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Dermatology > Troublesome rash > Flashcards

Troublesome rash Flashcards

1
Q

What are the 4 features of psoriatic nails?

A
  1. Periungal erythema
  2. Pitting
  3. Subungal hyperkeratosis
  4. Onycholysis (nail plate separates from the nailbed)
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2
Q

How to psoriasis patients typically present clinically?

A

They present with plaques on the;

  • Elbows
  • Knees
  • Scalp
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3
Q

What is the common shape of a lesion on the trunk in a psoriasis patient?

A

Annular

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4
Q

What is Koebner’s phenomenon?

A

When areas of the skin become lesions where the skin should not normally be raised (e.g. when someone scratches their skin and an immediate lesion appears)

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5
Q

What is Guttate psoriasis?

A

Widespread small plaques scattered on the trunk and the limbs

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6
Q

What is Palmo-plantar pustular psoriasis (PPPP)?

A

Multiple sterile pustules appear on the palms and soles. They first look yellowish monomorphic lesions then become brown over time.

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7
Q

Which patients are typically affected by palmo-plantar pustular psoriasis?

A

Smokers

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8
Q

What is generalised pustular psoriasis (GPP)?

A

Acutely erythematous skin which is very tender. There are skeets of monomorphic, sterile pustules which can develop over hours/days.

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9
Q

What does GPP generally indicate?

A

It usually indicates a very severe and unstable psoriasis

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10
Q

What is acropustulosis?

A

It is a very rare variant of psoriasis where there are pustules on the nails and fingertips associated with inflammation.

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11
Q

Who most commonly develops acropustulosis?

A

Young children

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12
Q

What is flexural psoriasis?

A

Well-defines erythematous areas in the axillae, groin, natal cleft, beneath the breasts and in skin folds

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13
Q

What is erythrodermic psoriasis?

A

This is a serious, even life-threatening condition, with confluent erythema affecting nearly all of the skin.

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14
Q

What are the triggers for the life-threatening erythrodermis psoriasis?

A
  1. Withdrawing from systemic steroids
  2. Infection
  3. Excessive alcohol intake
  4. Antimalarials
  5. Lithium
  6. Hypocalcaemia
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15
Q

What are the systemic complications of erythrodermis psoriasis?

A
  1. Heart failure
  2. Hypothermia
  3. Dehydration
  4. Low protein
  5. Oedema
  6. Secondary infection (encephalitis etc)
  7. Death
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16
Q

What is the pathophysiology of erythrodermic psoriasis?

A

Increased cutaneous blood flow and therefore excessive (insensible) fluid losses

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17
Q

What is Chronic Plaque psoriasis (CPP)?

A

Extensive plaques are present over the skin

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18
Q

What are the common areas of the body that are affected by Chronic plaque psoriasis?

A
  1. Ears
  2. umbilicus
  3. Genitals
  4. Knees
  5. Toe nails
  6. Finger nails
  7. Scalp
  8. Elbows
  9. Natal cleft
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19
Q

What percentage of psoriasis is chronic plaque psoriasis?

A

40%

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20
Q

When does guttate psoriasis commonly occur?

A

After a streptococcal sore throat

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21
Q

What proportion of patients with guttate psoriasis go on to develop chronic plaque psoriasis?

A

1/3

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22
Q

What is a joint complication of psoriasis?

A

Psoriatic arthropathy

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23
Q

What percentage of patients with psoriasis develop psoriatic athropathy?

A

5-20%

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24
Q

What percentage of patients with psoriatic arthropathy see that joint changes preceed the skin changes?

A

15%

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25
Q

What are the 5 subtypes of arthropathy patterns?

A
  1. Distal interphalangeal alone (DIP)
  2. Symmetrical polyarthritis (most common)
  3. Asymmetrical oligoarthritis
  4. Arthritis mutilans
  5. Spondyloarthropathy
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26
Q

What percentage of patients with DIP arthropathy have nail changes too?

A

80%

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27
Q

Describe asymmetrical oligoarthropathy

A

Hands and feet become very swollen and the fingers and toes become sausage shaped

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28
Q

What joints are affected in symmetrical polyarthtritis?

A

Hands, wrists and ankles

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29
Q

What happens to the skin of a patient who has arthritis mutilans?

A

The skin ‘telescopes’ as it becomes redundant when the bone of the digits becomes resorbed

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30
Q

What is the common cause of psoriatic arthritis?

A

A genetic predisposition and an environmental trigger

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31
Q

What percentage of patients who have psoriatic arthritis have a family history of psoriasis?

A

40%

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32
Q

What are the common triggers for psoriasis?

A
  1. Psychological stress
  2. Alcohol intake
  3. Iatrogenic - medications such as antimalarials, NSAIDs, B-Blockers, Lithium, Terbinafine
  4. Inherited
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33
Q

What is type 1 psoriasis?

A

75% of patients are type 1
They present when they are <40
There is a genetic link with HLA-CW6 (gene on chromosome 6)

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34
Q

What is type 2 psoriasis?

A

25% of patients are type 2
First presentation between 55 and 60
No genetic link

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35
Q

What must all psoriasis patients be prescribed as first line treatment for their condition?

A

Emollient use is a must

36
Q

What is the most appropriate first line treatment (drug, dosage, route etc.) for psoriasis affecting the following area; Palmoplantar?

A

Potent topical steroid ointment OD for 4 weeks

37
Q

What is the most appropriate first line treatment (drug, dosage, route etc.) for psoriasis affecting the following area; Trunk and limbs (<10% BSA)?

A

Potent topical steroid ointment - AM OD
Vitamin D analogue - PM OD

Both for 8 weeks

38
Q

What is the most appropriate first line treatment (drug, dosage, route etc.) for psoriasis affecting the following area; mild scalp involvement?

A

Tar based shampoo

39
Q

What is the most appropriate first line treatment (drug, dosage, route etc.) for psoriasis affecting the following area; Moderate scalp involvement?

A

Potent corticosteroid topically applied OD for 4 weeks

40
Q

What is the most appropriate first line treatment (drug, dosage, route etc.) for psoriasis affecting the following area; Severe scalp involvement?

A

Descale with salicylic acid/emollient or oils for 1 week

Potent corticosteroid OD for 4 weeks

41
Q

What is the most appropriate first line treatment (drug, dosage, route etc.) for psoriasis affecting the following area; Flexural genitalia/face/hairline?

A

Initially try a mild potency topical steroid (max. BD)

If not irritated use vitamin D analogue

42
Q

What would be a good initial management plan for someone with chronic plaque psoriasis over the body?

A
  1. Use emollient every 12 hours
  2. Use a soap substitute for the bath/shower
  3. Topically treat with vitamin D analogue for the trunk and limbs
  4. Use a mild topical steroid ointment for the face and flexures
43
Q

What are the 3 steps to psoriasis treatment?

A
  1. Topical therapy
  2. Phototherapy
  3. Systemic medication
44
Q

What are the 2 validated tools we an use to determine the severity of psoriasis?

A
  1. Psoriasis Area Severity Index (PASI)

2. Dermatology of Life Quality Index (DLQI)

45
Q

Who completed the PASI score?

A

The clinician

46
Q

What is the PASI scored out of?

A

72

47
Q

What does the following score on the PASI mean; 0-5?

A

Mild disease

48
Q

What does the following score on the PASI mean; 5-12?

A

Moderate disease

49
Q

What does the following score on the PASI mean; 12-20?

A

Severe disease

50
Q

What does the following score on the PASI mean; >20?

A

Very severe disease

51
Q

Who completes the DLQI?

A

The patient

52
Q

What does the following score on the DLQI mean; 0-1?

A

Psoriasis has no effect at all on the patient’s life

53
Q

What does the following score on the DLQI mean; 2-5?

A

Psoriasis has a small effect on the patient’s life

54
Q

What does the following score on the DLQI mean; 6-10

A

psoriasis has a moderate effect on the patient’s life

55
Q

What does the following score on the DLQI mean; 11-20?

A

Psoriasis has a very large effect on the patient’s life

56
Q

What does the following score on the DLQI mean; 21-30?

A

Psoriasis has an extremely large effect on the patient’s life

57
Q

What is another scoring tool that we can use to assess the severity of psoriatic arthritis?

A

The Psoriasis Epidemiology Screening Tool (PEST)

58
Q

In patients with psoriatic arthritis, what other medical speciality should be involved in their care?

A

Rheumatology

59
Q

What is the aim of phototherapy in relation to psoriasis?

A

This is used to slow down the excessive growth of keratinocytes and is believed to be partly immunosuppressive

60
Q

How many phototherapy sessions are usually delivered weekly and for how many weeks?

A

2-3 times per week for 10 weeks

61
Q

How many sessions of PUVA is an individual restricted to in their lifetime and why?

A

100 sessions due to the risk of developing skin cancer

62
Q

What treatment option is next available for those who have a poor response to phototherapy or for those who are not eligible to try phototherapy?

A

Systemic treatment of the skin

63
Q

What is ciclosporin?

A

An immunosuppressant that inhibits T-cells.

64
Q

How often is ciclosporin taken in someone being treated for psoriasis?

A

BD

65
Q

When do we normally see a response from patients who take ciclosporin for their psoriasis?

A

Within 4-6 weeks

66
Q

What are the common side effects of ciclosporin?

A
  1. Hypertension
  2. Renal impairment
  3. Lymphopenia (immune dysfunction)
  4. Hypertrichosis (increased hair growth)
  5. Gum hypertrophy
67
Q

What is the maximum amount of time someone can spend being treated with ciclosporin?

A

12 months

68
Q

How long does it take for methotrexate to reach its maximal efficacy in patients with psoriasis?

A

4-6 months

69
Q

How does methotrexate work when thinking about psoriasis?

A

It is an anti-inflammatory and reduces the number of cutaneous T-cells

70
Q

What are the common side-effects of taking methotrexate?

A
  1. Haematological toxicities (anaemia, lymphopenia, thrombocytopenia)
  2. Liver fibrosis
71
Q

Which patients are contraindicated to taking methotrexate for psoriasis?

A
  1. Those who are trying to conceive
  2. Those who are taking trimethoprim
  3. Those who have pre-existing liver conditions
72
Q

What is Acitretin?

A

An oral retinoid (Vitamin A derivative)

73
Q

How often is acitretin taken?

A

OD

74
Q

How does acitretin work?

A

It inhibits keratinocyte proliferation in the epidermis

75
Q

How long before wanting to conceive should acitretin be discontinued and why?

A

This drug has a very long half-life and should be discontinued 2 years before wanting to conceive due to its teratogenicity

76
Q

50% of patients who take acitretin will see a response within how many weeks?

A

12

77
Q

How do Fumaric acid esters (FAEs) work?

A

They shift T-helper 1 phenotype cells into T-helper 2 phenotype cells. As psoriasis is a T-helper 1 mediated condition, this shift will prevent/reduce the psoriasis effect.

78
Q

What type of drug is a Fumaric acid ester (FAE)?

A

An oral immunomodulatory drug

79
Q

What are the common side effects of Fumaric acid esters (FAEs)?

A
  1. Nausea
  2. Diarrhoea
  3. Lymphopenia (<0.7 lymphocyte count)
80
Q

Which patients should be started on Apremilast first?

A

Those with co-morbidities that need to be considered. This is because it causes minimal toxicities.

81
Q

When systemic therapies do not help to improve psoriasis, what treatments should be considered next?

A

Biological therapy

82
Q

Which patients are eligible for biological therapy due to the expensive nature of the monoclonal antibody treatment?

A

These patients must have;

  1. Tried 2 or more systemic agents without success
  2. Have a PASI and DLQI score of 10 or more
83
Q

Give 2 examples of Tumour Necrosis Factor (TNF) inhibitors

A
  1. Etanercept
  2. Infliximab
  3. Adalimumab
  4. Certolizumab
84
Q

Adalimumab is the most common TNF inhibitor given, how is it administered and how often?

A

SC injection

Every 2 weeks

85
Q

Name the 3 families of drugs that we can use as a biological therapy for psoriasis

A
  1. TNF inhibitor
  2. IL-12/23 inhibitor
  3. IL-17 inhibitor
86
Q

What chronic and acute health conditions are patients with psoriasis at increased risk of developing?

A
  1. MI
  2. T2DM
  3. Hyperlipidaemia
  4. Metabolic syndrome

Dermatology (8 decks)

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