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Y4 Lecture Day III > Psoriasis > Flashcards

Psoriasis Flashcards

1
Q

Pathophysiology of psoriasis

A
  • multifactorial and not yet fully understood
  • genetic: associated HLA-B13, -B17, and -Cw6 strong concordance (70%) in identical twins
  • immunological: abnormal T cell activity stimulates keratinocyte proliferation. This may be mediated by a novel group of T helper cells producing IL-17, designated Th17
  • environmental: psoriasis may be worsened (e.g. Skin trauma, stress), triggered (e.g. Streptococcal infection) or improved (e.g. Sunlight) by environmental factors
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2
Q

What are the subtypes of psoriasis?

A
  • plaque psoriasis: the most common sub-type resulting in the typical well-demarcated red, scaly patches affecting the extensor surfaces, sacrum and scalp
  • flexural psoriasis: in contrast to plaque psoriasis the skin is smooth
  • guttate psoriasis: transient psoriatic rash frequently triggered by a streptococcal infection. Multiple red, teardrop lesions appear on the body
  • pustular psoriasis: commonly occurs on the palms and soles
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3
Q

Presentation of psoriasis

A
  • red, scaly patches on the skin
  • nail signs: pitting, onycholysis
  • arthritis
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4
Q

Complications of psoriasis

A
  • psoriatic arthropathy (around 10%)
  • increased incidence of metabolic syndrome
  • increased incidence of cardiovascular disease
  • increased incidence of venous thromboembolism
  • psychological distress
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5
Q

Factors that may exacerbate psoriasis

A
  • trauma
  • alcohol
  • drugs: beta-blockers, lithium, antimalarials (chloroquine and hydroxychloroquine), NSAIDs and ACE inhibitors, infliximab
  • withdrawal of systemic steroids
  • Streptococcal infection may trigger guttate psoriasis.
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6
Q

What drugs may exacerbate psoriasis?

A
  • beta-blockers
  • lithium
  • antimalarials (chloroquine and hydroxychloroquine)
  • NSAIDs and ACE inhibitors
  • infliximab
  • withdrawal of steroids
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7
Q

What score to use as a screening tool for psoriasis?

A

Use the PEST score as a screening tool for psoriatic arthritis

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8
Q

What not to forget about during Hx taking of psoriasis?

A

Don’t forget the other organ systems – particularly joints and cardiovascular risk

i. e. Psoriasis is more than just a skin:
- Increased risk of IBD
- Psoriatic arthritis
- Metabolic syndrome
- Mental health

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9
Q

Why there is a possible metabolic syndrome in psoriasis?

A

Metabolic syndrome thought to occur due to:

  • increase total body inflammation → increased levels of circulating cytokines including TNF alpha
  • Defined as increased waist circumference, TGs, low HDL, high BP, high BMs
  • They are in a prothrombotic, proinflammatory state
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10
Q

Differentials for rashes that follow sore-throat

A
  • Guttate psoriasis
  • Small vessel vasculitis
  • EBV / Glandular fever
  • EBV treated with Ampicillin
  • Drug rash
  • Pityriasis rosea
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11
Q

Dangers of drinking alcohol in a patient suffering from psoriasis

A

Alcohol:

  • makes psoriasis worse
  • contributes to liver abnormalities in patients already at risk of NAFLD
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12
Q

Sort throat then rash - what Ix to ask about next?

A

ASOT and monospot

*ASOT Antistreptolysin O Titer. A blood test that looks for antibodies to the streptococcus A bacteria

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13
Q

Patterns of psoriasis

A
  • Chronic plaque
  • Guttate
  • Palmar plantar and palmar - plantar pustulosis
  • Erythroderma
  • Pustular
  • Flexural
  • Scalp
  • Nails
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14
Q

What to use to document the severity of psoriasis?

A

(area, erythema, scaling and induration)

Psoriasis Area and Severity Index (PASI)

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15
Q

How to describe psoriatic lesion?

A

Well demarcated plaques on the extensors, thick silvery scale

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16
Q

Common sites of psoriatic plaques

A
  • extensors
  • scalp
  • gluteal cleft
  • genitalia
  • intertriginous areas /obszary miedzyzebowe/
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17
Q

Difference between eczema and psoriasis (in terms of lesions)

A

Eczema is not so well defined and the scale is thinner

18
Q

Buzzwords: Rain droplets’ + Strep throat

What’s the diagnosis?

A

Rain droplets’ + Strep throat = Guttate Psoriasis

19
Q

What’s guttate psoriasis?

A

Guttate psoriasis:

  • more common in children and adolescents
  • may be precipitated by a streptococcal infection 2-4 weeks prior to the lesions appearing
  • *Features**
  • tear drop papules on the trunk and limbs
20
Q

Mangement of guttate psoriasis

A
  • most cases resolve spontaneously within 2-3 months
  • topical agents as per psoriasis
  • UVB phototherapy
  • tonsillectomy may be necessary with recurrent episodes
21
Q

The differential diagnosis for Guttate psoriasis

A

Pityriasis rosea – presents with a herald patch, improves spontaneously

22
Q

How to differentiate between Guttate psoriasis and Pityriasis Rosea?

A
23
Q

What’s that?

A

Palmar - plantar pustulosis → pattern of psoriasis

  • Sheets of tense sterile blisters
  • Resolve leaving yellow/brown macules
  • Usually current smokers
24
Q

Causes of erythroderma

A
  • Idiopathic
  • Drugs
  • Eczema
  • Psoriasis
  • Cutaneous lymphoma
25
Q

What’s that?

A

Erythrodermic psoriasis

  • may result from progression of chronic disease to an exfoliative phase with plaques covering most of the body. Associated with mild systemic upset
  • more serious form is an acute deterioration. This may be triggered by a variety of factors such as withdrawal of systemic steroids. Patients need to be admitted to hospital for management
26
Q

Define erythroderma

A

Erythroderma is a term used when more than 95% of the skin is involved in a rash of any kind

27
Q

What’s that?

A

Pustular and flexural patterns of psoriasis

  • Malaise and fever
  • Erythema studded with sterile pustules
  • Initally in intertiginous areas, but quickly progresses
  • Triggers; weaning oral steroids, infection, hypocalcaemia, pregnancy
  • Can be difficult to diagnose as scale is not prominent
  • Shiny, only slightly raised plaques in flexures, often misdiagnosed as fungal, but it is symmettical
  • Sebopsoriasis is scaling around the eyebrows, behind ears, ear canals
28
Q

Nail changes in psoriasis

A

Psoriatic nails (50% fingernail, 35% toenail)

  • Matrix: Pitting, leuconychia
  • Bed: Oil spots, onycholysis, subungal hyperkeratosis, splinter haemorrhage

*More frequent with coexistant psoriatic arthritis

29
Q

Types of psoriatic arthropathy

A
  • rheumatoid-like polyarthritis: (30-40%, most common type)
  • asymmetrical oligoarthritis: typically affects hands and feet (20-30%)
  • sacroilitis
  • DIP joint disease (10%)
  • arthritis mutilans (severe deformity fingers/hand, ‘telescoping fingers’)
30
Q

What’s shows up first (timewise) psoriasis or psoriatic arthropathy?

A

Usually psoriasis first → then arthropathy (10 years gap)

31
Q

Features of psoriatic arthropathy

A
  • Asymmetrical oligoarthropathy ≤4 joints
  • Symmetrical polyarthropathy ≥5 joints
  • DIP joint involvement
  • Axial/spondyloarthropathy
  • Arthritis mutilans – destructive with bone resorption and osteolysis
32
Q

How psoriatic arthropathy should be managed?

A
  • should be managed by a rheumatologist
  • treat as rheumatoid arthritis but better prognosis
33
Q

General steps in the treatment of psoriasis

A
  • Topicals
  • Light treatment
  • Systemic immunosuppression
  • Biologics
34
Q

What are the options used in the topical treatment of psoriasis?

A
  • Topical corticosteroids
  • Vitamin D3 analogues
  • Emollients
  • Coal tar
  • Dirthranol
35
Q

Topical steroids + vit D preparations used in psoriasis

A
36
Q

Coal Tar preparations used in psoriasis

A
37
Q

Dithranol preparations and use in psoriasis

A
38
Q

Light treatment in psoriasis

A
39
Q

Immunosuppressive treatments and SEs in psoriasis

A

Immunosuppression:

-Increased risk of infection and cancers (particularly skin cancers)

Ciclosporin

  • Renal function and blood pressure

Methotrexate

  • Liver function, alcohol intake, nausea
  • Hydroxycarbamide

Less effective

  • Fumaric acid esters

Flushing, GI upset, Lymphopenia, PML

  • Acitretin

Dry lips and eyes, triglyceride levels

40
Q

Biologics in psoriasis

  • when to use
  • what to use (names)
A

Y4 Lecture Day III (9 decks)

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