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Systems: Dermatology AB > Psoriasis > Flashcards

Psoriasis Flashcards

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Dermatology Board Prep flashcards
1
Q

Describe the history of treatment development for psoriasis.

A
  • 1950’s: Steroids
  • 1970’s: UVB and methotrexate
  • 1980’s: T-cell driven disease
  • 1990’s: Vitamin d3 analogues
  • 2000’s: Biologics
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2
Q

What is psoriasis?

A

-Chronic, immune mediated disease characterised by sharply demarcated erythematous plaque with micaceous scale

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3
Q

How many people are affected by psoriasis?

A
  • 3% of UK population, M=F
  • 2 peaks occur 20-30yrs & 50-60yrs.
  • 75% before 40yrs
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4
Q

How is psoriasis related to systemic disease?

A
  • 5-30% develop psoriatic arthritis
  • Psychosocial implications
  • Metabolic syndrome
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5
Q

Why does psoriasis develop?

A

Polygenic predisposition + environmental triggers

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6
Q

What environmental triggers are there for psoriasis?

A
  • Infection
  • Drugs
  • Trauma
  • Sunlight (+/-)
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7
Q

Describe the polygenic predisposition of psoriasis.

A
  • 35-90% have a family history (Both parents: 41%. One parent: 14%.)
  • HLA-Cw6 (Chromosome 6) leads to age of onset (indicates type of psoriasis)
  • Psoriasis susceptibility regions PSORS1-9
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8
Q

What is the pathogenesis of psoriasis?

A

-Adaptive immune system (T cells (epidermal: CD8, dermal CD4&8))
-Stressed keratinocytes
Activation of dermal dendritic cells (dDCs) by interleukins, TNF alpha
-dDCs act on lymph nodes, present uncertain antigen to naïve T cells
-Differentiation into Th (T helper) 1,17 and 22
Lead to psoriatic dermis and plaque formation

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9
Q

How is the cell cycle reduced in psoriasis?

A
  • Interleukins & TNF alpha amplify inflammatory cascade, stimulate keratinocyte proliferation
  • VEGF leads to angiogenesis
  • Neutrophils in acute, active, pustular disease
  • Cell cycle reduced from 28 days to 3-5
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10
Q

Describe the histology of psoriasis.

A
  • Hyperkeratosis (thickening of stratum corneum)
  • Neutrophils in stratum corneum (munro’s microabcesses)
  • Psoriasiform hyperplasia: Acanthosis (thickening of squamous cell layer) with elongated rete ridges
  • Dilated dermal capillaries
  • T cell infiltration
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11
Q

What is important when taking the history of someone with psoriasis?

A
  • Age & nature of onset
  • Distribution
  • Effective treatments
  • Medical history
  • Family history
  • Medications
  • Quality Of Life
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12
Q

What may be seen on examination of the patients skin?

A
  • Distribution!
  • Sharply demarcated, erythematous, papulosquamous plaques
  • Numerous small, widely disseminated papules & plaques
  • Erythroderma (>80% BSA)
  • Pustules
  • Scalp
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13
Q

What may be seen on examination of the patients nails?

A
  • Onycholysis
  • Pitting
  • Oil spots
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14
Q

Give examples of the subtypes of psoriasis.

A
  • Chronic plaque psoriasis
  • Palmo-plantar psoriasis
  • Scalp psoriasis
  • Nail psoriasis
  • Flexural/inverse psoriasis
  • Pustular psoriasis
  • Erythrodermic psoriasis
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15
Q

Describe chronic plaque psoriasis.

A
  • Symmetric

- Affects extensor surfaces

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16
Q

Describe guttate psoriasis

A
  • Children, adolescents.
  • Can be triggered by viral or bacterial infections. Check ASO titre.
  • May resolve, or may trigger chronic psoriasis in susceptible individuals.
17
Q

Describe palmo-plantar psoriasis

A
  • Studies show that psoriasis of the palms and soles tends to have greater impact on QOL compared to more extensive psoriatic involvement not involving the palms and soles.
  • Smoking
  • Sterile inflammatory bone lesions
18
Q

Describe scalp psoriasis

A

Can lead to alopecia at affected areas

19
Q

Describe nail psoriasis

A

Difficult to treat

20
Q

Describe flexural/inverse psoriasis

A
  • Less scale
  • Can be triggered or superinfected by localised dermatophyte, candida or bacterial infection (these are also differential diagnoses)
21
Q

Describe pustular psoriasis

A
  • Sterile pustules, sometimes systemic symptoms
  • Can be caused by pregnancy, rapid taper/stop steroids, hypocalcaemia, infection
  • Overlap with AGEP (pustular drug eruption)
22
Q

Describe erythrodermic psoriasis

A
  • Differential Dx ‘Red Man’ syndrome (vancomycin induced drug reaction)
  • > 80% body surface area involved
23
Q

How is a diagnosis of psoriasis made?

A
  • Clinical presentation

- Skin biopsy if atypical

24
Q

What is the differential diagnosis for psoriasis?

A
  • Seborrhoeic dermatitis
  • Lichen planus
  • Mycosis fungoides
  • Bowen’s disease
  • Drug eruption
  • Infection
  • Secondary syphilis
  • Contact dermatitis
  • Extra mammary Paget’s
25
Q

How should psoriasis be treated in primary care?

A
  • Emollients (Creams vs Ointments)
  • Soap substitutes
  • Vitamin D3 analogues: inhibit epidermal proliferation
  • Coal Tar creams
  • Topical Steroid – with care. Flexures, genitalia
  • Salicylic acid (keratolytic)
26
Q

How is psoriasis treated after a dermatology referral?

A
  • Crude Coal Tar (inpatient or day treatment)
  • Dithranol: since 1916. Can burn.
  • UVB Phototherapy (not the same as sunbed) (Guttate)
27
Q

What retinoid is used in psoriasis?

A

Acitretin

28
Q

What risks are there when using acritretin?

A
  • Teratogenic

- Monitor LFTs, lipids

29
Q

What immunosuppressants can be used in the treatment of psoriasis?

A
  • Methotrexate
    • Can treat PsArthritis
    • Max improvement 8-12 weeks
  • Ciclosporin
    • Renal, cancer risk
30
Q

How are biologics used in the treatment of psoriasis?

A
  • Qualifying criteria, cost
  • Anti-TNF: Etanercept, infliximab, adalimumab
  • IL-12,23: Ustekinumab
  • IL-17: Secukinumab
  • Patient can form antibodies to biologic
31
Q

What are the potential future treatments for psoriasis?

A
  • Further targeted biologics
  • IL-17,20,22
  • Kinase inhibitors
32
Q

How is erythrodermic psoriasis treated?

A
  • Recognition
  • Admit
  • FLUID BALANCE
  • Bloods / IV access
  • Thick greasy ointment emollients
  • ? Systemic or biologic treatment
  • ? Identify trigger
33
Q

How is the progress of psoriasis monitored?

A
  • Psoriasis Area Severity Index (PASI)

- Dermatology Life Quality of Index (DLQI)

34
Q

What does the PASI take into account?

A
  • Surface area
  • Plaque colour
  • Thickness
  • Scale
35
Q

What is the general outcome from psoriasis?

A

Majority good with correct treatment

36
Q

How does severe psoriasis affect life expectancy?

A
  • Men with severe psoriasis died 3.5 years earlier than controls.
  • Women with severe psoriasis died 4.4 years earlier than controls.
37
Q

What is psoriasis associated with?

A
  • CVD
  • Smoking
  • Alcohol
  • Metabolic syndrome
  • Depression
  • Suicide
  • Potentially harmful drug and light therapies
  • Possibly melanoma and non-melanoma skin cancers

Systems: Dermatology AB (11 decks)

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