Psoriasis

Question 1

What is the aetiology of psoriasis?

Answer 1

2% of population
Racial variation (lower in oriental)
Affects men and women equally
Two age groups of onset
Late teens to early 20s, earlier in females 
50s
Family history 36%
HLA-CW6

Question 2

How does psoriasis present on histology?

Answer 2

Acanthosis - thickening of epidermis 
Munro microabscesses
Elongation of rete ridges
Suprapapillary thinning
Dilated papillary blood vessels

Question 3

What are the aggravating factors?

Answer 3

Streptococcal throat infection 
Medications: beta blockers, lithium, antimalarials 
Stress
Alcohol and cigarettes 
Trauma, friction 
(Sunlight)

Question 4

What are the types of psoriasis?

Answer 4

Chronic plaque (90%)
Palmoplantar 
Flexural 
Guttate
Erythrodermic 
Pustular

Question 5

What is chronic plaque psoriasis?

Answer 5

Salmon pink patches and plaques
Well demarcated 
Silvery scales 
Extensor surfaces 
Symmetrical 
Nail changes: pitting, oncholysis, subungal hyperkeratosis

Question 6

What is the Koebner phenomenon?

Answer 6

Tendency for a skin condition to occur within scars or sites of trauma

Question 7

What is guttate psoriasis?

Answer 7

More common in children/adolescents 
Acute streptococcal infection 
Rain drop-like lesions 
Self resolving 
May precede chronic plaque psoriasis

Question 8

What is erythrodermic psoriasis?

Answer 8

More that 90% of body surface affected
Uncommon
Most likely preceding history or psoriasis
May not have other features of psoriasis
May be systemically ill

Question 9

What is pustular palmoplantar psoriasis?

Answer 9

Commoner in females 
Adults 
Associated with smoking 
Distinct from normal psoriasis 
Symmetrical

Question 10

What is pustular generalised psoriasis?

Answer 10

Rare 
Acute generalised pustular psoriasis (von Zumbusch)
Can occur with ordinary psoriasis 
Precipitated by steroid withdrawal 
Sheets of pustules, background erythema 
May be systemically unwell

Question 11

What are psoriasis associations?

Answer 11

Up to 10% have arthritis
Arthritis can occur without skin involvement, pieced skin involvement or succeed it
Peak age onset psoriatic arthropathy 40-60 years

Question 12

What are the features of psoriatic arthritis?

Answer 12

Monoarticular or asymmetrical oligoarticular, DIP
Symmetrical RA like
Axial AS like
Arthritis mutilans

Question 13

What is the impact of psoriasis?

Answer 13

Pain, bleeding, itching
Types of clothes worn, social and leisure, work
Self-confidence
Treatment takes time to apply and is messy

Question 14

What is the management of psoriasis?

Answer 14

Education 
Topical treatment 
Phototherapy 
Systemic treatment 
GP, hopsital outpatient

Question 15

What are the 1st line topical treatments?

Answer 15

Emolients, E45
Vitamin D3 analogues (calcipqotriol)
Topical corticosteroids, eumovate 
Keratolytics. 5% salicylic acid
Coal tar 
Dithranol (short contact, dithrocream)

Question 16

Which topical treatments are used for special sites?

Answer 16

SCALP:
Co cocois ung (tar and salicylic acid)
Coal tar shampoo- politer, capasal 
Vitamin 03 analogue scalp
Topical corticosteroid 
FACE:
Mild/moderate topical corticosteroid- 1% HC or eumovate 
FLEXURES: Mild/moderate topical corticosteroid- calcitriol (silkis) ointment

Question 17

What is the summary of topical treatments?

Answer 17

First line: emollients, vit D analogues, topical steroids
Thick plaques: salicylic acid or dithranol
Face: mid to moderate topical steroids
Flexures: mid to moderate topical steroids or calcitriol
Guttate- coal tar

Question 18

What is 2nd line phototherapy?

Answer 18

UVB
TL01 (narrowband UVB)
UVA plus tablets (8 methoxypsoralen)= PUVA
Side effects:
Erythema/pruritus 
Nausea (PUVA)
L/T- skin cancer

Question 19

What is PUVA?

Answer 19

Oral (8-mop or 5-mop)
Bath PUVA
Hand and foot PUVA
UVB:
Can combine with tar, dithranol 
(goeckerman, ingram)

Question 20

What is used to treat guttate psoriasis?

Answer 20

Emollients
Coal tar preparations
Calcipqotriol dovonex
TL01 narrowband UVB treatment

Question 21

How is erythrodermic psoriasis and generalised pustular psoriasis treated?

Answer 21

Admit, supportive treatment with careful monitoring of BP, temperature and urine output
Liberal emollients and potent topical steroids
Consider systemic treatment

Question 22

What are the 3rd line systematic treatments?

Answer 22

Methotrexate:
Psoriasis and psoriatic arthropathy
Long term effects on liver
Not if high alcohol intake
Ciclosporin:
Short term control
Hypertension, nephrotoxicity, carcinogenesis
Care if hypertensive or if past phototherapy
Acitretin:
Teratogenic (2 years)
Not young women wanting to start a family

Question 23

What are the side effects of systematic treatments?

Answer 23

Methotrexate: 
Teratogenicity, nausea and GI upset 
Liver fibrosis, marrow suppression 
LFT and FBC
Ciclosporin: 
Hypertrichosis, gum hypertrophy, tingling peripheries, carcinogenesis 
Hypertension, nephrotoxitiy 
Blood pressure, U&E
Acitretin: 
Teratogenic, dry skin and lips 
Hyperlipidaemia, hepatoxitity 
Fasting lipids and LFTs

Question 24

What are the biological treatments for psoriasis?

Answer 24

Adalimumab, etsnercept, infliximab (severe psoriasis)
S/C injection or IV
Etanercept, adalimumab, infliximab= TNF a antagonist
Ustekinumab= anti IL 12&23
Secukinumab= anti IL 17a