Papulosquamous Disorders Flashcards
Pityriasis Rosea
A benign common rash seen in otherwise healthy people
● Name means: “fine, pink scale”
● Acute, self-limiting papulosquamous eruption
Pityriasis Rosea pathophysiology
● Considered a viral exanthem
o Increased CD4 T cells and Langerhans
cells are present in dermis
● Has been linked to URIs
● Most often occurs in spring and winter
● Does not appear to be highly contagious;
no need to isolate
Pityriasis Rosea etiology
● May result from infections, medications, immunizations
Medication Causes
● Omeprazole, terbinafine, captopril,
isotretinoin, psychotropic medication,
etc
Vaccine Causes
● Smallpox, TB, flu, Tdap, yellow fever, COVID-19
(Moderna and others)
Pityriasis Rosea presentation
● In 50-90% of cases, the primary/
“herald” plaque is seen a week or more
before the smaller lesions erupt
o Initial plaque is often salmon
colored and oval and on the back
● Pruritus may be present (25-75%)
● The smaller lesions follow the lines of
cleavage of the skin on back and
abdomen mostly
o Christmas Tree Pattern
Pityriasis Rosea diagnosis
● Clinical
● Lab tests not typically needed
Pityriasis Rosea treatment
● Supportive – spontaneous resolution in
about 6 weeks
● UV radiation therapy
● Pruritus – zinc oxide, calamine lotion,
antihistamine, etc.
● If severe, topical or oral steroids
Psoriasis
● Psoriasis is a complex, chronic,
multifactorial, inflammatory
disease
● Involves hyperproliferation of the
keratinocytes in the epidermis
● An increased epidermal cell
turnover rate
● Environmental, genetic, and
immunologic factors play a role
● Has remissions and exacerbations
Psoriasis etiology
● Patients typically have a genetic
predisposition
● Commonly affects the elbows, knees,
scalp, lumbosacral areas, intergluteal
clefts, and glans penis
● Joints are affected in 30% of patients
● Is likely an autoimmune condition
o NOT CONTAGIOUS
Psoriasis pathophysiology
● Not completely understood
● No obvious trigger in many patients
● Once triggered, leukocytes are
recruited to the dermis and epidermis → psoriatic plaques
● Large numbers of activated T
cells → keratinocyte proliferation
● T-cell hyperactivity and proinflammatory mediators play a large role in the pathogenesis of psoriasis
● Low levels of lipids and cells with retained nuclei lead to a poorly adherent stratum
corneum → flaking, scaly lesions
Psoriasis key findings
o Vascular engorgement due to superficial blood vessel dilation
o Altered epidermal cell cycle → improper cell
maturation
Psoriasis etiology
Environmental Factors
● Stress
● Cold
● Trauma
● Infections (Strep)
● Alcohol
● Medications
Genetic Factors
● 40% of individuals with
psoriasis have a family history
of psoriasis
Other Factors
● Obesity
● Smoking
● Low Vitamin D levels
Psoriasis epidemiology
● Approximately 2-3.6% of the
US population has psoriasis
● Bimodal peak in ages: 20-30
years and 50-60 years
● Slightly more prevalent in
women
Psoriasis presentation
o Scaling, salmon-colored/ erythematous
macules, papules, and plaques
○ Macules are noted first and progress to
maculopapules and then
well-demarcated, silvery plaques
overlying glossy erythema
Ocular manifestations of psoriasis
○ May appear as conjunctivitis,
corneal dryness, etc.
○ Blepharitis is the most common
ocular finding
Psoriasis diagnosis
● Clinical
● If difficult to identify, consider
biopsy
● Auspitz sign = pinpoint drops
of blood appear after scales
are removed
● Can differentiate psoriatic
arthritis from RA and gout by
absence of lab findings
Psoriasis treatment
● Those with mild skin disease can often be managed with topical therapies
● Moderate to severe disease typically requires phototherapy or systemic
agents
Psoriasis treatment for mild disease
o Daily sun exposure, sea bathing, topical
moisturizers, and relaxation
● Daily moisturizing (eg. petroleum jelly)
● Limited lesions respond well to
o Topical corticosteroids
o Emollients
o Vitamin D analogs (eg. calcitriol)
o Coal tar
o Topical retinoids
Psoriasis treatment for mod-severe lesions
o Retinoids
o Methotrexate
o Cyclosporine
o Biologics (eg. adalimumab)
Psoriasis types
● Psoriasis vulgaris/Plaque psoriasis
● Guttate psoriasis
● Inverse psoriasis
● Pustular psoriasis
● Erythrodermic psoriasis
● Palmoplantar plaque psoriasis
● Nail psoriasis
● Psoriatic arthritis
Psoriasis
Presentation – Psoriasis vulgaris or
Plaque psoriasis
● Most common type
● Involves scalp, extensor surfaces of
knees and elbows, trunk, genitals,
umbilicus, and lumbosacral and
retroauricular regions
● Raised, inflamed lesions covered with a
silvery white scale
o Skin can be scraped away
● Gradual appearance
● No cure
Psoriasis
Treatment – Psoriasis vulgaris or
Plaque psoriasis
● Scalp – topical corticosteroids
● Consider adding a Vit D analog
● May use coal tar shampoo, anthralin, and
intralesional corticosteroid injections
● Consider systemic immunosuppressants
or biologics
● Prognosis – waxes and wanes, without cure
Psoriasis
Presentation - Guttate psoriasis
● Presents as small salmon-pink papules
● Most commonly on trunk in children
and young adults
● Appears suddenly, typically 2-3
weeks after URI or strep pharyngitis
Psoriasis
Treatment – Guttate psoriasis
● Often self limiting – 12-16 weeks
o May use topicals for Sx
o Strep infection – antibiotics
■ May have recurrence
● 1/3 may progress to plaque psoriasis
Psoriasis
Presentation - Inverse psoriasis
● Occurs on the flexural surfaces, armpit,
groin, under breast, and in skin folds
● Lesions are smooth and inflamed,
without scaling
Psoriasis
Treatment - Inverse psoriasis
● Topical corticosteroids, as low
potency as possible, short term
● If treatment failure, consider
tacrolimus ointment
Prognosis – waxes and wanes
Psoriasis
Presentation – Pustular psoriasis
● Rare
● Presents as pustules on the palms and
soles or diffusely across the body
● May cycle through erythema, pustules,
then scaling
Treatment – Pustular psoriasis
● Systemic retinoids or methotrexate
● Can be fatal if untreated
Psoriasis
Presentation – Erythrodermic psoriasis
● Rare
● Often caused by exposures –
o Medications (steroids), infections,
exposures, stress
● Presents as generalized erythema, pain,
itching, and fine scaling
● Typically encompasses almost the entire
body surface area
● May be accompanied by fever, chills,
hypothermia, and dehydration
Treatment – Erythrodermic psoriasis
● Steroids, tars, anthralin, and phototherapy
can exacerbate the condition
● Potent systemic immunosuppressants (eg,
methotrexate, cyclosporine)
● May require inpatient treatment
Prognosis – good with elimination of triggers
Presentation – Palmoplantar plaque psoriasis
● Hyperkeratotic plaques on palms and/or soles
Palmoplantar pustulosis – pustular
psoriasis localized to palms and/or soles
● Flare ups may be painful and disabling
Treatment - Palmoplantar plaque psoriasis
● Potent topical corticosteroids
● Psoralen plus ultraviolet A phototherapy (PUVA)
● Retinoids (acitretin), methotrexate, cyclosporine, biologics, etc.
Difficult to treat
Presentation – Nail psoriasis
● Oil spots may be present – most
specific nail finding
● May cause nail pitting
o Can be thickened and yellow
● Oil spots may be present – most
specific nail finding
● Onycholysis – nails separating
from the bed
● Affects 30-50% of patients
with other forms of psoriasis
● May resemble a fungal nail
infection
Treatment – Nail psoriasis
● Avoid trauma to the nail
● Wear protective gloves during wet
work or using harsh chemicals
● First-line – topical corticosteroids
and topical Vit D analog
● Second-line – topical tacrolimus
and topical tazarotene
Responds best to systemic therapy
but often unresponsive to treatment
Presentation – Psoriatic arthritis
● Affects approximately 10-30% of those with
skin symptoms
● Usually in the hands and feet
● Presents as stiffness, pain, and progressive
joint damage
Treatment - Psoriatic arthritis
● Start early, coordinate with specialists
● If mild, consider NSAIDs initially
● If no improvement, consider methotrexate
● If severe, consider TNF inhibitor
Patient Education for psoriasis
● Consider referral to the National Psoriasis Foundation
● Address the psychosocial aspects of the disease
● Weight loss can help psoriasis, no specific diet is shown to help
● Avoid OTC and other meds that can exacerbate symptoms,
including NSAIDs
A pruritic papulosquamous eruption/disorder
Lichen Planus
Pathophysiology of lichen planus
● Commonly thought to be
associated with Hep C
● Some association with medications
● Lesions may be cutaneous, affect
mucosal membranes (oral), or the
genitalia, scalp, or nails
● Often affects middle-aged adults
● Self limiting – 12-18 months
Lichen Planus etiology
● Exact cause is unknown
● It is immunologically mediated,
may be a T-cell driven autoimmune
disease directed at basal
keratinocytes
● Some individuals will have a
positive family history
Lichen Planus presentation - cutaneous
● Planar
● Pruritic
● Purple (slightly violaceous)
● Polygonal
● Papules or plaques
“A pruritic, violaceous, flat-topped,
papulosquamous eruption on the skin”
Koebner Reaction of lichen planus
The development of new skin lesions in
sites of trauma
Wickham’s Striae
● Fine white lines (“lace-like”) on the
surfaces of papules or plaques with lichen planus
Lichen Planus - oral presentation
● Can occur independently or with
cutaneous disease
● Wickham’s striae may be evident
on buccal mucosa
● Papular, erosive lesions may also be
present
Lichen Planus presentation - genitalia
Males: violaceous papules
on glans penis
Females: lesions typically occur on vulva
● Vulvo-vaginal-gingival syndrome
is an erosive form of LP
● Can be resistant to treatment
Lichen Planus diangosis
● Clinical findings
● Skin biopsy can confirm diagnosis
o Punch or shave (reach
mid-dermis)
● Test for Hep C infection
Lichen Planus treatment
● Typically self-limiting
● First-line – Topical corticosteroids
o High or super high potency
■ Betamethasone
● Intralesional corticosteroids
o Triamcinolone, Kenalog
o May cause skin atrophy and
hypopigmentation
● Second-line
o Oral corticosteroids
o Phototherapy
■ UVB and psoralen plus
UVA (PUVA)
o Oral retinoids (acitretin)
● Consider oral antihistamines
o High dose
