PAMS dermatology: Papulosquamous Diseases

Question 1

What is the epidemiology of psoriasis in Ireland

Answer 1

peak age = M: 20-40, F:30-60.
lifetime cases are equal in both gender. 73,000 cases in Ireland of which 9000 are severe.

Question 2

What is the aetiology of psoriasis ?

Answer 2

It is a systemic immune mediated genetic relapsing and remitting condition. approx 40% of the patients have one kin affected. more common in monozygotes.

Question 3

What are the genes implied in Psoriasis ?

Answer 3

PSORS1, IL-23 genes and TNF genes.

Question 4

What are the environmental triggers and causes of psoriasis?

Answer 4

• Obesity, smoking and alcohol
• HIV and strep infections
  *Medications: Beta blockers, lithium, antimalarial drugs.
  *Koebner Phenomenon and psychological stress.

Question 5

What is the pathophysiology of psoriasis ?

Answer 5

epidermal acanthosis , secondary to hyper and parakeratosis leading to scaly skin.

Question 6

What are the main psoriatic comorbidities ?

Answer 6

Psoriatic arthritis, UC and chron’s disease, psoriatic uveitis, depression and anxiety. There are many other as well.

Question 7

What is chronic plaque psoriasis ?

Answer 7

These are pruritic papules that coalesce to form erythematous well demarcated plaques with thick silvery scales symmetrically on lower back, extensor surfaces, scalp and gluteal clefts.

Question 8

Chronic plaque psoriasis is associated with ?

Answer 8

Koebner phenomenon.

Question 9

What is the presentation of palmo-plantar psoriasis ?

Answer 9

Thick silvery-white to
yellowish scales on the
palms and soles
* Scales are not easily
removed
* Associated with cracking and
fissuring

Question 10

What is Guttate Psoriasis?

Answer 10

It is typically seen in children and adolescents post strep infection phenomenon. Lesions up to 1.0 cm, discrete, salmon-pink papules. Typically resolves spontaneously. Some patients may develop plaque psoriasis later in life.

Question 11

What is inverse psoriasis ?

Answer 11

These are are bright red,
macerated and non-scaly lesions in the intertigenous areas. They are aggravated by sweat and rubbing, may have superimposed yeast infection.

Question 12

What is pustular psoriasis ?

Answer 12

These are post pyrexial pustular eruptions on the trunk, extremities, and palm or sole. Lukocytosis is seen in the psutules.

Question 13

What are erythrodermic psoriasis ?

Answer 13

It is an acute emergency percipitated by steroids, hypocalcemia, alcohol etc. evolves within days to weeks. Red, dry skin ALL OVER THE BODY
* Can lead to heart failure, shock and death

Question 14

What is the diagnostic approach in psoriasis ?

Answer 14

Usually based upon H & P
* Throat Culture or Antistreptolysin O Titer for strep (Guttate)
* FBC (Pustular)
* Skin Biopsy Dermatopathology

Question 15

What are the treatment options for limited psoriasis ?

Answer 15

Emollients (e.g., Ovelle)
* Topical Therapies
* Coal Tar
* Corticosteroids
* Vitamin D Derivatives
* Retinoids
* Calcineurin Inhibitors
* Intralesional Injections
* Phototherapy
* Excimer Laser

Question 16

What are the treatment option for generalised psoriasis ?

Answer 16

Systemic Therapies
* Methotrexate
* Systemic Calcineurin Inhibitor (Cyclosporine)
* Oral Retinoid (Acitretin)
* Apremilast (Otezla)
* Biologics
* Photochemotherapy
* UVB
* Psoralen + UVA (PUVA)

Question 17

What is the difference between psoriasis and Lichen planus ?

Answer 17

*Lichen planus the 6P lesions are on the flexor surface as opposed extensor surface in psoriasis.
* Mucosal involvement Wikham’s striae only LP.

Question 18

What is the aetiology of lichen planus ?

Answer 18

Autoimmune destruction of the stratum basale, can be drug induced or secondary to HCV.

Question 19

What is the epidemiology of lichen planus?

Answer 19

seen more in woman between the age of 30 to 60.

Question 20

Oral Lichen planus may transform to ?

Answer 20

Squamous cell carcinoma.

Question 21

What is the Dx approach to Lichen planus ?

Answer 21

Usually made clinically
* Biopsy shows hyperkeratosis, hypergranulosis and saw-tooth
rete ridges.

Question 22

What is the first line Tx of Lichen planus ?

Answer 22

Topical corticosteroids (1st Line Treatment)

Question 23

What are the second line Tx for LP?

Answer 23

*Intralesional steroid injections
* Oral corticosteroids for generalized lesions
* Narrow Band UVB
* Phototherapy with psoralens (PUVA)
* Oral Retinoids

Question 24

What is the prognosis of LP ?

Answer 24

Majority of cutaneous LP spontaneously remit within one to two
years
* Recurrences may occur
* Consider screening for Hepatitis C
* Regular follow-up required for oral and genital lesions

Question 25

What is Pityriasis Rosea?

Answer 25

It is a Papulosquamous Exanthem occurs from Adolescence through young adults. More common in spring and falls.

Question 26

What is the presentation of Pityriasis rosea ?

Answer 26

Classic “Herald Patch” followed by “Christmas Tree” pattern to
exanthem.

Question 27

What is the nature of Herald patch ?

Answer 27

Pink, salmon colored or
erythematous or lightly raised, fine collaret scale, trails the advancing border.

Question 28

What is the nature of Christmas tree xanthem in P. Rosea?

Answer 28

It is a Secondary lesions follow Langer’s Lines in V shape distribution.

Question 29

What is the symptomatic management of pruritus in P. rosea ?

Answer 29

• Antihistamines
• Calamine lotion
• Topical Steroids

Question 30

What is the prognosis of P. Rosea ?

Answer 30

Usually a benign course but may results in post-inflammatory
hyperpigmentation with the Rash lasting between 4-10 weeks

Question 31

What is the diagnosis approach to P. rosea ?

Answer 31

Usually diagnosed clinically
* Optional lab studies
* KOH preparation
* RPR