psoriasis Flashcards
psoriasis age of onset
bimodal peaks 20-30 and 50-60 mostly
psoriasis
chronic multi-system disease with predominantly skin and joint manifestations
plaque
scaly, erythematous patches, papules and plaques that are sometimes pruritic
inverse/flexural
lesions are located in the skin folds
guttate
presents with drop lesions, 1-10 mm salmon pink papules with a fine scale
erythrodermic
generalized erythema covering nearly the entire body surface area with varying degrees of scaling
pustular
generalized or palmoplantar
Guttate psoriasis
- acute onset of raindrop sized lesions on the trunk and extremities - often preceded by streptococcal pharyngitis - significant change for long term remission after single episode
guttate psoriasis
inverse/flexural psoriasis
erythematous plaques in the axilla, groin, and inframammary region and other skin folds
may lack sacle due to moistness of area
inverse flexural psoriasis
inverse flexural psoriasis
pustular psoriasis
- psoriatic lesions with pustules
- often triggered by corticosteroid withdrawal
- when generalized can be life threatening, hospitalization may be required
pustular psoriasis
pustular psoriasis
palmoplantar psoriasis
- may occur as either plaque or pustular type
- often functionally disabling
palmoplantar psoriasis
psoriatic erythroderma
involved almost the entire skin surface; skin is bright red
symptoms of psoriatic erythroderma
assoc with fever, chills, malaise - flu like symptoms
high morbidity and mortality
hospitalization is sometimes required
erythroderma
erythema affecting > 90% BSA body surface area
causes of erythroderma
drugs, psoriasis, atopic dermatitis, cutaneous lymphoma, underlying malignancy, others
management of erythroderma
extensive topical therapy, monitor fluids/electrolytes, and treat underlying cause
plaque psoriasis
well demarcated plaques with overlying silvery scale and underlying erythema
chronic plaque psoriasis is typically ____ and ____
symmetric and bilateral
auspitz sign
bleeding after removal of scale
koebner phenomenon
lesions induced by trauma
trauma can trigger or fuel psoriasis by icreasing cytokines
most common form of psoriasis
plaque psoriasis (80-90% patients affected)
how many patients with plaque psoriasis have mild to moderate disease
80% - localized or scattered covering <5% of body surface area
how many patients have moderate to severe disease
20% have moderate to severe affecting >5% of the body surface area or affecting crucial body areas such as hands, feet, face, or genitals
psoriasis pathogenesis
cytokines from immune cells trigger a hyperproliferative state resulting in thick skin and excess sale
- systemic treatments target these cytokines and immune cells
is there a genetic component?
yes - 33% with fam hx
patients with psoriasis may be at increaed risk for
metabolic syndrome, obesity, depression, smoking, alcohol use
psoriasis and HIV
more severe
characteristic locations for psoriasis
scalp
ears
elbows
knees (extensor surfaces)
umbilicus
gluteal cleft
nails
sites of recent trauma
erythematous plaque around the umbilicus
what elements in the history are important to ask when considering the diagnosis of psoriasis?
- fam hx
- medications
- recent illness/past medical history
- social history
steroid withdrawal
can cause psoriasis
erythematous and edematous foot, with dactylitis (sausage digit) of the 2nd toe
destruction of the DIP joints
also see onychodystrophy - nail pitting and onycholysis
subtypes of nail psoriasis
can occur in all subtypes
nail psoriasis and psoriatic arthritis
indicates higher risk for arthritis
fingernail onychodystrophy are involved in how many patients
toenails
50%
35%
pitting
punctuate depressions of the nail plate surface
onycholysis
separation of the nail plate from the nail bed
subungual hyperkeratosis
abnormal keratinization of the distal nail bed
also higher risk of joint disease
psoriatic arthritis PsA
seronegative spondyloarthropathies
mild to severe usually with relapsing/remitting oligoarthritis - distal inerphalangeal joints most common
subungual hyperkeratosis - abnormal keritinizatoin of the distal nail bed
onset of psoriatic arthritis in patients with psoriasis
30-50 age
more likely with severe skin disease
10-15%
psoriatic arthritis
swelling of the PIP joints of the 2-4th digits, DIP involvement of the 2nd digit
treatment of psoriatic arthritis
mandatory to prevent joint destruction
like the picture with desquamation of skin and joint swellig arthritis mutilins
treatment for localized psoriasis <5% BSA and first line agents
topical treatment
high potency topical steroid +/- calcipotriene (vit d analog)
topical medications for psoriasis are more effective when used with
occlusion - allows for better penetration of medicine
ex. saran wrap, wet wrap, gloves, socks
why do we do systemic treatment for psoriasis
used in addition to topical treatment for moderate - severe disease or for limited disease with high impact on quality of life (ex palmoplantar or genital)
Do we prescribe oral steroids for psoriasis?
oral prednisone should never be used as they can severely flare psoriasis upon discontinuation!!!
what is systemic treatment based on
patient preference,
side effect profile,
co-morbidities
3 types of systemic treatment
photo therapy
oral medications
biologic agents
phototherapy
narrow - UVB light or psoralen plus UVA liight PUVA
systemic treatment for psoriasis oral medications
methotrexate, acitretin, cyclosporine
biologic agents used for psoriasis systemic treatment
TNF alpha inhibitors (infliximab, etanercept, adalimumab)
IL 12/23 blocker (ustekinumab)
