Psoriasis Flashcards
What is the aetiology of psoriasis?
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
How does psoriasis present on histology?
Acanthosis - thickening of epidermis Munro microabscesses Elongation of rete ridges Suprapapillary thinning Dilated papillary blood vessels
What are the aggravating factors?
Streptococcal throat infection Medications: beta blockers, lithium, antimalarials Stress Alcohol and cigarettes Trauma, friction (Sunlight)
What are the types of psoriasis?
Chronic plaque (90%) Palmoplantar Flexural Guttate Erythrodermic Pustular
What is chronic plaque psoriasis?
Salmon pink patches and plaques Well demarcated Silvery scales Extensor surfaces Symmetrical Nail changes: pitting, oncholysis, subungal hyperkeratosis
What is the Koebner phenomenon?
Tendency for a skin condition to occur within scars or sites of trauma
What is guttate psoriasis?
More common in children/adolescents Acute streptococcal infection Rain drop-like lesions Self resolving May precede chronic plaque psoriasis
What is erythrodermic psoriasis?
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
What is pustular palmoplantar psoriasis?
Commoner in females Adults Associated with smoking Distinct from normal psoriasis Symmetrical
What is pustular generalised psoriasis?
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
What are psoriasis associations?
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
What are the features of psoriatic arthritis?
Monoarticular or asymmetrical oligoarticular, DIP
Symmetrical RA like
Axial AS like
Arthritis mutilans
What is the impact of psoriasis?
Pain, bleeding, itching
Types of clothes worn, social and leisure, work
Self-confidence
Treatment takes time to apply and is messy
What is the management of psoriasis?
Education Topical treatment Phototherapy Systemic treatment GP, hopsital outpatient
What are the 1st line topical treatments?
Emolients, E45 Vitamin D3 analogues (calcipqotriol) Topical corticosteroids, eumovate Keratolytics. 5% salicylic acid Coal tar Dithranol (short contact, dithrocream)
Which topical treatments are used for special sites?
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
What is the summary of topical treatments?
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
What is 2nd line phototherapy?
UVB TL01 (narrowband UVB) UVA plus tablets (8 methoxypsoralen)= PUVA Side effects: Erythema/pruritus Nausea (PUVA) L/T- skin cancer
What is PUVA?
Oral (8-mop or 5-mop) Bath PUVA Hand and foot PUVA UVB: Can combine with tar, dithranol (goeckerman, ingram)
What is used to treat guttate psoriasis?
Emollients
Coal tar preparations
Calcipqotriol dovonex
TL01 narrowband UVB treatment
How is erythrodermic psoriasis and generalised pustular psoriasis treated?
Admit, supportive treatment with careful monitoring of BP, temperature and urine output
Liberal emollients and potent topical steroids
Consider systemic treatment
What are the 3rd line systematic treatments?
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
What are the side effects of systematic treatments?
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
What are the biological treatments for psoriasis?
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
