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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