Mss 09: Inflammatory Disorders

Front 1

What family of steroids do topical corticosteroids belong to?

Back 1

Glucocorticoid family

Front 2

What is the mechanism of action of topical corticosteroids?

Back 2

1. Steroid hormone binds receptor in cytoplasm
2. Translocation of steroid-receptor complex to nucleus
3. Binding of complex to DNA regulatory site
4. Transcription
5. Translation
--> anti-inflammatory gene expression increased, also can prevent transcription of pro-inflammatory genes

Front 3

What are the side effects of topical corticosteroids?

Back 3

- Mainly restricted to area of application
- Hypopigmentation, hypertrichosis, skin atrophy, and telangiectasia (reversible)
- Stria (irreversible)
- Acne or perioral dermatitis (form of rosacea)
- Chronic use may increase risk of glaucoma and cataract

Front 4

How many classes of topical corticosteroids are there? Which are strongest/weakest?

Back 4

- Classes: I - VII
- Class I is the most potent, class VII is the weakest

Front 5

What are the "vehicles" of topical corticosteroids?

Back 5

- Ointment
- Cream
- Lotion and solution
- Foam
- Gel

Front 6

What are the pros and cons of ointment administration of topical corticosteroids?

Back 6

- Pros: occlusive barrier, better penetration, moisturizing
- Cons: greasy, patient non-compliance (texture of petroleum jelly)

Front 7

What are the pros and cons of cream administration of topical corticosteroids?

Back 7

- Pros: better patient compliance
- Cons: less potent for some steroids, can sting on open skin

Front 8

What are the pros and cons of lotion and solution administration of topical corticosteroids?

Back 8

- Pros: good for scalp and hair-bearing areas
- Cons: stinging
(same as foam)

Front 9

What are the pros and cons of foam administration of topical corticosteroids?

Back 9

- Pros: good for scalp and hair-bearing areas
- Cons: stinging
(same as lotions and solutions)

Front 10

What are the pros and cons of gel administration of topical corticosteroids?

Back 10

- Pros: good for intraoral use
- Cons: drying, stinging

Front 11

What measurement system is used to administer topical corticosteroids?

Back 11

"Fingertip unit" - stripe of medication from fingertip to DIP joint (0.5 g) - cover an area equivalent to an adult palm for 2 applications

Front 12

How do you estimate the amount of topical corticosteroid to prescribe?

Back 12

Use palm to estimate surface area involved and multiply by 15 g to get amount necessary for 1 month

Front 13

What are the inflammatory skin conditions?

Back 13

- Psoriasis
- Atopic Dermatitis
- Seborrheic Dermatitis
- Lichen Planus

Front 14

What is the cause / trigger of Psoriasis?

Back 14

- Immune-mediated, polygenic
- Trauma, infections, medications, etc may trigger disease in predisposed individuals

Front 15

What are the characteristic lesions in Psoriasis?

Back 15

- Well-demarcated erythematous papules and plaques
- Pinpoint to <20 cm in diameter
- Overlaying micaceous or silvery scale

Front 16

What are the clinical variants in Psoriasis?

Back 16

- Plaque psoriasis (most common, on extensor extremities)
- Inverse (flexural, axillae, groin, perineum, chest)
- Guttate psoriasis (numerous smaller lesions, often triggered by strep infection)
- Erythrodermic psoriasis (generalized erythema)
- Pustular psoriasis (broad patches of erythema and overlying pustules)

Front 17

What are the characteristics of Plaque Psoriasis?

Back 17

- Most common
- Symmetric
- Involves extensor elbows and knees most commonly
- Pink patches and plaques w/ overlying silvery scales

Front 18

What are the characteristics of Inverse Psoriasis?

Back 18

- Flexural locations
- Axillae, groin, perineum, chest

Front 19

What are the characteristics of Guttate Psoriasis?

Back 19

- Drop-like
- 2-10 mm (numerous and smaller)
- Symmetric trunk / proximal extremities
- Often triggered by Group A strep

Front 20

What are the characteristics of Pustular Psoriasis?

Back 20

- Pustules present on top of broad plaques of erythema
- May be localized to palms/soles or generalized
- Often cyclic
- Unexplained triggers

Front 21

What are the characteristics of Erythrodermic Psoriasis?

Back 21

- Generalized erythema
- Amount of scaling is variable
- Most severe

Front 22

How are nails affected by Psoriasis?

Back 22

- Pitting (pinpoint indentations)
- Thickening
- Yellow discoloration

Front 23

What non-cutaneous changes occur in Psoriasis?

Back 23

- Psoriatic arthritis (20-30%)
- Increased risk of metabolic syndrome
- Atherosclerotic CV disease

Front 24

What past medical history questions should be asked when suspecting Psoriasis?

Back 24

- Recent infections? --> trigger (Strep)
- Risk factors for HIV? --> worse dz
- Joint symptoms? --> arthritis common
- BMI? --> correlation between BMI and severity
- CV risk factors? --> increased risk
- Family hx (genetic predisposition, 1/3 have positive family hx)

Front 25

What medications can trigger or exacerbate Psoriasis?

Back 25

- Systemic corticosteroid withdrawal (especially pustular variant)
- Beta blockers
- Lithium
- Antimalarials
- Interferons

Front 26

What extracutaneous site may be affected DIRECTLY by psoriasis?

Back 26

Joints (20-30% affected by arthritis)
- Asymmetric oligoarthritis most common (knee, DIPs)
- Flexural deformities
- Pencil in cup deformity at MTP or MCP joints (tapering of bones)

Front 27

Which other ectodermal structures are most commonly affected by Psoriasis?

Back 27

Nails (25-50%)

Front 28

What is the Koebner phenomenon?

Back 28

Development of skin lesions at sites of injury (psoriasis)

Front 29

What is the Auspitz sign?

Back 29

Pinpoint bleeding points seen when scale removed (psoriasis)

Front 30

How should Psoriasis be treated?

Back 30

Depends on extent of disease:
- Localized / mild - topicals corticosteroids only (also retinoids, coal tar derivatives, calcineurin inhibitors (tacrolimus and pimecrolimus), topical vitamin D analogs)

- Generalized - combo therapy (systemic / phototherapy + topicals)
- Systemics: methotrexate, cyclosporine, acitretin, and biologics (target T cells and cytokines)
- TNF-alpha inhibitors: etancercept, inflixamb, adalimumab
- IL-12 and IL-12 inhibitors: ustekinumab

* AVOID Oral corticosteroids because withdrawal will cause psoriasis flare (often pustular)

Front 31

What topical corticosteroids are appropriate for face and groin?

Back 31

Weaker, class V - VI:
- Hydrocortisone 2.5%
- Aclomethasone
- Desonide
- Triagmcinolone 0.025%

Front 32

What topical corticosteroids are appropriate for body?

Back 32

Class III - IV
- Triamcinolone 0.1%
- Hydrocortisone valerate

Front 33

What topical corticosteroids are appropriate for hands and feet?

Back 33

Strong, Class I - II
- Betamethasone
- Diproprionate
- Clobetasol
- Fluocinonide

Front 34

What medications can be used for plaque type psoriasis? What are their side effects?

Back 34

- Topical steroids - skin atrophy, hypopigmentation, striae
- Tazarotene (topical retinoid) best w/ topical corticosteroids - skin irritation, photosensitivity
- Salicylic or Lactic Acid (keratolytic agents) that reduce scaling and soften plaques - systemic absorption can occur, decreases efficacy of UVB phototherapy
- Coal Tar - skin irritation, odor, staining of clothes

Front 35

What medications can be used for in combination with topical steroids for added benefit? Side effects?

Back 35

- Calcipotriene (vit. D derivative) - skin irritation, photosensitivity, no contraindication w/ UVB therapy
- Salicylic or Lactic Acid (reduces scaling and soften plaques - decreases efficacy of UVB therapy, systemic absorption can occur
- Tazarotene (topical retinoid) - skin irritation, photosensitivity

Front 36

What are Calcineurin inhibitors used for?

Back 36

- Tacrolimus and Pimecrolimus
- Off label use for facial and intertriginous psoriasis
- Can cause skin burning and itching

Front 37

What kind of phototherapy is used for psoriasis?

Back 37

- Narrowband UVB
- PUVA (psoralen + UVA)

Front 38

Patient has 4-week history of this facial eruption. Treated w/ 10 day course of cephalexin w/ no response. He occasionally scratches it but otherwise not bothered.

What is the diagnosis?

Back 38

Atopic Dermatitis

Front 39

What is the most common chronic inflammatory skin disease?

Back 39

Atopic Dermatitis (AD)

Front 40

When is the onset of Atopic Dermatitis?

Back 40

- Onset in infancy
- Delayed onset in adulthood may be seen
- Often w/ other disorders like allergic rhinoconjunctivitis and asthma

Front 41

What is a major predisposing factor to Atopic Dermatitis?

Back 41

Mutations in profillagrin gene (responsible for Ichthyosis Vulgaris - severe dry skin)

Front 42

What can commonly complicate Atopic Dermatitis?

Back 42

- Secondary infection w/ S. aureus - can aggravate AD by stimulating inflammatory cascade
- Rapid dissemination of Herpes Simplex Virus w/ areas of excema = Excema Herpeticum

Front 43

What are the characteristics of Atopic Dermatitis in infants?

Back 43

– Facial involvement predominates early – Tends to spare midface
– Oozing, crusting common
– Exacerbated by saliva, foods
– Extensor involvement late infancy
– Sparing of diaper area

Front 44

What are the characteristics of Atopic Dermatitis in childhood (>2yo to puberty)?

Back 44

– Distribution: flexural involvement, antecubital and popliteal fossae, wrists, ankles, neck, hands
– Less crusting

Front 45

What secondary change is specific to a chronic eczematous lesion?

Back 45

Lichenification (exaggerated skin lines)

Front 46

What physical exam finding may be seen in patients with Atopic Dermatitis?

Back 46

Dennie-Morgan Folds

Front 47

What are some potential complications of atopic dermatitis?

Back 47

- Infection
- Poor sleep (d/t itching)
- Failure to thrive

Front 48

How should you treat Atopic Dermatitis?

Back 48

- Topical corticosteroids - OINTMENTS, may add wet wrap to increase penetration (creams can sting)
- Immunomodulators (calcineurin inhibitors, tacrolimus, pimecrolimus)
- Anti-histamines (alleviate pruritus)
- Bleach baths to treat/prevent secondary infections
- Phototherapy (narrowband UVB)
- AVOD systemic steroids (rapid rebound)
- Systemic: Cyclosporine, methotrexate, mycophenolate mofetil, azathiprine

Front 49

What factors influence what topical corticosteroid to use for Atopic Dermatitis?

Back 49

- Duration of lesion: new will respond to weaker agents, chronic will need stronger agents
- Location of lesion: thin skin use lower strength d/t side effects, thicker skin use stronger strength to insure penetration/absorption

Front 50

What allergies are associated with Atopic Dermatitis?

Back 50

EGG allergy (greatest link to AD exacerbations)

Front 51

What mediates acute and chronic atopic dermatitis?

Back 51

- Acute: Th2 response (IL-4, -5, -10)
- Chronic: Th1 response (IFN-y, IL-12)