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4th year passmedicine by topic > Psoriasis > Flashcards

Psoriasis Flashcards

1
Q

Psoriasis prevalence

A

2%

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2
Q

patients with psoriasis are at increased risk of

A

arthritis and cardiovascular disease.

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3
Q

Pathophysiology psoriasis immunology?

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

Pathophysiology psoriasis genetics

A

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

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5
Q

Psoriasis is multifactorial and not fully understood

A

true

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6
Q

Environmental factors for psoriasis?

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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7
Q

Recognised subtypes of psoriasis

A

plaque psoriasis
flexural psoriasis
guttate psoriasis
pustular psoriasis

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8
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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9
Q

What is flexural psoriasis

A

in contrast to plaque psoriasis the skin is smooth

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10
Q

What is guttate psoriasis

A

transient psoriatic rash frequently triggered by a streptococcal infection. Multiple tear drop papules on the trunk and limbs

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11
Q

What is pustular psoriasis

A

commonly occurs on the palms and soles

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12
Q

Complications of psoriasis?

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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13
Q

Nail signs of psoriasis?

A

pitting
onycholysis
subungual hyperkeratosis
loss of nail

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14
Q

Psoriatic nail changes affect both fingers and toes

A

True

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15
Q

psoriatic arthropathy reflects severity of psoriasis

A

false

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16
Q

80-90% of patients with psoriatic arthropathy have nail changes

A

true

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17
Q

The following factors may exacerbate 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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18
Q

Which infection may trigger guttate psoriasis?

A

It may be precipitated by a streptococcal infection 2-4 weeks prior to the lesions appearing.

19
Q

Guttate psoriasis is more common in

A

children and adolescents

20
Q

Management of guttate psoriasis?

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

21
Q

Differentiate guttate psoriasis & pityriasis rosea prodrome?

A

Guttate: Classically preceded by a streptococcal sore throat 2-4 weeks

Pityriasus rosea:  majority of patients there is no prodrome, but a minority may give a history of a recent viral infection
herald patch (usually on trunk)
22
Q

Describe the appearance of pityriasis rosea?

A

Herald patch followed 1-2 weeks later by multiple erythematous, slightly raised oval lesions with a fine scale confined to the outer aspects of the lesions.

May follow a characteristic distribution with the longitudinal diameters of the oval lesions running parallel to the line of Langer. This may produce a ‘fir-tree’ appearance

23
Q

Mx pityriasis rosea?

A

Self-limiting, resolves after around 6 weeks

24
Q

What is Pityriasis rosea?

A

acute, self-limiting rash which tends to affect young adults. The aetiology is not fully understood but is thought that herpes hominis virus 7 (HHV-7) may play a role.

25
Q

Chronic plaque psoriasis first line?

A

regular emollients may help to reduce scale loss and reduce pruritus
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

26
Q

Chronic plaque psoriasis second line? When is this indicated?

A

if no improvement after 8 weeks then offer:

a vitamin D analogue twice daily

27
Q

Chronic plaque psoriasis third line? When is this indicated?

A

if 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

28
Q

Secondary care management psoriasis?

A

Phototherapy

Systemic therapy

29
Q

Describe phototherapy in psoriasis mx?

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)

30
Q

Phototherapy adverse effects?

A

adverse effects: skin ageing, squamous cell cancer (not melanoma)

31
Q

Describe systemic therapy in psoriasis?

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

32
Q

Scalp psoriasis management first line?

A

NICE recommend the use of potent topical corticosteroids used once daily for 4 weeks

33
Q

Scalp psoriasis management second line?

A

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

34
Q

Face, flexural and genital psoriasis management

A

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

35
Q

topical corticosteroid therapy may lead to

A

skin atrophy, striae and rebound symptoms

systemic side-effects may be seen when potent corticosteroids are used on large areas e.g. > 10% of the body surface area

36
Q

Which areas are particularly prone to steroid atrophy?

A

the scalp, face and flexures are particularly prone to steroid atrophy so topical steroids should not be used for more than 1-2 weeks/month

37
Q

What are the limits on using corticosteroids in psoriasis?

A

the scalp, face and flexures are particularly prone to steroid atrophy so topical steroids should not be used for more than 1-2 weeks/month
NICE recommend that we aim for a 4-week break before starting another course of topical corticosteroids
they also recommend using potent corticosteroids for no longer than 8 weeks at a time and very potent corticosteroids for no longer than 4 weeks at a time

38
Q

examples of vitamin D analogues include

A

calcipotriol (Dovonex), calcitriol and tacalcitol

39
Q

How do vitamin D analogues work?

A

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

40
Q

In vitamin D analogues adverse effects are common

A

false
adverse effects are uncommon
unlike corticosteroids they may be used long-term
unlike coal tar and dithranol they do not smell or stain
they tend to reduce the scale and thickness of plaques but not the erythema

41
Q

vitamin d analogues are safe in pregnancy

A

false

they should be avoided in pregnancy

42
Q

How does dithranol work?

A

inhibits DNA synthesis

wash off after 30 mins

43
Q

Adverse effects of dithranol?

A

adverse effects include burning, staining

44
Q

Coal tar

mechanism of action not fully understood - probably inhibit DNA synthesis

A

true

4th year passmedicine by topic (96 decks)

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