Papulosquamous Disorders

Question 1

Pityriasis Rosea

Answer 1

A benign common rash seen in otherwise healthy people
● Name means: “fine, pink scale”
● Acute, self-limiting papulosquamous eruption

Question 2

Pityriasis Rosea pathophysiology

Answer 2

● 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

Question 3

Pityriasis Rosea etiology

Answer 3

● 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)

Question 4

Pityriasis Rosea presentation

Answer 4

● 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

Question 5

Pityriasis Rosea diagnosis

Answer 5

● Clinical
● Lab tests not typically needed

Question 6

Pityriasis Rosea treatment

Answer 6

● Supportive – spontaneous resolution in
about 6 weeks
● UV radiation therapy
● Pruritus – zinc oxide, calamine lotion,
antihistamine, etc.
● If severe, topical or oral steroids

Question 7

Psoriasis

Answer 7

● 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

Question 8

Psoriasis etiology

Answer 8

● 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

Question 9

Psoriasis pathophysiology

Answer 9

● 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

Question 10

Psoriasis key findings

Answer 10

o Vascular engorgement due to superficial blood vessel dilation
o Altered epidermal cell cycle → improper cell
maturation

Question 11

Psoriasis etiology

Answer 11

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

Question 12

Psoriasis epidemiology

Answer 12

● 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

Question 13

Psoriasis presentation

Answer 13

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

Question 14

Ocular manifestations of psoriasis

Answer 14

○ May appear as conjunctivitis,
corneal dryness, etc.
○ Blepharitis is the most common
ocular finding

Question 15

Psoriasis diagnosis

Answer 15

● 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

Question 16

Psoriasis treatment

Answer 16

● Those with mild skin disease can often be managed with topical therapies
● Moderate to severe disease typically requires phototherapy or systemic
agents

Question 17

Psoriasis treatment for mild disease

Answer 17

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

Question 18

Psoriasis treatment for mod-severe lesions

Answer 18

o Retinoids
o Methotrexate
o Cyclosporine
o Biologics (eg. adalimumab)

Question 19

Psoriasis types

Answer 19

● Psoriasis vulgaris/Plaque psoriasis
● Guttate psoriasis
● Inverse psoriasis
● Pustular psoriasis
● Erythrodermic psoriasis
● Palmoplantar plaque psoriasis
● Nail psoriasis
● Psoriatic arthritis

Question 20

Psoriasis
Presentation – Psoriasis vulgaris or
Plaque psoriasis

Answer 20

● 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

Question 21

Psoriasis
Treatment – Psoriasis vulgaris or
Plaque psoriasis

Answer 21

● 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

Question 22

Psoriasis
Presentation - Guttate psoriasis

Answer 22

● 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

Question 23

Psoriasis
Treatment – Guttate psoriasis

Answer 23

● 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

Question 24

Psoriasis
Presentation - Inverse psoriasis

Answer 24

● Occurs on the flexural surfaces, armpit,
groin, under breast, and in skin folds
● Lesions are smooth and inflamed,
without scaling

Question 25

Psoriasis
Treatment - Inverse psoriasis

Answer 25

● Topical corticosteroids, as low
potency as possible, short term
● If treatment failure, consider
tacrolimus ointment
Prognosis – waxes and wanes

Question 26

Psoriasis
Presentation – Pustular psoriasis

Answer 26

● Rare
● Presents as pustules on the palms and
soles or diffusely across the body
● May cycle through erythema, pustules,
then scaling

Question 27

Treatment – Pustular psoriasis

Answer 27

● Systemic retinoids or methotrexate
● Can be fatal if untreated

Question 28

Psoriasis
Presentation – Erythrodermic psoriasis

Answer 28

● 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

Question 29

Treatment – Erythrodermic psoriasis

Answer 29

● 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

Question 30

Presentation – Palmoplantar plaque psoriasis

Answer 30

● Hyperkeratotic plaques on palms and/or soles
Palmoplantar pustulosis – pustular
psoriasis localized to palms and/or soles
● Flare ups may be painful and disabling

Question 31

Treatment - Palmoplantar plaque psoriasis

Answer 31

● Potent topical corticosteroids
● Psoralen plus ultraviolet A phototherapy (PUVA)
● Retinoids (acitretin), methotrexate, cyclosporine, biologics, etc.
Difficult to treat

Question 32

Presentation – Nail psoriasis

Answer 32

● 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

Question 33

Treatment – Nail psoriasis

Answer 33

● 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

Question 34

Presentation – Psoriatic arthritis

Answer 34

● Affects approximately 10-30% of those with
skin symptoms
● Usually in the hands and feet
● Presents as stiffness, pain, and progressive
joint damage

Question 35

Treatment - Psoriatic arthritis

Answer 35

● Start early, coordinate with specialists
● If mild, consider NSAIDs initially
● If no improvement, consider methotrexate
● If severe, consider TNF inhibitor

Question 36

Patient Education for psoriasis

Answer 36

● 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

Question 37

A pruritic papulosquamous eruption/disorder

Answer 37

Lichen Planus

Question 38

Pathophysiology of lichen planus

Answer 38

● 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

Question 39

Lichen Planus etiology

Answer 39

● 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

Question 40

Lichen Planus presentation - cutaneous

Answer 40

● Planar
● Pruritic
● Purple (slightly violaceous)
● Polygonal
● Papules or plaques
“A pruritic, violaceous, flat-topped,
papulosquamous eruption on the skin”

Question 41

Koebner Reaction of lichen planus

Answer 41

The development of new skin lesions in
sites of trauma

Question 42

Wickham’s Striae

Answer 42

● Fine white lines (“lace-like”) on the
surfaces of papules or plaques with lichen planus

Question 43

Lichen Planus - oral presentation

Answer 43

● Can occur independently or with
cutaneous disease
● Wickham’s striae may be evident
on buccal mucosa
● Papular, erosive lesions may also be
present

Question 44

Lichen Planus presentation - genitalia

Answer 44

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

Question 45

Lichen Planus diangosis

Answer 45

● Clinical findings
● Skin biopsy can confirm diagnosis
o Punch or shave (reach
mid-dermis)
● Test for Hep C infection

Question 46

Lichen Planus treatment

Answer 46

● 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