Psoriasis and dermatitis Flashcards by Marc Price

Two peaks of incidence in psoriasis?

histology?

20s and 50s
Absent granular layer and thick prickle cell layer
hyperkeratosis

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Precipitating factors for psoriasis?

stress
trauma
alcohol/smoking
infection (strep throat - guttate)

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what drugs can ppte psoriasis?

B blockers
lithium
anti-malarials 
hydroxychloroquine
swift withdrawl of topical/systemic steroids

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most common type of psoriasis - mildly itchy palpable scaly erythematous plaques??

chronic plaque psoriasis

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is chronic plaque psoriasis symmetrical or asymmetrical?

often symmetrical - plaque scale may be silvery

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whats auspitz sign??

removing scale causes pin point bleeding

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where does chronic plaque psoriasis typically develop on body?

extensor aspects of knees elbows sacrum and scalp

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where is scalp psoriasis m/c seen?

posterior aspect of the scalp, extending below the hairline and is ass with itch (no interruption to hair growth)

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When plaques of psoriasis (very similar to chronic plaque) develop at a site of trauma 2-6 weeks after trauma has occurred - called?

Koebner phenomenom

ppte trauma - physical, sunlight or another skin condition

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Younger patients (15-25) onset of well demarcated scaly erythematous plaques “pear drop” shaped and develop on trunk (typically 7-10 days post infection) - Dx?

guttate psoriasis

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most common precipitating infection for guttate psoriasis is ?

strep throat infection

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Flexural psoriasis (seen in groin, axilla and under breasts) usually seen in what patients ?

elderly

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erythematous glazed well demarcated plaques with or without scale in flexural distribution?

Flexural psoriasis

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Well demarcated plaques with absent scale and confluent full body erythema - onset ppte by removal of potent steroids - Dx?

Erythrodermic psoriasis

can develop de novo or in pts with deteriorating psoriasis

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is erythrodermic psoriasis serious? if so why?

YES - can lead to complete failure of the skin

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Sterile pustules within plaques of psoriasis and widespread erythema?

generalised pustular psoriasis

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generalised pustular psoriasis - other symptoms?

skin often painful and associated fever and malaise

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Multiple sterile yellow pustules that develop into brown macules that then develop a scale - on palms and soles - Dx??

Palmo-plantar pustulosis

distinct condition but related to psoriasis

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Palmo-plantar pustulosis

a) typical in what patients - age/gender?
b) strong association with what risk factor?

a) women over 50

b) smoking

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Psoriasis is also associated with what? (3)

nail disease (pitting, onchyolysis, subungual hyperkeratosis)

Psoriatic arthritis (pencil in cup on X ray)

CVS risk

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Management of psoriasis:

treatment to be used regularly and liberally by all patients to reduce scale loss and itch??

emollients

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1st line treatment for psoriasis?

duration of T initially ?

potent topical steroid (Betnovate) (applied OD)
+ potent vit D analogue (calcipotriol/calcitriol) (applied OD)

applied seperately - one in morning and one in evening

up to 4 weeks

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when cant you use a vit D analogue ??

if pregnant

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2nd line treatment for psoriasis considered if no improvement after how long ?

8 weeks

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2nd line treatment for psoriasis?

Offer vit D analogue twice daily

3rd line treatment for psoriasis (if no improvement after 8-12 weeks) ???

Offer either: potent corticosteroid twice daily for up to 4 weeks or coal tar preparation applied once or twice daily

another treatment of option for severe resistant psoriasis (only used in short term as burns/stains normal skin) ??

Dithranol

Treatment of scalp psoriasis ?

potent topical steroid lotion

Treatment of scalp psoriasis 2nd line (no improvement in 4 weeks) ??

Steroid in different form (eg shampoo) or topical agents to remove scale - salicylic acid before applying steroid

Shouldnt use potent steroids for more than how long ?

8 weeks

Shouldnt use very potent steroids for more than how long?

4 weeks

1st line topical T in psoriasis ?

Vit D analogue

smelly and messy T for psoriasis used if in hospital/severe?

coal tar

mild steroids used in what types of psoriasis?

flexural disease and palmar plantar disease

Treatment used to break down particularly hyper keratotic skin/ large scaly plaques ??

salicylate

Secondary care treatment that can be used in more severe widespread disease/ as 1st line in guttate psoriasis ??

photodynamic therapy | UVB or PUVA

SE's of photodynamic therapy?

sunburn reactions, conjunctivits, exacerbation of HSV infection

Very severe psoriasis/ non responsive disease to classic therapies - treatment option?

Systemic therapy: Methotrexate 1st line others = ciclosporin, retinoids, biologics (infliximab)

Itchy, ill defined erythematous rash, +/-scale, excoriations, papules, vesicles, ooze and crust - Dx?

Dermatitis (eczema)

chronic features of dermatitis rash?

scale, skin thickening, pigment changes and lichenification

Atopic dermatitis - risk factors?

``` higher socio-economic class family or personal Hx atopy (eczema asthma hayfever) ```

what is the atopic march?

clinical progression of atopy = eczema in infancy, asthma around age of 2 and then hay fever around the age of 7

normal age presentation of eczema?

6 mths - 5 years but really any age

rash distribution in infants? (eczema)

face, scalp (cradle cap) extensor surfaces involved, flexor surfaces and napkin area spared

rash distribution in children and adults?

flexor surfaces esp wrist, cubital fossa, popliteal fossa and ankles

triggers for eczema?

stress non compliance with treatment allergens - pets new skin products, temperature

Dx criteria for eczema = itch + 3 or more of: Histology?

``` visible flexural rash Hx of flexural rash PHx of atopy Dry skin in the past year Onset before age 2 ``` Spongiosis, acanthosis, hyperkertosis (mutation in fliagrin)

Pt with eczema - develops yellow weeping crust over their rash - Dx?

Bacterial infection with staph A

Viral infection of eczema which presents with monomorphic punched out lesions?

Eczema herpeticum (infection with herpes simplex)

Management of eczema herpeticum?

Emergency - require admission for IV aciclovir

Treatment for eczema - everyone should get ?

emoillients (constantly even when eczema not there)

For itch in eczema - T?

anti histamines

To treat a flare of eczema - T?

topical steroids

Mild eczema - T?

mild topical steroids (hydrocortisone, eumovate)

moderate eczema - T?

moderate topical steroids (eumovate/betnovate)

severe - T?

potent/very potent topical steroids (dermovate) UV light therapy Systemic i/s

Potent steroids must use ST. | Steroid sparing agents that can be used in pts relying on continual steroid use ? (Moderate- severe eczema)

Calinurin inhibitors (Topical tacrolimus)

If eczema not responding to potent topical steroids - T options? (2)

Light therapy (UVB or PUVA) Systemic i/s

Dermatitis caused by overgrowth of commensal yeast on the skin?

Seborrhoeic dermatitis

Development of seborrhoeic dermatitis associated with what risk factor?

immunosupression | HIV or drugs like ciclosporin

Itchy erythematous and scaly rash on the forehead nasolabial folds behind the ear and anterior chest in an adult?

Seborrhoeic dermatitis stressed student at exam type

Presentation if seborrhoeic dermatitis in a newborn?

Cradle cap, flexural surfaces and napkin area. might not be itchy.

Treatment of infantile seborrhoeic dermatitis (cradle cap)?

emollients (on their own first) | and topical steroids

Treatment of seborrhoeic dermatitis in an adult?

emollients + topical steroids + topical antifungal (ketoconazole)

If seborrhoeic dermatitis unresponsive to initial treatment or very widespread - T?

Oral ketoconazole

Erythematous rash with intensly itchy vesicles that burst to produce superficial erosions ? (Eczema on palms of hands and soles of feet)

Pompholyx

Type of eczema seen in elderly patients - dry skin with polygonal fissures - "crazy paving pattern" seen on the lower limbs ?

Azteototic eczema Treat - emollients

Eczema seen in elderly in lower limbs - dry scaly skin with a red/brown colour due to haemosiderin deposition?

venous eczema

why does venous eczema develop? | T?

due to venous insufficiency in the lower limbs Compression to T venous insufficiency

Type of eczema/dermatitis that develops as a consequence of chronic itch?

Discoid eczema

Discoid eczema - morphology?

widespread, disc shaped intensly itchy lesions | ass with atopic eczema and renal failure which causes itch

Contact dermatitis: | Dermatitis caused by repeated exposure to substance that abrades irritates and aggrevates the skin?

Irritant contact dermatitis

Is irritant contact dermatitis immune mediated?

NO | It does not require a previous exposure to have occured like with contact allergic

Common irritants in irritant contact dermatitis?

Soap/detergents, urine (nappy rash)

Occupations in which common to get irritant contact dermatitis?

Hairdressers Cleaners Hospital workers

Contact allergic dermatitis - type of reaction?

Type 4 T cell mediated hypersensitivity reaction in response to an antigen there has been previous exposure to. 1st exposure - sensitized and 2nd - reaction

Rash and skin changes typically occur how long after exposure to the antigen?

48-96 hours after exposure to the antigen

Common allergens in contact allergic dermatitis?

Rubber Nickel (belts and jewellery) Deodarants

Allergic dermatitis seen in what occupations?

those exposed to allergens builders mechanics hairdressers

Dx Ix for contact allergic ?

Patch testing

T for contact allergic dermatitis?

Allergen avoidance Regular emollients Topical steroids during flares