can be very frustrating for patient and provider alike.
1. Oftentimes, what will often be the key to helping patients with chronic urticaria?

  1. Always consider investigating what in the patient who’s history and physical suggest associated disease? 2

Be careful with how you use steroids for urticaria.

A
  1. managing symptoms and educating that time is the best medicine
  2. thyroid and/or for H. Pylori
60
Q
  1. The most important thing for the PCP to know about vitiligo is what?
  2. If you see frightening bullae with a positive Nikolsky’s sign WITHOUT what? call your local dermatologist immediately.
  3. If the mass (usually a cyst) is epidermal, it is going to feel more _____. If subcutaneous, generally ______.
A
  1. that it often occurs in the context of other autoimmune conditions such as pernicious anemia and hashimoto’s thyroiditis.
  2. history of trauma or burn
  3. fixed, mobile

Dermatology (12 decks)

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