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DERM
Psoriasis
| Question | Answer |
|---|---|
| Is psoriasis linked to genes | Yes, hereditary |
| Describe psoriasis | Well demarcated, erythematous PLAQUES, scaly |
| Common localization of psoriasis | Elbow, knees, SCALP |
| Name other variants of psoriasis | Palmoplantar (soles, palms); generalized pustular psoriasis; generalized erythrodermic psoriasis (entire body, life threatening if a/w ARDS); inverse psoriasis (flexural, intertriginous) |
| Definition of Intertriginous | Areas where skin may touch/rub eg axilla, digits, breast fold, anogenital |
| Name the types of primary psoriasis lesions | Plaques, pustular |
| Describe plaque psoriasis | Well demarcated plaques OR pustules salmon colored, thick silver scaling, Auspitz sign |
| Describe pustular psoriasis | Yellow lesions that coalesce into dark red crusty lesions |
| Explain the course of psoriasis | Recurrent, chronic +/- complete resolution |
| Peak incidence of psoriasis | Any age but commonly 20s and 50s |
| What is the Koebner phenomenom and why is it important for pts to know | Aka ISOMORPHIC RESPONSE where new psoriasis plaques erupt at/along the site of skin injury; tell them to avoid scratching (injury) |
| What is the etio and genetics of psoriasis | Unknown etio; 8% chance of dev if 1 parent, 41% if 2 parents; high a/w HLA-B13/17/Cw6/Bw57 and chr 6 (others as well) |
| Describe guttate psoriasis | Small salmon colored “drops” on surface of skin in peds and young adults; often post-group A strep infection |
| What does guttate mean | Drops |
| Causes vs triggers vs aggravating factors of psoriasis | Causes (hereditary, HLA, post group A strep infection); triggers (trauma, rubbing, scratching); aggravating (psychological stress, systemic steroids/IFN, lithium, anti-malarial, β(-), ACEI, EtOH, smoking, HIV |
| CC of psoriasis | Pruritis, joint pain (arthritis), von Zumbusch syndrome |
| What is von Zumbusch syndrome | Pustular psoriasis where CC fever, chills, weakness |
| How is psoriasis affected seasonally | Worse in winter (less humid, less natural UV exposure) |
| DDx of psoriasis vs seborhheic dermatitis | Lesions yellow, greasy, scales less thick in scalp |
| What is sebopsoriasis | When psoriasis and seborhhea co-exist or indistinguishable |
| DDx of psoriasis and lichen simplex chronicus | Paroxysmal pruritis, less # lesions, less thick scale |
| DDx of psoriasis vs tinea | Single lesion, scales at PERIphery, central CLEARING, (+) KOH prep |
| DDx of psoriasis vs psoriaform drug eruptions | Check hx of medications |
| DDx of psoriasis vs pityriasis rosea | OVAL papulosquamous lesions in Christmas tree +/- herald patch |
| DDx psoriasis vs atopic dermatitis | (+) FmHx asthma, allergic rhinitis, eczema. Lesions on flexural surfaces, FACE, NECK |
| DDx of 2/3 syphilis vs psoriasis | Hx STDs, recent S/S, do serology if needed |
| DDx of mycosis fungoides vs psoriasis | Chronic @ Bathing trunk area warrants biopsy |
| What are the three management modalities for psoriasis | Topical / systemic / UV light / injection |
| What are the different types/classes of topical tx for psoriasis | Corticosteroids, vita D based, retinoid based, immunosuppressant based, adjunctive agents |
| What are the different types/strengths of steroids and indications for use in psoriasis | Very high and high topical steroids are usually indicated at 1st visit tx; low potency is for maintenance and areas such as face & genitals |
| Example of very high topical steroid | Clobetasol (TEMOVATE) |
| Example of high topical steroid | Fluocinonide (LIDEX) |
| Example of Vita D based topical | Calcipotriene (DOVONEX) ointment qhs; irritating |
| Examples of retinoid based topicals | Tazarotene (TAZORAC) gel/cream 0.05%, 0.1% |
| Example of immunosuppressant based topical | Tacrolimus (PROTOPIC), ointment 0.03%, 0.01%; Pimecrolimus (ELIDEL) , cream 0.1% |
| Example of adjunct agents for tx of psoriasis | Topical salicylic acid (keratolytic) |
| What is the protocol for tx of psoriasis using UV light and pre-cautions | UV B alone OR UV A w/ psoralen (PUVA); risj of non-melanoma skin CA |
| Name the different classes of systemic agents used in tx of psoriasis | Immunosuppressants, biologic agents, Thiazolidinedione |
| Example of immunosuppressant tx | MTX, cyclosporine, etretinate |
| Example of biologic agents | TNF-R (-): etanercept (ENBREL), infliximab (REMICADE); Other: alefacept, efalizumab |
| Example of Thiazolidinediones | Experimental: AVANDIA, ACTOS |
| What is the treatment for moderate chr plaque psoriasis involving the trunk and EXTensor surfaces | Initial/exacerbx tx over <4 wks: MED to HIGH potency topical steroid cream/ointment + Vita D topical (calcipotriene) or single agent tx (topical steroid / vita D / retinoid); long term/maintenx >4wks: Vita D (calcipotriene) or retinoid (tazarotene) |
| What is the treatment for moderate chr plaque psoriasis involving the FLEXor surfaces | Moderate potency topical steroids(<4wks) or tacrolimus |
| What is the treatment for moderate chr plaque psoriasis involving the scalp | Exacerbation: brief (<4wks) use clobetasol 0.05% shampoo; Maintenance: anti-dandruff shampoo (T-gel/Selsun Blue) |
| What are the adjunct tx | Lac-hydrin or salicylic acid daily |
| What is the criteria for SEVERE chr plaque psoriasis and how do you tx | psoriasis refractory to initial treatment + plaques involving >20% body; triamcinolone inj 4-8mm/cc; PUVA, UV B; bio agents, MTX, acitretin (SORIATANE) |
| What is the treatment for moderate chr plaque psoriasis involving the FACE | Low potency topical steroid cream/ointment BID alternating w/ tacro/pimecrolimus qod |
| What is the treatment for moderate chr plaque psoriasis involving the SCALP | Tar / fluocinolone (CAPEX) / topical steroid lotion (CLOBEX/DIPROLENE) / topical steroid soln (CORMAX/LIDEX) / foam (OLUX/LUXIQ) / derma smoothe FS oil / calcipotriene (DOVONEX) 0.0005% / tazarotene gel 0.05%, 0.1% |
| After initial treatment what can be added/changed to the maintenance tx | Incr strength of steroid, apply steroid w/ occlusive dressing, injection at lesion w/ triamcinolone, UV B broad or narrow band TIW + PO psoralen + UV A 2-3x wks |
| when initiating bio agents for tx of severe psoriasis what should be done first | TB test |
| what is a good agent for arthritic psoriasis | etanercept (ENBREL) 50mg BIW SQ x3 mo then 25mg BIW |
| What is a good agent for tx of palmoplantar, erythrodermic, and pustular psoriasis | Acitretin (SORIATANE) 10-25mg daily |
| What is Re-PUVA | Retinoid + psoralen + UVA |
| What is the tx regiment for subsequent office visits in pts w/ sever psoriasis | Cont rotating steroid tx, research combined therapies in literature, PO cyclosporine (NEORAL), IV infliximab (REMICADE), PO mycophenolate mofetil (CELLCEPT), adalimumab (HUMIRA) |
| What are the risks and benefits a/w mycophenolate mofetil (CELLCEPT) | Less organ toxicity c/w cyclosporine and MTX; incr dev lymphoma |
| What are the risks and benefits a/w cyclosporine | Very effective for short term rapid tx of severe psoriasis; HTN, renal toxicity |
| What type of psoriasis is adalimumab (HUMIRA) effective in | arthritic psoriasis and generalized severe psoriasis |
Created by:
DrINFJ
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