Psoriasis

Question 1

What is the pathophysiology of Psoriasis?

Answer 1

Multifactorial
Genetic - HLA and PSORS
Immunological: Abnormal T cell activity releases cytokines and stimulates keratinocyte proliferation
May be worsen by triggers eg, stress, strep, or improved by sunlight

Question 2

What are the different types of psoriasis?

Answer 2

Plaque,
Guttate - triggered by strep throat
Pustular,
Erythrodermic
Flexural
Palmer/planter pustulosis

Question 3

What are some exacerbating factors for psoriasis?

Answer 3

Trauma,
alcohol,
drugs (BALI: Beta blockers, Anti-malarials, Lithium, Indomethacin (NSAIDs) and infliximab)
and steroid withdrawal.

Question 4

What are the nail changes that occur in psoriasis?

Answer 4

Pitting,
Onycholysis (nail becomes detached from underlying nail bed)
Subungual hyperkeratosis

Question 5

What is the Koebner phenomenon?

Answer 5

Psoriasis at sites of trauma/scars. Not Auspitzs which is pin point bleeding that occurs with itching.

Question 6

What does the following image show?

Answer 6

Guttate psoriasis. Small tear drop plaques of psoriasis. Can be triggered by a strptococcal infection 2-4 weeks before lesions appear.
Most resolve spontaneously within 2-3 months. Can use topical agents or UVB therapy

Question 7

What does the following image show?

Answer 7

Erythrodermic psoriasis. It is a lot more inflammatory

Question 8

What are the complications for psoriasis?

Answer 8

Psoriatic arthropathy,
Increased incidence of metabolic syndrome,
Increased risk of CV disease,
Increased incidence of VTE,
Psychological distress

Question 9

What are the topical managements for plaque Psoriasis?

Answer 9

All - Emollient
1st line - Topical steroid (Betnovate) and topical vitamin D (Dovonex) at different times of day
2nd Line if no improvement after 8 weeks - Stop steroid and use vitamin D twice a day.
3rd Line if no improvement after 8-12 weeks- Stop vitamin D and apply potent steroid 2x day or coal tar.
Dithranol and tar are alternatives

Question 10

What is the systemic treatment for Psoriasis?

Answer 10

1st line = Methotrexate,
2nd line = Ciclosporin (first line if palmoplantar or pregnancy),
3rd line = Acitretin.
Biologics - Infliximab, adalimumab, etranercept

Question 11

What is the phototherapy used for psoriasis?

Answer 11

First line - Narrow ultraviolet B 3x week
Photochemotherapy can also be used (Psoralen UV A - PUVA)

Question 12

what are the cautions with topical steroids?

Answer 12

Aim for 4 week break before starting another course.
Do not use potent steroids for > 8weeks and very potent > 4 weeks

Question 13

Explain features of Vitamin D analogues in the treatment of psoriasis?

Answer 13

Works by reducing cell division and differentiation which reduced epidermal proliferation. They can be used long term and side effects are uncommon.
They reduce scale and thickness but not erythema
Avoid in pregnancy

Before and after use.

Question 14

What are the side effects of methotrexate?

Answer 14

Pneumonitis
Hepatotoxicity (monitor LFTs)
Myelosupression which can lead to pancytopenia

Question 15

What are the side effects of Acitretin?

Answer 15

Teratogenic and hepatotoxicity

Question 16

What are the side effects of Anti-TNF drugs (adalimumab or infliximab)

Answer 16

Reactivation of TB so always do CXR before treatment

Question 17

What are the side effects of Ciclosporin?

Answer 17

5 H’s
Hypertrophy of gums,
Hypertrichosis,
Hypertension,
Hyperkalaemia,
Hyperglycaemia