Troublesome Rash

Question 1

Questions to ask in a rash history (10)

Answer 1

Duration
Temporal pattern (where first, how has it changed)
Distribution
Associated symptoms
Exacerbating and relieving factors
PMH (Associated/causative?)
DH
FH
How debilitating (work, socially)
Alcohol

Question 2

Features of psoriatic nails

Answer 2

Periungal erythema
Pitting - small depressions in the nail (parakeratotic cells lost from nail surface)
Subungal hyperkeratosis -accumulation of chalky looking material under the nail
Oncholysis - lifting of nail plate of the bed (white or salmon patch on nail)
Oil spots
Beau’s lines - transverse lines on nail, inflammation leading to transient arrest in nail growth
Splinter haemorrhages - leakage of blood from dilated tortuous capillaries (look like minute longitudinal black lines)

Question 3

What is parakeratosis?

Answer 3

Keratinocytes retain their nuclei throughout the epidermis. This would normally be lost at the skin surface. Hyperkeratosis is a characteristic feature of psoriasis.

Question 4

What is Auspitz sign?

Answer 4

When psoriatic plaques are removed from the skins surface, they reveal small dilated blood vessels

Question 5

Why is psoriasis erythematous?

Answer 5

Dilated and superficial blood vessels

Question 6

What causes inflammation, oedema and erythema in psoriasis?

Answer 6

Inflammatory polymorphs infiltrating the epidermis

Question 7

Variant of psoriasis that affects the hands and soles?

Answer 7

Palmoplantar pustulosis

Question 8

Clinical features of psoriasis

Answer 8

Plaques
Scaling
Erythema
Pustules

Question 9

Triggers of psoariasis

Answer 9

Stress
Trauma
Infection
Childbirth

Question 10

What is Koebner’s phenomenon?

Answer 10

Appearance of new skin lesions on areas of cutaneous injury

Question 11

Types of psoriasis (7)

Answer 11

Guttate psoriasis - scattered on trunk and limbs. Preceded by sore throat - β haemolytic streptococcus. Usually adolescents.
Chronic plaque psoriasis (40% of presentations)
Flexural psoriasis
Generalised pustular psoriasis (usually smokers, may be precipitated by oral steroids or potent topical steroids)
Erythrodermic psoriasis can be life threatening
Acrodermatitis pustulosa - children, pustules on nails and fingertips
Napkin psoriasis -in children. May be typical or exudative skin

Question 12

4 know triggers of psoriasis

Answer 12

Antimalarial medication (nsaids, β-blockers, lithium, terbinafine)
Psychological stress
Inherited
-type 1 (75% patients) <40 years HLA-CW6 (Psors 1 gene on C6)
-type 2 (25% patients) 55-60 years no HLA CW6 association
Alcohol

Question 13

Management of Psoriasis

Answer 13

Treatment (ADEEP)

Education - educate on psoriasis and council on use of treatments, provide leaflets

Question 14

Treatment of palmar/plantar psoriasis

Answer 14

Dovanbet gel OD
Diprosalic cream/ointment BD
Betnovate cream/ointment BD

Plus emollient of choice

Question 15

Treatment of mild scalp psoriasis

Answer 15

Shampoo:

Polytar
Alphosyl 2:1
Ceanel
Capasal
Nizoral
T-gel

Question 16

Treatment of moderate scalp psoriasis

Answer 16

Dovobet gel nocte
Betnovate scalp solution
Diprosalic scalp solution
Synalar gel

Question 17

Treatment of sever scalp psoriasis

Answer 17

Dovabet gel nocte

Sebco ointment nocte

Question 18

Treatment of trunk and limb psoriasis

Answer 18

Dovobet gel OD
Vitamin D analogues (calcitriol, tacalcitol)
Express lotion BD

PLUS EMOLLIENT

Question 19

Treatment of flexural and genitalia / face and hairline psoriasis

Answer 19

Canestan Hydrocortisone cream BD
Daktacort cream BD
1% hydrocortisone

If no improvement: trimovate (flexures/genitals) eumovate (face/hairline)

PLUS EMOLLIENT OF CHOICE

Question 20

When treating a patient for psoriasis, when should a patient return to clinic?

Answer 20

4 weeks initially
Check compliance and amount of treatment used

Improvement - 8 weeks
No improvement - 4 weeks, refer to specialist

Question 21

Criteria for referral to dermatology dept.

Answer 21

Erythroderma
>20% of body surface covered 
Severe disabling psoriasis 
Failure to respond to topical therapies
Unstable/ rapidly extending psoriasis

Question 22

Tool measuring psoriasis severity (objective)

Answer 22

PASI (Psoriasis Area Severity Index) 0-72

Mild 0-5
Moderate 5-12
Severe 12-20
Very severe >20

Question 23

Tool measuring impact of the disease on the patients life (subjective)

Answer 23

DLQI (Dermatology of Life Index) 0-30

0-1 no effect
2-5 small effect 
6-10 moderate effect
11-20 very large effect 
21-30 extremely large effect in patients life

Question 24

Score used to screen for Psoriatic arthritis (30% of patients)

Answer 24

PEST (Psoriasis Epidemiology Screening Tool)

Question 25

Forms of phototherapy

Answer 25

Narrow band UVB | PUVA (100 Sessions in lifetime)

Question 26

Systemic agents used to treat psoriasis (5)

Answer 26

``` Cyclosporin Methotrexate Acitretin (vitamin A derivative) Fumaric acids (fumaderm) Apremilast ```

Question 27

Criteria for biological treatment

Answer 27

Failed to respond to 2 other treatments | PASI and DLQI of at least 10

Question 28

What are the main biologicd treatments?

Answer 28

TNF inhibitors - (etanercept, infliximab, ADALIMUMAB) 2 weeks IL-12/23 inhibitors - Ustekinumab 12 weeks IL-17 inhibitors - Ixekizumab