Studied by 3 people
What is Psoriasis?
chronic inflammatory skin disease that involves hyper-proliferation of keratinocytes in the epidermis
What is the pathophysiology of Psoriasis?
complex immune mediated using T lymph, dendritic cells, cytokines: cell cycle shortened → dec turnover time → inc cells undergoing DNA synthesis → inc number of epidermal stem cells
What are the risk factors for Psoriasis?
age, genetics (HLA-B17: more severe), environmental, smoking, stress, medications
What would you see on a skin biopsy of Psoriasis?
parakeratosis, epidermal hyperplasia, neutrophils, absence of granular layer, leukocytes, and lymphocytes
What are the clinical features of Chronic Plaque Psoriasis?
erythematous plaques w/ silvery scale, sharply defined, well-demarcated margins, ± pruritus
What is Type 1 plaque psoriasis?
strong FMHx, sx before age 40, associated w/ HLA-cw6
What is Type 2 plaque psoriasis?
no FMHx, sx after age 40, not associated w/ HLA-cw6; associated w/ + Auspitz sign and Koebner phenomenon
Where does Chronic Plaque Psoriasis typically occur?
extensor surfaces, scalp, gluteal cleft, intertriginous areas, ear canal, umbilicus, nails, palms/sole → painful fissures
What is the tx for limited Chronic Plaque Psoriasis?
TCS: class 1-3 & emollients ± phototherapy
clobetasol
Vitamin D analogs
Topical Retinoids
Tazarotene
What is the tx for moderate/severe Chronic Plaque Psoriasis?
Phototherapy
Retinoids
DMARDS
methotrexate, cyclosporine
Anti-TNF (biologics)
Infliximab (Remicade), Adalimumab (Humira)
What are the clinical features of Guttate Psoriasis?
abrupt appearance of multiple small psoriatic papules and scales w/ raindrop appearance, < 1cm, may spontaneously remit
Where does Guttate Psoriasis typically occur?
trunk, back, proximal extremeties
What are the risk factors of Guttate Psoriasis?
age (children/young adult), associated w/ recent Streptococcal infxn
What would you see in a skin biopsy of Guttate Psoriasis?
early lesions: non-dx; mature lesions: hyperkeratosis, epidermal acanthosis, neutrophils in epidermis
What is the tx for Guttate Psoriasis?
1st line: UV phototherapy
alternative: TCS & Vit D analogs
not ideal due to disease being widespread
What is the cause of Pustular Psoriasis?
pregnancy, stress, infection, withdrawal of oral glucocorticoids
What are the clinical features of Pustular Psoriasis?
acute onset, erythematous pustules, local/general, associated w/ malaise, fever, diarrhea, leukocytosis, hypocalcemia, can be life-threatening
What are the variants of Pustular Psoriasis?
Von Zumbusch: most severe
Acrodermatitis continue of Hallopeau: localized to distal digits
Palmoplantar pustulosis: localized to palms/soles
What labs would see in pts w/ Pustular Psoriasis?
elevated WBC, inc ESR, hypocalcemia, hypoalbuminemia
What would you see in a skin biopsy of Pustular Psoriasis?
parakeratosis, elongation of rete ridges, spongiform pustules of Kogoj
What is the tx for Pusutlar Psoriasis?
Mild
1st line: Acitretin and Methotrexate
Severe/acute
Cyclosporine, Infliximab
What are complications that can arise due to Pustular Psoriasis?
Renal: AKI, Hepatic: abn LFTs, jaundice, Resp: ARDS; hair loss
What are the clinical features of Erythrodermic Psoriasis?
generalized erythema & exfoliation of most of the BSA, painful and pruritic scales, associated w/ fevers, chills, malaise, arthralgia, LAD; appears similar to SJS
What causes Erythrodermic Psoriasis?
resutls from exacerbation of unstable plaque psoriasis; most commonly pts stopped taking their meds
What labs findings would you see in pts w/ Erythrodermic Psoriasis?
leukocytosis w/ eosinophilia, anemia
What are the risk factors of Erythrodermic Psoriasis?
age, hx of psoriasis, infections -HIV, medications: systemic glucocorticoids, bactrum, bupropion, withdrawal of antipsoriatic meds
What are complications that can arise from Erythrodermic Psoriasis?
infections, sepsis, electrolyte imbalances
What would you see in a skin biopsy of Erythrodermic Psoriasis?
epidermal hyperplasia, marked dilation and coiling of vessels w/in the papillary dermis
What is the tx for Erythrodermic Psoriasis?
Stable = outpt/supportive
topical steroids
systemic psoriatic tx: Cyclosporine, Infliximab
Unstable = admit to ICU or inpt
fluid/electrolyte replacement
nutritional support
tx infections
topical steroids or systemic immunomodulators
What are the clinical features of Inverse (intertriginous) Psoriasis?
well-demarcated, smooth, shiny plaques w/ absent or minimal scale; often mis-dx as fungal/bacterial
Where does Inverse (intertriginous) Psoriasis typically occur?
intertriginous area, inguinal, perineal, genital, intergluteal axillary, infra-mammary
What is the tx for Inverse (intertriginous) Psoriasis?
Topical glucocorticoids (class 6-7)
Topical Vit D analog: Calcitriol
Topical Calcineurin inhibitor: Tacrolimus, Pimecorlimus
What are the clinical features of Nail Psoriasis?
common w/ psoriatic arthritis (80-90%), pitting, nail dystrophy, splinter hemorrhages, subungal hyperkeratosis, “oil drop sign”
What can you do to r/o onychomycosis when dx Nail Psoriasis?
KOH prep
What is the tx for Nail Psoriasis?
prevent nail trauma
TCS and topical Vit D analog
Calcipotriol
high potency (group 1) -Betamethasone
What are the clinical features of Palmoplantar Psoriasis?
hyperkeratotic plaques that may have associated fissures
Where is Palmoplantar Psoriasis typically located?
palms and soles
What is the tx for Palmoplantar Psoriasis?
based on severity: topical vs oral tx similar to plaque psoriasis
Topical steroids: high potency due to location
What is Psoriatic Arthritis?
oligoarthritis found in pts w/ psoriasis, caused by immunologic, environmental, hereditary factors
What are the clinical features of Psoriatic Arthritis?
associated nail involvement (80-90%), joint pain, joint stiffness in a.m., asymmetric, dactylitis “sausage digits”, “pencil in cup” deformity; similar to gout
Where is Psoriatic Arthritis typically located?
asymmetric peripheral joint involvement of UE, smaller joints
What are the risk factors for Psoriatic Arthritis?
psoriasis, gout
What labs can you get to exclude other conditions when dx Psoriatic Arthritis?
RF, ANA, ESR, CRP HLA-B27
What criteria is used to dx Psoriatic Arthritis?
CASPAR
What is the tx for Psoriatic Arthritis?
Mild axial disease
NSAIDS: naproxen, celecoxib
Moderate/severe axial disease
TNF inhibitors: Humira (1st), Enbrel, Infliximab
Dactylitis
DMARDS: Methotrexate
What non-pharm tx can help manage Psoriatic Arthritis?
exercise, wt loss, avoid alc & smoking
What is important to educate women taking biologics on?
must use contraceptive measures
What prescribing Methotrexate, what is important to also give pts?
MUST supplement folic acid
What is Acne Vulgaris?
inflammatory disorder of the pilosebaceous unit characterized by chronic/recurrent development of comedones, papules, pustules, and nodules
What are the main pathogenic factors of Acne vulgaris?
follicular hyperkeratinization, inc sebum production, cutibacterium acne, inflammation
Where is Acne vulgaris typically located?
face and trunk
What is the pathophysiology behind Acne vulgaris?
adrogen stimulate inc sebum → microcomedomes form from accumulation of sebum and bacteria → comedone or pustule → bacteria activates inflammatory response → follicular rupture
What are the types of Acne vulgaris?
acne mechanica, papulopustular acne, comedonal acne, nodulocystic acne
What are variants of Acne vulgaris?
infantile acne, acne conglobata (severe nodular), acne fulminans (rare)
What causes infantile acne?
elevated levels of androgens produced by immature adrenal glands or left over from the mother’s hormones
What is required to dx Acne vulgaris?
comedones
When prescribing Accutane what must you do?
LFTs, lipid panel, Beta-Hcg pregnancy test;
What is mild Acne vulgaris?
few scattered comedones or small inflammatory papules w/o scarring
What is the tx for Acne vulgaris?
Monotherapy
Benzoyl Peroxide, Topical Tretinoin, Salicyclic acid, or Azelaic acid
Combotherapy
Benzyol peroxide + Topical Tretinoin
Resistant
Topical dapsone
What can you not apply Topical dapsone (Aczone) with?
topical benzoyl peroxide
What is moderate Acne vulgaris?
prominent comedones, large inflammatory pustules and papules
What is the tx for moderate Acne vulgaris?
Topical combo therapy
benzoyl peroxide + topical tretinoin + topical abx
topical + oral combo therapy:
benzoyl peroxide + topical tretinoin + oral abx
topical Abx: erythro or clindamycin
oral Abx: doxy or minocycline
Alternative: intralesional triamcinolone
What is severe Acne vulgaris?
prominent comedones, large inflammatory pustules and papules, nodules, scarring, can affect many body parts
What is the tx for severe Acne vulgaris?
oral abx + topical retinoid + benzoyl peroxide ± topical abx
Refractory: Accutane
What are complications of Acne vulgaris?
psychological morbidity, scarring, G- folliculitis
What is Rosacea?
inflammatory acneiform disorder of the facial pilosebaceous units
What are the clinical features of Rosacea?
facial flushing, papules, pustules, telangiectasias, NO comedones, ± burning sensation, phymatous changes, ocular manifestations
What is Rosacea typically located?
face
What are the risk factors for Rosacea?
Fitzpatrick phototype 1 &2; genetics
What are aggravating factors for Rosacea?
alcohol, UV light, smoking, spicy foods, hot beverages, temperature extremes, psychological stress
What are phymatous skin changes characterized by?
tissue hypertrophy, dilated follicles, irregular nodular overgrowths caused by sebaceous gland hyperplasia/fibrosis
What make up the “Phyma” family?
Rhinophyma → Cauliflower-like nose
Metophyma → enlarged cushion-like swelling of forehead
Blepharophyma → swelling of the eyelids
Otophyma → cauliflower-like swelling of the earlobes
Gnathophyma → swelling of the chin
What is the tx for Rosacea?
mild/moderate
topic abx: Metronidazole
Alternative: azelaic acid gel
Oral abx: tetracyclines
Refractory: oral tretinoin (Accutane)
Non-pharm: pulse dye laser
What can Accutane not be taken with?
vit A, Tetracyclines
What is Perioral Dermatitis?
skin condition that presents w/ multiple small, inflammatory papules around the mouth, nose, or eyes
What are the clinical features of Perioral Dermatitis?
discrete erythematous micropapules and microvesicles, no comedoens, associated w/ atopy
What is Perioral Dermatitis typically located?
perioral or periorbital skin; spares narrow area around the vermillion border
What are the risk factors for Perioral Dermatitis?
age, F > M, Topical steroid use
What is the tx for Perioral Dermatitis?
non-pharm
STOP cortiosteroid usage using taper
Topical erythromycin or clindamycin gel
Topical metronidazole gel
Topical Calcineurin inhibitors
moderate/severe
oral Tetracyclines
What is Hidradenitis Suppurativa?
chronic inflammatory disorder characterized by follicular occlusion, relapsing inflammation, mucopurulent discharge, progressive scarring
What are the clinical features of Hidradenitis Suppurativa?
recurrent inflamed, painful nodules and abscess, malodorous drainage, bands of severe scar formation, open comedones
Where is Hidradenitis Suppurativa typically located?
intertriginous regions: axilla, inframammary folds, inner thigh, groin, buttocks, gluteal cleft
What is the pathophysiology behind Hidradenitis Suppurativa?
follicular occlusion + mechanical stress → inflammation & leakage of antigens = perifolliculitis → rupture → sinus tracts → bacterial infections → scarring and extension of lesion
What are the most common bacteria in Hidradenitis Suppurativa?
Coagulase negative Staph and anaerobic bacteria
How is Hidradenitis Suppurativa staged?
Hurley stages: 3 stages
1: abscess w/o tracts or scars
2: recurrent abscess w/ tract and scar
3: diffuse multiple interconnected tracts and abscesses
What are complications of Hidradenitis Suppurativa?
squamous cell carcinoma (rare), psychosocial stress, strictures/contractures, scarred tissue, lymphatic obstruction, lymphedema
How do you tx Hurly stage 1 (mild) Hidradenitis Suppurativa?
Abx
1st line: topical clindamycina
refractory: oral tetra + antiandrogenic drugs (spirono) + metformin
Intralesional triamcinolone
Hod do you tx Hurly stage 2 (moderate) Hidradenitis Suppurativa?
oral tetracycline
combo: clinda + rifampin
oral retinoids
dapsone
humira (preferred)
infliximab
What is the tx for Hurly stage 3 (severe) Hidradenitis Suppurativa?
wide excision
What is Epidermoid Cysts?
most common type of cutaneous cyst; may be a result from trauma of the follicular epithelium or comedones
What is another name for Epidermoid Cysts?
Epidermal Inclusion Cyst
What are common sites of Epidermoid Cysts?
face, neck, upper trunk, scrotum
What is the pathophysiology behind Epidermoid Cysts?
derived from the follicular infundibulum; trauma or occlusion of pilosebaceous unit → proliferation and implantation of epidermal cells in the dermis
What are the clinical features of Epidermoid Cysts?
skin-colored benign dermal nodules, visible central punctum, non-tender, freely moveable, filled w/ thick malodorous keratin material
What is the tx for Epidermoid Cysts?
Asx: no tx necessary
Surgical excision -definitive tx
What are the clinical features of Milia (Milium)?
1-2 mm, white papules, filled w/ keratin/sebaceous material; cannot squeeze out
What are Milia (Milium)?
painless, tiny subepidermal keratin cysts
What is Milia en plaque?
rare, inflammatory condition characterized by a cluster of milia on an erythematous and edematous bed in the periauricular region
What are common sites of Milia (Milium)?
eyelids, cheeks, forehead
What is the tx for Milia (Milium)?
Asx: no tx necessary
Neonatal: spontaneously resolve
Definitive: incision and expression of contents
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