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Dermatology > Psoriasis and Papulosquamous Diseases > Flashcards

Psoriasis and Papulosquamous Diseases Flashcards

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Dermatology Board Prep flashcards
1
Q

Define Papulosquamous Diseases

A 
Papule = palpable
Squamous = epidermal changes
Inflammatory disorders
Has discrete borders
Most are chronic T-cell mediated disorders
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2
Q

Define Psoriasis

A

Common chronic inflammatory genodermatosis which has to do with abnormal T-cell function and communication

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3
Q

What areas does psoriasis affect?

A

skin, nails and joints

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4
Q

What cytokines are behind Psoriasis presentation?

A

Th17 and IL23 –> treated with IL23 and IL17 blockers

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5
Q

What are the common areas affected by chronic psoriasis distribution?

A

knees, head, genitalia and between the buttocks and elbows

Rarely on the face and neck, feet and palms

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6
Q

What are the clinical subtypes of psoriasis?

A
  1. Plaque - most common, 80% of cases = raised, red sclay lesions - scalp and groin
  2. Gluttate - small dot like lesions after strep infection
  3. Erythrodermic - intense redness head to toe, look sick, medical emergency, some scaling, brought on by drug exposure to something they are allergic
  4. Pustular - pus-filled lesions - generalized pustular patients are sick. Get admitted for fluid management and treatment. Some localized to palms and soles
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7
Q

What does chronic psoriasis look like on presentation?

A

Ham color on ear, joints, very discrete borders with normal skin
Nail - pitting - occurs when the psoriasis is involved high up in the nail matrix. If at the bottom of the nail matrix - you get oil on the top. Full thickness - nails fall apart

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8
Q

Gluttate psoriasis is precipitated by?

A

strep infection

Gluttate psoriasis is unstable, comes on all of a sudden

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9
Q

What are the characteristics of erythrodermic psoriasis?

A

unstable
progressively creeping up the body
very deeply ham colored

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10
Q

What does Pustular psoriasis look like?

A
  • Localized palms and soles

- Uncomfortable but not as limiting as having full hand or foot involvement

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11
Q

How common is psoriasis?

A
  • Bimodal onset - 20 and 50years

- Present in 1-2% of the US population

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12
Q

What are the risks associated with Psoriasis?

A
  • 50% increased mortality risk with severe psoriasis
  • Top causes of death among severe psoriatics - CVD, infection, cancer
  • Th1/17 inflammation
  • Co-morbidities: genetics, diabetes, obesity, smoking, alcohol
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13
Q

What are the options for treatment of psoriasis?

A
  1. topicals - most commonly. effective as monotherapy. typically applied twice a day. Used for mild to moderate psoriasis.
  2. phototherapy
  3. systemics
    However, remember that psoriasis is not curable but can be controlled. Also note that the physical and emotional burden of this skin disease is severely under-appreciated.
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14
Q

What is involved in topical treatment of psoriasis?

A
  1. coal tar - admission and apply tar – about 6month remission
  2. anthralin - produces longterm remission. But produces this staining of the skin
  3. topical steroids - most commonly used
  4. calcipotriene/calcipotriol (vitamin D)
  5. Tazarotene (retinoid)
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15
Q

What is involved in phototherapy?

A
  • Light unit or lasers
  • for moderate to severe psoriasis
  • localized areas of stubborn plaques
  • UVB = effective - use 2-5X per week
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16
Q

What are the risks of use of UVB?

A
  • acute photoreaction (subnurn)
  • activation of herpes virus
  • photoaging, skin cancer very unlikely
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17
Q

How can you increase the efficacy of phototherapy?

A

Combine with:

  • coal tar, anthralin, tazatorene, calcipotriene
  • acitretin
  • biologics
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18
Q

Options for systemic therapy?

A

Methotrexate
Cyclosporine
Acitretin

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19
Q

How does methotrexate work and what are some contraindications to watch for?

A
  • originally a chemo drug
  • folate antagonist
  • slows fast-dividing cells
  • potential liver toxicity
    DO not give bactrim
    Effective for psoriatic arthritis
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20
Q

What are the limitations of acitretin?

A
  • Teratogenic. Should not be used in women of child-bearing age
  • Also have the retinoid side effects including alopecia
  • Cannot give blood after treatment with acitretin because it can be given to a pregnant woman
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21
Q

How does cyclosporine work?

A

originally and organ transplant drug

Inhibits IL2 production/release

22
Q

What are the side effects of PUVA? (Psolarens + Ultraviolet A)

A
  • risk of acute photoreactions and chronic photoaging of skin
  • increased risk of SCC (with greater than 200 PUVA sessions)
  • probable increased risk of melanoma

Remember that:

  • can be used for maintenance
  • combinantion with acitretin is more potent
23
Q

What is the side effect of Cyclosporine?

A

nephrotoxicity

Limit treatment to one year at a time

24
Q

What are the options for biologics in treatment of psoriasis?

A
  1. Anti-T cell therapies like Ustekinumab and Secukinumab
  2. Anti-TNF alpha therapies like Humira, Enbrel and Remicade
  3. Other = otezla (apremilast) which is an oral PDE4 inhibitor
25
Q

What is a PASI score?

A
  • A composite of scores for the degree of erythema, induration and desquamation
  • IN order for a drug to get on the market, you need a high PASI score (Psoriasis Area and Severity Index)
  • This is the standard measure of efficacy in psoriasis trials
26
Q

What is Seborrheic Dermatitis

A

This is a common papulosquamous disorder

Etiology - Pityrosporum yeast

27
Q

The clinical presentation of Seborrheic dermatitis is different in children vs. adults. What is the presentation of Seborrheic dermatitis adults?

A

In adults –> areas where the sebacceous glands are more concentrated?. Shows up as moist, transparent to yellow, greasy scaling papules.
- Scalp margins, central face, presternal areas
- eyebrows, the base of eyelashes, nasolabial folds, paranasal skin, and external ear canals
- flexural skin may be similarly involved
Adults tend to have a chronic course with remissions and exacerbations.

28
Q

What is Pityriasis Rosea?

A

Common self-limited usually asymptomatic papulosquamous disorder.
Goes away without any scarring spontaneously in 1-2 weeks
Differential diagnosis is secondary syphilis - don’t shake hands

29
Q

What is the characteristic presentation of Pityriasis Rosea?

A
  • Christmas Tree pattern
  • 75% of patients between ages 10 and 35years
  • See seasonal clustering of cases
  • patients report and mild prodrome
  • Typically shows up on the main torso of the breast/chest and back. very rarely below the hips and elbows and above the neck. Also uncommon on the buttocks, arm and neck.
  • Distribution –> short wet suit
30
Q

Describe this lesion and give a potential diagnosis.

A

Pityriasis Rosea

Salmon colored. There is a thin collar scale at the edges

31
Q

What is lichen planus?

A

Itchy rash
inflammatory papulosquamous disorders
unknown etiology
10% of patients have a positive family history

32
Q

What are some characteristics of Lichen planus?

A

Uncommon infections. Affects skin, nails, hair and mucus membranes
Rare in children aged under 5

33
Q

How does lichen planus present?

A
  • 5P’= purple, polyglonal pruritic papules and plaques
  • Wickem’s striae
  • Koebner phenomen

Usually occurs in the wrists and ankles.
Scratch then you have very brief relief before it starts to hurt
- There are a ton of lymphocytes right under the epidermis
- Darker skinned patients, the pigment lasts for years
- Can show up genitals and mouth (incredibly painful)

34
Q

What is wichem’s striae?

A
  • lacy reticulated epidermal change overlying a lesion of

- seen in lichen planus

35
Q

Koebner phenomenon

A

lesions develop in areas of injury

e.g. seen in Psoriasis and lichen planus

36
Q

What is the clinical course of lichen planus?

A
  • Clinical course is variable and unpredictable
  • Itching is variable, but is usually intermittent and insatiable
  • Several oral lichen planus may degenerate to squamous cell in an estimated 3% of cases
37
Q

What are the types of patients typically affected by lichen sclerosus and how does it typically present?

A
  • Very uncommon
  • Mostly women over age of 60 but can occur at any age
  • Female to Male ratio is 10:1
  • Can affect the both skin and mucosal surfaces
  • Have a predilectional for the anogenital skin
  • Most typically the vaginal area
  • Painful.
  • Does occur in men - equal distribution
  • Itching that keeps them up at night. Cannot have sex
38
Q

What is important consideration about lichen sclerosus?

A

Can develop squamous cell carcinoma

consider pre-cancerous more than lichen planus

39
Q

What is the appearance of lichen sclerosus lesions?

A

Ivory colored and a discrete (lilac at the edge) border to the lesions
Destroys normal tissue in that area - hairs, glands etc
get black heads where the structures used to be
If not treated - get chronic scarring

40
Q

What are some characteristics of lichen sclerosus in males?

A
  • Balanitis sclerotica which progresses to phimosis if untreated – same disease as in women with same sort of scarring.
  • Also can degenerate into cancer - SCC in 3% of mucosal lesions.
  • It is painful on mucosal areas. Skin lesions are often symptomatic
  • Variant can also see blood vessels in lichen sclerosus areas
  • Seen typical changes seen in squamous cell carcinoma
41
Q

If you see Lichen sclerosus in pre-pubertal girls suspect?

A

Pre-pubertal girls –> suspected child abuse in a kid under age 5

42
Q

What is the treatment of lichen sclerosus?

A

high dose topical steroids nightly for the rest of their life.

43
Q

What is a risk factor amongst patients with pustular psoriasis?

A

Risk factor –> smoking

44
Q

How do patients with lichen sclerosus typically present?

A

Women complain of chronic vulvar pruritis, dysuria or dyspareunia

45
Q

What is the common distribution of lichen sclerosus?

A

Between cheeks. Around nipple area and the genital area.

Rarely shows up below the knees, elbows and above the neck. Commonly also in the main torso - back and front.

46
Q

What is the natural clinical course of Pityriasis Rosea?

A
  • First lesion - called a herald patch. 1-2cm.
  • Has a thin collarette of residual scale inside the border.
  • 1-2weeks later, numerous similar but smaller lesions show up in a christmas tree pattern.
  • Usually clear spontaneously in 4-12 weeks.
  • Post-inflammatory hyperpigmentation may take months to resolve in darker-skinned people.
47
Q

The clinical presentation of Seborrheic dermatitis is different in children vs. adults. What is the presentation of Seborrheic dermatitis children/infants?

A
  • yellow greasy adherent scale “cradle cap”
  • minimal underlying redness
  • scale may become thick and adherent –> often seen on the top of the scalp of infants because mothers are afraid to scrape off the crust.
  • diaper area and axillary skin with redness more than scaling
  • usually a self-limited condition often not requiring treatment
48
Q

What are the new drugs for treating psoriasis?

A

Ixekizumab and JAK inhibitors

49
Q

What are the potential Psoriasis PASI score endpoints?

A

In most psoriasis trials, several levels of efficacy are recorded:

  1. PASI 75 = greater than 75% reduction from baseline
  2. PASI 50 = greater reduction from baseline
  3. PGA AC/C = Physician Global Assessment “almost clear” or “clear”
50
Q

What is the PASI score based on?

A

Scale ranging from 0-72 based on:

  • Area involved by region: head, trunk, arms, legs
  • Severity of process in each body: erythema, thickness and scaling
51
Q

What are the side effects of Acitretin?

A
  1. Dose-dependent retinoid side effects including alopecia
  2. Start with low doses, increase if needed and tolerated
  3. Very limited drug interactions
  4. Follow LFTs, tryglcerides - Gemfibrozil (Lopid) 3-600mg BID, if needed
    - Teratogenic and long-half life
  5. should never give blood after taking acitretin
  6. Potential liver toxicity
  7. teratogenic
52
Q

How does acitretin work?

A

synthetic retinoid. Long half life.

Potentiates other treatment modalities.

Dermatology (8 decks)

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