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