Psoriasis

Question 1

x

Question 2

ETIOLOGY OF PSORIASIS ?

Answer 2

multifactorial and not yet fully understood
genetic: associated HLA-B13, -B17, and -Cw6. Strong concordance (70%) in identical twins

abnormal T cell activity stimulates keratinocyte proliferation

Question 3

it is recognised that psoriasis may be worsened by ?

Answer 3

Skin trauma

stress

Streptococcal infection - glutamate psoriasis

trauma

alcohol

drugs: beta blockers,
lithium,
antimalarials (chloroquine and hydroxychloroquine),
NSAIDs and
ACE inhibitors,
infliximab
withdrawal of systemic steroids

flexural - sweat , friction

Question 4

it is recognized that may be improved by ?

Answer 4

(e.g. Sunlight) by environmental factors

Question 5

what are the recognised subtype of psoriasis ?

Answer 5

plaque psoriasis: the most common
well-demarcated red, silver scaly patches affecting the extensor surfaces, sacrum and scalp

flexural psoriasis: in contrast to plaque psoriasis the skin is smooth
occurs commonly in skin folds - armpit , groin

guttate psoriasis: transient psoriatic rash frequently triggered by a streptococcal infection. Multiple red, teardrop lesions appear on the body

pustular psoriasis = commonly occurs on the palms and soles

Question 6

what is Auspitz’s sign

Answer 6

he appearance of small bleeding points after successive layers of scale have been removed from the surface of psoriatic papules or plaques

Question 7

what are some of the major complications of psoriasis ?

Answer 7

psoriasis is more related to arthropathy and cardiovascular diseases
increased incidence of venous thromboembolism
psychological distress

Question 8

Chronic plaque psoriasis management ?

Answer 8

first-line: NICE recommend:
potent corticosteroid applied once daily + vitamin D analogue applied once daily

should be applied separately, one in the morning and the other in the evening)

for up to 4 weeks as initial treatment

Question 9

if no improvement after how many weeks do we start second line treatment for Chronic plaque psoriasis

Answer 9

8 weeks

Question 10

if no improvement after 8 weeks, what do we start as second line treatment for Chronic plaque psoriasis?

Answer 10

a vitamin D analogue applied twice daily

Question 11

when do we start third line treatment for chronic plaque psoriasis ?

Answer 11

if no improvement after 8-12 weeks

Question 12

third line treatment for chronic plaque psoriasis ?

Answer 12

potent corticosteroid applied twice daily for up to 4 weeks,

a coal tar preparation applied once or twice daily

short-acting dithranol can also be used

Question 13

what secondary therapy can be given in chronic plaque psoriasis ?

Answer 13

narrowband ultraviolet B , 3 times a week

photochemotherapy is also used - psoralen + ultraviolet A light (PUVA)

Question 14

if chronic plaque psoriasis affects systematically such as joint - psoriatic arthritis ?

Answer 14

mild peripheral arthritis/mild axial disease may be treated with ‘just’ an NSAID

if more moderate/severe disease then methotrexate is typically used as in RA

=====
ciclosporin

systemic retinoids

biological agents: infliximab, etanercept and adalimumab
( TNF alpha is a pro-inflammatory cytokine )

ustekinumab (IL-12 and IL-23 blocker) is showing promise in early trials

apremilast: phosphodiesterase type-4 (PDE4) inhibitor → suppression of pro-inflammatory mediator synthesis and promotion of anti-inflammatory mediators

Question 15

Scalp psoriasis management

Answer 15

potent topical corticosteroids used once daily for 4 weeks

Question 16

if no improvement of scalp psoriasis after 4 weeks what is given

Answer 16

use a different formulation of the potent corticosteroid (for example, a shampoo or mousse)

and/or a topical agents to remove adherent scale (for example, agents containing salicylic acid, emollients and oils) before application of the potent corticosteroid

Question 17

management of face / flexural or genital psoriasis management ?

Answer 17

mild or moderate potency corticosteroid applied once or twice daily for a MAXIMUM OF 2 WEEKS

Question 18

what re some of the side effects of topical steroids ?

Answer 18

skin atrophy,
striae
and rebound symptoms

Question 19

which type of psoriasis are most affected by topical steroid side effect ?

Answer 19

the scalp, face and flexures are particularly prone to steroid atrophy so topical steroids should not be used for more than 1-2 weeks/month

Question 20

systemic side-effects may be seen when potent corticosteroids are used how ?

Answer 20

> 10% of the body surface area

Question 21

NICE recommends using potent corticosteroids for no longer than

Answer 21

8 weeks at a time and very potent corticosteroids for no longer than 4 weeks at a time

Question 22

what are examples of fit D analogues ?

Answer 22

Dovonex

Question 23

how does fit d analogue help psoriasis ?

Answer 23

↓ cell division and differentiation → ↓ epidermal proliferation

Question 24

coal tar and dithranol they do not smell or stain
they tend to reduce the scale and thickness of plaques but not the ?

Answer 24

erythema

Question 25

vit d analogues and coal should be avoided in ?

Answer 25

pregnancy -
Dithranol
inhibits DNA synthesis
wash off after 30 mins

Coal tar - inhibit DNA synthesis

Question 26

puva in psoriasis increase risk for ?

Answer 26

squamous cell carcinoma