Psoriasis

Question 1

most common presentation of psoriatic arthritis

Answer 1

the most common presentation is asymmetric oligoarthritis of the small joints of the hands and
feet.

Question 2

Where di we find neutrophils in psoriasis skin biopsy ?

Answer 2

The presence of neutrophils in the epidermis, either in

spongiform pustules of Kogoj

or

in microabscesses of Munro

is a typical histopathologic feature of psoriasis, especially acute or pustular forms.

Neutrophils are typically prominent in active lesions and in the marginal zone of expanding plaques, but, in contrast to T ce]]s, they are not a consistent feature of lesionalskin.

Although activated neutrophils could contribute to its pathogenesis, they are not considered to be the primary cause of psoriasis.

Question 3

ustekinumab and role of cytokines in psoriasis

Answer 3

The striking response of psoriasis to ustekinumab, a human monoclonal antibody against the

p40 subunit of IL-12 and IL-23,

provides additional evidence for the role of cytokines.

Question 4

Which cell produces IL-23.?

Answer 4

Dendritic cells

Question 5

Which cytokine whose circuoating levels correlate with disease severity? And why ?

Answer 5

circulating levels of IL-22 correlate with disease severity.

It is thought that IL-23 (produced by DCs) stimulates Th 17 cells to release IL- 17 and IL-22 ; the
concerted action of these cytokines leads to proliferation of keratinocvtes and dermal inflammation (see Fie. 8.1 ).

It has also been proposed that there is a distinct subset of IL- 22-producing T helper cells (Th22 cells) that contribute to the pathogenesis of psoriasis.

Question 6

Which upregulated pathway explains several phenotypic alterations such as vasodilation (by the induction of iNOS) and accumulation of T cells (via the expression of various chemokines).

Answer 6

The IFN-γ-activated pathway is a key feature of psoriasis.

Question 7

Which innate immune cytokines are upregulated in psoriatic skin

Answer 7

The innate immune cytokines

IL-l, IL-6 and TNF-a are upregulated in psoriatic skin.

TNF-a is a particularly relevant
cytokine and its importance is underscored by the therapeutic
efficacy of TNF-a inhibitors (see Treatment tg ).

Question 8

Which chemokine mediates the often-prominent infiltration by neutrophils?

Answer 8

CXCL8

is thought to mediate the often-prominent
infiltration by neutrophils.

Question 9

Which chemokines are implicated in attracting T cells to the psoriatic plaque.

Answer 9

CCL17, CCL20, CCL27, and CXCL9- 11.

Question 10

Which chemokine might contribute to the early recruitment of pDCs into psoriatic lesions ?

Answer 10

pDC-attracting chemokine, chemerin,which is increased in psoriatic skin.

Question 11

Which cells are invooved in innate immune pathways

Answer 11

DCs (myeloid DCs and pDCs)
, NK T cells,
γδT cells, 
ILCs, and 
neutrophils (see above)
as well as epidermal keratinocytes.

Question 12

What is lag time between the trauma and the appearance of skin lesions in koebner phenomenon

Answer 12

usually 2-6 weeks.

can also be induced by other forms of cutaneous injury, e.g. sunburn, morbilliform drug eruption,
viral exanthem.

Question 13

What is the most common infection provoking psoriasis, and perhaps why ?

Answer 13

Streptococcal infections, especially pharyngitis, are the most common offenders.

In the palatine tonsils of psoriasis patients, immune responses have been shown to be dysregulated, with elevated expression of CLA and the IL-23 receptor.

Streptococci can also be isolated from other sites of infection, e.g. dental abscesses, perianal cellillitis. imnetigo.

Question 14

True / False

HIV infection has also been shown to aggravate psoriasis

Answer 14

True

Question 15

Which electrolyte abnormality is associated with generalized pustular psoriasis(trigger) and pustular psoriasis of pregnancy ?

Answer 15

Hypocalcemia

Question 16

Several drugs have been incriminated as inducers of psoriasis :

Answer 16

in particular lithium, IFNs, beta-blockers, and antimalarials.

Rapid taper of systemic corticosteroids can induce pustular psoriasis as well as flares of plaque psoriasis.

Question 17

Wioronoff’s ring.

Answer 17

psoriatic lesions are sometimes surrounded by a pale blanching ring, which is referred to as Wioronoff’s ring.

Question 18

Auspitz sign,

Answer 18

If the superficial silvery white (micaceous) scales are removed, then a wet surface is seen with
characteristic pinpoint bleeding. This finding, called Auspitz sign, is the c]inica] ref]ection of e]ongated vesse]s in the derma] papillae together with thinning of the suprapapillary epidermis.

Question 19

Compare ibfantile psoriasis with atopic dermatitis

Answer 19

Figure 8.6 B
Infantile psoriasis with a well-demarcated erythematous plaque of the diaper area, along with involvement of the penis and scrotum. This is in contrast to atopic dermatitis where there is often sparing of the diaper area.

Question 19

Compare ibfantile psoriasis with atopic dermatitis

Answer 19

Figure 8.6 B
Infantile psoriasis with a well-demarcated erythematous plaque of the diaper area, along with involvement of the penis and scrotum. This is in contrast to atopic dermatitis where there is often sparing of the diaper area.

Question 20

clues to the diagnosis ol psoriatic erythroderma include

Answer 20

previous plaques in classic locations
characteristic nail changes
and central facial sparing.

Question 21

What are the triggering factors for pustular psoriasis ?

Answer 21

triggering factors include :

pregnancy
rapid tapering of corticosteroids (or other systemic therapies)
hypocalcemia
infections,
and, in the case of the localized pattern, topical irritants.

Question 22

Impetigoherpetiformis stands for

Answer 22

Generalized pustular psoriasis during pregnancy

Question 23

Which inherited autoinflammatory disorders have a similar presentation as generalized pustular psoriasis.

Answer 23

The clinical presentation of several inherited autoinflammatory disorders (e.g. DIRA, DITRA,
CARD14-mediated pustular psoriasis, ADAM17 deletion) resembles generalized pustular psoriasis
(see Table 45.7 t@ )52.

Question 24

What are the different variants and sub-variants of pustular psoriasis ?

Answer 24

GENERALIZED PUSTULAR PSORIASIS

1) Von Zumbech -generalized , ill, fever, erytgema & pustulation , pustules resolve and scale is seen.
2) annular type , pustules+scale at edge of annular lesion,with healing in center.
3) Exanthematic type - pusules that appear and disappear over few days / trigger by infection / medication e.g lithium. Overlap with AGEP.
4) Localized pattern : pustules appear within or at the edge of existing psoriatic plaques during the unstable phase/ following irritants such as anthralin /tars.

PUSTULOSIS OF PALMS &SOLES

Acrodermatitis Continua of Hallipou

Question 25

Which type of psoriasis is related with SAPHO syndrome ( short for )?

Answer 25

Pustulosis of the palms and soles

Pustulosis of the palms and soles is one of the entities most
commonly associated with sterile inflammatory bone lesions
within the context of SAPHO syndrome,

which consists of 
synovitis, 
acne, 
pustulosis, 
hyperostosis and 
osteitis. 

Severalneutrophilic dermatoses are associated with SAPHO (see Table 26.18) also most common acne conglobata, and acne fulminans.

Question 26

(annulus migrans) is associated with….

Define it

Answer 26

acrodermatitis continua of Hallopeau and generalized pustular psoriasis.
Migratory annular erythematous lesions with hydrated white scale (annulus migrans).
Most common : Tongue, simikarvto geographic tongue

Question 27

True / False

Patients with nail involvement appear to have an increased incidence of psoriatic arthritis.

Answer 27

True

Question 28

Psoriasis affects the nail matrix, nail bed, and hyponychium.
What are common nails changes in psoriasis and why do they happen ?

Answer 28

Nail pitting : Small parakeratotic foci in the proximal portion of the nail matrix (see Ch. 7 1 S ).

Leukonychia and loss of transparency (less common findings) are due to invo[vement of the midportion of the matrix.

whitish, crumbly, poorly adherent “nail” : involvement of entire nailmatrix is involved

Psoriatic changes of the nail bed result in the “oil drop” or “salmon patch” phenomenon, which reflects exocytosis of leukocytes beneath the nail plate.

Splinter hemorrhages are the resu[t of increased capillary fragilityand subungual hyperkeratosis a

distal onycholysis are due to parakeratosis of the distal nail bed. Vigorous remova] of dista] subungua]
debris may be an exacerbating factor.

Question 29

Does psoriatic arthritis mire commonly occur before or after skin psoriasis?

Answer 29

In a minority of patients (IO- 15%), the symptoms of psoriatic arthritis appear before involvement of
the skin.