PAPULOSQUAMOUS

Kodas

100

Name the disorder

PRP (pityriasis rubra pilaris)

• Biphasic incidence: 10-20 yo then 60 yo

• Mostly acquired, but inherited forms are associated with what mutations? CARD14 and PSORS2

• Clinical features:

• Perifollicular hyperkeratosis on an erythematous base (nutmeg grater)

• Papules coalesce into orange to salmon plaques with islands of sparing on trunk and extremities- can progress to erythroderma and exfoliation

• 6 subtypes

200

Name this disease

PLEVA (pityriasis lichenoides et varioliformis acuta)

• Rapid onset of widespread pink papules, evolves in vesicular, ulceronecrotic, purpuric, and crusted papules, heals with varioliform scars

• Associated with high TNF-alpha levels
  
  PLEVA and PLC on two ends of disease spectrum

• Affect children more, male predominance

• PLEVA= crusted and occasionally vesiculopustular

• Associations with HIV, parvo B19, medications (estrogen, progesterone, TNFi, statin, contrast dye)

300

Name this disease

PLC - pityriasis lichenoides chronica

• Widespread, scaly, red-brown scaly papules and plaques

• Resolves with hypopigmentation 

• Lasts longer than PLEVA

• More common in adults

• Distribution is important

• Diffuse distribution = shorter avg duration (11 mo)

• Peripheral distribution = longest avg duration (33 mo)

• Central distribution = intermediate duration

400

Name this disease

Small plaque parapsoriasis 

• SPP: <5cm lesions

• LPP: >5cm lesions

• Predominantly CD4 T cell infiltrates

• Carries risk of progressing into MF: LPP >SPP

• Unclear if they are true entities vs condition on the spectrum of clonal dermatitis

• M>F 3:1

• Fifth decade of life

500

This patient had erythrodermic psoriasis and then developed this finding. What was the medication?

Cyclosporine

Side effects include: 

-nephrotoxicity

-HTN

-gingival hyperplasia

-hair growth

- Increased K, decreased Mg

-GI , neuro symptoms

600

What is this disorder?

Sneddon-Wilkinson / Subcorneal pustular dermatosis

-crops of sterile subcorneal vesicles/pustules with erythematous base, often annular, on flexural skin

-different from pustular psoriasis! *Has subcorneal pustules in the ABSENCE of spongifrm pustules and epidermal changes of psoriasis

-*great response to dapsone

Biopsy: subcorneal pustule with neutrophils. Normal surrounding epidermis

700

This patient has high fever, LAD, arthritis, GI, pulm involvement. What is the eponym?

Mucha Habermann (febrile ulceronecrotic) variant of PLEVA

-fevers, LAD, arthritis, GI/pulm involvement

More Kodas

100

What is this, and what is a common trigger?

Guttate psoriasis --Group A Strep or URI

-MC in kids. Favors trunk, proximal extremities

-40% will progress to plaque stage

200

Name this variant:

Inverse psoriasis

-breasts, groin, buttock, axillae

300

Name this clinical finding and one disease that causes it!

Pityriasis amiantacea 

--Psoriasis is the most common cause

Other causes: seborrheic dermatitis, secondarily infected AD, and tinea capitis

400

What is on the differential for this patient? (name 2)

Erythrodermic psoriasis

-DDX includes Sezary, PRP, drug reaction, seb derm 

500

Name the disease and 2+ findings in this photo

NAIL PSORIASIS

• Proximal matrix: pits

• Distal matrix: leukonychia, hyperkeratosis

• Nail bed: oil spots, onycholysis, hyperkeratosis

600

 What is name of this variant?

ACRODERMATITIS CONTINUA OF HALLOPEAU 

-rare

-lakes of pus

-leads to scale, crust, nail shedding

700

What psoriasis variant has this associated finding?

(extra credit- what is this presentation called?)

Associated with pustular psoriasis 

Annulus migrans of the tongue

Meds

100

Name a combined IL-12/23 inhibitor

Ustekinumab (Stelara)

200

Name two IL-17 inhibitors 

ixekizumab (Taltz), secukinumab (Cosentyx), brodalumab (Siliq)

300

Name two IL-23 inhibitors (NOT involving IL-12)

Tildrakizumab (Ilumya), Risankizumab (Skyrizi), Guselkumab (Tremfya)

400

Treatment that (maybe) hastens clearance of pityriasis rosea?

Oral erythromycin 

500

Laser wavelength that can treat small areas of psoriasis

308nm

Excimer laser

-good for small areas, nail psoriasis

600

Treatment of choice for Sneddon-Wilkinson (subcorneal pustular dermatosis)?

DAPSONE

--resolution usually within 4 weeks, then taper

700

Treatment of choice for this condition:

ACITRETIN

Best for Pustular (von Zumbusch) variant (better than cyclosporine, MTX, biologics)

More meds

100

What systemic medication for psoriasis is NOT immunosuppressive?

Apremilast (Otezla)

--PDE4-inhibitor

--Side effects of diarrhea, weight loss, depression, and insurance issues

200

Which topical steroid is indicated for ONCE daily use

Mometasone 

(the others are BID)

300

Name two contraindications to cyclosporine

Immunosuppression

Malignancy history

Active infection

Uncontrolled HTN

Concurrent infection

400

One drug and one infectious trigger of pityriasis rosea?

DRUG: ACE-inhibitors, NSAIDs, gold, bismuth, B-blockers, barbituates, isotretinoin, metronidazole, clonidine

INFECTIOUS: HHV-6, HHV-7

500

Lab abnormalities in generalized pustular psoriasis? (give me one of three)

Hypocalcemia, hypoalbuminemia, leukocytosis

600

Name two CONTRAINDICATIONS to Acitretin

Acitretin (soriatane) is an amazing option for pustular psoriasis and is great in older patients. Takes 3 months to see effect.

Do not use if:

PREGNANCY

Severely impaired liver function

Chronically elevated blood lipids

In combo with tetracyclines or MTX

700

In addition to topical steroids, what are two topical medications that can be used for psoriasis (separately or in combination)

Calcipotriene + tazarotene has similar efficacy as clobetasol

Synergistic effect by combining drugs with different mechanisms of action

(JAAD 2002)

Also true for calcipotriene + betamethasone (works better together than separate) = taclonex

Path party

100

Name 2+ pathology findings in psoriasis

Regular bulbous club shaped acanthosis

Thin suprapapillary plates 

Alternating neutrophils and parakeratosis in stratum corneum = sandwich sign

Little to no serum in stratum corneum

Neutrophilic spongiform pustules

Little spongiosis in adjacent epidermis

200

Describe the Auspitz sign

Pinpoint bleeding when you scrape psoriasis scale due to dilated capillaries and suprapapillary plate thinning 

300

Differential diagnosis for neutrophils in the stratum corneum (name 4 of 6)

PTICSS

• Psoriasis 

• Tinea 

• Impetigo

• Candida

• Seborrheic dermatitis

• Syphilis

400

Differential for this finding: (name 4 of 7)

Subcorneal pustules: CATPISS

• Candida

• Acropustulosis of infancy

• Transient neonatal pustular melanosis

• Pustular psoriasis

• Impetigo

• Sneddon-Wilkinson (and IgA pemphigus) 

• Staph scalded skin syndrome

500

Name the disease

PRP

Checkerboard alternating ortho and para

Follicular hyperkeratosis with parakeratosis in shoulder of follicular plug  

600

What is this disease?

Granular parakeratosis

• Affects intertriginous areas including axillae > inguinal fold, inframammary area, abdominal folds

• Infantile form – diaper area

• Pathogenesis: likely irritation induces parakeratosis and failure of degradation of keratohyalin granules in patients with underlying cornification defects

• Has been linked to defect in processing of profilaggrin to filaggrin

• Most commonly middle-aged women

• Pruritic

Pathology: 

Marked compact parakeratosis 

Small blue-gray granules in stratum corneum = keratohyaline granules

700

What is this and what might you see on path?

Pityriasis rosea

• Herald patch: initial solitary lesions appears on the trunk and enlarges over several days; may be multiple

• In the next few days, numerous small thin papules and plaques

• “Christmas tree pattern” or “fir tree pattern” – long axis of oval lesions following Langer’s lines of cleavage on back

• May see minute pustules

• Involves trunk and proximal extremities, spares face, palms and soles

• +/- HHV6, HHV7

PATH: focal mild spongiosis, mound-like (focal, non-confluent) parakeratosis, and extravasated erythrocytes are characteristic and a clue to this diagnosis when considering other causes of spongiotic dermatitis that may appear similar clinically, such as nummular dermatitis

Random Rumba

100

Strongest HLA association in psoriasis?

HLA-Cw6

200

What antimicrobial peptides are secreted from keratinocytes? (name one)

hBD 1-2, cathelicidin LL-37

300

Through what pathway does coal tar work?

Aryl hydrocarbon receptor (taparinof is an upcoming drug to target this)

400

Name two systemic diseases associated with psoriasis

Increased risk for cardiovascular disease, obesity, hypertension, diabetes, NASH, and IBD (share HLA-B27 type)

500

What is the most important song to listen to today?

600

What cytokine is decreased in psoriasis?

IL-10

700

Name three medications associated with development of psoriasis:

• Short latency <4 weeks? Terbinafine, NSAIDs

• Intermediate latency 4-12 weeks? Antimalarials, ACE-I

• Long latency >12 weeks? Beta-blockers, lithium

• Which trigger pustular psoriasis or plaque psoriasis flares? Lithium, Beta-blockers, IFNs, TNF-alpha inhibitors, antimalarials, taper of systemic steroids

• What can TNF alpha inhibitors induce? May lead to plaque psoriasis and/or palmoplantar psoriasis