Eczema & Psoriasis

Question 1

What is eczema?

Answer 1

a chronic inflammatory skin condition that is NOT autoimmune

it typically affects the FLEXURES

a.k.a dermatitis

Question 2

Who typically presents with eczema symptoms?

Answer 2

it most frequently presents in childhood with 70-90% cases onset being before 5 years of age

Question 3

What are the typical symptoms associated with eczema?

Answer 3

• dry skin
• itching
• erythematous lesions
• present on the flexures

it is an episodic disease of flares (exacerbations occurring as many as 2-3x a month) and remissions

in severe cases, disease activity can be continuous

Question 4

What can happen to the skin in chronic eczema?

Answer 4

lichenification

• this involves thickening of the skin with hyperpigmentation + exaggerated skin lines

Question 5

What are the RFs for eczema?

Answer 5

• past medical history or FHx of atopy (food allergies, hay fever, asthma)
• Filaggrin gene mutation
• environmental triggers - pets, pollen, house dust-mites

Question 6

What are the potential complications associated with eczema?

Answer 6

infection:
* infection with Staphylococcus aureus, herpes simplex or a superficial fungal infection can occur

• herpes simplex infection can result in widespread eczema herpeticum

psychosocial issues:
* e.g. missing school, reduced self confidence, disturbed sleep, depression

Question 7

How is eczema diagnosed?

What should be assessed at each consultation?

Answer 7

it is a clinical diagnosis

• at each consultation, the severity of the eczema + the psychosocial impact should be assessed

investigations may be performed to exclude differential diagnoses

Question 8

What is the first line treatment for eczema?

Answer 8

emollients

these are first-line treatments for acute flares and remissions

these are moisturising treatments that will soothe and hydrate the skin

Question 9

What is the treatment for eczema when skin is red and inflamed?

Answer 9

topical corticosteroids

• the lowest potency and amount of topical corticosteroid necessary for symptom control is prescribed

Question 10

What is meant by the “finger tip rule”?

Answer 10

1 finger tip unit (FTU) = 0.5g

this is sufficient to treat a skin area twice the size of the flat of an adult hand

Question 11

If there is persistent, severe itch despite topical corticosteroids, what treatment might be given?

Answer 11

a 1 month trial of a non-sedating antihistamine

if itching is affecting sleep - a short course of a sedating antihistamine is considered

Question 12

If eczema is crusted, weeping, there are pustules or fever, what might be considered?

Answer 12

there is a chance of a secondary bacterial infection

antibiotic treatment should be prescribed

Question 13

What is the definition of psoriasis?

Answer 13

a common, chronic autoimmune skin disorder characterised by hyperproliferation of keratinocytes

it tends to affect EXTENSOR surfaces

Question 14

How does psoriasis tend to present?

Answer 14

• red/purple scaly patches on the skin
• dry / flaky skin
• itching / pain
• present on the extensors / scalp

patients with psoriasis are at increased risk of arthritis and CVD

Question 15

What is involved in the pathophysiology of psoriasis?

Answer 15

it is multifactorial and not fully understood

• involves genetic and environmental factors
• it is often worsened by stress / trauma and improved by sunlight

Question 16

What is plaque psoriasis?

Answer 16

• the most common sub-type that results in well-demarcated red, scaly patches
• affects the extensor surfaces, sacrum + scalp

Question 17

What is flexural psoriasis?

Answer 17

psoriasis affecting the flexural surfaces

the skin is smooth

Question 18

What is guttate psoriasis?

Answer 18

• transient psoriatic rash that is often triggered by streptococcal infection
• multiple red, teardrop lesions appear on the body

Question 19

What is pustular psoriasis?

Answer 19

plaques / pustules that appear on the hands and soles of the feet

Question 20

As well as the skin lesions, what other features are associated with psoriasis?

Answer 20

• symmetrical polyarthritis
• nail signs - onycholysis and pitting

Question 21

What are the complications associated with psoriasis?

Answer 21

• psoriatic arthropathy in 10%
• increased incidence of metabolic syndrome
• increased incidence of CVD
• increased incidence of VTE
• psychological distress

Question 22

What is the first-line treatment for chronic plaque psoriasis?

Answer 22

• a potent corticosteroid applied once daily
• • vitamin D analogue applied once daily
• one is applied in the morning and the other in the evening
• trialled for 4 weeks as initial treatment
• regular emollients can be used alongside to reduce itching / scale loss

Question 23

What is the second-line management for psoriasis?

Answer 23

if there is no improvement after 8 weeks:

• a vitamin D analogue is applied twice daily

Question 24

What is the third-line management for psoriasis?

Answer 24

if there is no improvement after 8-12 weeks:

• a potent corticosteroid can be applied twice daily for up to 4 weeks
• OR a coal tar preparation applied once or twice daily

Question 25

What are the recommendations for the use of potent corticosteroids?

Answer 25

• potent corticosteroids should be used for no longer than 8 weeks at a time
• very potent corticosteroids should be used for no longer than 4 weeks
• there should always be a 4 WEEK BREAK before starting another course of topical corticosteroids

Question 26

What are the side effects of using topical corticosteroids?

Which places are more prone to these?

Answer 26

side effects:
* skin atrophy
* striae
* rebound symptoms

sensitive areas:
* the scalp, face and flexures are more prone to steroid atrophy

• topical steroids should not be used for more than 1-2weeks in a month

Question 27

What are examples of vitamin D analogues?

How do they work?

Answer 27

they decrease cell division + differentiation, resulting in reduced epidermal proliferation

includes calcipotriol (Dovonex), calcitriol and tacalcitol

Question 28

What are the benefits of using vitamin D analogues?

Answer 28

• unlike corticosteroids, they can be used in the long-term
• adverse effects are uncommon
• they do not smell or stain

they reduce the scale / thickness of the plaques, but not the erythema

cannot be used in pregnancy

Question 29

What is a mild topical corticosteroid?

Answer 29

hydrocortisone (0.5-2.5%)

Question 30

What are moderate topical corticosteroids?

Answer 30

• betamethasone valerate 0.025% (Betnovate)
• clobetasone butyrate 0.05% (Eumovate)

Question 31

What are examples of potent topical corticosteroids?

Answer 31

• fluticasone propionate 0.05% (Cutivate)
• betamethasone valerate 0.1% (Betnovate)

Question 32

What is an example of a very potent topical corticosteroid?

Answer 32

clobetasol propionate 0.05% (Dermovate)