what is the most common papulosquamous disease?
psoriasis
Name four papulosquamous diseases
psoriasis, lichen planus, pityriasis rosea, drug eruptions
psoriasis presentation
raised plaques, large, rough, silvery/white scales, redness, inflammation, fissure might crack and bleed, demarcated, thickened stratum corneum, pitting of nail bed, nail doesnt stick to nail bed, subungal discoloration-whitish, various itching, pain, arthralgias, depression
location psoriasis presents
elbows, knees, scalp are most common *extensor surfaces
also hands and feet
possible condition presenting with psoriasis
psoriatic arthritis- same signal from immune system attacks skin (1st) and joints (2nd)
define “pitting nails”
ice pick makes small dots on nail
tx and work up for pitting and discoloration of nail in psoriasis
steroid under bed of nail
send clipping of nail to test for fungus
DDx psoriasis vs atopic dermatits
location! atopic dermatitis is in flexural regions, psoriasis is extensor regions
DDx psoriasis vs shingles
pattern! shingles follows dermatomal pattern, psoriasis does not
psoriasis has __ _ times its normal production
epidermal thickening 7
psoriasis etiology
unknown
possibly Tcell mediated auto immune disease,
possibly genetic predisposition,
flares can be caused by drugs: lithium, beta blockers, NSAIDs,
psoriasis increases risks of..
- CV disease
- Lymphoma
- Metabolic disorders
- Cancer
- Obesity (also worsened by obesity)
most common type of psoriasis
plaque psoriasis
drugs that cause a flare in psoriasis
lithium, beta blockers, NSAIDs
what age group does psoriasis target?
all ages, commonly around 30 years
define koebnar phenomenon
appearance of lesions in areas of trauma
ex. psoriasis in scar or abrasion
ex. lichen planus in scar or abrasion
onset of psoriasis
gradual onset usually but can be sudden
-sudden onset occurs after streptococcal infection
this infection leads to guttate psoriasis or worsens current type
steptococcal infection
Describe guttate psoriasis
flare caused by strep or upper respiratory infections
tiny pink perfect circles with scaly lesions on trunk/extremities
tx: uv light but this can go away on its own
Describe pustular psoriasis
small pustules on hand and feet (raised small white fluid filled bumps)
painful and can break open
-generalized pustulosis- whole body is covered; this is emergent and treated like a burn in hospital
Describe palmar/plantar psoriasis
lesions found only on palms and soles
thick, scaly plaques
very painful if crack- will bleed
Describe inverse psoriasis
found in skin folds red with or without scales thick, flat small scales uncomfortable rule out tinea infections
name 5 types of psoriasis
- plaque
- guttate
- pustular
- palmar/plantar
- inverse
general tx for psoriasis
no cure!!! want to control symptoms- topical/phototherapy/systemic: depends on location severity, symptoms, and insurance
NEVER GIVE ORAL STEROIDS risk of rebound flare once pt is off them
Topical tx for psoriasis:
- topical steroid - decrease inflammation
- calcipotriene (dovonex) - vitamin D analog that binds to keratinocyte receptors to alter keratinocyte proliferation
- Tazarotene (Tazorac) - topical retinoid that causes peeling effect of skin to thin out plaque (like shingles on a roof)
- Taclonex - combo of topical steroid and dovonex - decrease inflammation and keratinocyte proliferation
- Tar -inhibits DNA synthesis but is smelly and orange staining
- Ointments -with saran wrap occlusion
use of topical steriods
decrease inflammation
calcipotriene/dovonex
vitamin D analog that binds to keratinocyte receptors to alter keratinocyte proliferation
tazarotene/tazorac
topical retinoid that causes peeling effect of skin to thin out plaque (like shingles on roof)
taclonex
combination of topical steroid and dovonex used to decrease both inflammation and keratinocyte proliferation
tar
inhibits DNA synthesis
phototherapy tx for psoriasis
good for widespread lesions; if lesions are small use Excimer Laser
light penetrates deep and causes a reaction- clearing up psoriasis
expensive and time consuming, burning, increase risk for skin cancer, photo aging, return of disease
list of systemic tx for psoriasis
- Methotrexate (oral)
- Soriatane (oral)
- Cyclosporine (transplant drug)
- Biologics (SQ injection/IV/infusion/oral)
systemic tx for psoriasis
- Methotrexate (oral)-inhibit cell proliferation (also helps with arthritis symptoms); liver toxic can not drink alcohol, nausea, liver biopsy every 2 weeks and blood work often (CBC/HFP/BUN/Creat)
- Soriatane (oral)-vitamin A derivative effects keratinization and causes peeling of plaque; used with phototherapy and in palmar psoriasis; teratogenic, cant donate blood or get pregnant for 3 years after use, dryness of lips, check cholesterol and triglycerides in blood work often (CBC/HFP/CHOL/Triglycerides)
- Cyclosporine (transplant drug)-inhibits T cell production; used in super severe ppl!!!! ; dont use for more then 1 year and taper dose; monitor BP and do labs this can effect kidney (CBC/HFP/Lytes/Chol/Triglycerides
- Biologics (SQ injection/IV/infusion/oral)-common now; suppress inflammation thru T cell interference; good for arthritis and skin; PPD/Labs needed because increased risk of infection due to lowering immune system (TB & HEP screening); costly. Ex: Enbrel, Humira, Remicade, Otezla
NEVER GIVE ORAL STEROIDS in psoriasis
methotrexate
oral, inhibits cell proliferation also good to treat psoriatic arthritis problems with drug: liver toxic-get blood work done often causes nausea cant drink any alcohol needs liver biopsy every 2 weeks labs (CBC/HFP/BUN/Creat)
soriatane
used with phototherapy
common use with palmar psoriasis
vitamin A derivate causes peeling effect by effecting keratinization
teratogenic (causes birth defects) - wait three years to have babies
cant donate blood until off it for 3 years
effects cholesterol and triglycerides
dryness of lips
get blood work done often: CBC/HFP/Chol/Triglycerides
cyclosporine
used for severe cases of acute flare
transplant drug that inhibits t cell production
cant use for more then one year and need to taper dose
effect on kidneys-monitor BP and do labs often
CBC/HFP/Chol/Triglycerides/Lytes
biologics
newer tx that suppresses inflammation thru T cell interference
used for arthritis and skin
costly
increased risk of infection because lowering immune system so get PPD/TB test/HEP screening
examples:humira,enbrel,remicade,otezia
drug examples of biologics
humeria, enbrel,remicade,otezia
HERO
work up for psoriasis
CBC/BUN+Creatine levels/Liver function test/Hep Panel/TB screening
DDx for psoriasis
acute dermatitis
tinea infections
shingles
list of topical tx for psoriasis
topical steroids calcipotriene/dovonex tazarotene/tazorac taclonex tar ointment (TCTTTO)
Pityriasis Rosea looks like..
christmas tree with herald patch
pityriasis rosea presentation
herald patch (1 pinkish scaly patch 2-6 cm appears for 1 week) then rash blossoms into pink/red/brown scaly patches
very itchy, trunk and proximal extremeties
6-12 weeks after blossom it will be cleared
occurs during spring and fall usually
pityriasis rosea etiology
unknown
maybe viral
maybe environmental
younger people
pityriasis rosea work up
tests for syphilis if there are les then a few perfectly typical lesions or if there are any plantar, oral, or palmer lesions
pityriasis rosea DDx
tinea corporis (would have less lesions then p.r.)
lichen planus
psoriasis
pityriasis rosea tx
IF NO SYMPTOMS DO NOT TREAT!! it will go away in time
alleviate itch
topical steroids and oral antihistamines (clariton, benedril, zertec)
sunlight/phototherapy
Lichen Planus presentation
varying itch, flat topped, purple (violalceous) papules with white/gray fine streaks within lesions “wickham’s striae”
nail deformity, scarring alopecia
can occur on skin, scalp, nails, mucous membranes (check for oral lesions which are lacey white patches/network on buccal mucosa)
follows koebner phenomenon (occurs in areas of trauma)
lichen planus etiology
unknown
maybe associated with Hep C
lichen planus work up
biopsy
Hep testing
refer to oral surgeon if oral lesions
DDx lichen planus
drug eruptions that look “lichenoid” (looks like LP but is a drug rxn)
psoriasis, lichen simplex chronicus, syphilis
Tx lichen planus
can go away on its own 6mo-2 yrs but come back if stressed
- topical steroids -to alleviate itch and slow skin eruption
- systemic steroids if severe
- phototherapy
- plaquenil- antimalarial med-anti-inflammatory with few side effects
Drug Eruptions presentation
symmetric!!!! hives or bright papular rash starts proximally and moves distally occurs within 1 week of new medication discomfort/joint pain/fever/headache can occur
Drug eruptions etiology
- antibiotics -bactrim, penicillin, cephalosporins, sulfonamides*
- diuretics- furosemide
- NSAIDs (anti inflammatory)
- blood products during transfucions
examples of antibiotics that cause drug eruptions
bactrim, penicillin, sulfonamides, cephalosporins
example of diuretic that causes drug eruption
furosemide
DDx drug eruptions
Lichen planus
pityrisis rosea
urticaria
type 4? test for more Ig levels??
tx drug erruptions
-D/C (remove) suspected drug and it should clear after about 4 weeks
make sure replacement rx is not needed with the prescribing dr
-topical steroids / supportive care
Fixed Drug Eruption presentation
1 or more oval/annular red isolated patch that has a blister or necrotic tissue in center
itching, burning, pain
demarcated
common on lips hips sacrum genitals
took med PRN by mouth -exposure to drug causes lesion
lesion will come back to same spot if taken again, over time tho it will move somewhere else and the old lesion will lighten up
delayed about 2 weeks after drug taken
will last days-weeks and fade slowly but will leave hyperpigmented patch
if reexposed to meds it will appear 30 min -16 hrs
fixed drug eruption etiology
as needed meds
laxatives
pain relievers
antibiotics
fixed drug eruption work up
biopsy
drug eruption work up
biopsy- wont tell u specifically which drug tho
fixed drug eruption tx
- supportive tx for itch etc
- remove drug and it will resolve itself!
fixed drug eruption DDx
drug eruption lichen planus eczema pityriasis rosea psoriasis urticaria