Dermatology Book

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PsoriasisAka: Chronic Plaque Psoriasis, Guttate Psoriasis

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  1. Epidemiology
    1. Onset in young adulthood between ages 30 to 40 years
    2. Prevalence: 1-2% of general population
    3. Men and women affected equally
  2. Pathophysiology
    1. Autoimmune
      1. Viral infection may precipitate process
      2. T-Cell-mediated autoimmune response
        1. Cytokines released and stimulate Keratinocytes
    2. Keratinocytes proliferate
      1. Epidermal cells proliferate too fast
        1. Cells cycle in 4 days instead of normal 3-4 weeks
      2. Abnormal keratin production
      3. Dermal inflammation
  3. Associated environmental factors
    1. Suppressed by:
      1. Sun and humidity
    2. Provocative
      1. Injury to skin (Koebner Reaction)
      2. Streptococcal Pharyngitis
      3. Emotional upset
      4. HIV Infection (severe exacerbations)
      5. Medications
        1. Antimalarials
        2. Beta Blockers
        3. Lithium
        4. NSAIDS
  4. Symptoms
    1. Pruritus is present in >80% of psorisis
      1. Psora is greek for itching
  5. Signs: Chronic Plaque Psoriasis
    1. Description
      1. Widespread
      2. Sharply demarcated
      3. Bright pink Plaques
      4. Overlying loose, silvery scale
    2. Location: Symmetrical
      1. Over joints and extensor surfaces of extremities
      2. On trunk, especially lower back and buttocks
      3. Palms and soles
      4. Scalp
      5. Umbilicus
    3. Signs suggestive of psoriasis
      1. Auspitz Sign
      2. Koebner Phenomenon
  6. Signs: Associated findings
    1. Location specific signs
      1. Nail
        1. Nail Pitting
        2. Onycholysis
          1. Separation of distal edge of nail from nail bed
          2. Accumulation of crumbly subungual debris
      2. Gluteal cleft
        1. Eroded pinkness in crease
      3. Penis
        1. Pink Macules or Plaques on penis
      4. Large joints
        1. Hyperkeratosis over elbows, knees, and ankles
      5. Tongue
        1. Geographic Tongue (rare)
    2. Uncommon Clinical Variants
      1. Guttate (drop-like)
      2. Inverse (flexural)
      3. Pustular
      4. Erythroderma
    3. Systemic Signs
      1. Psoriatic Arthritis
      2. Uveitis (up to 20% of Psoriatic Arthritis cases)
    4. Severe widespread psoriasis systemic signs
      1. Benign Lymphadenopathy
      2. Fever, chills, and Hyperthermia
      3. Increased cardiac demand
      4. High output Heart Failure
      5. Increased Sedimentation Rate and Uric Acid
      6. Decreased Serum Albumin
      7. Iron Deficiency Anemia
  7. Differential diagnosis
    1. Lichen Simplex Chronicus
    2. Nummular Eczema
    3. Seborrheic Dermatitis
    4. Tinea Corporis
  8. Associated Conditions (related to psoriatic medications)
    1. Non-Melanoma skin cancer
    2. Lymphoma
  9. Approach: Moderate chronic Plaque psoriasis
    1. Trunk and extensor surface involvement
      1. Initial and exacerbation therapy (<4 weeks only)
        1. Protocol 1: Steroid and Calcipotriene
          1. High potency Topical Corticosteroid qAM
          2. Calcipotriene applied qPM
        2. Protocol 2: Single agent
          1. High potency Topical Corticosteroid or
          2. Calcipotriene or
          3. Tazorotene (Tazorac)
      2. Long-term maintenance (beyond 4 weeks)
        1. Calcipotriene or
        2. Tazorotene (Tazorac)
    2. Flexor surface involvement
      1. Moderate Topical Corticosteroids (<4 weeks) or
      2. Tacrolimus or Pimecrolimus
    3. Scalp involvement
      1. Exacerbations
        1. Topical Corticosteroid (brief use)
        2. Example: Clobetasol 0.05% shampoo
      2. Maintenance
        1. Anti-Dandruff shampoo
        2. Examples: T-gel or selsun
    4. Adjuncts
      1. Lac-Hydrin or salicylic acid applied daily
  10. Approach: Severe chronic Plaque psoriasis
    1. Criteria
      1. Psoriasis refractory to above therapy
      2. Chronic Plaque psoriasis involving >20% of body
    2. Protocol usually managed by dermatology
      1. Use above topical agents
      2. See Ultraviolet light below
      3. See Systemic Agents below
  11. Management: Topical Preparations
    1. Topical Corticosteroids
      1. High Potency Topical Steroids (Usually indicated)
        1. Very high potency: e.g. Clobetasol (Temovate)
        2. High potency: e.g. Fluocinonide (Lidex)
      2. Low Potency Topical Steroids
        1. Face
        2. Genitals
        3. Maintenance Therapy
    2. Vitamin D based topicals
      1. Calcipotriene (Dovonex)
      2. Used in combination with Topical Corticosteroids
    3. Retinoid based topicals
      1. Tazarotene (Tazorac)
      2. More irritating than Calcipotriene
    4. Immunosuppressant based topicals
      1. Tacrolimus 0.1% or Pimecrolimus 0.1% creams
        1. Effective in facial and intertriginous psoriasis
        2. Lebwohl (2004) J Am Acad Dermatol 51:723
    5. Adjunctive agents in combination with above
      1. Topical Salicylic Acid (Keratolytic Agent)
    6. Poorly tolerated topicals (use Calcipotriene instead)
      1. Historically used with UVB light exposure
      2. Anthralin (Anthra-Derm)
      3. Coal Tar (e.g. Zetar)
  12. Management: Ultraviolet Light
    1. Risk of non-Melanoma skin cancer
    2. Protocols
      1. Ultraviolet B exposure alone
      2. Ultraviolet A exposure with psoralen (PUVA)
        1. Increased risk of non-Melanoma skin cancer
  13. Management: Systemic agents (most are higher risk)
    1. Immunosuppressants
      1. Etretinate
      2. Cyclosporine
      3. Methotrexate (unclear efficacy)
    2. Biologic agents (Cost from $10k to >$20k/year)
      1. Tumor necrosis factor (tnf) receptor blockers
        1. Etanercept (Enbrel)
          1. Leonardi (2003) N Engl J Med 349:2014
        2. Infliximab (Remicade)
          1. Winterfield (2004) Dermatol Clin 22:437
      2. Other mechanisms
        1. Alefacept (Amevive)
        2. Efalizumab (Raptiva)
          1. Lebwohl (2003) N Engl J Med 349:2004
    3. Thiazolidinedione (Avandia, Actos) - experimental
      1. Appears effective in Psoriasis even in non-diabetics
      2. Only small trials support to date
      3. Ellis (2000) Arch Dermatol 136(5):609
  14. References
    1. Luba (2006) Am Fam Physician 73:636
    2. Mason (2002) Br J Dermatol 146:351

Psoriasis (C0033860)

Definition (MSH)A common genetically determined, chronic, inflammatory skin disease characterized by rounded erythematous, dry, scaling patches. The lesions have a predilection for nails, scalp, genitalia, extensor surfaces, and the lumbosacral region. Accelerated epidermopoiesis is considered to be the fundamental pathologic feature in psoriasis.
Definition (CSP)common polygenetically determined, chronic, squamous dermatosis characterized by rounded erythematous, dry, scaling patches.
Definition (NCI)A chronic disease of the skin marked by red patches covered with white scales.
Definition (NCI)A common genetically determined, chronic, inflammatory skin disease characterized by rounded erythematous, dry, scaling patches. Psoriatic lesions have a predilection for nails, scalp, genitalia, extensor surfaces, and the lumbosacral region; the pathology involves an accelerated epidermopoiesis. Psoriasis is associated with increased risk for melanoma, squamous cell carcinoma, and basal cell carcinoma. --2004
ConceptsDisease or Syndrome (T047)
MSHD011565
BasqueARTROPATIADUN EDO GABEKO SORIASIA
DanishPsoriasis
DutchPsoriasis
EnglishPsoriases, Psoriasis, Psoriasis unspecified
FinnishPSORIASIS
FrenchPsoriasis
GermanPsoriasis
Hebrewpsoriazis
Hungarianpsoriasis
ItalianPsoriasi
NorwegianPSORIASIS MED/UTEN ARTROPATI
PortuguesePsoriase
SpanishPsoriasis, psoriasis no especificada, soriasis
SwedishPSORIASIS
Parent ConceptsDermatitis (C0011603), skin disorder (C0037274), Hypertrophic disorder of skin, unspecified (C0263630), ECZEMETOUS ABNORMALITIES (C0549659), Diagnosis/Diseases Component (C0497531), Skin (C1123023), Skin Diseases, Papulosquamous (C0162818), Other psoriasis (C0477485), Acquired disorder of keratinization (C1302732), Cutaneous hypersensitivity (C0585186), Duplicate concept (C1274013), Cell-mediated cytotoxic disorder (C1960691)
SourcesAOD, COSTAR, CSP, CST, DXP, ICPC, ICPCBAQ, ICPCDAN, ICPCDUT, ICPCFIN, ICPCFRE, ICPCGER, ICPCHEB, ICPCHUN, ICPCITA, ICPCNOR, ICPCPOR, ICPCSPA, ICPCSWE, LCH, MEDLINEPLUS, MSH, NCI, NDFRT, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)


Guttate psoriasis (C0343052)

ConceptsDisease or Syndrome (T047)
EnglishGuttate psoriasis, Psoriasis guttata
Spanishpsoriasis en gotas, psoriasis guttata, soriasis en gotas, soriasis guttata
Parent ConceptsPsoriasis (C0033860), Maculopapular eruption (C0423791)
SourcesSCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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