Troublesome rash Flashcards
What are the 4 features of psoriatic nails?
- Periungal erythema
- Pitting
- Subungal hyperkeratosis
- Onycholysis (nail plate separates from the nailbed)
How to psoriasis patients typically present clinically?
They present with plaques on the;
- Elbows
- Knees
- Scalp
What is the common shape of a lesion on the trunk in a psoriasis patient?
Annular
What is Koebner’s phenomenon?
When areas of the skin become lesions where the skin should not normally be raised (e.g. when someone scratches their skin and an immediate lesion appears)
What is Guttate psoriasis?
Widespread small plaques scattered on the trunk and the limbs
What is Palmo-plantar pustular psoriasis (PPPP)?
Multiple sterile pustules appear on the palms and soles. They first look yellowish monomorphic lesions then become brown over time.
Which patients are typically affected by palmo-plantar pustular psoriasis?
Smokers
What is generalised pustular psoriasis (GPP)?
Acutely erythematous skin which is very tender. There are skeets of monomorphic, sterile pustules which can develop over hours/days.
What does GPP generally indicate?
It usually indicates a very severe and unstable psoriasis
What is acropustulosis?
It is a very rare variant of psoriasis where there are pustules on the nails and fingertips associated with inflammation.
Who most commonly develops acropustulosis?
Young children
What is flexural psoriasis?
Well-defines erythematous areas in the axillae, groin, natal cleft, beneath the breasts and in skin folds
What is erythrodermic psoriasis?
This is a serious, even life-threatening condition, with confluent erythema affecting nearly all of the skin.
What are the triggers for the life-threatening erythrodermis psoriasis?
- Withdrawing from systemic steroids
- Infection
- Excessive alcohol intake
- Antimalarials
- Lithium
- Hypocalcaemia
What are the systemic complications of erythrodermis psoriasis?
- Heart failure
- Hypothermia
- Dehydration
- Low protein
- Oedema
- Secondary infection (encephalitis etc)
- Death
What is the pathophysiology of erythrodermic psoriasis?
Increased cutaneous blood flow and therefore excessive (insensible) fluid losses
What is Chronic Plaque psoriasis (CPP)?
Extensive plaques are present over the skin
What are the common areas of the body that are affected by Chronic plaque psoriasis?
- Ears
- umbilicus
- Genitals
- Knees
- Toe nails
- Finger nails
- Scalp
- Elbows
- Natal cleft
What percentage of psoriasis is chronic plaque psoriasis?
40%
When does guttate psoriasis commonly occur?
After a streptococcal sore throat
What proportion of patients with guttate psoriasis go on to develop chronic plaque psoriasis?
1/3
What is a joint complication of psoriasis?
Psoriatic arthropathy
What percentage of patients with psoriasis develop psoriatic athropathy?
5-20%
What percentage of patients with psoriatic arthropathy see that joint changes preceed the skin changes?
15%
What are the 5 subtypes of arthropathy patterns?
- Distal interphalangeal alone (DIP)
- Symmetrical polyarthritis (most common)
- Asymmetrical oligoarthritis
- Arthritis mutilans
- Spondyloarthropathy
What percentage of patients with DIP arthropathy have nail changes too?
80%
Describe asymmetrical oligoarthropathy
Hands and feet become very swollen and the fingers and toes become sausage shaped
What joints are affected in symmetrical polyarthtritis?
Hands, wrists and ankles
What happens to the skin of a patient who has arthritis mutilans?
The skin ‘telescopes’ as it becomes redundant when the bone of the digits becomes resorbed
What is the common cause of psoriatic arthritis?
A genetic predisposition and an environmental trigger
What percentage of patients who have psoriatic arthritis have a family history of psoriasis?
40%
What are the common triggers for psoriasis?
- Psychological stress
- Alcohol intake
- Iatrogenic - medications such as antimalarials, NSAIDs, B-Blockers, Lithium, Terbinafine
- Inherited
What is type 1 psoriasis?
75% of patients are type 1
They present when they are <40
There is a genetic link with HLA-CW6 (gene on chromosome 6)
What is type 2 psoriasis?
25% of patients are type 2
First presentation between 55 and 60
No genetic link
What must all psoriasis patients be prescribed as first line treatment for their condition?
Emollient use is a must
What is the most appropriate first line treatment (drug, dosage, route etc.) for psoriasis affecting the following area; Palmoplantar?
Potent topical steroid ointment OD for 4 weeks
What is the most appropriate first line treatment (drug, dosage, route etc.) for psoriasis affecting the following area; Trunk and limbs (<10% BSA)?
Potent topical steroid ointment - AM OD
Vitamin D analogue - PM OD
Both for 8 weeks
What is the most appropriate first line treatment (drug, dosage, route etc.) for psoriasis affecting the following area; mild scalp involvement?
Tar based shampoo
What is the most appropriate first line treatment (drug, dosage, route etc.) for psoriasis affecting the following area; Moderate scalp involvement?
Potent corticosteroid topically applied OD for 4 weeks
What is the most appropriate first line treatment (drug, dosage, route etc.) for psoriasis affecting the following area; Severe scalp involvement?
Descale with salicylic acid/emollient or oils for 1 week
Potent corticosteroid OD for 4 weeks
What is the most appropriate first line treatment (drug, dosage, route etc.) for psoriasis affecting the following area; Flexural genitalia/face/hairline?
Initially try a mild potency topical steroid (max. BD)
If not irritated use vitamin D analogue
What would be a good initial management plan for someone with chronic plaque psoriasis over the body?
- Use emollient every 12 hours
- Use a soap substitute for the bath/shower
- Topically treat with vitamin D analogue for the trunk and limbs
- Use a mild topical steroid ointment for the face and flexures
What are the 3 steps to psoriasis treatment?
- Topical therapy
- Phototherapy
- Systemic medication
What are the 2 validated tools we an use to determine the severity of psoriasis?
- Psoriasis Area Severity Index (PASI)
2. Dermatology of Life Quality Index (DLQI)
Who completed the PASI score?
The clinician
What is the PASI scored out of?
72
What does the following score on the PASI mean; 0-5?
Mild disease
What does the following score on the PASI mean; 5-12?
Moderate disease
What does the following score on the PASI mean; 12-20?
Severe disease
What does the following score on the PASI mean; >20?
Very severe disease
Who completes the DLQI?
The patient
What does the following score on the DLQI mean; 0-1?
Psoriasis has no effect at all on the patient’s life
What does the following score on the DLQI mean; 2-5?
Psoriasis has a small effect on the patient’s life
What does the following score on the DLQI mean; 6-10
psoriasis has a moderate effect on the patient’s life
What does the following score on the DLQI mean; 11-20?
Psoriasis has a very large effect on the patient’s life
What does the following score on the DLQI mean; 21-30?
Psoriasis has an extremely large effect on the patient’s life
What is another scoring tool that we can use to assess the severity of psoriatic arthritis?
The Psoriasis Epidemiology Screening Tool (PEST)
In patients with psoriatic arthritis, what other medical speciality should be involved in their care?
Rheumatology
What is the aim of phototherapy in relation to psoriasis?
This is used to slow down the excessive growth of keratinocytes and is believed to be partly immunosuppressive
How many phototherapy sessions are usually delivered weekly and for how many weeks?
2-3 times per week for 10 weeks
How many sessions of PUVA is an individual restricted to in their lifetime and why?
100 sessions due to the risk of developing skin cancer
What treatment option is next available for those who have a poor response to phototherapy or for those who are not eligible to try phototherapy?
Systemic treatment of the skin
What is ciclosporin?
An immunosuppressant that inhibits T-cells.
How often is ciclosporin taken in someone being treated for psoriasis?
BD
When do we normally see a response from patients who take ciclosporin for their psoriasis?
Within 4-6 weeks
What are the common side effects of ciclosporin?
- Hypertension
- Renal impairment
- Lymphopenia (immune dysfunction)
- Hypertrichosis (increased hair growth)
- Gum hypertrophy
What is the maximum amount of time someone can spend being treated with ciclosporin?
12 months
How long does it take for methotrexate to reach its maximal efficacy in patients with psoriasis?
4-6 months
How does methotrexate work when thinking about psoriasis?
It is an anti-inflammatory and reduces the number of cutaneous T-cells
What are the common side-effects of taking methotrexate?
- Haematological toxicities (anaemia, lymphopenia, thrombocytopenia)
- Liver fibrosis
Which patients are contraindicated to taking methotrexate for psoriasis?
- Those who are trying to conceive
- Those who are taking trimethoprim
- Those who have pre-existing liver conditions
What is Acitretin?
An oral retinoid (Vitamin A derivative)
How often is acitretin taken?
OD
How does acitretin work?
It inhibits keratinocyte proliferation in the epidermis
How long before wanting to conceive should acitretin be discontinued and why?
This drug has a very long half-life and should be discontinued 2 years before wanting to conceive due to its teratogenicity
50% of patients who take acitretin will see a response within how many weeks?
12
How do Fumaric acid esters (FAEs) work?
They shift T-helper 1 phenotype cells into T-helper 2 phenotype cells. As psoriasis is a T-helper 1 mediated condition, this shift will prevent/reduce the psoriasis effect.
What type of drug is a Fumaric acid ester (FAE)?
An oral immunomodulatory drug
What are the common side effects of Fumaric acid esters (FAEs)?
- Nausea
- Diarrhoea
- Lymphopenia (<0.7 lymphocyte count)
Which patients should be started on Apremilast first?
Those with co-morbidities that need to be considered. This is because it causes minimal toxicities.
When systemic therapies do not help to improve psoriasis, what treatments should be considered next?
Biological therapy
Which patients are eligible for biological therapy due to the expensive nature of the monoclonal antibody treatment?
These patients must have;
- Tried 2 or more systemic agents without success
- Have a PASI and DLQI score of 10 or more
Give 2 examples of Tumour Necrosis Factor (TNF) inhibitors
- Etanercept
- Infliximab
- Adalimumab
- Certolizumab
Adalimumab is the most common TNF inhibitor given, how is it administered and how often?
SC injection
Every 2 weeks
Name the 3 families of drugs that we can use as a biological therapy for psoriasis
- TNF inhibitor
- IL-12/23 inhibitor
- IL-17 inhibitor
What chronic and acute health conditions are patients with psoriasis at increased risk of developing?
- MI
- T2DM
- Hyperlipidaemia
- Metabolic syndrome
