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MBBS 4 Dermatology > Psoriasis > Flashcards

Psoriasis Flashcards

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Dermatology Board Prep flashcards
1
Q

What is psorisis?

A

Chronic, non-infectious, auto-inflammatory skin disease with exacerbations and remissions

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2
Q

Psoriasis is characterized by?

A

well-demarcated erythematous plaques topped by silvery scale on certain predilection areas
Note; has a high psycosocial burden

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3
Q

Epidemiology?

A
  1. Prevalence 1-4% of the population worldwide
    – US 3.7%
    – Africans, African Americans and Asians: 0.4-0.7%
    – East Africa: data not sufficient
  2. Men= Women
  3. Psoriasis can occur in children but is less common as atopic dermatitis
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4
Q

Psoriasis triggers?

A
  1. Infection
    e.g. streptococcus, HIV
  2. Drugs
    e.g. β-blockers, lithium, antimalarials, ACE inhibitors, nonsteroidal anti-inflammatory drugs
  3. Stress
  4. Trauma
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4
Q

Pathophysiology key findings?

A
  1. Abnormal epidermal proliferation and differentiation: from 23 d to 3-5 d
  2. Inflammation
  3. Increased angiogenesis
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5
Q

Pathophysiology of psoriasis caused by triggers?

A
  1. Trigger leads to activation of T cells, dendritic cells and macrophages
  2. These activated cells release interleukins and chemokins
  3. This leads to a proliferation of the keratinocytes
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6
Q

Histopathology of psoriais?

A
  1. Parakeratosis (persistence of nuclei in stratum corneum)
  2. Acanthosis
  3. Inflammation
  4. Increased angiogenesis
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7
Q

Different variants of psoriasis?

A
  1. Classic plaque psoriasis
  2. Scalp psoriasis
  3. Flexural or inverse psoriasis
  4. Nail psoriasis
  5. Palmoplantar psoriasis
  6. Pustular palmoplantar psoriasis
  7. Guttate psoriasis
  8. Erythrodermic psoriasis
  9. Psoriatic arthritis
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8
Q

General findings of psoriasis?

A
  1. Sharply demarcated erythemato-squamous plaques, with silvery white scales
  2. Usually asymptomatic, although some patients have mild pruritis
  3. Limited - generalized
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9
Q

Typical general phenomena of psorisis?

A
  1. Candle-wax or silvery scales
  2. Koebner phenomenon
  3. Auspitz sign
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10
Q

Predilection sites psoriasis?

A
  1. Scalp 80%
  2. Elbows 78%
  3. Legs 74%
  4. Knees 57%
  5. Arms 54%
  6. Trunk 53%
  7. Sacral 38%
  8. Palms and soles 12%
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11
Q

Describe chronic plaque psoriasis?

A
  • Diagnosed in 80-90% patients
  • Symmetrical distributed, sharply defined erythematous squamous plaques
  • Coin to palm sized plaques usually present months to years
  • Nails in 10 to 55%
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12
Q

Describe scalp psoriasis?

A
  • Most commonly involved
  • Especially hairline and temporal regions
  • Spread 1-2 cm into adjacent skin
  • Usually no hair loss
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13
Q

Describe flexural/inverse psoriasis?

A

Psoriasis in intertriginous areas
1. Sharply demarcated shiny, red/pink plaque
2. Different appearance
– No scaling
– Plaques are thinner
– Often pruritic
3. Often centrally fissure
4. Fungal/bacterial infections are a common trigger

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14
Q

Describe nail psoriasis?

A
  • 30-80%
  • Finger nails more common than toe nails
  • Pain + restriction in daily activities
  • Most patients with psoriatic arthritis have nail involvement
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15
Q

Describe features of nail psoriasis?

A
  1. Pits
  2. Distal onycholysis
  3. Oil spots
  4. Subungual hyperkeratosis
  5. Splinter hemorrhages
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16
Q

Describe palmoplantar psoriasis?

A
  1. symmetric, sharply demarcated, erythematous plaques
  2. Adherent scaling
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17
Q

Describe pustular palmoplantar psoriasis?

A
  • Individual or coalescing sterile pustules 1mm to 1 cm: Begin yellow then turn brown
  • Mainly in women
  • Smoking ++
  • Rare in children
  • 70%: hands and feet, 20% only feet, 10% only hands
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18
Q

How to tell if it is erytrodermic psoriaisis?

A
  1. Previously classic plaques
  2. Facial sparing
  3. Nail changes
  4. More adherent scaling
18
Q

Describe guttate psoriasis?

A
  • “Droplet” lesions mainly trunk
  • Usually children and young adults
  • Sudden onset
  • Spares palms and soles
  • Often preceded by infection: streptococcal
  • In children good prognosis, in adults tend to be chronic
18
Q

Describe erytrodermic psoriasis?

A

Difficult to distinguish from other causes of erythroderma

19
Q

Pathophysiology of psoriatic arthritis?

A
  1. Inflammation and TNF-a cause abnormal fast epidermal turnover
    > Plaques on the surface
  2. TNF-a causes inflammation of synovial membranes and lead to
    bone erosions, hyperostoses and deformation
19
Q

Describe psoriatic arthritis?

A
  • 20 % of cutanous psoriasis pts have psoriatic arthritis
  • Seronegative (rheumafactor negative) spondyloarthritis
  • Mainly hands, feet, knees, wrists and ankles
  • Erosive changes (X-ray)
20
Q

Describe the relationship between psoriasis and HIV?

A
  • Development of eruptive psoriasis or sudden exacerbation of a pre existent psoriasis can be due to HIV infection
  • Severity increases with degree of immunodeficiency
  • Less responsive to treatment
  • Often negative family history
21
Q

Predeliction of sites of psoriasis in HIV?

A
  1. Face, often seborrhoic distribution
  2. Flexures
  3. Palmoplantar surfaces – Nails
  4. More often erythroderma
22
Q

Ddx for chronic plaque psoriasis?

A
  1. Discoid eczema
  2. Tinea corporis
  3. Bowen’s disease
  4. Subacute lupus erythematosis
  5. Mycosis fungoides
23
Q

Ddx for Guttate psoriasis?

A
  1. Secondary syphilis
  2. Tinea corporis
  3. Pityriasis rosea
24
Q
A
25
Q

Ddx for erytroderma?

A
  1. Atopic dermatitis
  2. Pityriasis rubra pilaris
  3. Drug reactions
  4. Sezary syndrome
25
Q

Ddx for pustular palmoplantar psoriasis?

A
  1. Eczema
  2. Fungal Infection
25
Q

Explain the high social burden of psoriasis?

A
  1. Difficulty finding a job
  2. Job complications e.g time off work, discrimination
  3. Financial distress
  4. Embarrassment when show psoriasis in public
  5. Sexual activity concerns
25
Q

Management of psoriasis?

A
  1. patient education
  2. lifestyle modification
  3. medical treatment
26
Q

Comorbidities associated with Psoriasis?

A
  1. Cardiovascular disease
  2. Metabolic syndrome
  3. Obesity
  4. Depression
  5. Increased risk for infection (most clearly in patients with erythrodermic psoriasis)
  6. Malignancies
  7. Psoriatic arthritis
  8. Other immune-mediated inflammatory diseases (Crohn’s disease)
27
Q

Explain patient eductaion?

A
  1. Chronic skin disorder which waxes and wanes
  2. Disease course can be very unpredictable
  3. Treatment is to get control of the disease and not to cure it
  4. Complete clearance may not be achievable
  5. Get rid of myths that its contagious or a sign of cancer
  6. Explain how to apply topical therapies
28
Q

Lifestyle modification?

A
  1. Healthy diet (As less sugar as possible, lots of fresh vegetables)
  2. No smoking/alcohol
  3. Sleeping
  4. Exercise
  5. Stress management: mindfulness/meditation
29
Q

Medical treatment?

A
  1. topical
  2. phototherapy
  3. systemic
30
Q

Topical treatment?

A
  1. Corticosteroids
  2. Vitamin D3 analogue (Calcitriol)
  3. Tar
  4. Dithranol
31
Q

Phototherapy treatment?

A
  1. Sunlight
  2. UVB
  3. PUVA
32
Q

Systemic treatment?

A
  1. MTX
  2. Ciclosporin
  3. Fumarates
  4. Retinoids (acitretin)
  5. Apremilast
  6. Biologicals
33
Q

Treatment for mild psoriasis?

A

Only topical treatment
1. First remove scaling
– Salicylic acid 10%
– Application of emollients
2. Potent corticosteroids (+/- vit. D. derivate)/Tar/Dithranol
- Potent corticosteroid under occlusion (2x/wk, leave on for 2-3 days)

34
Q

Moderate/severe psoriasis treatment?

A
  1. Continue local therapy with emollient/salicylic acid
  2. Treatment with UVB/PUVA therapy or exposure to sunlight: 2-3 times a week, 3 months
35
Q

Severe psoriasis treatment?

A
  1. systemic therapy
  2. fumarates
  3. biological
36
Q

What is the systemic therapy in treating severe psoriasis?

A
  1. Methotrexate
    - more suitable for long term treatment, but hepatotoxic
  2. Ciclosporin
    - rapid response, but risk of hypertension and nephrotoxicity
  3. Acitretin
    - oral retinoid
    - mono therapy mainly effective in pustular and erytrodermic psoriasis,
    combination with PUVA is effective in chronic plaque psoriasis
37
Q

Methotrexate dose?

A

10-25 mg ONCE a week

38
Q

Investigations to be done when administering methotrexate?

A

Lab-Tests:
1. Cellular Blood count+ diff. at baseline,
- after 1 & 2 weeks, then 2-monthly,
(Bone marrow !)
2. Renal FT, Liver FT.

39
Q

Contraindications of methotrexate?

A
  1. Family planning (female)
  2. Pregnancy/Breast feeding
  3. Severe infections
  4. Severe reduced Liver and renal function
  5. Alcohol abuse
  6. Hematologic disease
  7. Restricted lung capacity
  8. Severe heart insufficiency

MBBS 4 Dermatology (21 decks)

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