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Papulosquamous/Desquamation Flashcards

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1
Q

Most successful Rx for Psoriasis?

A

Immune-mediating medications

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2
Q

What is the etiology of Psoriasis?

Hint: influences and triggers

A

Psoriasis is influenced by genetic & immune-mediated components.

With or Without triggers, substantial leukocyte recruitment to dermis (activated T cells that induce keratinocyte proliferation)

Ramped-up,degregulated inflammatory process with large production of various cytokines

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3
Q

Psoriasis is assocated with increased production of what various cytokines?

A

Tumor necrosis factor-α [TNF-α]

Interferon-gamma

Interleukin-12

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4
Q

What particular cytokine production correlates with psoriasis flare ups?

A

TNF-α

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5
Q

Psoriasis Pathophysiology:

Explain what occurs and the characteristics of why that happens?

A

Vascular engorgement due to telangiectasis

Altered epidermal cell cycle (hyperplasia, turnover from 23 days to 3-5 days –improper cell maturation)

Parakeratosis (cells retain nuclei in stratum granulosum)

Cells fail to relesase adequate levels of lipids

Poor adherent stratum corneum –> flaking, scaling

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6
Q

Name the 4 skin layers?

A

From top to bottom:

Keratin surface (cornified cells)

Stratum granulosum

Stratum Spinosum

Stratum Basale)

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7
Q

What’s wrong with this picture?

A

Hyperkeratosis w parakeratosis

loss of granular layer

Acanthosis (diffused epidermal hyperplasia)

Enlongated rete regions (hyperproliferation)

Vascular dilation

Inflammation, T-lymphocytes in the dermis & epidermis

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8
Q

How will a pt present w Psoriasis?

A

Common (2-3% of world’s pop), Chronic

Erythematous, sharply demarcated papules & rounded plaques, covered by silvery micacous scale

Variably pruritic

Koebner’s phenomenon

Exacerbated by external factors (infections, stress, meds (lithium, beta blockers, anti-malarials))

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9
Q

What type of Psoriasis is pictured below?

A

Plaque-type (discoid)

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10
Q

How will a pt present w Plaque-type (discoid) psoriasis?

A

Most common form

Stable, slowly enlarging, indolent course

Unchanged for long periods

Usually symmetrical (elbows, knees, gluteal cleft & scalp)

Needs to be tx to resolve, will spontaneously remit

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11
Q

What type of skin lesion is pictured below?

A

Inverse psoriasis

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12
Q

How will a pt present w Inverse Psoriasis?

A

Shaply demarcated plaques

May be moist & w/o scales due to their location (intertriginous regions…axilla, groin, submammary region, navel, scalp, palms, soles

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13
Q

What type of Psoriasis follows infection w hemolytic Streptococci, withdrawl from steroids or anti-marlarial use?

A

Guttate Psoriasis (eruptive psoriasis)

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14
Q

Name the skin disorder pictured below.

A

Guttate psoriasis (eruptive psoriasis)

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15
Q

How will a pt present w Guttate Psoriasis?

Provide the DDx

A

Most common in children & young adults

Acute w no h/o psoriasis

small erythematous, scaling papules

DDx = Pityriasis rosea, 2nd syphilis

Acquire med hx and recent illnesses (typically follows infection w hemolytic Strept, withdrawl from steroids, antimalarial use)

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16
Q

Name this skin disorder.

A

Pustular psoriasis

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17
Q

Name this skin disorder

A

Erythrodermic psoriasis (i.e. severe pustular)

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18
Q

How will a pt present w Pustular Psoriasis?

A

Localized to palms/soles or generalized

Painful, erythematous w pustules (excudate: inflammatory or infected if cloudy)

Variable scale depending on location

Similar in size to eczema when limited to palms/soles

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19
Q

How will a pt present w Erythrodermic Psoriasis?

A

Generlized, often recurrent, w fever 102-104 for days

Sterile pustules

intense erythema (erythrodermic)

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20
Q

What is the eitology of Erythrodermic psoriasis?

A

Local irritants

Pregnancy

Medications

Infections

Systemic glucocorticoid withdrawl may precipiate

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21
Q

What is the tx for pt w Erythrodermic psoriasis?

A

Oral retinoids for non-pregnant pts

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22
Q

Name the disorder pictured along w characteristics

A

Nail psoriasis

Characteristics include:

Punctated pitting

onycholysis

nail thickening or subungual hyperkeratosis

Helpful in non-classic presentation

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23
Q

Name this disorder

A

Psoriatic arthritis

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24
Q

How dose Psoriatic arthritis present?

A

10-30% pt w skin sx

Hands & feet, sometimes large joints

Stiffness, pain & progressive joint damage

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25
Name this disorder and characteristics.
Oral psoriasis white lesions on oral mucosa, change severity daily Can be severe cheilosis w extension crossing vermillion border Geographic tongue may be a form
26
Name this skin lesion.
Lichen Planus
27
Name this skin lesion.
Lichen Planus
28
What is the distribution of Lichen Planus?
Predilection for wrists, shins, lower back, & genitalia May affect skin, scalp, nails, & mucous membranes.
29
Name the 4 P's and what disorder they describe.
Purple (violaceous) Polygonal Pruritic Papule (flat-topped) Papulosquamous disorder = Lichen Planus
30
What is Wickham's striae and what disorder does it belong to?
Superficial network of gray lines indicating Lichen Planus (can be seen in oral lichen planus too)
31
Describe how Lichen Planus will present in areas other than skin.
Scalp - lichen planopilaris, may lead to scarring alopecia Nail - may lead to permanent deformity or loss of fingernails/toenails Mucous Membrane - most common buccal, mild, white reticulate eruption of mucosa to severe erosive stomatitis. May last years = increased risk for oral squamous cell carcinoma
32
What is the DDx including Lichen Planus?
similar cutaneous eruptions occur w numerous drugs: thiazide, diurectics, gold, antimalarials, penicillamine, & phenothiazines w chronic graft-vs-host diease Psoriasis (more red lesions and chronic) associated w Hep C infection
33
What is the duration & tx for Lichen Planus?
variable duration, most have spontaneous remission 6 mo to 2 yrs Tx w topical glucocorticoids
34
How will a pt typically present w Pityriasis Rosea?
Occurs more commonly in Spring & Fall Initially Herald patch (2-6 cm annular lesion) Followed by (days to weeks) smaller annular, oval, papular, scaling lesions on the trunk Red to brown Occurs as crops last up to 3-8 wks DDx 2nd syphilis but its more common on palms/soles --rare in PR Post-inflammatory hyper/hypopigmentation Pregnancy = risk of miscarriage PCR may show (Human Herpes Virus) HHV-7/HHV-6 in DNA tissues & secretions
35
What is this lesion and what skin disorder does it suggest?
Herald patch = 2-6 cm annular lesion First lesion to appear for Pityriasis Rosea
36
Name the lesion below.
Christmas Tree shape lesion Pityriasis rosea
37
What are the tx of Pityriasis rosea?
Primary goal = relief of pruritus mid-potency topical corticosteroids (systemic not recommended, no pruritic reflief, may prolong disease) oral antihistamines UV-B (may not help pruritis, result in post-inflammatory pigmentation changes High dose Acyclovir (800 mg qid or 400 mg 5x) may help shorten disease if given early
38
What is the pathophysiology for Erythema multiforme?
Not totally understood Most likely immunologically mediated (keratinocyte is ultimate target of immune response) Keratinocyte necrosis = 1st patho finding Hypersensitivity rxn triggered by: Bacterial Viral (HSV) Fungal Chemical products (drugs (50% prevalence): slow acetylators w alt pathway oxida. by P450 ex sulfa, also anticonvulsants, barbituates). Contact exposure: metals, flavoring & preservatives, tattooing, cold, foods, malignancy, hormonal 50% idiopathic
39
Describe the 2 types of cell-mediated immune rxns.
Primary cell-mediated immune rxn = 9-14 days after the start of offending drug 2nd cell-mediated immune response = rxn hours to 1 or 2 days after recurrent exposure. Associate w EM
40
List predisposing conditions for EM.
2:1 males to females Rare \<3 yo or \>50 yo HIV infection Corticosteroid exposure Bone marrow transplant SLE (systemic lupus erythematosus) GVHD (graft-vs-host disease) IBD (inflammatory bowl disease) pts undergoing radiation, chemotherapy, neurosurgery for brain tumors
41
What is the prognosis of EM Minor?
Lesions evolve over 1-2 wks & ultimately subside w/i 2-3 wks w/o scarring Recurrences common (33% of cases assoc. w/ apparent or subclinical HSV infection)
42
What is the prognosis of EM major?
Mortality rate \< 5% - directly proportional to total BSA of sloughed epithelium More protracted course; may require 3-6 weeks Heal with hyper/hypopigmentation, scarring only if 2nd infection
43
What skin disorder is pictured below?
Target or Iris lesion assoc. w EM
44
Describe the target lesion assoc. w EM.
Reg round shape w 3 concentric zones: - dusky or darker red center - paler pink or edematous zone - peripheral red ring Some have only 2 zones: dusky or darker red center pink or lighter red border May not be apparent until several days after onset
45
How will a pt present w EM Minor?
Prodromal sx are usually absent or mild flu-like illness Abrupt onset of rash, occurs w/i 3 days, spread distal to central Pruritis is gen absent
46
How will EM Major present?
50% of pts have flu-like prodrome (1-14 pre rash) Spread same as Minor (distal to central) Promient mucosal involvment, oral mucosa erosions, conjunctival inflammation, genital lesions (paintful urination)
47
What are the tx for EM?
#1 tx symptoms Most cases **self limited** (oral antihistamines, analgesics, local skin care, soothing mouthwash) **Severe cases** - meticulous **wound care**, Burrow or Domeboro solution dressings **Hydration**/monitor fluid status for extensive skin involvment (66-75% fluid resuscitation for similar size burn) **Drug suspected - withdraw drug** (reduce risk by 30%/day) All med started in the preceding 2mo D/C all unnecessary meds **Infections tx** after tests & antiseptics to avoid superinfection Topical lubricants for dry eyes, sweep conjunctival fornices, removal of fresh adhesions HSV assoc EM - antiviral for prevention (started after eruption of EM has no effect)
48
What is the general rule of tx for all Psoriasis presentations?
Avoid excess drying or irriation of skin Maintain adequate cutaneous hydration
49
What is the tx for localized, plaque-type psoriasis?
Mid-potency topical - long-term use complicated by tackyphylaxis ( loss of effect) & atrophy Topical vit D analogue (Calcipotriene) Retinoid (tazarotene) Coal tar, salicylic acid, & anthralin replaced bu previous topical agents
50
What are the tx for Mild/Moderate widespread Psoriasis?
UV light, natural or artificial, UV-B light, narrowband UV-B, & UV-A spectrum w either oral or topical psoralens (PUVA) extremely effective Long-term use of UV light assoc w increased incidence of non-melanoma & melanoma skin cancer UV-light therapy is contraindicated in pt receiving cyclosporine (should be used w great care in immunocompromised pts due to increased risk of developing skin cancers)
51
What are the tx for severe, widespread Psoriasis?
Methotrexate (esp for pt w psoriatic arthritis) Acitretin (esp when immunosuppression must be avoided, teratogenicity limits use Cyclosporin No oral glucocorticoids (risk of Pustular Psoriasis when d/c)
52
What is the class, route, freq, and possible AEs for Methotrexate?
C:Anti-metabolite R: Oral F: Weekly AEs: Hepatotoxicity, pulmonary toxicity, pancytopenia, potential for increased malignancies, ulcerative stomatitis, nausea, diarrhea, teratogenicity
53
What is the class, route, freq, and possible AEs for Acitretin?
C: Retinoid R: Oral F: Daily AEs: Teratogenicity, osteophyte formation, hyperlipidemia, IBD flare up, hepatoxicity, depression
54
What is the class, route, freq, and possible AEs for Cyclosporine?
C: Calcineurin inhibitor R: Oral F: BID AEs: Renal dysfunc, hypertension, hyperkalemia, hyperuricemia, hypomagnesemia, hyperlipidemia, increased risk of malignancies
55
What does tx w Cyclosporine or Biologics target?
Serves as Psoriasis tx, immunoregulation directed at T cell-mediated disorder Immunosuppressive agents Biologic agents - more selective immunosuppressive properties, better safety profiles
56
What are some concerns of Biologic tx for Psoriasis?
TNF-inhibitors may worsen CHF, also assoc. w PML (progressive multifocal leukoencephalopathy) Not be initiated if severe infection Routine screening for TB required (reactivation risk) Malignancies, risk of certain ones - may limit use
57
Name the Biologics approved for Psoriasis or Psoriatic Arthritis?
Alefacept Etanercept Adalimumab Infliximab
58
Name this lesion.
EM Minor (notice 2 zones, central red and outer lighter red/pink)
59
What are the 4 etiologic categories of SJS, TEN & combo?
Infectious (HSV, AIDS, viral, bacterial, 50% report URI) seen most common in children Drug-induced: antibiotics (PCN & sulfa), analgesics, cough/cold meds, NSAIDs, psychoepileptics, & antigout. Assoc w multiple HLA (human lymphocytic antigen) alleles w drug exposure Malignancy-related (above 2 common in adults) Idiopathic (25-50% cases)
60
How will SJS, TEN, combo present in pt?
Begins w nonspecific URI lasting 1-14 days Mucocutaneous, non-pruritic lesions develop abruptly in cluster (2-4 wk). Can be urticarial but nonpruritic Fever or localized worsening = superimposed infection Oral mucositis - may limit ability to eat/drink..dysuria Conjunctival or corneal inflammation (27-50%)
61
How do you distinguish btw SJS, TEN, combo?
SJS (Stevens-Johnson Syndrome) = minor form of TEN w \<10% BSA detachment SJS/TEN combo = detachment of 10-30% BSA TEN (Toxic Epidermal Necrolysis) = detachment of \>30% BSA
62
What are the general characteristics of SJS/TEN?
Immune-complex-mediated hypersensitivity complex involving skin & mucous membranes (oral, nasal, eye, vaginal, urethral, GI, LRT) GI and respiratory involvement may progres to necrosis Biopsy = only specific test applicable DDx w EM (r/o due to acute disseminated epidermal necrosis)
63
What are the 2 main forms for Bullous pemphigoid?
Generalized bullous form & vesicular form
64
How will a pt present w generalized bullous form of Bullous pemphigiod?
Most common w tense bullae on any part of the skin surface. Predilection for flexural areas rare oral & minor ocular mucosa involvement heal w/o scarring or milia formation
65
How will a pt present w vesicular form of Bullous pemphigoid?
Less common groups of small tense blisters often on urticarial or erythematous base
66
What are the tx for Bullous pemphigoid?
Anti-inflammatory agents (corticosteroids, tetracyclines, dapsone) Immunosuppressants (azathioprine, methotrexate, mycophenolate, mofetil, cyclophosphamide) Anti-CD20 antibody (rituximab, specific in targeting antibody-producing B cells)
67
What is the general presentation of Bullous pemphigoid?
onset: acute or subacute Blisters are large & tense, round or oval chronic, autoimmune, subepidermal, blistering skin disease Urticarial plaques/bullae start as urticarial eruption, over wk to months - develop into bullae Lesions usually pruritic May be tender at site of erosion Typically clear fluid, can be hemorrhagic localized or generalized throughout body (10-25% mucous membranes) Presence of IgG autoantibodies
68
What is the prognosis for Bullous pemphigoid?
untreated = persist for months to yrs w spontaneous remissions & exacerbations treated = remits w/i 1.5 to 5 yrs increased morbidity & mortality: aggressive or widespread disease high dose corticosteroids/immunosuppressive agents required for control underlying medical conditions - comorbiditis, avg age 65
69
What history may be important relating to Bullous pemphigoid onset?
Recent UV irradiation, X-ray therapy, exposure to certain drugs (furosemide, NSAIDs, captopril, penicillamine, antibiotics) Recent vaccinations (common in children) urticarial lesions
70
Identify this skin lesion.
Bullous pemphigoid
71
What are the 2 important goals of tx for Bullous pemphigoid?
Reduce inflammatory response Reduce autoantibody production

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