Psoriasis

Question 1

What is SAPHO?

Answer 1

Sinovitis (inflammation joints)
Acne (conglobata, fulminans)
Pustulosis (palmoplantar pustular psoriasis)
Hyperostosis (inc in bone substance)
Osteitis (inflammation bones)

Can also get HS and dissecting cellulitis of the scalp

Skin biopsies can show neutrophillic abscesses

Question 2

Medication inducers of psoriasis

Answer 2

Lithium, interferons, anti PD-1 antibodies, beta blockers, anti malarials, rapid withdrawal of corticosteroids, TNF inh, Dupilumab

Question 3

Cells and cytokines of pso

Answer 3

T helper cells, dendritic cells
IFNy, IL2, IL17, IL22, IL23.
Reduced levels of IL10 (anti-inflammatory cytokine)

Question 4

Genes psoriasis and pustular psoriasis

Answer 4

MHC class II antigen
PSORS1-9 genomic regions
- most imp PSORS1 on chromosome 6, HLA-Cw6 allele
Hundreds of other single nucleotide polymorphisms

Pustular psoriasis:
Loss of function of IL36RN which encodes IL36 receptor antagonist

Question 5

Name of sign? Differentials

Answer 5

Pityriasis amiantacea

Ddx
Seb derm
Pso
Tinea
Head lice

Question 6

What is the genetics of overlap of psoriasis and prp? Clinical features?

Answer 6

CARD14 mutation
Early age onset
Fam hx pso
Distribution: cheeks, chin, ears
Poor response topical steroids or systemic therapy
Responds to ustekinumab

Question 7

Triggers for generalised pustular psoriasis

Answer 7

Abrupt withdrawal systemic steroids
Hypocalcemia
Pregnancy (impetigo herpetiformis)
Infections
Topical irritants (
localised pattern)

Question 8

4 phenotypes of genetalised pustular psoriasis

Answer 8

1. Von zumbusch pattern - generalised abrupt, fever, painful, scaly ++
2. Annular pattern - annular w pustules at advancing edge, then resolve and scaly
3. Exanthemic type - overlap w agep, infection or meds, acute abrupt sml pustules.
4. Pregnancy (impetigo heroetiformis)

Question 9

Mucosal sign in psoriasis?

Answer 9

Annulus migrans (similar to geographic tongue), seen in acro dermatitis continua of hallopeau and GPP

Question 10

What are the signs of psoriasis in nails?

Answer 10

Pits (foci of proximal nail matrix involvement).
Leukonychia and loss of transparency (mid portion of matrix).
White crumbling (entire nail matrix)
Oil drop or salmon patch (exocytosis of leukocytes beneath the nail plate).
Splinter haemorrhages (increased capillary fragility).
Subungual hyperleratosis, distal onycholysis (due to parakeratosis of the distal nail bed)

Question 11

Classification of PRP?

Answer 11

1. Adult - classic
2. Adult - atypical
3. Juvenile - circumscribed (focal)
4. Juvenile - classic (generalised)
5. Atypical juvenile (generalised).
6. HIV associated

Question 12

Drug triggers of PRP (4)

Answer 12

Infliximab
Tyrosine kinase inhibitors (eg imatinib).
Antivirals (eg. sofosbuvir).
Vaccines

Question 13

Medical comorbidity associations w PRP (3)

Answer 13

Thyroid disease.
Solid organ malignancy (renal, lung, liver).
HIV.

Question 14

Name 10 triggers for psoriasis

Answer 14

• Triggering factors:
■ External: trauma (Koebner phenomenon/isomorphic response)—1- to 3-week lag time
■ Systemic: infections (streptococcal pharyngitis #1), HIV, endocrine factors (e.g., hypocalcemia in generalized pustular psoriasis and pregnancy in impetigo herpetiformis), stress, drugs (lithium, IFNs, β-blockers, antimalarials, TNF-α inhibitors, and corticosteroid [CS] tapers in pustular psoriasis), alcohol consumption, smoking, and obesity
○ Latency period between drug initiation and skin eruption varies:
♦ Short latency (<4 weeks): terbinafine, NSAIDs
♦ Intermediate latency (4–12 weeks): antimalarials, angiotensin-converting enzyme (ACE) inhibitors
♦ Long latency (>12 weeks): β-blockers, lithium
○ TNF-α inhibitors (adalimumab and infliximab most commonly) may → plaque psoriasis and/or palmoplantar pustulosis

Question 15

Pustular psoriasis - what do you want to monitor on bloods

Answer 15

Can get hypercalcemia

Question 16

Generalised Pustular psoriasis tx ladder

Answer 16

Emollients
Acitretin
CSA
MTX
Biologics - ixekizumab
Spesolimab (IL36)

Question 17

Which biologic in pregnancy?

Answer 17

Humira

Question 18

Drug triggers PSO

Answer 18

Lithium
Withdrawal of systemic steroids
TNFa
Beta blockers
NSAIDs
Plaquinel
Interferons

Question 19

What is in the NAPSI score? Nail matrix x 4, Nail bex x 4

Answer 19

Nail Matrix:
1. Pitting
2. Leukonychia
3. Red spots in lanula
4. Crumbling

Nail Bed:
1. Onycholysis
2. Oil drop sign
3. Subungual hyperkeratosis
4. Splinter haemorrhage

Question 20

10 conditions that koebnerise

Answer 20

PSO
Vitiligo
Lichen planus
Morphoea
Pyoderma gangrenosum
Sweet Syndrome
Bechets
Darier disease
Hailey Hailey
Milia
Molluscum
Warts

Question 21

Why doesn’t psoriasis get infected?

Answer 21

PSO lesional skin produces antimicrobial peptides defensin and SKALP/elafin.