02-17 Psoriasis

Question 1

What is meant by the term “papulosquamous”?

Answer 1

lesion of scaly papules and plaques that literally means “bumpy and scaly”

—term to describe the lesions in the papulosquamous family

Question 2

scale vs. crust?

Answer 2

“Scale” denotes an abnormally thick, flaky stratum corneum. “Crust” is synonymous with “scab” and denotes dried blood and serum.

Question 3

Psorasis

• Prevalence?
• Presentation
• Triggers/Inheritance/Risk Factors
• Pathophys
• Path Findings
• Tx
• Assoc’d Conditions

Answer 3

Prevalence?

• Common - 3% of people will have an episode at some point in their lives
• Bimodal presentation: late 20s + early 50s

Presentation

• HAM: Dull, red, silver scale-y lesions on any cutaneous surface
• usu. extensor surf (elbows knees)
• sharp borders
• Commonly symmetric
• Pitting, oil spotting (looks yellow infraungal), and dystrophy of nails common
• Auspitz sign: pinpoint bleeding if picked b/c dilated caps and thin epiderm over dermal papillae

Triggers/Inheritance/Risk Factors

• Physical trauma (Koebner or isomorphic rxn): appearance after 10-14d; scars, areas of friction.
• Humid, temp, sunlight -
• Contact dermatitis, drug rashes
• Specific Rx aggravation: lithium, antimalarials, ß blockers, systemic (and~ topical) corticosteroid withdrawal, trazodone, terbinafine
• Infection: usually strep pharyng → acute guttate (drop-like) psoriasis; HIV

Pathophys

1. Proliferation: mitoses above basal, shorter cell cycle, reduced cell transit time to surface
2. Inflammation: vasodil → PMNs → microabscess Tx

Path Findings

• Acanthosis (thick epiderm) w/ regular elongation of rete ridges
• Hyperkeratosis w/ retention of nuclei in horny layer (parakeratosis)
• Munro microabscesses of PMNs high in epidermis
• Hypogranulosis
• Dilatation and tortuosity of capillaries
• Chronic dermis inflam

Tx (see other card)

• Topical
• Systemic
• Phototherapy

Assoc’d Conditions

• Arthritis
  
  • 7% of psoriasis pts, usually s/p skin; usu oligoarticular, asymm, distal joints of hands/feet
• HLA B27 in up to 50%
  
  • highest in those with spondylitis and mutilating distal disease

Question 4

Variant Psoriasis Presentations

Answer 4

• a. Guttate: (drop-like), especially acute in children after strep, (superantigen driven?); tx infx to tx skin
• b. Pustular
  
  • deep, dark brown spots with ham around
  • (1) Localized, especially palms and soles
  • (2) Generalized, with systemic symptoms
• c. Intertriginous “Inverse”: axilla, inframammary, gluteal cleft, post- auricular
• d. Erythrodermic: total body redness and scale, often with systemic symptoms; can become pustular

Question 5

Risks of Psoriasis

Answer 5

• 50% increased mortality risk with severe psoriasis (5 years of life lost)
• Top causes of death among severe psoriatics
  
  • # 1 CVD (34%) high output failure (perfusing all that skin)
  • # 2 Infection (22%) usually opportunistic
  • # 3 Cancer (21%)
• Th1/ Th17 inflammation
• Co-morbidities: embarrassment, genetics, diabetes, obesity, smoking, alcohol

Question 6

Topical Psoriasis Tx

Answer 6

• Coal Tar (slows epidermal proliferation)
• Anthralin (stains)
• Topical steroids! – (most common, strength-site matched: thinning risk
• Calcipotriene/ calcipotriol (vitamin D)
• Tazarotene (retinoid)

Question 7

Phototherapy Tx Options for Psoriasis

Answer 7

UVB Phototherapy

• Use 2 to 5x/week
• Takes several weeks!
• Risks: sunburn, activation of zoster , aging; skin cancer very unlikely
• Combinations increase efficacy: Coal tar, anthralin, tazarotene, and calcipotriene, Acitretin, Biologics

PUVA Phototherapy

• PUVA = Psoralens + Ultraviolet A (PUVA)
• Side effects:
  
  • acute photoreactions & chronic photoaging
  • Increased risk of SCC (with > 200 PUVA sessions)
  • Probable increased risk of melanoma
• Can be used for maintenance
• Combination with acitretin more potent

Question 8

List Systemic Rx Options for psoriasis

Answer 8

1. MTX
2. cyclosporine
3. Acitretin
4. Biologics
   
   • Anti TNF-α
   • Anti-T-cell

Question 9

MTX

Answer 9

• Originally a chemotherapy drug
• Folate antagonist
• Slows fast-dividing cells
• Potential liver toxicity
• Effective for psoriatic arthritis
• Donʼt co-prescribe w/ Bactrim: myelosuppressive

Question 10

Cyclosporine

Answer 10

• Originally an organ transplant drug
• Inhibits IL-2 production/ release
• Nephrotoxicity
  
  • Irreversible loss of GFR w/in one year of use
• The FDA recommends continuous cyclosporine treatment be limited to one year at a time

Question 11

Acitretin

Answer 11

• Similar to, but persists longer T1/2 than, isotretinoin
• Potentiates other treatment modalities!
• Synthetic retinoid

ADRs

• Teratogenic
• Potential liver toxicity
• Dose-dependent retinoid side effects include alopecia
• Start with low doses, increase if needed & tolerated
• Very limited drug interactions
• Follow LFT’s, triglycerides
  
  • Gemfibrozil (Lopid) 3-600 mg BID, if needed
• Shouldn’t give blood after taking acitretin

Question 12

Systemic Tx Options - BIOLOGICS

Answer 12

• Ustekinumab (Stelara)
  
  • Hits P40 which stabilizes plaques → M.I.
  • p40 = subunit of interleukin 12, a cytokine that acts on T and natural killer cells
• Anti-TNF-alpha
  
  • Adalimumab (Humira)
  • Etanercept (Enbrel)
  • Infliximab (Remicade)

Question 13

PASI

Answer 13

Psoriasis Area and Severity Index

• Way to score
• area of body
• severity: Erythema! • Thickness! • Scaling!

New Txs must score a particular score in order to be approved vs. most other FDA approval processes where you just have to show safety + better than placebo

Question 14

Seborrheic Dermatitis in Adults

• Etiology
• Lesion appearance
• Distribution on body
• Natural Hx

Answer 14

• Common papulosquamous disorder
• Etiology related to Pityrosporum yeast
• Clinical presentations differ in adults vs. infants:
  
  • Often scaly as air dries in winter
  • Becomes red in the spring
  • Body is responding to yeast or its waste products
  • Moist, transparent to yellow, greasy scaling papules
• Distribution favors areas w/ high conc of seb glands (yeast eats sebum)
  
  • scalp margins, central face and presternal areas
  • eyebrows, the base of eyelashes, nasolabial folds and paranasal skin, and external ear canals
  • Flexural skin may be similarly involve
• Adults tend to have a chronic course with remissions and exacerbations

Question 15

Infantile Seborrheic Dermatitis

Answer 15

• Yellow greasy adherent scale “cradle cap” (“cradle crap”)!
• Minimal underlying redness!
• Scale may become thick and adherent! – Need to teach parents to remove it !
• Diaper area and axillary skin with redness > scaling!
• Usually a self-limited condition often not requiring treatment!

Question 16

Pityriasis Rosea

Answer 16

• Weird disorder!
• Common, self-limited, usually asymptomatic, clinically distinctive papulosquamous disorder (i.e. epidermal ∆s)!
• More than 75% of patients are between 10 and 35 years of age!
• Many patients report a mild prodrome!
• Seasonal clustering of cases! – ?post-viral rash! – Donʼt present until after the virus clears.!

PRESENTATION

• Short wetsuit appearance

• First lesion or **herald patch** (HY) !
• Oval plaque of 1–2 cm, salmon color!
• thin collarette of residual scale inside the border!
• 1–2 weeks later numerous similar but smaller lesions, “Christmas Tree” pattern (w/in oval)!
• usually clear spontaneously in 4–12 weeks, without scarring!
• post-inflammatory hyperpigmentation may take months to resolve in darker-skinned people!

Question 17

What is this?

Answer 17

Christmas tree lesion of pityriasis rosea

Question 18

What is this?

Answer 18

sentinel lesion of pityriasis rosea

Question 19

Lichen Planus

• Prevalence
• Presentation

Answer 19

PREVALENCE

• uncommon, inflammatory papulosquamous disorder of unknown etiology!
• Rare in children aged under 5!
• More common in women than in men!
• 10% of patients have a positive family history!
– May be familial response to environmental stiumulus.!

PRESENTATION

• High Yield: The 5“Ps”: purple polygonal pruritic papules and plaques
• distal legs, arms + mouth (also: hair, nails, Muc Memb)
• Clinical course variable and unpredictable
• Itching is variable, but is usually intermittent and insatiable
• Severe oral lichen planus may degenerate to squamous cell in an estimated 3% of cases
• Wickham’s striae-lacy reticulated in epidermis
• Koebner phenomenon-lesions develop in areas of injury

Question 20

Lichen Sclerosus Distribution

Answer 20

Question 21

Lichen Sclerosus

—PREVALENCE

—PRESENTATION

—COMPLICATIONS

Answer 21

PREVALENCE

• uncommon chronic papulosquamous disease T-cell mediated reaction of unknown etiology
• female to male ratio is 10 : 1
• more common in women over 60 years of age, but can occur at any age

PRESENTATION

• Itching is unbelieveable
• affects both skin and mucosal surfaces w/ predilection for the anogenital skin

??”skin lesions are often asymptomatic”

• Affected women complain of chronic vulvar pruritus, dysuria or dyspareunia

COMPLICATIONS

• Men have persistent balanitis* which, if untreated, tends to progress to phimosis**
• Squamous cell carcinoma develops in 3% of mucosal lesions
• Consider lichen sclerosus to be a pre- cancerous condition

*swollen foreskin & head | **can’t pull back foreskin