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13.02.26 Psoriasis clinic

Drugs
    • Topical
    • Phototherapy
      • Psoralen + UVA (PUVA)
    • Methotrexate
    • Cyclosporine
    • Retinoids
      • Acitretin
    • Biologicals
      • Anti-TNF
        • Etanercept
        • Infliximab
        • Golimumab
      • Anti-IL-12/23
        • Ustekinumab


    PASI score - Out of 72

    Side-effects of biologicals

    • Malignancy
      • Lymphomas
      • Possibly melanomas
    • NOT benign tumours
    • Infection
      • cf Surgery

    Side-effects of other systemics
    • MTX
      • Liver fibrosis
        • cf Alcohol contraindicated
      • Skin lymphoma
      • Reactivation of latent TB
        • Check specifically for symptoms + do CXR before starting
    • Risk of downward trend in lymphocytes
    • Cyclosporine => Renal damage


    Pityriasis rosea
    • URTI may precede all other symptoms in as many as 69% of patients
    • A single, 2- to 10-cm oval red "herald" patch appears, classically on the abdomen
      • May occur in a 'hidden' position and not be noticed
    • 7-14 days after the herald patch, large patches of pink or red, flaky, oval-shaped rash appear on the torso
    • In 6% of cases an inverse distribution may occur, with rash mostly on the extremities
    • The more numerous oval patches generally spread widely across the chest first, following the rib-line in a characteristic "christmas-tree" distribution
    • Small, circular patches may appear on the back and neck several days later
    • It is unusual for lesions to form on the face, but they may appear on the cheeks or at the hairline
    • About one in four people with PR suffer from mild to severe symptomatic itching
    • The rash may be accompanied by low-grade fever, headache, nausea and fatigue

    Erythema multiforme
    • Skin condition of unknown cause
    • Possibly mediated by deposition of immune complex (mostly IgM) in the superficial microvasculature of the skin and oral mucous membrane that usually follows an infection or drug exposure
    • Common disorder; Peak incidence in the second and third decades of life
    • Presentation
      • Mild, self-limited rash to severe, life-threatening erythema multiforme major that also involves mucous membranes
        • May be related to Stevens–Johnson syndrome
      • Often takes on the classical "target lesion" appearance, with a pink-red ring around a pale center
      • Resolution within 7–10 days is the norm
    • Causes
      • Bacteria
        • BCG vaccination, haemolytic Streptococci, legionellosis, leprosy, Neisseria meningitidis, Mycobacterium, Pneumococcus, Salmonella, Staph, Mycoplasma pneumoniae, Chlamydia
      • Fungal
      • Parasitic
        • Trichomonas species, Toxoplasma gondii
      • Viral
        • Especially Herpes simplex
      • Drug reactions
        • Antibiotics (including sulphonamides, penicillin), anticonvulsants (phenytoin, barbiturates), aspirin, antituberculoids, allopurinol
      • Physical factors
        • Radiotherapy, cold, sunlight
      • Others
        • Collagen diseases, vasculitides, non-Hodgkin lymphoma, leukaemia, multiple myeloma, myeloid metaplasia, polycythemia


    Post-inflammatory change



    Ehlers–Danlos syndrome
    • Group of inherited connective tissue disorders caused by a defect in the synthesis of collagen (Type I or III)
    • Severity of the mutation can vary from mild to life-threatening
    • There is no cure, and treatment is supportive
      • Close monitoring of the digestive, excretory and particularly the cardiovascular systems
      • Physical therapy, bracing, and corrective surgery may help with the frequent injuries and pain that tend to develop in certain types of EDS


    Notes
    • Hydroxychloroquine
      • SLE
      • RA
      • Sjögren's
      • Porphyria cutanea tarda
    • Mycophenolate mofetil
      • For eczema, not psoriasis
    • Stopping and starting biologicals can => anti-drug antibodies
      • But must stop 1 month pre-surgery due to infection risk
    • DLQU index
    • Link between psoriasis + metabolic syndrome/weight gain
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