Psoriasis Flashcards
Most common type of psoriasis in children? Followed by ??
Plaque psoriasis
Guttate psoriasis
Gene involved in psoriasis?
HLA-cw6
Marker for sacroiliitis associated psoriasis??
HLA-B27
PSOR1 gene encodes for??
Corneodesmosin
Target cells in psoriasis?
Interfollicular epidermis
How does psoriasis induction occur??
TNF-a and IFN-a release from plasmacytoid DC via TLR-9
What is the key for entrance?
Psoriatic T-cells express a1b1 integrin that interact with BM collagen type 4
What cells prominent in active lesions and marginal zones of expanding plaque ??
And what histology is seen??
Neutrophils
Spongiform pustules of kogoj +
Munro microabsess
What’s responsible for prominent angiogenesis??
VEGF
What IL that decreases in psoriasis??
10
Which subunit does ustekinhmab work on ??
P40
What do dendritic cells secrete??
TNF-a
IFN-a
IL-23
What does IL-23 do ??
Stimulates Th-17 = release of IL-17 and 22 leading to keratinocytes proliferation and dermal inflammation
Which IL that it’s levels correlate with psoriasis severity ??
IL-22
What cells release ?
IFN-a
IFN-gamma
a: DC
Gamma: activated T-cells and NK T-cells
What pathway is key feature of psoriasis??
IFN-gamma (vasodilation and T-cell accumulation)
What mediates neutrophilic migration?
CXCL8
What are the anti microbial peptides that increase in psoriasis?
Beta-defensin 1
Secretory leukocyte protease inhibitor
What causes keratinocyte proliferation in psoriatic plaques??
STAT3
What promotes chemotactic activity ?
Human b defensin 2 binds to TLR4 = high CCR6
Mention 7 causes of psoriasis ?
1- external
2-infection
3-HIV
4-drugs
5-habits
6-psychology
7-endocrine
External causes of psoriasis?
Sunburn
Morbillifirm drug eruption
Viral exanthem
Infections causing psoriasis?
Strep pharyngitis
Dental abscess
Impetigo
Perianal abscess
Strep pharyngitis induces psoriasis via ??
Expression of Il-23R and CLA
Endocrine causes of psoriasis?
Hypocalcemia (but not abnormal viD levels)
Drugs causing psoriasis
Lithium
Imiquimod
Rapid tapering of steroids
TNFai
B-blocker
Antimalarial
What is impetigo herpetiformis ?
Pustular psoriasis of pregnancy
Auzpitz signs ??
Pinpoint bleeding after removal of silvery white micaceous scales
What causes auzpitz sign ?
Elongated vessels in dermal papillae + thinning of suprapapillary epidermis
What indicates unstable psoriasis?
Presence of pinpoint papules
Whats wornoff ring sign ?
Pale blanching rings surrounding psoriatic lesions
What are 9 types of psoriasis?
Chronic plaque, guttate, pustular, nail, oral mucosa, scalp, psa, flexural, erythrodermic
Percentage of genetalia involvement?
45%
Percentage of remitting plaque psoriasis in 5 years ?
15%
Types of psoriasis?
1-type 1: positive family hx and positive HLA-cw6
2-type 2: negative
What’s the most common cause of guttate psoriasis ??
URTI (> 50% have positive ASI and Anti DNAse)
Characteristic of erythrodermic psoriasis?
Nail changes
Face is spared centrally
What are pustular variants?
1- generalized
2-palmoplantar pustulosis
3-acrodermatitis continua of hallopeau
What triggers generalized pustular psoriasis??
Pregnancy, steroids tappering? Hypocalcemia, infections, topical irritation
Genes involved in generalized pustlar psoriasis ?
ADAM17, CARD14, DIRA, DITRA
Types of generalized pustular psoriasis?
Von zumbach pattern
Annular pattern
Exathemic pattern
Localized pattern
What is von zumbach pattern?
Fever + painful erythema and pustules
Gene mutation of von zumbach pattern ?
Homozygous IL-35R gene mutation
What is annular pattern?
Erythema and scaling with pustulation at advancing edge (central healing )
Exanthemic type ?
Follows infection
Acute eruption of small pustules appearing and disappearing over few days
What is the localized pattern pustular psoriasis ??
Pustules at the edge of pre existing psoriatic plaque (reflects unstable phase) after application of topical anthralin or tar
Palmoplantar pustulosis ??
Sterile pustules + yellow brown macules
More chronic
What triggers pamoplantar pustulosis ?
Smoking
Stress
Local infection
Palmoplantar pustulosis is seen in ??
SAPHO
SYNOVITIS, acne, pustulosis, hyperostosis, osteitis
What is acrodermatitis continua of hallupeau ?
Pustules on distal portions of fingers and toes and nails
= nail shedding( pustules on nail bed)
acrodermatitis continua of hallupeau is associated with??
Annulus migrans of tongue
Most common sites of scalp psoriasis?
Periphery of face
Retroauriculae area
Posterior upper neck
Name the scalp psoriasis scales ?
Asbestos like (pityriasis amianticia)
Causes of pityriasis amiantacea ?
Seb dermatitis
Scalp psoriasis
Secondary infected atopic dermatitis
Tinea capitis
If scalp psoriasis is associated with alopecia, think of ?
TNF-ai induced psoriasis
Describe flexural psoriasis ?
Shiny pink-red sharply demarcated thin plaques + central fissuring
Most common site of flexural psoriasis?
Retroauricular
Intergluteal cleft
Inguinal crease
Axilla
What causes flexural psoriasis?
Localized dermatophyte, candida, bacteria
What is the manifestation of oral mucosa psoriasis?
Annulus migrans
(Migratory annular erythematous lesion with white scales)
Most common site of annulus migrans ?
Tongue
What causes nail pitting ?
Focal parakeratosis of proximal portion of nail matrix
Nail parts that are affected in nail psoriasis??
Nail bed, matrix and hyponychium
What are 7 nail changes in psoriasis??
Pitting
Oil drop/salmon patches
Subungual hyperkeratosis
Onycholysis
Leukonychia and loss of transparency
White pourly adherent nail
Splinter hemorrhage
What causes subungual hyperkeratosis and onycholysis ??
Parakeratosis of distal nail bed
What causes leukonychia ??
Involvement of midportion of nail matrix and if total matrix is involved = white pourly adherent nail
What causes oil drop patch ??
exocytosis of WBC beneath nail plate (involving nail bed)
What causes splinter hemorrhage??
Capillary fragility
Wgat could exacerbate nail psoriasis??
Trying to remove it
What helps the most in nail psoriasis??
IL-17
JAKi
MTX
Risk factors for PSA ?
1- early age
2- female
3- polyarticular involvement
4- positive family history
5-radiologic findings
Most common type of PSA ??
Mono-asymmetrical-oligoarthritis (DIP)
5 major types of PSA ?
1- mono-asymmetrical-oligoarthritis
(Sausage digits)
2- DIP arthritis
3- RA-like
4- arthritis mutilans
5- spondylitis and sacroiliitis
DIP arthritis presentation??
Fixed flexed position joints
Arthritis mutilans presentation?
Severe rapidly progressive joint inflammation- osteolysis = short wide digits = telescoping phenomenon
What are juxta articular manifestations?
Tendonitis
Enthesitis
Dactylitis
What are other 4 associations with psoriasis??
1- skin diseases
2- cancer
3- infection
4- systemic internal disease
What are skin diseases that increase in psoriasis??
Lichen simplex chrinicus
Seborrheic dermatitis
What are skin diseases that decrease in psoriasis??
AD, allergic contact, asthma , urticaria
What cancer related to psoriasis??
Non melanoma skin cancer (SCC)
Risk factors to develop skin cancer in psoriasis??
PUVA >200
Cyclosporine
Common infections in psoriasis?
- onychomycosis
- candida esp (flexural psoriasis)
What reflects risk to develop CVS disease ?
CRP
Life expectancy of psoriasis?
3.5-4.5 years reduction
What causes dyslipidemia in psoriasis?
IL-6 and TNF-a (target adipocyte)
What chronic diseases associated with psoriasis?
- CVS
- dyslipidemia
- DVT
- non alcoholic steatohepatitis
- crohn disease
non alcoholic steatohepatitis is related to ??
Obesity, dyslipidemia and PSA
AST:ALT RATIO > 1
Other disorders??
- ILVEN
- Reactive arthritis
- Sneddon-Wilkinson disease
- AGEP
ILVEN ??
Inflammatory linear verrucous epidermal nevus- follows blasckow lines
Reactive arthritis triad ?
Conjunctivitis + urethritis + arthritis (polyarthritis or sacroiliitis)
What causes urethritis in rieters disease?
Chlamydia trachomatis
Less shigella and salmonella
Ocular changes in reactive arthritis?
Conjunctivitis
Iritis
Uveitis with glucoma
Keratitis
Skin lesions in rieters syndrome?
5%
Keratoderma blennorhagicum
Balanitis circunata
Tt of rieter ??
Self limited
Antibiotics +NSAID
Steroids
Subcorneal pustular dermatosis??
Sneddon wilkinson disease
Describe sneddon wilkinson disease ??
Annular polycyclic lesions on flexural areas + gravity induced demarcation (clear fluid superior and pus filled inferior) in vesiculopustules
What is associated with sneddon wilkinson disease ??
IgA paraproteinemia
Main ddx of sneddon Wilkinson disease ??
Subcorneal eosinophilic igA pemphigus
Best tt of sneddon Wilkinson??
Dapsone
AGEP ?
- acute febrile drug eruption starting on the face
Causes of AGEP ?
- drugs
- enteroviral infection
- mercury
Genes responsible for AGEP ??
HLA-B5
HLA-DR11
HLA-DQ3
Mutation of AGEP ??
IL-36R
Test prior sensitization ??
Skin patch test (0.75% metronidazole)
Sign and symptoms of AGEP ??
Fever + rash starting on face and intertriginous zones (axilla and groin)
Followed by dissemination
Percentage of mucosal involvement in AGEP ??
50%
Most common involved organ in AGEP ??
Liver > kidney > lung
Electrolyte abnormalities in AGEP ?
Hypocalcemia
Drugs causing AGEP ??
Aminopenicillin
Cephalosporine
Clindamycin
Diltiazem
Tt of AGEP ??
Withdrawal of causative agent + topical cs
First line tt of psoriasis ??
Topical cs
How to increase lipophilicity of topical CS ??
1- add hydroxyl group
2- add propionate, furuate, valerate (have anti inflammatory effects)
Does increase frequency of application makes tt better ?
No
Once is same as twice
Best topical for maintenance ??
Betamethasone dipropionate (for 12w)
What is the problem of topical CS in psoriasis ??
Fast development of tachyphylaxis and rebounding
What is the maximum dise of super potent and potent steroid ??
Super : 50g/w
Potent : 100g/w
Contraindications of topical steroids ??
1- active bacterial, viral, fungal infections.
2- skin atrophy
3- allergic contact
4- pregnancy/ lactation
What are the 3 viD analogs ??
1- calcipotriene (calcipotriol)
2- calcitriol
3- ta-calcitol
Fxn of ViD analog??
1- inhibition of keratinocyte proliferation
2- inhibition of neutrophils
3- activation of TGase (enhances cornified lipid envelope)
Side effects of overdose ViD analogue??
Hypercalcemia
What is daivobet ??
Calcipotriene + betamethasone dipropionate
Dose of anthralin ??
Not more than 3x weekly (highly irritant)
Fxn of anthralin ?
Similar to ViD analog
1- inhibition epidermal proliferation
2- inhibition of mitogen induced T lymphocytes proliferation
3- inhibition of neutrophils
Contraindications of anthralin ??
1- unstable progressive plaque psoriasis
2- pustular psoriasis
3- erythrodermic psoriasis
Which FDA approved psoriasis topical treatment??
Tazarotene
What are targets of tazarotene ??
Inhibitors of K16, and TGase
Changes of psoriasis??
Increase K6,16
Increase Involucrin
Decrease K10,1
Decrease loricrin
Decrease IL-10
Contraindications of topical retinoids ??
1- unstable progressive plaque psoriasis
2- allergic contact
3- erythrodermic psoriasis
4- pregnancy/lactation
Other topicals ::
10% salicylic acid
Coal tar
TCI (face and flexures)
AFDA approved systemic 1st line tt of psoriasis??
MTX
What is the maximum dose of MTX in psoriasis??
25mg
Systemic tt of psoriasis ??
- MTX
- cyclosporine
- retinoid
- biologics
- apremilast
Dose of acitritin in types of psoriasis ??
1- pustular : 1mg/kg/day
2- chronic plaque : 0.5 mg/kg/day
3- erythrodermic: 0.25 mg/kg/day
Biological tt of psoriasis??
All are human ab except ?
- infliximab (chimeric ab)
- ixekizumab (humanized)
What are category B biologics ??
1- TNF-ai
2- ustekinumab
3- secukinumab