Psoriasis

Question 1

Generalized pustular psoriasis

• describe clinical features
• describe lab findings

Answer 1

• fever, sterile pustules on erythematous skin; trunk, exts, nail beds, palms, soles; fingertips become anonychic and atrophic
• hypocalcemia, hypoalbuminemia, leukocytosis

Question 2

Origin of nail changes and clinical features

Answer 2

• nail matrix give pits (most common), represents focal psoriasis of proximal nail matrix and leuconychia
• nail bed leading to salmon spots, onycholysis, subungual hyperkeratosis, splinter hemorrhages

Question 3

Most common type of psoriatic arthritis

Answer 3

Asymmetric oligoarthritis of small joints of hands

Question 4

Drugs that exacerbate psoriasis

Answer 4

Steroid withdrawal 
Lithium
Beta-blockers
Interferons
ACEi
GCSF

Question 5

Biologics for psoriasis

- name and mechanism (6 total)

Answer 5

• etanercept (enbrel), recombinant fusion protein to TNF receptor, binds soluble TNFalpha
• adalumimab (humira), antibody towards TNF alpha
• infliximab (remicade), monoclonal ab which inhibits TNF alpha; contraindicated in CHF, may cause drug induced SLE
• ustekinumab (stelara), human ab that blocks IL12 and IL23; get PPD
• alefacept (amevive), protein that blocks interaction of LFA3 and Fc of IgG; LFA3 is a receptor for CD2 and increased in CD45 Ro T cells; check CD4 count
• efalizumab (raptiva), humanized ab that binds CD11a component of LFA1, which binds to ICAM1 on APC and endothelial cells; category C

Question 6

Oral agents for psoriasis
MTX, cyclosporine, acitretin
- MTX mechanism, dose, side effects

Answer 6

• synthetic analog of folic acid, competitively inhibits DHFR, inhibits S phase of cell cycle
• 10-30mg once per wk
• leukopenia, thrombocytopenia; needs leucovorin rescue
• kidney dysfunction (renal excretion)
• liver toxicity; cumulative dose of 1.5g -> liver biopsy
• acute interstitial pneumonitis (rare)

Question 7

Oral agents for psoriasis
MTX, cyclosporine, acitretin
- cyclosporine, mechanism, side effects

Answer 7

• inhibits release of cytokines IL-2 by binding and deactivating calcineurin
• effective in erythrodermic and generalized pustular psoriasis
• 2.5 to 4mg/kg per day as high as 5.5mg/kg per day
• renal impairment, reduce dose 25% if cr increases to 30% or greater than baseline
• ## hypertension, treat with ACEi

Question 8

Generalized vs localized pustular psoriasis

• name acute, generalized type
• name two distinct types of localized

Answer 8

• Von Zumbusch

- pustulosis palmaris et plantaris; acrodermatitis continua of hallopeau