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Psoriasis

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Question
Answer
Is psoriasis linked to genes   Yes, hereditary  
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Describe psoriasis   Well demarcated, erythematous PLAQUES, scaly  
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Common localization of psoriasis   Elbow, knees, SCALP  
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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)  
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Definition of Intertriginous   Areas where skin may touch/rub eg axilla, digits, breast fold, anogenital  
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Name the types of primary psoriasis lesions   Plaques, pustular  
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Describe plaque psoriasis   Well demarcated plaques OR pustules salmon colored, thick silver scaling, Auspitz sign  
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Describe pustular psoriasis   Yellow lesions that coalesce into dark red crusty lesions  
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Explain the course of psoriasis   Recurrent, chronic +/- complete resolution  
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Peak incidence of psoriasis   Any age but commonly 20s and 50s  
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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)  
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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)  
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Describe guttate psoriasis   Small salmon colored “drops” on surface of skin in peds and young adults; often post-group A strep infection  
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What does guttate mean   Drops  
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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  
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CC of psoriasis   Pruritis, joint pain (arthritis), von Zumbusch syndrome  
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What is von Zumbusch syndrome   Pustular psoriasis where CC fever, chills, weakness  
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How is psoriasis affected seasonally   Worse in winter (less humid, less natural UV exposure)  
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DDx of psoriasis vs seborhheic dermatitis   Lesions yellow, greasy, scales less thick in scalp  
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What is sebopsoriasis   When psoriasis and seborhhea co-exist or indistinguishable  
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DDx of psoriasis and lichen simplex chronicus   Paroxysmal pruritis, less # lesions, less thick scale  
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DDx of psoriasis vs tinea   Single lesion, scales at PERIphery, central CLEARING, (+) KOH prep  
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DDx of psoriasis vs psoriaform drug eruptions   Check hx of medications  
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DDx of psoriasis vs pityriasis rosea   OVAL papulosquamous lesions in Christmas tree +/- herald patch  
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DDx psoriasis vs atopic dermatitis   (+) FmHx asthma, allergic rhinitis, eczema. Lesions on flexural surfaces, FACE, NECK  
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DDx of 2/3 syphilis vs psoriasis   Hx STDs, recent S/S, do serology if needed  
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DDx of mycosis fungoides vs psoriasis   Chronic @ Bathing trunk area warrants biopsy  
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What are the three management modalities for psoriasis   Topical / systemic / UV light / injection  
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What are the different types/classes of topical tx for psoriasis   Corticosteroids, vita D based, retinoid based, immunosuppressant based, adjunctive agents  
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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  
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Example of very high topical steroid   Clobetasol (TEMOVATE)  
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Example of high topical steroid   Fluocinonide (LIDEX)  
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Example of Vita D based topical   Calcipotriene (DOVONEX) ointment qhs; irritating  
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Examples of retinoid based topicals   Tazarotene (TAZORAC) gel/cream 0.05%, 0.1%  
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Example of immunosuppressant based topical   Tacrolimus (PROTOPIC), ointment 0.03%, 0.01%; Pimecrolimus (ELIDEL) , cream 0.1%  
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Example of adjunct agents for tx of psoriasis   Topical salicylic acid (keratolytic)  
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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  
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Name the different classes of systemic agents used in tx of psoriasis   Immunosuppressants, biologic agents, Thiazolidinedione  
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Example of immunosuppressant tx   MTX, cyclosporine, etretinate  
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Example of biologic agents   TNF-R (-): etanercept (ENBREL), infliximab (REMICADE); Other: alefacept, efalizumab  
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Example of Thiazolidinediones   Experimental: AVANDIA, ACTOS  
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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)  
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What is the treatment for moderate chr plaque psoriasis involving the FLEXor surfaces   Moderate potency topical steroids(<4wks) or tacrolimus  
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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)  
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What are the adjunct tx   Lac-hydrin or salicylic acid daily  
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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)  
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What is the treatment for moderate chr plaque psoriasis involving the FACE   Low potency topical steroid cream/ointment BID alternating w/ tacro/pimecrolimus qod  
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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%  
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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  
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when initiating bio agents for tx of severe psoriasis what should be done first   TB test  
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what is a good agent for arthritic psoriasis   etanercept (ENBREL) 50mg BIW SQ x3 mo then 25mg BIW  
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What is a good agent for tx of palmoplantar, erythrodermic, and pustular psoriasis   Acitretin (SORIATANE) 10-25mg daily  
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What is Re-PUVA   Retinoid + psoralen + UVA  
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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)  
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What are the risks and benefits a/w mycophenolate mofetil (CELLCEPT)   Less organ toxicity c/w cyclosporine and MTX; incr dev lymphoma  
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What are the risks and benefits a/w cyclosporine   Very effective for short term rapid tx of severe psoriasis; HTN, renal toxicity  
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What type of psoriasis is adalimumab (HUMIRA) effective in   arthritic psoriasis and generalized severe psoriasis  
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