Papulosquamous Diseases- Alavian Flashcards
What is “Papulosquamous”?
Eruptions that consist of papules with Scaling
Note: Scaling is the abnormal shedding or accumulation of stratum corneum in perceptible flakes.
What are some of the Papulosquamous Disease?
- Psoriasis
- Seborrheic Dermatitis
- Pityriasis Rosea
- Lichen Planus
Describe the visible features of Psoriasis
- Well defined red plaques with silvery scale (psoriasis vulgaris)
- Extensor elbows, knees, scalp, hands, feet, genitals
- Inverse Psoriasis may involve the flexures
- Auspitz sign
- Symptoms improved in the summertime sun.
What is the epidemiology of Psoriasis?
-2 peak age distribution:
20-30 and 50-60
-Guttate psoriasis is the most frequent in children.
What is the Psoriasis HLA association?
HLA-CW6 (PSORS1 locus)
Describe the pathogenesis of Psoriasis
- TH1 (and some TH2) are the cause
- Found in the epidermis and dermis.
Results in increased inflammatory mediators that stimulate:
- epidermal proliferation
- Differentiation
- Angiogenesis
What are some triggers of Psoriasis?
- Trauma
- HIV
- Infection (strep pharyngitis especially in Guttate form)
- Smoking
- Hypocalcemia
- Alcohol
- Drugs (Beta blockers, lithium, anti-malarials, interferon, rapid steroid taper)
Describe the clinical Psoriasis patterns
- Psoriasis Vulgaris
- plaque type - Guttate (drop like; children)
- Inverse (within the skin foldings; flexures)
- Palmoplantar
- Erythrodermic
- Pustular
- Psoriatic nail involvement
What is the most common Psoriasis variant?
-Chronic Plaque Psoriasis
- Auspitz sign
- Frequently itchy
- sometimes painful
Describe Guttate Psoriasis
- Guttate = drop
- Common form in children and young adults
-Often preceded by a URI (group A hemolytic strep) 2-3wks prior to onset.
Note: Look for positive antistreptolysin
Note: Spontaneous remission in children; chronic in adults.
Psoriasis is better in the sun…but…
Guttate can erupt in photodistributed area. This is Koebner phenomenon.
What is Erythodermic Psoriasis?
- Erythoderma is defined as redness/scaling involving greater than 90% of TBSA.
- Often caused by withdrawal of Systemic steroids or Methotrexate.
- Emergency
Manifestations:
- Peripheral Edema
- Tachycardia
- Dehydration
- High output CHF
- Hypothermia
- Protein loss
Describe Psoriasis nail involvement
Up to 50% of Psoriatics
- Affects nail matrix and nailbed
- Nail pitting
- Oil Spots
- Oncholysis
Describe Psoriatic Arthritis
- Up to 30%
- Erosive changes with negative Serologies (rules out RA)
- Asymmetrical Oligoarthritis (DIP/PIPs)
- Can have Sausage digits (arthritis mutilans)
What is the vulgar name for Arthritis Mutilans?
Sausage fingers
Name some Mild to Moderate Psoriasis treatment
Topical:
- salicylic acid
- corticosteroids
- calcineurin inhibitors (tacrolimus)
- urea preparations
- retinoids
- vitamin d3
What is the topical for Psoriasis that starts with a “D”?
Dovonex
What is the RX for Moderate to Severe Psoriasis?
- Phototherapy (psoralen +UVA) = PUVA
- Systemic retinoids
- PUVA + sys retinoids
- Methotrexate
- Cyclosporin
- Biological agents
Name the biological agents used to treat Psoriasis
Infliximab (binds TNF-a)
K
Etanercept (binds TNF-a)
Adalimumad (binds TNF-a)
What is Seborrheic Dermatitis?
Inflammatory skin disorder involving the skin areas rich in sebaceous glands.
The skin manifestations in seborrheic dermatitis are different from psoriasis in that they are…
- not well demarcated
- appear as light red plaques with white to Greasy yellow scale
- Flexures
- Sebaceous skin regions
Describe the Epidemiology of SD
Bimodal
- 1-3 months and 40s-60s.
- M>F
- Common in Parkinson’s and HIV disease
Describe leading hypothesis for SD pathogenesis
- Skin overgrowth of the yeast Malassezia furfur.
- Metabolic products and antigens of the yeast cause inflammation.
-Increased colonies in patients with SD.
What is the mildest form of seb derm?
Dandruff.
What is a major differential for Seb derm vs Lupus when the rash appears on the face?
SD will involve the nasolabial folds. Lupus will not.
In addition, there will be erythema with scale on the chest where there is abundant chest hair in SD (example).
What is the major risk factor we should screen for in a patient with SD?
HIV infection.
What’s the name of the yeast involved with Seborrheic Dermatitis?
Malassezia furfur
What is a central Rx for Seborrheic Dermatitis?
Ketoconazole and steroids
Head and shoulders shampoo for dandruff.
Describe the etiology of Pityriasis Rosea
- Viral etiology- Associated with HHV-7
- Immunologic Factors
Describe the presentation of Pytriasis Rosea
- Herald patch appears on trunk (misdiagnosed often as tinea corporis)
- Papular eruption appears days/weeks later on the trunk. (Christmas tree distribution). Lesions follow the Langer lines of Cleavage.
Note: Prodromal URI symptoms may precede the Herald patch.
- Pruritic
- Spontaneous remission.
RX:
- Topical steroids
- antihistamines
- UV light therapy (if severe)
What differentials should we consider for Pytiriasis rosea? What test should we do?
- Secondary Syphilis (perform RPR to rule out)
- Drug induced Pityriasis Rosea (GABAMIB)
- Gold
- Arsenic
- Beta blockers
- ACE inhibitors
- Metronidazole
- Isotretinoin
- Barbituates - Nummular eczema
- Guttate Psoriasis
Describe the pathological cause of Lichen Planus
- Autoimmune reaction
- Directed against epitopes on lesional keratinocytes, which have been modified by viral or drug antigens.
Describe the epidemiology of Lichen Planus
- No racial predilection.
- Typical onset between 5th and 6th decade
Name the 4 Ps associated with LP followed by the general appearance.
Purple
Pruritic
Polygonal
Papules
- Wickham’s striae
- Koebner phenomenon
- Flexure wrist/forearms
- Dorsal hands
- Anterior lower legs
- Genitals
- ORAL membranes
75% of patients with LP also have what other manifestation?
-Mucosal Lichen Planus
- Reticular pattern in the Buccal mucosa.
- Annular pattern on the glans penis.
10% have this manifestation in Lichen Planus
Nail Lichen Planus
Presents with either/and:
- Lateral thickening
- Longitudinal ridges
- Pterygium (skin growing over the nails)
What virus is most associated with LP? And which type?
- Hep C
- Oral Lichen Planus
What are the Rx options for LP?
MC(a)TTPASS
Topical steroids Topical immunomodulators Phototherapy Antimalarials Systemic retinoids Systemic steroids Methotrexate Cyclosporin
