Psoriasis

Question 1

Psoriasis overview

Answer 1

-chronic autoimmune inflammatory dx
-mostly white ppl
-onset around 33yo
-may appear twice over a lifetime
-series of exacerbations and remissions

Question 2

Psoriasis patho

Answer 2

-rapid proliferation of keratinocytes
=thick-scaly white plaques
-believed to involve complex interplay between genetic and environmental factors
-immune dysregulation
-cytokine release
-vascular changes

Question 3

Immune dysregulation in psoriasis

Answer 3

-autoimmune
-immune cells attack skin cells
-Th17 cells and IL-23

Question 4

Cytokine release in psoriasis

Answer 4

-Th17 produce IL-17 and IL-22
=stimulate keratinocyte proliferation and inflammation

Question 5

Vasc changes in psoriasis

Answer 5

-inc inflammation
=blood vessels dilate
=leak fluid into skin
=redness/swelling

Question 6

Genetic predisposition psoriasis

Answer 6

-highly heritable
-multiple genes involved

Question 7

Psoriasis clinical presentation

Answer 7

-face
-armpit
-trunk
-groin
-nails
-knees
-elbows
-butt
-scalp

Question 8

Types of psoriasis

Answer 8

-plaque
-scalp
-psoriatic

Question 9

Psoriasis classifications

Answer 9

-limited <5% BSA
-mod: 5-10%
-severe: >10%

-20% have severe

Question 10

Psoriasis triggers

Answer 10

-stress!
-environement (cold)
-injury
-infection
-hormones
-smoking/EtOH
-air pollution
-drugs
-diet

Question 11

Psoriasis comorbidities

Answer 11

-70% of pt have at least one:
-psoriatic arthritis (1/3)
-inc risk of:
-CVD
-hyperlipidemia
-obesity
-HTN
-DM
-anxiety/depression

Question 12

Psoriasis goals of tx

Answer 12

-dec sx, BSA, swelling
-improve QOL
-clearing of lesions
-prolong periods between exacerbations
-topical>systemic

Question 13

Non-rx psoriasis tx

Answer 13

-sun
-bath
-emollients
-keratolytics (salicylic acid 2%)

Question 14

Psoriasis tx approach

Answer 14

-topical
-UV phototx
-systemic
-biologics

Question 15

mild-mod psoriasis tx

Answer 15

1. topical
   -add phototx or moisturizers if inadequate
   -add systemic agent if inadequate

Question 16

Mod-severe psoriasis tx

Answer 16

1. systemic (MTX) +/- topical or phototx (consider biologic if comorbidities exist)
   -switch. to more potent systemic agent or biolgic (can double up on systemic but rare) and add mositurizer if inadequate
   -biologic +/- other agents last-line

Question 17

Psoriasis topical tx

Answer 17

-most effective when used to tx localized plaques (<20% BSA)
-70% of pt receive only topical tx
-corticosteroids! (high potency)
-emolients (all pt)
-vit D analogs (no tachyphylaxis)
-cort + vit D (steroid sparing)
-cort + tazarotene (steroid sparing)
-calcineurin inhibitor (face and flexures)

Question 18

Topical steroids for psoriasis

Answer 18

-development of tolerance (tachyphylaxis)
-may alt w other topicals to avoid tolerance
-high potency
-mild potency after intial tx
-DO NOT use on face
-limit to <2weeks and <50g/week
-plastic wrap + T-shirt inc penetration for 6h

Question 19

Phototx

Answer 19

-limited and resistant plaques
-mild-mod w no response to topicals
-combo w biologic in severe
-role in mx tx

Question 20

Immunomodulatory effect of phototx

Answer 20

-UVA penetrates thicker lesions better than UVB
-NB-UVB better for initial tx, targets thinner lesions 2-3x week (better cost)

Question 21

phototx side effeccts

Answer 21

-UVA>UVB
-skin aging
-skin cancer

Question 22

Tx for severe psoriasis

Answer 22

1. biologic: (TNF, CTLA-4)
2. systemic tx (oral retinoid, cyclosporine, methotrexate)

Question 23

Oral systemic tx used in psoriasis

Answer 23

-apremilast (PDE-4)
-Azothioprine (immunosuppressant)
-MTX (immunosuppressant)
-Mycophenolate mofetil (immunosup)
-cyclosporine (calcineurin inhibitor)
-tofactinib (JAK inhibitor, psoriatic arthritis)

Question 24

Biologics for psoriasis

Answer 24

-TNF
-IL-17
-IL-12/23

Question 25

TNFs for psoriasis

Answer 25

-certolizumab -enteracept -adalimumab -inflixumab -golimumab (psoriatic arthritis only)

Question 26

IL-17 for psoriasis

Answer 26

-secukinumab -brodalumab (psoriasis only) -ixekizumab

Question 27

IL-12/23 for psoriasis

Answer 27

-tildrakiumab (psor only) -risankinumab (psor only) -ustekinumab -guselkumab

Question 28

Biologic considerations

Answer 28

-$$$$ -PA and step tx usually required -reserve for pt w extensive, mod-severe dx who have failed other tx -well tolerated -monitor for infections/bleeding -many pt will require supplemental topicals!! -AVOID live virus vax

Question 29

Psoriasis tx once controlled

Answer 29

-general measures +/- emollients -topical again -some dermatologists use continuous tx