Psoriasis Dan Flashcards
when does Pso start?
2 peaks
16-22yrs
57-60yrs
Early onset form is more severe and more likely to have an affected 1st degree relative and is associated w/ HLA-Cw6
T/F
Female psoriasis pts present earlier
True
T/F
prevalence of Pso is 1.5-3.0%
True About 2.5% in Europeans 14% with 1 affected parent 41% with both affected parents 6% with 1 sibling affected
What is the psoriasis gene?
PSORS1 on Chr 6
Accounts for 35-50% of heritability of psoriasis
Strongly associated with guttate but not associated with palmoplantar pustulosis and late-onset psoriasis vulgaris
T/F
Epidermal keratinocyte cell cycle times is reduced in Pso
False
7x increase in number of cycling cells in basal and suprabasal epi but cell cycle time unchanged
Which factors provoke Pso?
SITE DAMP + HIV Sunlight - in about 5% Infection - esp Group A beta-haemolytic Strep Trauma - koebnerises Endocrine - Puberty, menopause, Oestrogens Drugs - BLAIN ACEi Alcohol + smoking - can flare Pso Metabolic - hypoCa, dialysis, Wt gain Psychological - stress HIV/AIDS- can flare or precipitate Pso
What are the links between smoking and Pso?
Smoking is independent risk factor for developing Pso and may be dose-dependent (BJD 2014)
Smoking has been linked to pustular Pso
Increased incidence of smoking in psoriatics
Smoking contributes to cardiovascular risk
How is Pso affected by pregnancy?
40% improves
40% stable
20% worsens
T/F
Systemic agents for psoriasis can modify cardiovascular risk
True
Acitretin - raise serum cholesterol and triglycerides
MTX - Reduces cardiovascular morbidity and mortality
CsA - Increases BP and serum cholesterol and triglycerides
TNF inhibitors reduce cardiovascular events and ustekinumab may also
T/F
Psoriatic arthritis is a risk factor for cardiovascular disease?
True
PsA is an additional risk factor for CVD over Pso alone, BJD 2014
What are the associations of Pso?
PsA
HTN - causes Inrisk of Pso also Pso increases the risk of uncontrolled HTN
Metabolic syndrome
CVD
IBD - 48x inc risk of Crohns or UC
Vitiligo
MS
BP
Lymphoma - Inc risk all types especially CTCL, Hodgkin’s
SAPHO syndrome
(Synovitis, Acne, Pustulosis, Hyperostosis, Osteitis)
Psychological - poor self-esteem, sexual dysfunction, anxiety, depression, and suicidal ideation
T/F
Pso is not itchy
False
often is itchy
T/F
Pso increases risk of skin SCC
False
but Inc risk from PUVA - rarely used for Pso now
What are the criteria for metabolic syndrome?
Need 3 out of 5 of; HOT Bacon Butty HDL low or treated Obese - elevated waist circumference >102m/88f cm Triglycerides high or treated BP high or treated (>130 sys /85 diast) BSL>5.5
Causes 2-3x risk DM or CVD, 1.6x mortality risk
What is a PASI score? How do you calculate PASI?
Psoriasis Area Severity Index; score Zero-72
Score Erythema, Thickness and Scale 1-4 for each of the 4 areas and sum the scores for each
Multiply the score by the Area score for each area
1 90%
Adjust the final number by a correction factor then sum the 4 scores to get the PASI. Correction factors;
Head 0.1
Arms 0.2
Trunk 0.3
Legs 0.4
How does the Australian Consensus Treatment Goals classify mild, mod and severe Pso?
Mild
- PASI ≤ 10 and DLQI ≤ 10
- But if one or more special features significantly impair quality of life then upgrade classification to Mod/Severe
Mod/Severe - PASI >10 and/or DLQI >10 - Or presence of a special feature; • Visible areas • Major parts of scalp • Genitals • Palms and/or soles • Onycholysis or oncychodystrophy of 2+ fingernails • Pruritus leading to excoriation
Whata re the types of Psoriasis by morphological lesion type and distribution?
Morpgology/ Lesion type; Vulgaris (classic plaque) guttae Rupioid; limpet-like cone shaped lesions Elephantine; large, hyperkeratotic, peristant Ostraceous; ‘Oyster shell’ Pustular
Distribution; widespread classical - plaque, guttate Localised eg Linear; rare ?mosaic Pso susceptibility mutation, Penis/vulva-can be isolated, Palmoplantar, nails Inverse Erythrodermic
Sebospsoriasis is both a regional and morphological variant
What is unstable psoriasis? What are the causes?
Significant flare of Pso which threatens progression to erythroderma or pustular psoriasis Triggers include; Withdrawal of intensive systemic or topical corticosteroids Drugs ‘BLAIN Ace’ Hypocalcaemia Acute infection Irritants (tar, dithranol, UV radiation) Severe emotional upset
Whatare the types of erythrodermic Pso?
Exfoliative erythrodermic Pso - extensive 'normal' Pso - some spared areas - responds to Rx, good prognosis Unstable erythrodermic Pso - more common in pts w/ PsA - triggers as for unstable Pso - Whole skin involved - Pso characteristics lost - Systemic symptoms (fever, malaise) - Course often prolonged and relapses are frequent - Appreciable mortality - Itch is often severe
T/F
Psoriasis can cause cicatricial alopecia
True
if severe prolonged scalp Pso
Psoriatic erythroderma often associated with significant alopecia
What are the features of inverse psoriasis?
affects older pts
Genital area may be involved
lesions have a glazed red hue and minimal scale with sharp edges
can koebnerise other dermatoses in intertriginous areas
lesions often have reduced sweating but macerated as increased sweat produced by surrounding skin
fissuring is common
T/F
Nails are involded in 10-20% of psoriatics
False
25-50%
Fingernails & toenails affected equally
What are the nail findings in psoriasis?
Irregular pitting
Oil spot/Salmon patch (lifting of nail from bed away from edge)
Onycholysis
Leukonychia
subungual hyperkeratosis - not prominent
Splinter haemorrhage - dermal ridge haemorrhage
Beau’s lines
Acrodermatitis continua of hallopeau
Can get secondary tinea, yeast or psedomonas infection
Can get acute or chronic paronychia
Treatment ladder for nail psoriasis?
JAMADerm guidelines 2014
Evaluate for PsA – refer to rheum if appropriate
Consider extent of Pso – do they qualify for systemic/biologic based on skin severity?
Exclude onychomycosis or other infection and treat
Gen measures - hand and nail cares, avoid wet work and trauma including manicures, frequent moisturiser, keep nails short
Topicals first line;
- Potent TCS (clobetasol in studies)
- Daivobet gel
ILCS 2.5mg/ml – 1st line non systemic if failed topicals
MTX – 1st line non biologic systemic
Acitretin – 2nd line non biologic systemic
Biologics – Adalimumab>etanercept (then ILCS) >ustekinumab
2nd line systemics – MTX>Acitretin> infliximab>apremilast
If skin, nails and joint disease;
- Adalimumab>etanercept>ustekinumab>infliximab> MTX>apremilast>golimumab
What are the features of psoriasis in children?
Congenital is very rare
Can start in young kids esp w/ infective trigger
Psoriasiform napkin eruptions
More likely to progress to eczema than psoriasis
Toe cleft intertrigo in children may be psoriatic as tinea is less common
Affects the face more commonly in children
Pityriasis amiantacea
Nail involvement may be the only sign
Follicular psoriasis over the extensor prominences may be
T/F
There is no mucosal type of psoriasis
False Geographic tongue (benign migratory glossitis) Psorisiform mucositis of the dorsum tongue
What eye complications can occur with pso?
Blepharitis, conjunctivitis, keratitis, symblepharon, chronic uveitis
What are the types of pustular psoriasis?
4 classical forms; Localised pustular psoriasis (confined to hands and feet; chronic) - Palmoplantar pustulosis - Acrodermatitis continua of hallopeau Generalised pustular psoriasis - GPP (whole body; subacute/acute/fulminating/life-threatening) - Acute - Of pregnancy (herpes gestationis) - Infantile and juvenile - Circinate - Localised (not hands and feet) Annular PP - Most common type in kids – ave age 6 yrs Exanthematic PP (?same as AGEP)
T/F
Palmoplantar pustulosis usually occurs without psoriasis elsewhere
True
But can be Pso so should always look for it
What are the associations of Palmoplantar pustulosis?
90% are previous or current smokers
F>M
Reported triggers include; smoking, lithium, tonsillitis, TNF-alpha blockers or other drugs
Other associtions;
Hyper/hypo thyroidism and antithyroid antibodies
Tendency to develop DM i
Antigliadin antibodies/coeliac disease
Arthropathies including SAPHO - ask about joints
What are the differentials of Palmoplantar pustulosis?
eczema/pompholyx
tinea
allergic contact
What is Acrodermatitis continua of hallopeau?
How is it treated?
Rare, chronic, sterile, pustular eruption affecting initially tips of fingers or toes F>M, middle age Distal phalanx red and scaly then pustules develop Polycyclic lakes of pus Skin shiny and atrophic in appearance Nail fold & nail bed involved - nail dystrophy often gross Nail plate may be completely destroyed, can be bone destruction of phalanx (osteolysis) Can get fissured or geographic tongue can turn into GPP Rx Potent TCS Acitretin Low dose CyA (1.25mg/kg/d) MTX slower than in GPP Hydroxyurea 500-1500mg/d Tetracycline & colchicine used Hand foot PUVA very useful but slow
T/F
Generalised pustular psoriasis is associated w/ HLAB27
True
T/F
Generalised pustular psoriasis is always a complication of exisitng Pso
False
can be first presentation of Pso
What are the types of Generalised pustular psoriasis (GPP)?
what are the variants?
1) Classical early onset psoriasis converts w/ or w/out a known provoking factor
2) Later onset psoriasis often with an atypical acral or flexural distribution w/ rapid and spontaneous progression to GPP
3) Newly described AR familial form – mutation in gene for the IL-36 receptor antagonist
4) Also recently described childhood cases due to mutation in CARD14 gene – early onset, severe and resistant
Variants;
- Generalised pustular psoriasis of pregnancy
- Infantile or Juvenile pustular psoriasis
- Circinate/annular - some include as variant of GPP
What are the triggers of Generalised pustular psoriasis (GPP)?
Withdrawal of intensive systemic or topical corticosteroids Meds ‘BLAIN Ace’ Hypocalcaemia Acute infection Irritants (tar, dithranol, UV radiation) Severe emotional upset Pregnancy – Impetigo herpetiformis Withdrawal of CSA
What are the clinical features of Generalised pustular psoriasis (GPP)?
Pre-existing lesion become fiery red + pin-point pustules
Sheets of erythema and pustulation spread to involve previously unaffected skin, especially to genital or flexural regions
Nails are thickened and onycholysis secondary to lakes of pus under the nail
Geographic or fissured tongue
High fever
malaise
Burning pain from skin
What are the features of Generalised pustular psoriasis of pregnancy?
Onset usually in last trimester + persists until delivery
Symmetrical GPP features starting in the flexures
Pustules on inflamed skin with centrifugal extension
Tongue, buccal mucosa & oesophagus may be involved
Constitutional features often severe; Delirium, diarrhoea, vomiting & tetany
Death due to renal or cardiac failure
Heal with reddish-brown pigmentation
If severe and prolonged risk placental insufficiency and foetal death
What are the laboratory findings of GPP?
Hypocalcaemia is common - also low Zn
Lymphopenia at onset followed by leucocytosis
High ESR
low albumin
What is the management and prognosis of GPP?
Admit
usual gen measures for severe acute dermatosis
monitor for complications
Try to establish trigger and remove
If on topical or systemic steroids wean slowly
Balnd emollients
moderate potency TCS can be used
Acitretin 1st line - high dose 1mg/kg
CsA good as fast acting - can start on CsA and switch over to acitretin gradually
MTX
nbUVB, PUVA
3rd line - pred, dapsone, hydroxyurea
Pregnant - nbUVB good choice
Pred 1st line systemic, CsA second
Consider delivery in pregnant patients with Impetigo herpetiformis if threatening maternal life or foetal distress
May need MTX, acitretin or PUVA post-delivery to hold
prognosis
Returns to normal form of psoriasis or erythroderma in days-weeks
Relapses are common
Poorer prognosis in elderly with underlying medical problems
Generally those with preceding psoriasis have a better prognosis
What are the DDs of GPP?
AGEP Reiter's syndrome Rampant impetigo or candidiasis Pustular drug eruption due to halides Subcorneal pustular dermatosis (Sneddon-Wilkinson disease)
What are the complications of psoriasis?
PsA
Alopecia - if prolonged scalp pso (scarring) or erythroderma
Infection - unusual; concern for joing surgery as plaques harbour staph
Depression, social isolation, alcoholism
renal impairment - due to strep causing psoriasis and glomerulonephritis; due to erythrodermic or pustular pso; due to drugs esp CsA
Liver failure - due to erythrodermic or pustular psoriasis; due to drugs(MTX), alcoholism
Pulmonary fibrosis - complication of psoriatic spondylosis
Amyloidosis - Rare sequele of erythrodermic or pustular psoriasis
T/F
50% of Pso pts get PsA
False
5-30% (about a quarter) of patients with cutaneous psoriasis
In 10-15% of patients, symptoms of psoriatic arthritis appear before involvement of skin
In 10-15.5% of pts with psoriasis PsA is present but undiagnosed
T/F
PsA is familial
True
genetic component
30-55x higher risk if 1st degree relative has PsA
What are the types of PsA?
Distal interphalangeal joints Mono- and asymmetrical oligoarthritis Arthritis mutilans Rheumatoid arthritis-like presentation Spondylitis and sacroiliitis
Wht are the Pso Treatment goals from the Australian Consensus Treatment Guidelines?
Induction phase = treatment period until week 16-24
Maintenance phase = treatment period after induction phase
Treatment success after/during induction/maintenance phase = PASI75% (i.e. reduction in PASI of 75% from pre-induction PASI)
Treatment failure after/during induction/maintenance phase = PASI50% not achieved
Intermittent response after/during induction/maintenance phase = between PASI50 and PASI75 then DLQI and patient preference should be used in deciding whether to continue or modify treatment regimen (DLQI ≤5 is success but >5 is failure)
Special situations
High DLQI >10 and low PASI ≤10 may be influenced by other factors than the psoriasis itself (e.g. comorbidities, psychiatric issues, unrealistic patient expectations)
What general measures are important when treating Pso?
Explain chronic nature of psoriasis with remissions and relapses
No cure
Not contagious
Determine how patient perceives their disability - assess psychological impact and coping mechanisms
Various treatment options including side effects, monitoring
Focus not only on the skin but also on the comorbidities that exist or might develop (e.g. metabolic syndrome) - think of Triggers, Associations and Complications
Assess CVD risk and modifible risk factors
Always consider/assess for PsA, IBD, Coeliac Dx, lymphoma and HIV
Advise weight loss – beneficial for Pso, PsA and CVD risk including if gastric bypass surgery used
Gluten free diet of celiac or if antibody (IgA anti-gliadin antibodies) positive even if coeliac not confirmed histologically – can help pso
Advise stop smoking – triggers Pso and pustular Pso, bad for CVD risk
T/F
80% of Pso patients have mild disease that can be treated with topicals
True
T/F
calcipotriol should not be used concurrently with agents that alter pH, such as lactic acid or salicylic acid
True
Can use with UVB but apply after UVB exposure as may be degraded
T/F
Calcipotriol can be prescribed BD
True
start BD and reduce to OD
What is the maximum amount of calcipotriol you can use?
max 100g/week in adults and 45g/week in children
to prevent hypercalcaemia and hypercalciuria
and do not use with calcium or vid D supplements
T/F
Calcipotriol can be prescribed in pregnancy
True
localised use okay as minimal absorption likely but is cat B1 so not recommended
T/F
Tazarotene can be used for psoriasis
True
Tazarotene 0.1% gel apply once daily
Often used with TCS
TCS reduces irritancy of tazarotene; synergistic effect
Can use with UVB but apply after UVB exposure as photosensitivity risk
T/F
Topical calcineurin inhibitors are good fo nail psoriasis
False
Good for intertriginous and facial psoriasis
T/F
Salicylic acid should be applied shortly before phototherapy
False
avoid this as sal acid acts as sunscreen
T/F
Salicylic acid is safe in pregnancy
True
but dont use widespread - localised areas only approx 5% BSA max
In any pt limit to 20% BSA to avoid Systemic absorption causing salicylism (tinnitus, nausea, vomiting)
T/F
Coal tar sensitises skin to UVA but not UVB
True
T/F
PASI scoring is unreliable between clinicians
False
PASI scoring has good inter-observer reliability in clinical practice (AJD, 2015)
T/F
Should consider serology testing for melioidosis for pts from FNQ or NT as part of pre-systemic screening
True
Other than biologics what systemics can be used for Pso after CsA, MTX and acitretin?
Hydroxyurea Fumaric acid esters (not in Aus) Apremilast 6-Thioguanine AZA
What are the PBS criteria for biologics for chronic plaque pso?
Will receive biologic treatment as systemic monotherapy (apart from MTX)
AND
Whole body lesions present for >6 months and PASI >15
OR
Face, or palm of hand, or sole of foot present for >6 months
AND
At least 2 of the 3 PASI symptoms (erythema, thickness, scaling) are rated as severe(3) or very severe(4);
OR
Skin affected is ≥30% of face, palm of a hand or sole of a foot
AND
Failed to achieve an adequate response following min 6 weeks treatment to 3 out of 4 treatments or ceased due to toxicity (tox criteria) or contraindications
What are the minimum doses for the 4 pre-biologic treatments?
All need 6 week minimum trial; nbUVB - 3x/wk Acitretin 0.4mg/kg/day MTX 10mg/week CsA 2mg/kg/day
When is the first assessment done after starting biologic?
assess after first 12 weeks of starting new biologic
then assess after every 24 weeks on continuous treatment
T/F
Lasers have no place in the treatment of Pso
False
can use 308nm Excimer laser for localised disease
What are the types of palmoplantar psoriasis?
Classic plaque
Keratoderma
Palmoplantar pustulosis
What are the treatments for palmoplantar psoriasis?
Remember gen measures inc stop smoking
Coal tar and steroids are mainstay of topical therapy
- Dirthranol too difficult there and calcipotriol doesnt work well
Acitretin and CsA work well – can start CsA and transition to acitretin
MTX is an alternative
Topical (bath) PUVA or nbUVB
Biologics may help but TNFα inhibitors have been known to cause psoriasiform acral keratoderma and to trigger palmoplantar pustulosis
T/F
Dithranol short contact is good for psoriasis of palms and soles
False
too difficult to keep localised
What are the PBS criteria for biologics for face, hand and foot pso?
Pso of face, or palm of hand, or sole of foot present for >6 months
AND
At least 2 of the 3 PASI symptoms (erythema, thickness, scaling) are rated as severe(3) or very severe(4);
OR
Skin affected is ≥30% of face, palm of a hand or sole of a foot
AND
Failed to achieve an adequate response following min 6 weeks treatment on 3 out of 4 treatments
How long after Pso does PsA tyoically present?
Usually have Pso for about 12 years before get arthritis
T/F
CRP and ESR are normal in psoriatic arthritis
F
elevated in at least 50%
elevated CRP and ESR is part of PBS criteria for biologics in PsA
Raised ESR is a marker for increasaed risk of progressive joint damage
RF is negative = seronegative arthritis
T/F
Delay in diagnosis of PsA for 6 months or more is assoc w/ worse radiographic and functional outcomes
T
T/F
Enthesopathies presenting as tendonitis may be the only feature of PsA
T
ask pts about sore achilles tendons and tennis elbow
How is a diagnosis of PsA established?
CASPAR criteria
Established inflammatory articular disease and at least 3 points from 6 max;
Pso of skin (2 points; all other parameters 1 pt) or personal or fam Hx of pso
Psoriatic nail disease
Dactylitis
negative RF
New bone formation nr joints on hand or foot X-rays
What is the Early ARthritis for Psoriatic patients (EARP) risk assessment tool?
Score ≥3 correlates with PsA according to Rheumatologist assessment
Sensitivity 85.2, specificty 91.6
10 questions, 1 point for each positive response;
1. Do your joints hurt?
2. Have you taken anti-inflammatory more than twice a week for joint pain in the last 3 months?
3. Do you wake up at night because of low back pain?
4. Do you feel stiffness in your hands for more than 30 minutes in the morning?
5. Do your wrists and fingers hurt?
6. Do your wrists and fingers swell?
7. Does one finger hurt and swell for more than 3 days?
8. Does your Achilles tendon swell?
9. Do your feet or ankles hurt?
10. Do your elbow or hips hurt?
What should you do if you suspect PsA on Hx or with scoring questionairre?
take further history and try to exclude OA (major DD)
Check for nail disease and document in letter to Rheum
Blds - RF, ESR, CRP
Get Xrays if any symptoms or signs in hands or feet
What are some Xray findings of PsA?
Syndesmophytes – pathognomonic
Loss of joint space
Pencil in cup deformity
Erosions adjacent to tendon insertions in enthesitis + new bone formation
T/F
synovitis and enthesitis show up well on Xrays
F
some features may be seen esp if advanced
USS or MRI better for effusion and synovitis detection, erosions, dactylitis, tenosynovitis and enthesitis
What treatments are used for PsA?
Physio NSAIDs alone if mild MTX Sulfasalazine Leflunomide (improves Pso) Biologics - infliximab, etanercept, adalimumab, ustekinumab, golimumab, certolizumab pegol (all TNF inhibitors except ustekinumab)
What are criteria for biologics for PsA?
Severe active PsA
Failed trial of minimum of 3 months of Methotrexate 20mg weekly and either Sulfasalazine 2g/day or leflunomide 20mg daily
Severity indicated by ESR >25 and/or CRP >15 and at least 4 large joints or 20 small joints w/ active disease
