PSORIASIS

Histology

100

Justify the utility of a punch biopsy in diagnosing psoriasis

Differentiation from Other Conditions: Psoriasis can sometimes mimic other skin disorders like eczema, lichen planus, or cutaneous lupus. A punch biopsy allows for a detailed examination of the skin layers under a microscope, helping to distinguish psoriasis from these other conditions

• Confirmation of Diagnosis: While psoriasis is often diagnosed based on clinical examination, a biopsy can provide definitive confirmation. This is particularly important in atypical cases where the visual symptoms alone are not conclusive

• Assessment of Disease Severity: The biopsy can reveal the extent of inflammation and other histological features, which can help in assessing the severity of the disease and guiding treatment decisions

• Rule Out Other Pathologies: By examining the skin sample, doctors can rule out other potential causes of the symptoms, ensuring that the treatment plan is appropriate for psoriasis and not another underlying condition.
  
  

200

Which specific layer of the epidermis is thin in psoriasis  

The stratum granulosum is thinned or absent, and extensive overlying parakeratotic scale is seen

300

Explain the cause for the "spongiform pustules" found with plaque psoriasis 

The accumulation of neutrophils in the superficial epidermis is indicating that the immune system is mistakenly attacking healthy skin cells, leading to the rapid turnover of skin cells and the formation of these pustules

400

Both teams - Draw on the board!!!

Identify and explain the function and contents of the layers within the epidermis 

(see pic for reference) 

1. Stratum Basale (Stratum Germinativum):

   • This is the deepest layer of the epidermis.
   • It contains basal cells that continuously divide to form new skin cells.
   • Melanocytes, which produce the pigment melanin, are also found here.

2. Stratum Spinosum:

   • Located above the stratum basale.
   • This layer consists of keratinocytes held together by desmosomes, which give the skin its strength and flexibility.
   • It is sometimes referred to as the “prickle cell layer” due to the spiny appearance of the cells under a microscope.

3. Stratum Granulosum:

   • Positioned above the stratum spinosum.
   • Cells in this layer contain keratohyalin granules, which help form a waterproof barrier.

4. Stratum Lucidum:

   • Found only in the thick skin of the palms and soles.
   • This thin, clear layer helps reduce friction between the stratum granulosum and the stratum corneum.

5. Stratum Corneum:

   • The outermost layer of the epidermis.
   • Composed of dead keratinocytes (corneocytes) that provide a tough, protective barrier.
   • This layer is responsible for the skin’s ability to shed and renew itself.

500

List two histological features indicative of psoriasis not previously mentioned

1. Parakeratosis: This is the presence of nuclei in the stratum corneum, which is normally anucleate
2. Acanthosis: This refers to the thickening of the epidermis, particularly the prickle cell layer (stratum spinosum)
3. Absence of the Granular Layer: The stratum granulosum is typically absent or significantly reduced in psoriatic lesions
4. Munro’s Microabscesses: These are small collections of neutrophils within the stratum corneum
5. Spongiform Pustules of Kogoj: These are collections of neutrophils within the epidermis.
6. Dilated Blood Vessels: The dermal papillae often show dilated and tortuous blood vessels
7. Inflammatory Infiltrate: There is a presence of T lymphocytes, particularly CD4+ cells in the dermis and CD8+ cells in the epidermis

Drugs

100

Explain how the components of calcipotriene-betamethasone cream works 

1. Calcipotriene: A synthetic form of vitamin D that helps to slow down the growth of skin cells it helps to prevent the buildup of scales and reduces the thickness of plaques
2. Betamethasone: A corticosteroid that reduces inflammation, redness, and itching.

200

Explain the rationale behind avoiding sudden discontinuation of steroid topicals 

1. Adrenal Insufficiency: Long-term steroid use suppresses the adrenal glands’ ability to produce cortisol, a vital hormone for stress response, metabolism, and immune function. Stopping steroids suddenly can cause adrenal insufficiency, where the body doesn’t produce enough cortisol, leading to symptoms like fatigue, weakness, nausea, and low blood pressure

2. Withdrawal Symptoms: Abrupt discontinuation can result in withdrawal symptoms such as joint pain, muscle stiffness, fever, and general malaise. These symptoms occur because the body needs time to adjust and resume normal cortisol production

3. Risk of Flare-Ups: For conditions like psoriasis, asthma, or rheumatoid arthritis, stopping steroids suddenly can cause a rebound effect, leading to a flare-up of the underlying condition

300

Draw on the board!!!

Make a T Chart discussing the pros and cons of:

 Team 1: immune modifying drugs including biologics such as ustekinumab 

Team 2: topical calcineurin inhibitors such as tacrolimus

check table 

400

Relate the progression of psoriasis symptoms to the appropriate treatments

• Mild Psoriasis: Topical treatments and moisturizers.
• Moderate Psoriasis: Topicals, phototherapy, and systemic treatments.
• Severe Psoriasis: Biologics, systemic treatments, and combination therapy.
• Acute Flare-Ups: Hospitalization, systemic steroids, and biologics.

500

List and explain adjuvant and integrative approaches for treating psoriasis 

check table

S&S

100

What are some of the most common affected areas in psoriasis?

Elbows, knees, scalp, lumbrosacral, intergluteal folds 

200

Both Teams - Draw on the board!!

Name at least two nail changes seen with psoriasis 

 yellow-brown discoloration (often likened to an oil slick)

pitting, dimpling

separation of the nail plate from the underlying bed (onycholysis)

 thickening and crumbling

300

Describe what is meant by "erythodema" seen in psoriasis

Erythrodermic psoriasis is a rare and severe form of psoriasis characterized by widespread redness and scaling of the skin. 

1. Extensive Redness: The skin becomes intensely red and inflamed, often covering large areas of the body
2. Peeling and Scaling: The affected skin peels off in large sheets, and there is significant scaling

400

Relate how the clinical presentation of psoriasis can effect a patient's quality of life

1. Pain and Discomfort
2. Physical Limitations: Severe forms, such as psoriatic arthritis, can cause joint pain and stiffness, limiting mobility and daily activities.
3. Sleep Disturbances

Emotional and Psychological Impact

1. Self-Esteem and Body Image: Visible lesions, especially on exposed areas like the face and hands, can lead to self-consciousness and low self-esteem.
2. Social Isolation: Fear of stigma and negative reactions from others can cause patients to withdraw from social interactions.
3. Mental Health: The chronic nature of the disease and its visible symptoms can lead to anxiety, depression, and stress

500

What is the koebner phenomenon?

The Koebner phenomenon, also known as the isomorphic response, is a reaction where new skin lesions appear on previously healthy skin following trauma or injury.

(local inflam response that becomes self-perpetuating) 

Pathophys

100

What is the prevalence of psoriasis in the US and what are some risk factors/comorbidities that may present? 

1-2% of US (Robbins)

Comorb: Arthritis, myopathy, enteropathy, AIDS

Risk Factors: Genetics, obsesity, stress, trauma, medications like beta blockers 

200

T cells create an abnormal microenvironment by stimulating secretion of cytokines and growth factors that induce _____ proliferation, leading to psoriatic lesions 

keratinocytes

300

CD4+ and CD8+ T cells, dendritic cells, and keratinocytes create a "cytokine soup", dominated by:

(think inflamation) 

Th1, Th17 cytokines

IL-12, IL-17

TNF-A

400

What is a commonly associated genetic variation associated with psoriasis and downstream effects of these variations?

HLA variations

The Human Leukocyte Antigen (HLA) system is a group of genes located on chromosome 6 that play a crucial role in the immune system by helping the body distinguish between self and non-self molecules. These genes are highly polymorphic, meaning they have many different variants, which allows for a diverse range of immune responses.

Key HLA Gene Variants:

1. HLA Class I Genes: They present peptides from inside the cell (such as viral proteins) to cytotoxic T cells (CD8+ T cells)
2. HLA Class II Genes: They present extracellular peptides to helper T cells (CD4+ T cells)

Sensitized populations of CD4 and activated CD8 cause T cells to accumulate in epidermis

500

Both teams- Draw on the board!!!

Relate the pathophysiology of psoriasis to the presentation of clinical symptoms 

Team 1: Focus/elaborate on acute 

Team 2: Focus/elaborate on chronic 

The immune system’s overactivity in psoriasis leads to chronic inflammation and rapid skin cell turnover, which manifest as the characteristic red, scaly plaques, itching, pain, and other symptoms.

• Chronic Psoriasis: Long-term, persistent with periods of remission and flare-ups.
• Acute Psoriasis: Sudden, severe outbreaks often triggered by external factors

5th Grade

100

A word, phrase, or sequence that reads the same forward and backward is called what?

 A palindrome

200

The Tropic of Capricorn lies in which hemisphere?

Southern Hemisphere

300

What is the capital of Australia?

Canberra

400

Between 1 and 100, how many multiples of 7 are odd numbers?

7

500

Who is the only singer to win the Grammy Awards for Album, Record, and Song of the Year twice? Both of the winning albums had titles that were two-digit numbers.

Adele