Psoriasis (Final Exam) Flashcards
psoriasis is a _-cell mediated inflammatory disease due to a complex interplay between genetic and environmental factors
T
the result of psoriasis is this type of skin disorder, where there is an increased cell turnover
hyperkeratosis
what is the major gene locus for psoriasis
PSOR1
what are some environmental factors that may cause psoriasis
- trauma
- stress
- infections
what are some medications that may cause psoriases
- beta-blockers
- lithium
- antimalarials
- steroid withdrawal
what is the Koebner phenomenom
induction of psoriasis due to trauma (tattoo, sunburn)
this type of psoriasis is associated with strep infections
guttate (drop-like) psoriasis
true or false: HIV induced immune alterations may produce acute onset, severe psoriasis
true
this can be associated with psoriasis. may be severe and may lead to excoriations. antipruritic agents can be used to treat this such as hydroxyzine (Atarax) - can be sedating therefore take at night
itching
this occurs in 5-20 pts with psoriasis. may be severe and psoriatic nail involvement is common. treatment is similar to RA
psoriatic arthritis
true or false: psychiatric disorders are common in people with psoriasis
true - depression is common due to physical appearance of plaques
this may be associated with psoriasis; is a strong predictor of CVD, stroke, DM. cluster of risk factors include abdominal obesity, dyslipidemia, hypertensions, insulin resistance/glucose intolerance, prothromotic state, pro inflammatory state
metabolic syndrome
what are some other immune-mediated disorders that may be present with psoriasis
- chron’s disease
- MS
this is a possible comorbidity of psoriasis; cutaneous T-cell lymphoma, non-melanoma skin cancer (basal-cell carcinoma, squamous cell carcinoma)
malignancies
this is the most common type of psoriasis
plaque psoriasis
this type of psoriasis is often preceded by a strep infection
guttate (drop-like) psoriasis
this type of psoriasis spares areas commonly involved with plaque psoriasis. appears in skin fold (e.g. back of knees)
inverse psoriasis
this type of psoriasis may be an emergency if generalized. pustules can merge to form “lakes of pus”
pustular psoriasis
this type of psoriasis is usually life-threatening. presents with erythema, desquamation and edema
eryhtrodermic psoriasis
this type of psoriasis only affects the palms of hands and soles of feet
palmar/plamtar psoriasis
clinical manifestations of this type of psoriasis include:
- plaque like lesions with silvery-white, loosely adherent scales
- Auspitz sign (when scales are lifted, some lesions show fine bleeding points)
- lesions have sharply defined borders which are palpable
- lesions are bright, red/violet color
- lesions are possible on scalp, arms, legs, trunk, face, back, etc.
- can have yellowish lesions on nails
- thicker lesions on elbows and knees
plaque psoriasis
what are some non-pharmacological tx for psoriasis
- stress reduction
- non-medicated moisturizers (fragrance free)
- avoid irritants on skin
- avoid skin trauma (wear loose fitting garments + SPF)
what is the algorithm for treating mild-moderate psoriasis
- topical agents
- topical agents + phototherapy
- topical agent + systemic agents
(+ moisturizers)
what is the algorithm for moderate-severe psoriasis
- systemic agent (e.g. MTX) +/- topical agent or phototherapy; consider biologic agent esp if comorbidities
- more potent systemic agent or biologic agent +/- topical agent
- biologic agent (if not already used) +/- other agents
(+ moisturizers)
what is the potency of the following topical corticosteroids
- hydrocortisone 0.5%, 1%
- desonide 0.05%
low
what is the potency of the following topical corticosteroids
- betamethasone dipropionate 0.05% cream/gel, fluocinonide 0.05%, halocinonide 0.1%
high
what is the potency of the following topical corticosteroids
- betamethasone dipropionate 0.05% ointment, colbetasol propionate 0.05%
super high
what is the potency of the following topical corticosteroids
- betamethasone valerate 0.05%, 0.1%, betamethasone dipropionate 0.05% lotion
medium
true or false: cream bases are more potent than ointment or lotions
false - ointment is the most potent
what potency of corticosteroid should be used for trunks, arms and legs
start with medium potency than titrate up or down as needed
this potency of corticosteroids is used for face and skin folds
low
this potency of corticosteroids is used for thicker plaques such as palms, soles and elbows
higher
what are some local a/e of topical corticosteroids
- skin atrophy
- striae
- telangiectasia (abnormal dilation of capillaries and arterioles)
- steroid rosacea, acne
- hypopigmentation
- delayed wound healing
- contact sensitization
- decreased skin elasticity
what are some systemic a/e of topical corticosteroids
- HPA axis suppression (from potent topical steroids)
- Cushing syndrome
- Addisons crisis
- retarded growth in children
- hyperglycaemia, glaucoma, cataracts
this treatment option is used for mild-moderate psoriasis. normalizes keratinocyte differentiation and has anti-proliferative and anti-inflammatory effects. e.g. Tazarotene and Tretinoin
Topical retinoids
what are some a/e of topical retinoids
skin irritation - erythema, purities, burning (especially upon initial use)
which group of individuals should topical retinoids not be used in
women of childbearing age unless effective contraception is being used (teratogenic - contraindicated in pregnancy)
this treatment option can be sleeted as initial therapy for mild to moderate psoriasis. it enhances keratinocyte differentiation and inhibits proliferation and may be anti-inflammatory. e.g. Calcipotriol/Cacipotriene (Dovobet) and Calcitrol
vitamin D analogs
this can be used for mild to moderate psoriasis. is keratolytic and may have anti proliferative and anti-inflammatory effects. it is staining and has an unpleasant odour. may cause stinging or other irritation
coal tar
this treatment option has a direct anti-proliferative effect on epidermal keratinocytes. used only on thick plaque areas. highly irritating to normal skin. usual concentration 0.1-0.4%. SCAT has 10x higher concentrations therefore duration of application is only 20 mins - 2 hrs and normal skin should be protected using zinc oxide ring
Anthralin
what are the two types of phototherapy
PUVA (UVA + psoralens)
UVB alone
is broadband or narrow band UVB preferred
narrow
what is the most common type of phototherapy used and why
NB-UVB because efficacious and decreased risk of cancer
this is a systemic therapy option for psoriasis. it is an oral retinoid. it is more potent if used with PUVA. this is teratogenic. a/e include hypervitaminosis A, hyperostosis, hyperlipidemia, increase in liver enzymes, hepatitis, leukopenia, cataracts
acitretin
low doses of this medication are usually used in psoriasis and is only taken once weekly
MTX
what are some s/e of methotrexate
hepatotoxicity, microcytic anemia, pulmonary fibrosis, severe skin reactions
true or false: MTX can be used in pregnancy
false
this medication is doses at lower doses for psoriasis. s/e include nephrotoxicity, increased BP, decreased magnesium, tremor, gum hyperplasia. numerous drug interactions.
monitoring: BP, renal function, TG’s, CBC, uric acid, potassium, magnesium
cyclosporine
these inhibit JAK1, JAK2, JAK3 and TyK2. can be taken as 5 mg BID or 11 mg daily (XR formulation therefore can’t be split)
JAK inhibitors (Tofacitinib)
what are some side effects Tofacitinib (JAK inhibitor)
bone marrow suppression, lymphopenia, neutropenia, anemia, serious infections, CV 9 reduced HR and prolonged PR interval), GI perforations, hepatotoxicity
what needs to be monitored for Tofacitinib
CBC, Hb, Scr, LFT’s, lipids at baseline and periodically
true or false: it is common for Tofacitinib to be used with other DMARDs and immunosuppressants z9e.g. cyclosporine)
false - these shouldn’t be used together
these lead to increased intracellular cAMP, one end effect = reduced production of pro-inflammatory mediators
selective PDE-4 inhibitors
this is an oral selective PDE-4 inhibitor that is approved for tx of psoriasis and psoriatic arthritis
apremilast
this is a topical selective PDE-4 inhibitor that is an ointment approved for utopian dermatitis with limited clinical trial evidence for psoriasis
Crisaborole
what are some side effects common to all biologics
increased risk of infection
potential risk of malignancies
________ have a potential risk of worsening CHF or new onset CHF
TNF-inhibitors
what do the following biologics target:
Infliximab (Remicade), adalimumab (Humira), Etanercept (Enbrel)
TNF-alpha
what does the following biologic target
Ustekinumab (Stelara)
IL-12 and IL-23
what do the following biologics target:
Secukinumab (Cosentyx), Ixekizumab (Taltz), Brodalumab (Siliq) and Bimekizumab (Bimzelx)
IL-17 inhibitors
what do the following biologics target
Guselkumab (Tremfya), tildrakizumab (Ilumya) and Risankizumab (Skyrizi)
IL-23
