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Dermatology > Psoriasis > Flashcards

Psoriasis Flashcards

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Dermatology Board Prep flashcards
1
Q

Describe psoriasis

A

A chronic inflammatory condition characterised by scaly erythematous plaques, which typically follows a relapsing and remitting course

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2
Q

What is the pathogenesis of psoriasis?

A

Hyperproliferation of keratinocytes in the epidermis and infiltration of inflammatory cells. Blood vessels in the dermis dilate.

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3
Q

What is the most common type of psoriasis?

A

Chronic plaque psoriasis

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4
Q

What types of psoriasis are there?

A 
Chronic plaque 
Flexural 
Guttate 
Pustular 
Generalised, erythrodermic 
Seborrhoeic
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5
Q

Describe chronic plaque psoriasis

A

Symmetrical, well defined red plaques with a silvery scale on extensor surfaces - knees, elbows and also on scalp and sacrum

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6
Q

Describe flexural psoriasis

A

Plaques mostly in moist flexural areas - axillae, groin, submammary, umbilicus. Are less scaly and can be misdiagnosed as fungal infection (the skin can appear smooth)

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7
Q

Describe guttate psoriasis

A

Large numbers of small, tear drop shape plaques. Usually over trunk and limbs in young - esp after a strep infection (tonsillitis) and usually lasting 3-4 months (transient)

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8
Q

Describe pustular psoriasis

A

Yellow/ brown pustules within plaques affecting the palms and soles

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9
Q

Describe erythrodermic psoriasis

A

Total body redness - may cause severe systemic upset e.g dehydration, HF, infection, hypothermia, protein loss, oedema

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10
Q

What kind of nail changes are seen with psoriasis?

A

Pitting
Onycholysis - separation from nail bed
Thickening
Subungual hyperkeratosis

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11
Q

What is Auspitz sign?

A

Scratch and gentle scale removal causes capillary bleeding

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12
Q

What percentage of people with psoriasis develop associated psoriatic arthropathy?

A

5-8%

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13
Q

What are some triggers for psoriasis?

A 
Stress
Infections e.g streptococcal infection and guttate psoriasis 
Skin trauma - Koebner phenomena 
Drugs - beta blockers, lithium, antimalarials, iodides 
Alcohol
Obesity 
Smoking
Vitamin D deficiency 
Climate
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14
Q

Psychological and social effects of psoriasis are common. What should be considered?

A 
Depression
Impact on body image 
Impact on relationships 
Impact on work/ school 
Effects of treatment
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15
Q

What non cutaneous manifestations should be considered?

A 
Joint disease
Cardiovascular disease
Metabolic syndrome
Venous thromboembolism 
Mental health
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16
Q

What educational measures should be discussed with the patient?

A

Explain that it is a relapsing and remitting condition. Unlikely to be cured.

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17
Q

What topical treatment options are there?

A 
Emollients 
Corticosteroids 
Vitamin D analogues 
Coal tar 
Dithranol 
Topical retinoids
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18
Q

What topical treatments should be used for plaque psoriasis?

A

First line: topical corticosteroids e.g Betnovate once a day e.g in the morning, plus a topical vitamin D preparation applied once a day e.g at night for up to 4 weeks

Second line: If not improvement after 8w then offer a vit D analogue BD

Third line: offer a potent corticosteroid BD or a coal tar preparation OD or BD . Short acting dithranol can also be used

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19
Q

Potent corticosteroids should not be used over how many weeks?

A

8 weeks maximum

And there should be a treatment break of 4 weeks before being restarted (during which vit D analogues can be continued)

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20
Q

When should phototherapy be used?

A

Guttate or plaque psoriasis that cannot be controlled with topical treatments or when disease is widespread.

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21
Q

When should oral therapies be considered?

A

For extensive or severe psoriasis or psoriasis with systemic involvement

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22
Q

What oral therapies are there?

A

First line: Methotrexate - avoid in young in view of long term risk of hepatic fibrosis
Ciclosporin (be aware of side effects)
Acitretin - oral retinoid

Biological agents - infliximab, etanercept

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23
Q

What are the side effects of topical corticosteroids?

A 
Skin thinning
Striae
Telangiectasia 
Worsening of untreated infection
Triggering an episode of pustular psoriasis

Systemic SEs if potent corticosteroids used on large areas

24
Q

How do vitamin D analogues work?

A

Reduce cell division and differentiation, so reduce scaliness of plaques
Unlike corticosteroids, adverse effects uncommon and may be used long-term.
Avoid in pregnancy

25
Q

Give some examples of vitamin D analogues

A

Calcipotriol
Calcitriol
Tacalcitol

26
Q

Vit D analogues tend to reduce scale and thickness of plaques, but not…

A

The erythema

27
Q

Vit D analogues should be avoided when…?

A

In pregnancy

28
Q

How does coal tar work?

A

Inhibits DNA synthesis

29
Q

What are the 2 peaks of incidence?

A

15-25

50-60

30
Q

What lifestyle advice should be given?

A 
Smoking cessation 
Reduce weight
Reduce alcohol intake 
Avoid sun exposure 
Manage stress
Blood pressure control
31
Q

What are the side effects of vit D analogues?

A

Irritation

Hypercalcaemia if overuse

32
Q

What are side effects of retinoids?

A 
Teratogenic 
Dry mucous membranes 
Hepatotoxic 
Deranged lipids 
Increased sunburn susceptibility
33
Q

In secondary care management, phototherapy can be done. What is the treatment of choice?

A

Narrow band UV B light

Photochemotherapy also used : psoralen + UV A (PUVA)

34
Q

When is oral methotrexate of particular use?

A

If there is associated joint disease

35
Q

What can cause erythrodermic psoriasis?

A 
Infections
Low calcium 
Withdrawal of oral corticosteroids 
Withdrawal of excessive use of strong topical corticosteroids 
Strong coal tar preparations 
Certain medications including lithium
36
Q

Describe the onset of erythrodermic psoriasis

A

Usually - known worsening or unstable psoriasis
Uncommonly - first presentation of psoriasis

Can be acutely over a few days or weeks or gradually evolving over several months

37
Q

What kind of dosing is methotrexate?

A

Weekly

38
Q

What monitoring needs to be done for methotrexate?

A

FBC, U&E and LFTs every 1-2 weeks until therapy stabilised, then every 2-3 months

Report any signs of infection, especially sore throat

39
Q

Treatment choices for psoriasis depend on a number of factors e.g

A 
Disease pattern 
Severity - body surface area (BSA) affected and Psoriasis Area and Severity Index (PASI) score 
Dermatology Life Quality Index (DLQI) 
Patient preference 
Patient age and general health 
Comorbidities - liver or renal disease, psoriatic arthritis 
Other meds 
Conception plans or pregnancy
40
Q

What is the Koebner phenomenon?

A

The tendency of several skin conditions to affect areas subjected to injury
E.g in case of psoriasis - development of plaques in areas of sunburn

41
Q

Are baths helpful?

A

Soaking in warm water can soften the psoriatic plaques and lift the scale
Soap substitutes and bath oils are useful

42
Q

Why are emollients useful?

A

Softens psoriasis and adds moisture to skin - improves dryness and scaling

Use regularly
Different options of lotions e.g creams or ointments

43
Q

Topical steroids can be used in combination with salicylic acid. What is the benefit of salicylic acid in psoriasis?

A

It is a de-scaling agent

44
Q

Weak topical steroids should be used on what sites?

A

Face, flexures, genital areas

45
Q

Why are vitamin D analogues not usually suitable for facial psoriasis?

A

Can cause facial rash

46
Q

Coal tar is particularly effective for…

A

Scalp psoriasis and large thin plaque psoriasis

47
Q

What care needs to be taken following application of coal tar treatment?

A

Can irritate skin on initial use
Can be messy - stain skin, hair and clothes
Sunlight can interact with it to cause sun burn like photocontact dermatitis

48
Q

What type of psoriasis can dithranol be recommended for?

A

Chronic plaque psoriasis

49
Q

What practical drawbacks does dithranol have?

A

Method of application complex
Apply directly to psoriasis only then wash off after 10-60 mins
Strength gradual increased every few days until it is effective

50
Q

Who is phototherapy best avoided in?

A

Very fair skin, who take immunosuppressive medications or precious history of skin cancer

51
Q

What is phototherapy not effective for?

A

Scalp or flexural psoriasis

52
Q

Methotrexate is often taken with what?

A

Folic acid supplements

53
Q

What stimulates keratinocyte proliferation in psoriasis?

A

Abnormal T cell activity

54
Q

What drugs can trigger psoriasis?

A 
Lithium
Beta blockers
Antimalarials 
NSAIDS
ACE inhibitors 
Infliximab
55
Q

The withdrawal of what drunk can exacerbate psoriasis?

A

Systemic steroids

56
Q

In cases of guttate psoriasis, should antibiotics be prescribed to eradicate streptococcal infection?

A

No

Dermatology (35 decks)

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