28. Inflammatory Disorders Flashcards Preview

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Flashcards in 28. Inflammatory Disorders Deck (56)
1

Most common psoriasis

Plaque (most common) • Extensor extremities most common; pink patches and plaques with overlying silvery scale

2

Inverse – Flexural psoriasis are located:

• Axillae, groin, perineum, chest

3

• Drop-like, 2-10mm, symmetric trunk/proximal extremities • Often triggered by Group A Strep What type of psoriasis is this?

Guttate

4

– Pustular psoriasis is usually located on:

• May be localized to palms and soles or be generalized

5

Generalized erythema; amount of scaling is variable, what kind of psoriasis is this?

– Erythrodermic

6

immune-mediated polygenic skin condition. Mutlifactoral triggers disease in predisposed individuals. lesions are well-demarcated erythematous papules and plaques, 
ranging in size from pinpoint to < 20 cm in diameter, with overlying micaceous or silvery scale

Psoriasis

7

Other signs of psoriasis besides skin changes

 Nail changes can also be seen with pitting 
(pinpoint indentations in the nail plate), thickening, and yellow discoloration. 
20-30% developing psoriatic arthritis have
increased risk of metabolic syndrome and atherosclerotic cardiovascular disease 

8

When evaling a pt with psoriasis, what other things should we take into consideration?

recent infections
– may trigger flares, particularly Streptococcal
•  risk factors for HIV
– HIV patients often have worse disease
• Ask about joint symptoms
– Up to 20% also have psoriatic arthtitis
• Evaluate body mass index (BMI)
– Correlation between obesity and prevalence and 
severity of psoriasis

• Ask about CV risk factors– see increased risk for CV 
 

9

10

Genetics and psoriasis

• Ask about other family members with 
psoriasis
– Strong genetic predisposition for psoriasis
– Multiple psoriasis genes identified
– 1/3 with a positive family history

11

How can mediation be involved in pt presenting with psoriasis

 can be triggered or exacerbated by 
many medications, including:
– Systemic corticosteroid withdrawal
– Beta blockers (propranolol, metoprolol)
– Lithium
– Anti-malarials (chloroquine, hydroxychloroquine)
– Interferons

12

What is this... what types of pts may have this

Pencil in cup deformity seen in pts with psoriasis arthritis 

Psoriasis arthritis seen in 20-30% pts

13

What joint issues should we keep in mind with psoriasis pts?

oligoarthritis (common in knee) and psoriasis arthritis. See sausage fingers, pencil in cup deformities, flexure deformities and bone destruction

14

What type of nail changes do we see with psoriasis?

Pitting, discoloration, onycholysis in 25-30% pts

15

In psoriasis we see development of skin lesions at site of injury... this is called:

Koebner phenomenon

16

Pt has psoriais: 
– Localized (<5% BSA) 

Tx recommendation?
 

topicals alone 

17

Pt has psoriasis that can be chacterized as:

Generalized 
Tx?

- systemic/phototherapy + topicals
• Refer to dermatologist for management 

18

What are some aggravating factors

 

– Concurrent infection
– Medications
– Obesity

19

For localized or mild psoriasis, tx?

opical corticosteroids are first-line therapy. Other topical agents include retinoids, coal tar derivatives, and calcineurin inhibitors 

20

used in psoriasis 
to induce terminal differentiation and inhibit proliferation of keratinocytes, as well as modulating 
the immune response. 

Topical vitamin D analogues (e.g. calcipotriene, calcitriol) 

21

Psoriasis: extensive disease or recalcitrance to topical 
corticosteroids, treatment with what two things should we consider?

phototherapy or systemic medications may be indicated. 

22

Systemic agents used in the treatment of psoriasis include

methotrexate, cyclosporine, acitretin, 
and targeted immune modulators (“biologics”). 

23

Biologic therapies target 

T cells and cytokines 
involved in the pathogenesis of psoriasis. TNF-α inhibitors used for psoriasis include etanercept, 
infliximab, and adalimumab. 

24

What should we avoid in pts with psoriasis?

Oral corticosteroids should be avoided in patients with psoriasis as withdrawal of the corticosteroids will provoke a flare of their disease, often pustular. C

25

TNF alpha blockers for psoriasis

Entanercept, Infliximab, Adalimumab

26

IL-12, IL23 blocker used for psoriasis tx

Ustekinumab

27

What UV is used for phototherpy of psoriasis

narrrowband UVB and sometimes UVA 

28

psoriasis on face an groin, used what class of topical coritcosteroids?

Class V and VI

29

Psoriasis on the body... what class of corticosteoids should we use

Class III to IV

30

What class of coriticosteroids should we use for psoraisis on hands and feet

Class I and II, strongest

31

Inflammatory disease of skin, hair, nails and 
mucous membranes
• Flat-topped (planar) polygonal pruritic pink or 
violaceous (purple) papules or plaques
• Flexural lower legs, ankles, wrists, genitalia 
most common

Lichen Planus

32

Describe this lichen planus

• Flat-topped (planar) polygonal pruritic pink or 
violaceous (purple) papules or plaques

SUPER itchy 

33

What exposures are associated with increased incidence of Lichen Planus?

– Viruses (Hepatitis C)

– Hepatitis B vaccine
– Drugs
• Beta-blockers
• ACE inhibitors
• Thiazide diuretics
• Antimalarials
• Gold and metals
• Penicillamine

34

– Thinning of nail plates
– Longitudinal ridging
– Pterygium formation (scarring)

--What does this pt have?

Nail Lichen Planus: 10% of LP patients have nail involvement
• Isolated nail LP may occur
 

35

Most common locations for mucosal lichen planus

Mucosal Lichen Planus
– Oral most common
– Genital
– Pharynx, esophagus, GI tract
 

36

What are the two types of Lichen planus?

– Reticulated: • Linear lace-like pattern of tiny white papules,  Buccal mucosa most common, Typically asymptomatic
– Erosive, Gingiva or tongue, Typically painful

37

Topical Tx options for Lichen Planus

Topical corticosteroids
• Topical calcineurin inhibitors 
• NBUVB phototherapy
 

38

Systemic Tx options for Lichen planus

– Oral corticosteroids
– Metronidazole, Griseofulvin
– Antimalarials
– Acitretin (retinoid)
– Mycophenolate mofetil
– Methotrexate
– Cyclosporine

39

4 week history of this facial eruption. Was treated with a 10 day course of cephalexin with no response Mother reports seeing him occasionally scratch at it, but otherwise not particularly bothered by this. Dx?

Atopic Dermatitis

40

most common chronic inflammatory skin disease. Onset in infancy is typical,

Atopic dermatitis (AD) 

41

What do we tend to see in infants with atopic dermatitis?

– Facial involvement predominates early
– Tends to spare midface
– Oozing, crusting common
– Exacerbated by saliva, foods
– Extensor involvement late infancy
– Sparing of diaper area

42

What childhood disease would we expect this guy to have had?

Dennie-Morgan folds show evidence of atopic dermatitis

43

 where else do we expect to see atopic dermatitis in childhood (NOT infants)

Flexural involvement: antecubital and popliteal fossa, wrists, ankles, neck and hands... less crusting

44

Kiddo presents with atopic dermatitis on the foot... has new tender lesions that is not typcial of her eczema according to mom.. What may be going on?

Secondary infection with Staph. Aurues or Staphylococcus

45

Infection with Herpes overlying eczema:

Eczema herpaticum

46

Treating a Flare of AD:

Topicals – Corticosteroids
• Ointments preferred
 Immunomodulators : 

Calcineurin inhibitors: Tacrolimus , Pimecrolimus
• Antihistamines for pruritus
• Treat/prevent secondary infections
– Bleach baths

47

Factors to consider when choosing topicals for AD

– DURATION of lesion; New lesion will often respond to weaker agents, Chronic lesion requires stronger treatment
– LOCATION of lesion; Thin skin (e.g. face, axilla, groin), Higher risk for side effects, should use lower strength med VS Thicker skin (e.g. palms, soles)
– Lower penetration/absorption, higher strength med often equired 

48

Systemic Tx of AD 

• Phototherapy – Narrowband UVB
• Systemic agents: Cyclosporine, Methotrexate,  Mycophenolate mofetil, Azathioprine

49

Management of Atopic Dermatitis:
 

Maintenance
• Gentle skin care: Daily baths, Gentle cleansers , Thick moisturizer twice daily
• Petrolatum/Aquaphor > Cream > Lotion
– Avoidance of irritants (i.e. fragrance)

50

• Pathogenesis of AD
 

– Barrier-disrupted skin (abnormal barrier)
– Triggers : Allergens, Microbes (especially S. aureus)
 and Scratching
 

51

 Immune dysregulation of Atopic Dermatitis
• Acute:
• Chronic:

• Acute: Th2
• Chronic: Th1

52

DX?

Cradle cap or Seborrheic Dermatitis

53

Mom presents with child that has cradle cap... what can it progress to?

Seborrheic Dermitis
– Evolves to moist erythematous intertriginous
patches in 
• Can be secondarily infected with Candida or 
Streptococcus specis
– Dissemination with scaly papules, patches, and 
plaques resembling atopic dermatitis/psoriasis 
may occur as well

54

This 50 yo male presents 
with complaints of itching 
and flaking in the scalp for 
as long as he can 
remember.

Adult form of seborrheic Dermatitis

Seen as yellow-red papules, erythema and scaling

Mostly on the scalp--> aslo forehead, medial eyebrow, skin and ear or presternal

55

Tx for seborrheic dermatitis in infants

Low potentcy topical steroid, ketoconazol cream, mild shampoos, gentle skin care

56

Tx for Seborrheic derm in Adults

Azole cream or shampoo, Low potentcy topical steroid, Shampoos (tar, zinc, sulfide)