Papulosquamous Diseases Questions

Question 1

What is psoriasis?

Answer 1

A chronic inflammatory condition caused by epidermal proliferation resulting in thickened stratum corneum (outer layer)

Question 2

What can contribute to the flaring of psoriasis?

Answer 2

Emotional stress, skin trauma (koebner phenomenon), certain drugs like lithium/beta blockers/NSAIDS, and obesity

Question 3

What is the pathophysiology of psoriasis?

Answer 3

An immune system trigger causes hyperproliferation (epidermal skin cells do not shed, build up as a plauque)
The cause for this is unknown, yet could be T-cell mediated autoimmune disease
These immune system components then cause itching/inflammation, burning/cracking/bleeding

**can be genetic/hereditary

Question 4

What does psoriasis treatment depend on?

Answer 4

Severity, location, symptoms, insurance, patient preference

Question 5

What are the signs/symptoms of plaque psoriasis?

Answer 5

Hallmark sign: well demarcated erythematous plaque with silvery scale
Commonly on elbows, knees, scalp but can be anywhere
Plaques fissure/bleed
Pruritis, pain
**may have joint pain

Question 6

What is nail psoriasis? What are the common symptoms? Is it easy to treat?

Answer 6

Pitting/inflammation in the nail bed causing changes in the nail plate
Subungal (beneath nail plate) discoloration - no vascularization = no color
Can happen in fingernails&toenails but most commonly fingernails
Hard to treat: hard to penetrate nail

Question 7

What is guttate psoriasis? What is it usually triggered by?

Answer 7

Multiple small plaques that are peppered throughout the body
can be triggered by strep infection
**may predispose you to developing plaque psoriasis
**may be mistaken for tinea

Question 8

What is pustular psoriasis?

Answer 8

Small pustules, common on hands/feet
Can have generalized pustulosis: emergent because it can cause electrolyte imbalance when these burst all over the body

Question 9

What is palmar/plantar psoriasis?

Answer 9

Red, flaky, cracked skin confined to palms and soles

Question 10

What is inverse psoriasis?

Answer 10

Psoriasis that occurs in skin folds (under breasts, ect.)
**Commonly mistaken for candidal infection

Question 11

What are the systemic effects of psoriasis?

Answer 11

Psoriatic arthritis: inflammatory process may affect joints (~30%)

Underlying inflammation: increased risk of cancer, cardiovascular disease, obesity

Depression/Anxiety: because condition is so visible can cause mental health struggles, make sure to screen for these things

Question 12

What are the topical treatments for psoriasis?

Answer 12

Topical steroids: decrease inflammation

Calcipotriene: slows down proliferation, Vitamin D analog binds to keratinocyte

Tazarotene: topical retinoid, helps peel/thin plaque “peeling shingles off the roof”

Tar (baths): inhibits DNA synthesis/anti-inflammatory (messy and smelly)

Ointments: sit on skin, help medication penetrate (messy,greasy, can use saran wrap to help penetrate thick plaques)

Emolients: gentle skincare

Question 13

What is light therapy for psoriasis? Why are the advantages/disadvantages of light therapy?

Answer 13

UVA and UVB wavelengths penetrate skin for a photochemical reaction

Advantages: if used correctly (small amount of time/sunscreen) good for widespread disease, target specific areas

Disadvantages: time consuming, expensive, not long after completion psoriasis will return, risk of skin cancer/burns

Question 14

What’s a Ddx for psoriasis symptoms?

Answer 14

-candidiasis (inverse)
-atopic derm
-tinea
-seb derm
-nummular eczema

Question 15

What’s the first line treatment preferred for moderate to severe psoriasis?

Answer 15

SubQ injection/IV infusion to suppress inflammation, good for joints and skin
IMMUNE SYSTEM INTERFERENCE
-puts pt. at a higher risk for infection (like lymphoma)

-very expensive

Question 16

What are the systemic treatments for psoriasis?

Answer 16

Methotrexate: oral med, inhibits proliferation/immunosuppressant (can be used for arthritic symptoms.
common: nausea
HEPATOTOXIC: blood tests/lab work required to check liver function

Soriatane: oral med, Vitamin A derivative (inhibits keratinization), pill form of “peeling shingles off of a roof”, used with phototherapy, good for palmo/plantar
common: dryness
NO PREGNANCY: must be continued 3 years prior

Otezla (Apremilast): PD4 inhibitor that reduces cytokine production, expensive, good for skin&joints
common: diarrhea/mood changes
START AT LOW DOSE/WORK WAY UP

Question 17

What is pityriasis rosea?

Answer 17

An acute, self limited eruption (no known cause, maybe viral etiology) one patch usually blossoms into a rash
(Usually occurs in younger populations in the spring/fall)

Question 18

What are the clinical features of pityriasis rosea?

Answer 18

Blossoming red/pink/brown scaly patches that begin at trunk and extend to proximal extremities (christmas tree rash!)
Usually begins as one herald patch (pink/isolated) before the rest of the rash blossoms a few days/week later
Intense pruritis
Ddx: Guttate psoriasis, tinea, secondary syphillis, nummular eczema

Usually wont, but can reoccur

Question 19

What are the treatments available for pityriasis rosea?

Answer 19

Will resolve on its own (6-12 weeks)
To alleviate associated pruritis: topical steroids, oral antihistamines, phototherapy
(relieving pruritis reduces chance of secondary infection)

Question 20

What is lichen planus?

Answer 20

An uncommon inflammatory condition with unknown cause
A raised eruption that can be seen on the skin, mouth, buccal mucosa, hair follicle (may disrupt hair growth)

Question 21

What are the four P’s of lichen planus?

Answer 21

Pruritic
Purple
Polygonal
Papules or plaques

Question 22

What are the clinical features of lichen planus?

Answer 22

Possible pruritis, skin lesions (flat topped/raised) on ankles, wrists, scalp, nails, mucous membranes
Can have oral erosions/lacy white patches, sloughing
Scarring alopecia
Nail deformity

**Wickham’s Striae: fine white streaks/grey lines in lesions

Question 23

What are the diagnostic practices used in the diagnosis of lichen planus?

Answer 23

Biopsy
Hep C testing
Referral to oral surgeon if any oral lesions

Question 24

What associated diagnosis is sometimes related to lichen planus?

Answer 24

Hepatitis (good to test for it as well- Hep C panel)

Question 25

What are the treatments for lichen planus?

Answer 25

Will spontaneously resolve (6mos-2yrs), but commonly recurs at any time
Topical steroid/IL steroids, systemic steroids if severe, phototherapy

Question 26

What is a drug eruption?

Answer 26

A sudden systemic onset reaction (rash/hives) in response to a medication

Question 27

What are common medications associated with a drug eruption?

Answer 27

Antibiotics (bactrim, penicillins, cephalosporins)
Diuretics (Furosemide)
NSAIDS
Blood products

Question 28

What are the characteristics of a drug eruption?

Answer 28

Hives or bright/generalized papular rash
Starts proximally and proceeds distally
Usually begins within 1 week of new med, but can happen at any time

Question 29

What can diagnose a drug eruption, but CANNOT tell you which drug the patient is allergic to?

Answer 29

Biopsy

Question 30

What are the treatments available for drug eruptions?

Answer 30

Discontinue suspecting drug (make sure you collaborate with providers when replacing a drug)
Supportive care for any rash/itching (topical/oral steroids, baths, etc.)

Question 31

What is a fixed drug eruption?

Answer 31

One or more annular/oval/dusky/erythematous patches that form when exposed to a systemic drug

When re-exposed to the drug, same spot as original reaction occurs, and new spots may form as well

Question 32

What are the clinical features of a fixed drug eruption?

Answer 32

Plaques that are round/oval, sharply demarcated, dusky, erythematous/edematous
Commonly found on lip, hip, sacrum, genitalia
Symptoms include pruritis, burning, pain

*center of plaque can blister/become necrotic

Question 33

What is the treatment for a fixed drug eruption?

Answer 33

Avoid the offending drug, self resolves
Other supportive treatment for symptoms

Plaques will fade gradually/may leave residual hyperpigmentation

Question 34

What medications are commonly associated with a FIXED drug eruption?

Answer 34

Medications taken episodically (once a week, once a month, PRN)

Examples: pain relievers, antibiotics, laxatives