1
Q
Prevalence:
A
-2 % worldwide
2
Q
% of patients with psoriatic arthritis?
A
- 5-30%
3
Q
Age of onset:
A
- bimodal distribution peaking at 20-30 years, and 50-60 years
4
Q
General pathogenesis of psoriasis:
A
- caused by environmental triggers in genetically predisposed patients
5
Q
triggers for psoriasis:
A
SICK LAB - stress/smoking - Infection (group A strep, URI) - hypoCalcemia - Koebnerization - Lithium - antimalarias/ACEI/alcohol - Beta blockers Others: TNF alpha inhibitors!!!, CCB’s, NSAIDs
6
Q
most important psoriasis susceptibility region is ___ which is present in ____ % of patients
A
- PSORS1 - 50%
7
Q
strongest HLA association:
A
- HLA cw6 (C-wia-six)
8
Q
HLA cw6 is positive in ____ % of early onset psoriasis
A
- 90%
9
Q
strongest HLA risk factor for early onset disease is_____
A
- HLA cw6
10
Q
HLA-B27 is a/w
A
- sacroiliitis-associated psoriasis - PsA - pustular psoriasis
11
Q
HLA cw6 is a/w which subtype of psoriasis?
A
- guttate
12
Q
HLA- B13 and HLA-B17 a/w:
A
- guttate and erythrodermic psoriasis
13
Q
HLA A,B,C encode _____
A
- MHC class 1 on nucleated cells
14
Q
HLA DR, DP, DQ encode ____
A
- MHC class 2 on APC’s
15
Q
Name the variants of psoriasis:
A
- guttate - palmoplantar - inverse - erythrodermic - pustular (including impetigo herpetiformis in pregnancy, and Von Zumbusch)
16
Q
The two generalized pustular psoriasis are:
A
- impetigo herpetiformis - Von Zumbusch
17
Q
Impetigo herptiformis presentation and management:
A
- presents in pregnant patients, begins in flexures then generalizes w/ toxicity - early delivery recommended
18
Q
Von Zumbusch presentation:
A
- rapid and generalized, painful skin, fever, leukocytosis, hypoalbuminemia
19
Q
Risk factor for Von Zumbusch :
A
- hypocalcemia
20
Q
Palmoplantar pustulosis presents as ____ and has a ____ course.
A
- pustules and yellow-brown macule localized to plams/soles - chronic course
21
Q
Palmoplantar pustulosis may be a/w sterile inflammatory bone lesions in _____
A
SAPHO syndrome
22
Q
Acrodermatitis of Hallopeau presents as:
A
- lakes of pus on distal fingers, toes, and nail beds–> nail shedding - think of “lake hallopeua”
23
Q
1 cause of pityriasis amianacea is ____
A
psoriasis
24
Q
Nail findings in psoriasis:
A
- Proximal matrix= Pits - Distal matrix= leukonychia and loss of transparency - nail bed= oil spots, splinter hemorrhages, onycholysis, sublingual hyperkeratosis
25
Psoriatic arthritis is more likely if ____ and ____ are involved.
- nails - scalp
26
PsA presents as \_\_\_\_
- morning stiffness \>30-45 mins
27
5 types of PsA:
- oligoarthritis with swelling and tenosynovitis of hands (60-70% of cases!!!!!!) - asymmetric DIP with nail damage - RA-like - Arthritis mutilans (rare and most severe) - Ankylosing spondylitis
28
most common type of PsA
oligoarthritis with swelling and tenosynovitis of hands (60-70% of cases!!!!!!)
29
Good way to distinguish RA from PsA
- PsA affects PIPs, DIPs, usually spares MCPs - RA affects MCPs, PIPs, spares DIPs
30
Common trigger for guttate psorisasis
- group A strep infection (oropharynx or perianal)
31
Dactylitis is ____ and seen in ____ % of patients with PsA
- swelling of fingers (sausage digit) - 15-30%
32
Histology of psoriasis:
- confluent PK - Munro's micro abscesses (collections of neuts in the stratum corneum, neuts in horn) - decreased or absent granular layer - regular acanthoses with thinning over dermal papilla, which contain dilated capillaries
33
Munro's microabcesses are:
- collections of neutrophils in stratum corneum (neuts in the horn)
34
The granular layer in psoriasis is \_\_\_\_\_
- decreased or absent
35
7 basic steps of psoriasis immunology in order:
1. environmental triggers + genetic susceptibility 2. Keratinocyte injury and increased antigen presentation 3. Increased production of proinflammatory cytokines (IL-23, IL-12, IL-17, IFN-gamma, TNF, and IL-22) 4. Activation of T cells by myeloid dendritic cells leading to Th1 and Th17 activation and proliferation 5. epidermal acanthuses and abnormal keratinocyte proliferation 6. Increased production of beta defensins, cathelicidin LL37.
36
Th17 cells are stimulated by ____ . This in turn increases release of _____ and ____ which causes keratinocyte replication
- IL-12 and IL-23 - Th17 cells lead to release of IL-17 and IL-22
37
Th1 cells are stimulated by _____ and lead to production of \_\_\_\_\_\_\_\_\_\_\_\_.
- stimulated by IL-12
38
Two main cytokines involved in the increase in keratinocyte replication:
- IL-17 and IL-22 (these are released by Th17 cells.
39
IL-12, which stimulates Th1 cells promotes CD8 T cells to secrete:
- IFN-gamma - IL-2,6,8,12
40
IFN-gamma activates _____ to secrete ____ and \_\_\_\_\_
- macrophages - TNF-alpha and IL-23
41
Th17 cells release \_\_\_\_, ____ and \_\_\_\_
- IL-17 - IL-22 - TNF-alpha
42
Th2 cells are stimulated by ____ and produce \_\_\_\_\_, which is decreased in psoriasis
- IL-4 - produce IL-10
43
IL-10 is an anti-inflammatory cytokine which inhibits \_\_\_\_\_
- Th1 cells - since there is less IL-10, there are more Th1 cells that release more pro inflammatory cytokines
44
Mechanism of topical corticosteroids:
- decrease pro-inflammatory cytokines like TNF-alpha and increase IL-10 (anti-inflammatory cytokine)
45
MOA of Calcipotriene:
- vitamin D analog that decreases KC proliferation and blocks IL-2, IL-6, and IFN-gamma
46
Which molecule leads to neutrophil chemotaxis and micro abscess of munro formation?
- CXCL8
47
Associated comorbidities of psoriasis:
- decreased risk of allergies and superinfections - increased risk of cardiovascular diseases, HLD, HTN, DM, metabolic syndrome
48
Micropustules of Kogoj are\_\_\_\_\_
- collection of neutrophils in stratum spinosum
49
Where are micro pustules of Kogoj and munro microabcesses located in skin?
- munro are neuts in the stratum corneum - Kogoj are neuts in the stratum spinosum - remember "Marilyn Monroe is always on top"
50
First line tx for mild-moderate psoriasis?
- topical CS
51
Fist line tx for moderate-severe psoriasis?
- NB-UVB (311-313nm)
52
How often does psoriasis spontaneously remiss?
\<35% of the time, the rest tend to have chronic course
53
Woronoff ring is \_\_\_\_
- pale blanching ring around psoriatic lesion
54
Scraping of psoriasis scale off will lead to ____ which is called _____ sign.
- pinpoint bleeding - auspitz sign
55
Auspitz sign occurs due to\_\_\_\_
- dilated capillaries and supra-papillary plate thinning
56
