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Derm P year > Psoriasis > Flashcards

Psoriasis Flashcards

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Dermatology Board Prep flashcards
1
Q

What is it and what does it increase the risk o f

A

red, scaly patches on the skin although it is now recognised that patients with psoriasis are at increased risk of arthritis and cardiovascular disease.

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2
Q

Genetic association

A

HLA-B13, -B17, and -Cw6. Strong concordance (70%) in identical twins

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3
Q

Immunological pathophysiology

A

abnormal T cell activity stimulates keratinocyte proliferation. There is increasing evidence this may be mediated by a novel group of T helper cells producing IL-17, designated Th17. These cells seem to be a third T-effector cell subset in addition to Th1 and Th2

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4
Q

What are the environmental triggers

A

it is recognised that psoriasis may be worsened (e.g. Skin trauma, stress), triggered (e.g. Streptococcal infection) or improved (e.g. Sunlight) by environmental factors

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5
Q

wHAT EXACERBATES PSORIASIS

A

trauma
alcohol
drugs: beta blockers, lithium, antimalarials (chloroquine and hydroxychloroquine), NSAIDs and ACE inhibitors, infliximab
withdrawal of systemic steroids

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6
Q

What are the subtypes

A

Plaque, flexural, guttate, pustular

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7
Q

What is plaque psoriasis

A

the most common sub-type resulting in the typical well-demarcated red, scaly patches affecting the extensor surfaces, sacrum and scalp

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8
Q

What is flexural psoriasis

A

in contrast to plaque psoriasis the skin is smooth

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9
Q

What is guttate psoriasis

A

transient psoriatic rash frequently triggered by a streptococcal infection. Multiple red, teardrop lesions appear on the body

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10
Q

What is pustular psoriasis

A

commonly occurs on the palms and soles

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11
Q

How does it effect nails

A

Affects both finger and toe nails (80% of those with psoriatic arthropathy have it)

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12
Q

What nail changes will be seen

A

pitting
onycholysis (separation of the nail from the nail bed)
subungual hyperkeratosis
loss of the nail

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13
Q

What are the other features of psoriasis

A

nail signs: pitting, onycholysis
arthritis

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14
Q

Complications

A

psoriatic arthropathy (around 10%)
increased incidence of metabolic syndrome
increased incidence of cardiovascular disease
increased incidence of venous thromboembolism
psychological distress

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15
Q

What is seen in chronic plaque psoriasis

A

erythematous plaques covered with a silvery-white scale

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16
Q

Where is plaque psoriasis located

A

extensor surfaces such as the elbows and knees. Also common on the scalp, trunk, buttocks and periumbilical area - clear delineation between normal and affected

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17
Q

How big are the plaques

A

1-10cm

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18
Q

What happens when the plaques are removed

A

Auspitz sign

19
Q

Who gets guttate psoriasis

A

Kids and teens

20
Q

What is guttate precipitated by

A

streptococcal infection 2-4 weeks prior to the lesions appearing.

21
Q

What are the features of guttate

A

tear drop papules on the trunk and limbs
gutta is Latin for drop
pink, scaly patches or plques of psoriasis
tends to be acute onset over days

22
Q

How to manage guttate

A

most cases resolve spontaneously within 2-3 months
there is no firm evidence to support the use of antibiotics to eradicate streptococcal infection
topical agents as per psoriasis
UVB phototherapy
tonsillectomy may be necessary with recurrent episodes

23
Q

Management of chronic plaquers

A

regular emollients may help to reduce scale loss and reduce pruritus
first-line: NICE recommend:
a potent corticosteroid applied once daily plus vitamin D analogue applied once daily
should be applied separately, one in the morning and the other in the evening)
for up to 4 weeks as initial treatment

24
Q

What is second line

A

if no improvement after 8 weeks then offer a vitamin d analogue

25
Q

What is third line

A

f no improvement after 8-12 weeks then offer either:
a potent corticosteroid applied twice daily for up to 4 weeks, or
a coal tar preparation applied once or twice daily
short-acting dithranol can also be used

26
Q

What secondary management may be used

A

Phototherapy and systemic therapy

27
Q

What is involved in phototherapy

A

narrowband ultraviolet B light is now the treatment of choice. If possible this should be given 3 times a week
photochemotherapy is also used - psoralen + ultraviolet A light (PUVA)
adverse effects: skin ageing, squamous cell cancer (not melanoma)

28
Q

What is involved in systemic therapy

A

oral methotrexate is used first-line. It is particularly useful if there is associated joint disease
ciclosporin
systemic retinoids
biological agents: infliximab, etanercept and adalimumab
ustekinumab (IL-12 and IL-23 blocker) is showing promise in early trials

29
Q

What to do for scalp psoriasis

A

NICE recommend the use of potent topical corticosteroids used once daily for 4 weeks
if no improvement after 4 weeks then either use a different formulation of the potent corticosteroid (for example, a shampoo or mousse) and/or a topical agents to remove adherent scale (for example, agents containing salicylic acid, emollients and oils) before application of the potent corticosteroid

30
Q

What to do for Face, flexural and genital psoriasis

A

NICE recommend offering a mild or moderate potency corticosteroid applied once or twice daily for a maximum of 2 weeks

31
Q

How long to use topical steroids on scalp face and flexures

A

should not be used for more than 1-2 weeks/month - skin atrophy

32
Q

When are systemic side effects seen

A

> 10% body use

33
Q

How long in between using another corticosteroid

A

4 week break

34
Q

How long can you use potent corticosteroids

A

8 weeks at a time

35
Q

How long can you use very potent

A

No more than 4 weeks

36
Q

Examples of Vit D analogues

A

calcipotriol (Dovonex), calcitriol and tacalcitol

37
Q

How do the Vin D analogues work

A

they work by ↓ cell division and differentiation → ↓ epidermal proliferation

38
Q

What are the benefits of Vitamin D use

A

adverse effects are uncommon
unlike corticosteroids they may be used long-term
unlike coal tar and dithranol they do not smell or stain

39
Q

What do they do to plaques

A

they tend to reduce the scale and thickness of plaques but not the erythema

40
Q

Maximum dose and when should be avoided

A

they should be avoided in pregnancy
the maximum weekly amount for adults is 100g

41
Q

How does dithranol work

A

inhibits DNA synthesis
wash off after 30 mins
adverse effects include burning, staining

42
Q

How to treat flexor psoriasis

A

Remember that the treatment of flexural psoriasis differs from extensor psoriasis. The skin of flexure areas of the body is much thinner and more sensitive to steroids compared to the extensor surfaces. Flexural surfaces that tend to be affected are the groin, genital region, axillae, inframammary folds, abdominal folds, sacral and gluteal cleft.

In this case, the patient’s axillae are affected and treatment should begin with a mild- or moderately-potent corticosteroid (applied once or twice daily) for up to two weeks, as per NICE guidelines.

Vit D not found to be beneficial for this case

43
Q

You are reviewing a 46-year-old man with a known diagnosis of chronic plaque psoriasis affecting his elbows and knees. He was seen by one of your colleagues 8 weeks ago and was given a combination of vitamin D and a potent corticosteroid for a flare of symptoms. He has been using this daily. Prior to this, he was only using emollients.

There has been some improvement, but you both agree that he needs further treatment to control this flare. Which of the above would be the next most appropriate step in management?

A

A topical vitamin D preparation alone

This patient has had 8 weeks of a potent steroid. According to NICE this should be stopped now and the next line in treatment should be applying a vitamin D analogue twice daily. You would review him again after 8-12 weeks.

According to NICE guidance, he should have been started on a potent steroid and a separate vitamin D preparation. Combined preparations are recommended much later in the treatment algorithm. In practice however, you will find that not everyone will follow guidelines strictly. In this case, it is important to remember to limit potent steroid applications to 8 weeks followed by at least a 4-week break.

Derm P year (31 decks)

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