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JoAnne M. LaRow, D.O. Psoriasis, Seb Derm, Pustular Psoriasis, etc. P214-239 ANDREWS’ DISEASES OF THE SKIN. Seborrheic dermatitis. 2- 5 % of the population Chronic, superficial, inflammatory disease of the skin

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joanne m larow d o psoriasis seb derm pustular psoriasis etc

JoAnne M. LaRow, D.O.Psoriasis, Seb Derm, Pustular Psoriasis, etc.




seborrheic dermatitis
Seborrheic dermatitis
  • 2- 5 % of the population
  • Chronic, superficial, inflammatory disease of the skin
  • Predilection for the scalp, eyebrows, eyelids, nasolabial creases, lips, ears, sternal area, axillae, submammary folds, umbilicus, groin, and gluteal crease
  • Characterized by scanty, loose, dry, moist, or greasy scales, and by crusted pink or yellowish patches of various shapes and sizes
clinical features
Clinical features
  • Remissions and exacerbations
  • No to mild itching
  • On the scalp is the most common
  • Pityriasis steatoides – oily type, accompanied by erythema and accumulation of thick crust
  • Frequently spreads beyond the scalp
seborrhea seborrheic dermatitis
Seborrhea & Seborrheic Dermatitis
  • Occurs predominantly in areas with active sebaceous glands
  • Often assoc with sebum overproduction
  • But the amount of sebum produced does not seem to be decisive risk factor
  • P. acnes has been found to be greatly reduced in seborrheic dermatitis
  • Therefore may be linked more to a major imbalance of microbial flora
Extreme cases involve the entire scalp and may have an offensive odor
  • Cradle cap
  • Marginal blepharitis – edges of the lids becoming erythematous and granular. Conjunctiva may be injected
  • On and in the ears may be mistaken for otitis externa caused by a fungal infection
  • KOH –
The presternal area is a favored site on the trunk
  • Common in the groin and the gluteal crease
  • In acute stages the inflammation may be intense, with moist exudation from the scalp and ears and papulovesicles on the palms and soles. Secondary infections, impetiginization, or furunculosis may ensue
May progress to a generalized exfoliative state
  • In the newborn this type of severe and generalized seborrheic dermatitis is known as erythroderma desquamativum
  • May be associated with or accentuated by several internal diseases
  • Parkinson’s, HIV, DM,
etiology and pathogenesis
Etiology and pathogenesis
  • Remains unresolved
  • Genus Malassezia comprises 7 species
  • Presence of lipophilic yeast Malassezia furfur (Pityrosporum ovale) in large numbers in scalp lesion
  • Also demonstrated in those without seborrheic dermatitis
  • Healthy individuals have been found to have higher IgG antibodies to the organism
  • No simple stoichometric relationship between yeast # & severity of seb derm
The significance of M. furfur in infantile seborrheic dermatitis has not been fully evaluated
  • Familial tendency toward infantile and adult seborrheic dermatitis
  • Epidermis is acanthotic
  • There is overlying focal scale crust often adjacent to follicular ostia
  • Slight spongiosis
  • Adult seb derm has superficial perivascular & perifollicular lymphocytic infiltrate composed mainly of lymphocytes
  • Older lesions show irregular acanthosis & focal parakeratosis
  • Histo features are combination of psoriasis & spongiotic derm
differential diagnosis
Differential diagnosis
  • Psoriasis, heavier scale and erythema, Auspitz’s sign, resistance to treatment, nail involvement
  • Crusted scabies of the scalp in immunodeficiency syndromes
  • Otitis externa, blepharitis, tinea corporis, pityriasis rosea, keratosis lichenoides chronica
treatment adolescent adult
Treatment-Adolescent & Adult
  • Regular use of medicated shampoos: sulfide, tar, zinc, pyrithionate, resorcin shampoos
  • Nizoral shampoo & cream
  • Loprox shampoo & solution
  • Elidel cream
  • Corticosteroid solution
  • If pruritus problematic intermittent use of topical steroid scalp solutions & foams
  • Pts with severe scale may need coal tar-salicylic acid preparations
Cortisporin otic usually brings about prompt clearing
  • Desonide Otic Lotion, 0.05% Desonide and 2% acidic acid is also effective
  • Topical steroids should not be used for blepharitis, since steroid preparations used in area may induce glaucoma and cataracts
infantile seborrheic dermatitis
Infantile seborrheic dermatitis
  • Responds well to topical therapy
  • Hydrocortisone 1% on the face & skin folds
  • This may be combined with an antifungal agent for skin folds
  • Mid-potency topical steroid (betmethasone valerate 0.05%) may be required for trunk & limbs if 1% hydrocor. Fails
  • Remove scale after softening with an oil preparation or a weak keratolytic agent
  • Application of hydrocortisone will prevent reappearance of erythema & re-accumulation of scalp scale
  • A common, chronic, recurrent, inflammatory disease of the skin characterized by round, circumscribed, erythematous, dry, scaling plaques of various sizes, covered by grayish white or silvery white, imbricated and lamellar scales
  • Predilection for the scalp, nails, extensor surfaces, elbows, knees, umbilical, and sacral region
Typically symmetrical
  • May be a solitary macule to more than 100
  • Usually develops slowly but may be exanthematous, with a sudden onset of numerous guttate lesions
  • Subjective symptoms such as itching or burning may be present and cause extreme discomfort
Scales are micaceous
  • Auspitz’s sign may be observed
  • Annular, lobulated, and gyrate figures may be produced
  • Old patches may be thickened and tough, and covered with lamellar scales like the outside of an oyster shell – psoriasis ostracea
Various other descriptive terms
  • Psoriasis guttata
  • Psoriasis follicularis
  • Psoriasis figurata, psoriasis annulata, psoriasis gyrata
  • Psoriasis discoidea
  • Psoriasis rupioides
  • Plaque psoriasis
seborrheic like psoriasis
Seborrheic-like psoriasis
  • In some cases of psoriasis prominent features of seborrheic dermatitis may occur not only if the typical sites of psoriasis vulgaris but also in the flexural areas such as the antecubital areas, axillae, under the breasts, groins, umbilicus, and intergluteal areas
  • Sebopsoriasis or seborrheic psoriasis
inverse psoriasis
Inverse psoriasis
  • Flexural psoriasis or volar psoriasis
  • Selectively and almost exclusively involves folds, recesses, and flexural surfaces
  • Scalp quite often participates as well
  • Onycholysis, “Oil spots”, and nail pitting may be seen
napkin psoriasis
“Napkin” psoriasis
  • Diaper dermatitis caused by the irritative effects of urine in the wet diaper area, may imitate a psoriasiform eruption
  • In addition there is commonly an infection with Candida albicans
  • Lesions typically clear
  • Infants may be at risk for psoriasis in adulthood
psoriatic arthritis
Psoriatic arthritis
  • The incidence of psoriasis is 10 times greater in persons with seronegative arthritis than in persons without arthritis
five clinical patterns
Five clinical patterns
  • Asymmetrical distal interphalangeal joint involvement with nail damage, 16%
  • Arthritis mutilans with osteolysis of phalanges and metacarpals, 5%
  • Symmetrical polyarthritis-like rheumatoid arthritis, with claw hands, 15%
  • Oligoarthritis with swelling and tenosynovitis of one or a few hand joints, 70%
  • Ankylosing spondylitis alone or with peripheral arthritis, 5%
Radiographic findings suggestive of psoriatic arthritis include: erosion of terminal phalangeal tufts, tapering of phalanges or metacarpals, “cupping’ of proximal ends of phalanges, , bony ankylosis, osteolysis of metatarsals, predilection for distal and proximal interphalangeal joints, paravertebral ossification, asymmetrical sacroiliitis, and rarity of “bamboo spine”when the spine is involved
  • Nearly half the patients with psoriatic arthritis have HLA-B27
Rest, splinting, passive motion, and aspirin or NSAIDs are appropriate
  • Methotrexate, cyclosporine, oral retinoids, sulfasalazine, tacrolimus, etanercept, and PUVA are all likely to help both the psoriasis and arthritis
  • Systemic steroids however, the long term complications and potential for rebound in cutaneous disease restricts their use
guttate psoriasis
Guttate psoriasis
  • This distinctive form of psoriasis typical lesions are the size of water drops
  • Usually occurs as an abrupt eruption following some acute infection, such as streptococcal pharyngitis
  • Occurs mostly in patients under age 30
  • Recurrent episodes are likely, because of pharyngeal carriage of the responsible streptococcus
  • This type of psoriasis is usually rapidly responsive to topical steroids or UVB
generalized pustular psoriasis von zumbusch
Generalized pustular psoriasis(von Zumbusch)
  • Typical patients have had plaque psoriasis and often psoriatic arthritis
  • The onset is sudden, with formation of lakes of pus periungally, on the palms, and at the edge of psoriatic plaques
  • Pruritis and intense burning cause extreme discomfort
  • There is a fever, and a fetid odor develops
  • The pustules dry up to form yellow-brown crusts over a reddish-brown shiny surface
generalized pustular psoriasis von zumbusch45
Generalized pustular psoriasis(von Zumbusch)
  • Mucous membrane lesions are common on the tongue and in the mouth
  • The lips are red and scaly, and superficial ulcerations of the tongue and mouth occur
  • May go through several stages
  • A number of cases of acute respiratory distress syndrome associated with pustular and erythrodermic psoriasis have been reported
  • Systemic complications include pneumonia, CHF and hepatitis
generalized pustular psoriasis von zumbusch46
Generalized pustular psoriasis(von Zumbusch)
  • Etiology unclear
  • Iodides, coal tar, steroid withdrawal, terbinafine, minocycline, hydroxychloroquine, acetazolamide, and salicylates may trigger the attacks
  • May occur in infants
  • Acitretin is drug of choice, with a rapid and predictable response
  • Isotretinoin, cyclosporine, methotrexate, dapsone
  • The course of psoriasis is unpredictable
  • Usually begins on the scalp or elbows
  • May first be seen over the sacrum
  • Onset may be sudden and widespread
  • First lesions may be limited to the fingernails
  • Two of the chief features of psoriasis are its tendency to recur and persist
However, patients may remain completely free of lesions for years
  • Koebner’s phenomenon – the appearance of typical lesions of psoriasis at sites of eve trivial injury
  • Auspitz’s sign – pinpoint bleeding when the psoriatic scale is forcibly removed, this occurs because of severe thinning of the epidermis over the tips of the dermal papilla
  • Woronoff ring – is concentric blanching of the erythematous skin at or near the periphery of the healing psoriatic plaque
On the scalp absence of itching or hair loss, marked predilection for frontal scalp margin, deep erythema, and resistance to effective therapy for seborrheic dermatitis all suggest psoriasis
  • The palms and soles are often, sometimes exclusively, affected
  • “flexural” or inverse psoriasis shows salmon-red, demarcated plaques that frequently become eczematized, moist and fissured
Numerous cases of psoriasis of the mucous membranes have been reported
  • Fingernails and toenails may be involved. Characteristic changes include pits, onycholysis and cracking of the free edges
  • Many studies report an association of hepatitis C and psoriasis
  • Hepatitis C has also been implicated in psoriatic arthritis
  • The cause of psoriasis is still unknown
  • Heredity is of significance in some cases
  • Evidence that susceptibility to psoriasis is linked to class I and II major histocompatibility complex on human chromosome 6 (17q)
  • HLA associations include -Cw6, -B57, and -DR7 for early onset and -Cw2 for late onset psoriasis
It is believed also that any individual that has –B13 or –B17 has a fivefold risk of developing psoriasis
  • In pustular psoriasis HLA-B27 may be seen
  • -B13 and -B17 are increased in guttate and erythrodermic psoriasis
  • Equal frequency in both sexes
  • Mean age of onset is 27 years, range is wide
  • Sunlight improves
  • Emotional stress aggravates
  • 39% of patients experience complete periodic disappearance of psoriasis during its course
  • Seen in 1-2% of US population. Not seen in Native Americans
Distinct tendency to improvement with pregnancy
  • Exacerbation is common after childbirth
  • Characterized by three main pathogenic features: abnormal differentiation, keratinocyte hyperproliferation and inflammation
  • Accelerated epidermopoiesis has been considered to be the fundamental pathologic event in psoriasis
  • The transit rate of psoriatic keratinocytes is increased, and the deoxyribonucleic acid synthesis time is decreased
Early lesion are infiltrated predominantly by lymphocytes in the papillary dermis
  • The cause of T-lymphocyte activation and the role of these cell populations remains unclear
  • Studies have shown a positive correlation between stress and the severity of disease
drug induced psoriasis
Drug-induced psoriasis
  • May be induced by many drugs: beta blockers, lithium, and antimalarials, terbinafine, calcium channel blockers, captopril, glyburide, and lipid lowering agents such as gemfibrozil
  • Regular epidermal hyperplasia with long, test-tube-shaped rete ridges
  • Thinning of dermal papillae
  • Granular layer is thin or absent
  • Overlying parakeratosis
  • Small collections of neutrophils (Munro microabcesses) may be present in the stratum corneum
  • There is a perivascular mononuclear cell infiltrate
differential diagnosis65
Differential diagnosis
  • Seborrheic dermatitis, pityriasis rosea, lichen planus, eczema, psoriasiform syphilid, and lupus erythematosis
  • Distribution, quality of the scale and presence of Auspitz’s sign, symptoms, serologic testing
  • Topical
  • Systemic
  • Combination
  • Rotating therapeutic approaches, especially with systemic agents that have varying toxicities
topical treatment
Topical treatment
  • In many patients topical applications alone will suffice to keep psoriasis under control. Numerous local medications are available
  • Most frequent therapy
  • Ointments are more effective
  • Creams are preferred in the intertriginous areas and in exposed areas
  • Effectiveness may be augmented by an occlusive dressing, prompt response is usually noted
  • Side effects include miliaria, pyoderma, epidermal atrophy
Intralesional corticosteroid injections
  • Good results when treating psoriatic nails
  • The staining property and the odor of the tars may hinder their use
  • Coal tar or liquor carbonis detergents is applied to the lesions before ultraviolet treatment in the Goeckerman method
  • Anthralin exerts its direct effect on keratinocytes and leukocytes by suppressing neutrophil superoxide generation and inhibition of monocyte derived IL-6, IL-8, and TNF-alpha
  • Highly irritating and stains skin, clothing and bedding
  • Appears to treat psoriasis by modulating keratinocyte differentiation and hyperproliferation, as well as suppressing inflammation
  • Produces local irritation
  • Combination with topical corticosteroids aids in patient acceptance
vitamin d
Vitamin D
  • Vitamin D3 affects keratinocyte differentiation partly through its regulation of epidermal responsiveness to calcium
  • Has been shown to be very effective in the treatment of plaque-type and scalp psoriasis
  • Combination therapy with high-potency steroids may provide greater response
salicylic acid
Salicylic acid
  • Aids in removing of the scale and promoting the efficacy of other topical agents
  • Usually in a 3% to a 5% concentration
  • Widespread application may lead to salicylate toxicity
  • Tinnitus, acute confusion, refractory hypoglycemia
ultraviolet light
Ultraviolet light
  • In most instances sunlight improves psoriasis remarkably
  • However, burning of the skin may cause Koebner’s phenomenon and an exacerbation
  • UVB
  • Tar applications or baths before UVB exposure have been credited with enhancing its effects
  • Maintenance UVB phototherapy after clearing contributes to the duration of remission
goeckerman technique
Goeckerman technique
  • 2 to 5% tar preparation is applied to the skin, and a tar bath is taken at least once daily. The excess tar is removed with mineral or vegetable oil and ultraviolet light is given
ingram technique
Ingram technique
  • Consists of a daily coal tar bath in a solution such as 120 ml liquor carbonis detergens to 80 L of warm water
  • This is followed by exposure to an ultraviolet light for daily increasing periods
  • Anthralin paste is then applied to each psoriatic plaque
  • Talcum powder is sprinkled over the lesions, and a stockinette dressing is applied
puva therapy
PUVA therapy
  • UVA given 2 hours after ingestion of 8-methoxypsoralen (Oxsoralen), and given two to three times a week
  • Maintenance treatment is needed
  • Risk of enhanced carcinogenesis is proven
  • Reversal of the usual ratio of squamous cell carcinomas to basal cell carcinomas
  • Accelerated actinic elastosis, melanocyte dysplasia, and possible increased incidence of melanoma should be considered
surgical treatment
Surgical treatment
  • Denervation by surgery has long been known to abolish psoriatic plaques
  • Excision to the depth of the reticular dermis
  • In a group of 14 patients with pharyngeal colonization by streptococci unresponsive to antibiotic therapy 9 cleared after tonsillectomy
lasers in psoriasis
Lasers in psoriasis
  • Psoriatic plaques can be cleared by destruction of the upper dermis
  • Blood vessels in the psoriatic dermal papillae can be selectively destroyed with yellow lasers effectiveness with flashlamp pulsed dye laser
  • Some success with CO2 resurfacing laser
occlusive treatment
Occlusive treatment
  • Report of clearing of psoriatic lesion by occluding them with tape
  • Has been shown that hydrocolloid occlusion (with Actiderm) had a similar effect on small lesions
systemic treatment
Systemic treatment
  • Corticosteroids
  • Methotrexate
  • Cyclosporine
  • Diet
  • Oral antimicrobial therapy
  • Retinoids
  • Dapsone
  • Biologic Agents
  • The side effects of orally administered prednisone are so dangerous that its use should be limited to patients with unusual individual circumstances
  • There is a great risk of “rebound” or induction of pustular psoriasis when it is stopped
  • Was the first effective systemic drug for psoriasis and is the standard for systemic therapy
  • Methotrexate has greater affinity for dihydrofolic acid reductase than has folic acid
  • The synthesis of deoxyribonucleic acid is blocked when dihydrofolic acid reductase is bound and thereby cell division is decreased
May also affect the inflammatory elements of psoriasis
  • Indications for its use include psoriatic erythroderma, moderate to severe psoriatic arthritis, acute pustular psoriasis, more than 20% total body surface involvement, localized pustular psoriasis, psoriasis that affects certain areas of the body so that normal function and employment are prevented, lack of response to phototherapy, PUVA, or retinoids
Prior to start of treatment ensure that there is no history of liver or kidney disease
  • Alcohol abuse, cirrhosis, severe illness, debility, pregnancy, anemia should be considered
  • AST, ALT, bilirubin, serum albumin, creatinin. Alkaline phosphatase, CBC, platelets, Hep B and C serology, and UA should all be evaluated prior to tx
Most patients with no risk factors for liver disease the first liver biopsy should be obtained at approximately 1.0 to 1.5 g of cumulative methotrexate and repeated every subsequent 1.5 g until a total of 4 g is reached
  • 3 divided oral doses 12 hrs apart weekly, once weekly doses orally and single weekly subcutaneous injections are effective treatment schedules
  • The therapeutic benefit of the immunosupressive features of cyclosporine in psoriatic disease may be related to down modulation of proinflammatory epidermal cytokines
  • Biopsies of the kidney in 30 patients after 2 years of cyclosporine treatment found features consistent with cyclosporine-induced nephrotoxicity
Another study concluded that cyclosporine may be used long-term (5-10 years) in severe, recalcitrant psoriasis if renal function is closely monitored
  • Induction of therapy with 2.5 to 3.0 mg/kg given as a divided dose twice daily and may be increased to 5.0 mg/kg/day until a clinical response is noted
  • Controlled studies evaluating various dietary restrictions, especially those of low protein intake, showed no appreciable difference in the course of psoriasis
  • Another study found psoriasis to be more severe in patients trying herbal remedies, vitamin therapy, and dietary manipulation
Most recent trials have demonstrated the antiinflammatory effects of fish oils rich in n-3 polyunsaturated fatty acids in rheumatoid arthritis, inflammatory bowel disease, psoriasis and asthma
oral antimicrobial therapy
Oral antimicrobial therapy
  • Recent evidence suggest that Staphylococcus aureus and streptococci secrete a large family of exotoxins that are superantigens, producing massive T-cell activation
  • Oral antibiotic for psoriasis patients infected with these organisms is imperative
  • Treatment with 13-cis-retinoic acid can produce good results, especially in pustular psoriasis
  • It is a potent teratogen
  • Combinations of retinoic acids with photochemotherapy for chronic plaque psoriasis may also be very affective
  • Etretinate
  • Acitretin, avoid pregnancy for up to 3 years following cessation of therapy
  • Use is limited largely to palmoplantar eruptions
combination therapy
Combination therapy
  • Patient on methotrexate may have their dose minimized with concomitant topical steroid use
  • PUVA with Acitretin
  • PUVA with cyclosporine
  • PUVA with methotrexate
  • Topical Dovonex with Acitretin, cyclosporine, methotrexate, and phototherapy
The principle behind combination therapy is the use of agents win which the side effects profile is different or partly opposing
  • Hydroxyurea and sulfalsalazine have been used in severe cases and in combination with other modalities, such as PUVA
  • Particularly useful in topical therapy, where the risk profiles are considerably less
biologic agents
Biologic Agents
  • Alfecept (Amieve)
  • Efalizumab (Raptiva)
  • Etanercept (Embrel)
  • Infliximab
  • These are indicated for moderate-to-severe plaque psoriasis
  • Fusion protein that prevents activation of T cells by antigen-presenting cells (APCs)
  • This causes a depletion of memory T cells
  • Efficacy of 15 mg IM once weekly: 21% of pts achieved PASI 75 at 2 weeks after last dose (after 12 weeks of tx)
  • 33% of pts received PASI 75 (during 12 weeks of tx & at 12 weeks follow-up)
  • 43% of pts achieved PASI 75 (during second course of 12 weeks tx & 12 weeks follow-up)
alfacept safety profile
Alfacept-safety profile
  • Occurred with an incidence of at least 2% higher than placebo
  • Pharyngitis, dizziness, increased cough, nausea, pruritus, myalgia, chills, injection-site inflammation, & accidental injury
  • Should not be used in pts with CD4 count< normal (250 cells/microliter)
  • Should monitor CD4 counts weekly during tx
  • Hold tx for CD4 counts<normal discontinue if CD4 counts remain abnormal for > 1 month
  • Humanized monoclonal antibody that blocks T-cell activation, reactivation, & trafficking into skin
  • This is reversible
  • Efficacy summary: 27% of pts achieved PASI 75 at 3months
  • 44% of pts achieved PASI 75 at 6 months
  • 55% of pts achieved PASI 75 at 24 months
efalizumab safety profile
Efalizumab-safety profile
  • Most common adverse events were headache, chills, fever, nausea occurring after first 1 or 2 doses
  • 8 pts out of 2762 in clinical trials had reversible thrombocytopenia
  • Check platelet counts monthly during first 3 months of tx & quarterly thereafter
  • After abrupt discontinuation rebound occurred (PASI>125% of baseline) in 14% of tx pts & 11% of placebo
  • Rebound appears to be higher in pts who did not achieve at least a PASI 50 during tx
  • Fusion protein that blocks TNF-alpha & TNF-beta, thereby preventing the excessive stimulation of keratinocyts & other cell types by these cytokines
  • Approved for psoriasis, ankylosing spondylitis, RA, JRA & PA
  • Efficacy of tx with 25 mg SC twice weekly: 34% of pts received PASI 75 at 12 weeks
  • 44% achieved PASI 75 at 24 weeks
  • AT 50 mg SC BIW for 12 weeks followed by 25 mg BIW 49% of pts achieved PASI 75 @ week 12 & 54% achieved it at week 24
etanercept safety profile
Etanercept-safety profile
  • Most common injection-site rxns, headache, URI, & injection-site ecchymosis
  • Rare cases of TB observed in pts tx with TNF-alpha antagonists as well as serious infections & sepsis
  • Do not initiate therapy in pts with active infections (chronic or localized included)
  • Pts who develop new infections on tx should be monitored closely and discontinue tx if serious or sepsis occurs
  • Postmarketing reports also of worsening CHF & rare reports of new CHF & new onset or exacerbation of CNS demyelinating disorders
  • Evaluate pts prior to tx for latent TB or predisposition of infection or CNS demyelinating disorders
  • Chimeric (approx 30% murine, 70% human) monoclonal antibody that binds TNF-alpha
  • Evidence also that it can cause apoptosis of cells expressing transmembrane TNF-alpha
  • Approved for tx of RA & Crohn’s dz not yet approved for psoriasis
  • Efficacy: PASI at 10 weeks 73%; at 18 weeks 42%; at 26 weeks 14% (dose of 3 mg/kg IV)
  • Need IV infusion at weeks 0, 2, 6 & every 8 weeks thereafter, by a healthcare provider
  • In the study pts receiving both 5mg/kg & those receiving 3 mg/kg had a slow decline in PASI score over 16 weeks
  • Many pts develop neutralizing antibodies making it necessary to increase the dose & injection frequency to maintain efficacy
treatment strategies for biologic agents
Treatment strategies for biologic agents
  • More experience is needed to determine how best to use each biologic agent on long-term basis
  • Most important factor in choosing a biologic agent for a pt must be tx safety
  • All should be used with caution in those at risk of malignancy
  • Use caution when combining immunosuppressive agents
  • Package inserts for etanercept & infliximab indacate that use can use these in combination with methotrexate
  • It is not recommended to combine efalizumab or alefacept with other immunosuppressants because efficacy has not yet been established
reiter s syndrome
Reiter’s syndrome
  • Characteristic clinical triad consisting of urethritis, conjunctivitis, and arthritis
  • May also be other features that involve the skin , mucous membranes, gi tract, and cardiovascular system
  • American Rheumatism Association criterion of peripheral arthritis of more than 1 month duration, in association with urethritis and/or cervicitis
  • Occurs chiefly in young men of HLA-B27 genotype
clinical features109
Clinical features
  • Any one of the triad of urethritis, conjunctivitis, or arthritis may occur first, accompanied by fever, weakness, and weight loss.
  • A nonbacterial urethritis may develop with painful and bloody urination and pyuria
  • About 1/3 of patients develop conjunctivitis
  • Keratitis is usually superficial and very painful. Iritis is common
An asymmetric arthritis afflicts synovial joints, especially those that are weight bearing
  • Onset is sudden with heat and tenderness and swelling
  • Pain in one or both heels is a frequent symptom
The skin lesions start as multiple, small, yellowish vesicles that break, become confluent and form superficial erosions
  • Develop frequently on the genitals and palms
  • Eruption on the glans penis occurs in 25% of patients
  • Lesions on the soles start as pustules, become crusted or hyperkeratotic
The eruption is known as keratoderma blennorrhagicum
  • Penile lesions are frequent
  • Characterized by perimeatal balanitis, these become crusted and form circinate lesions
  • Similar lesion are seen on the vaginal mucosa of women
Nails become thick and brittle, with development of subungal keratosis
  • Endocarditis, pericarditis, and myocarditis, as well as aortic insufficiency occur in some
  • In children conjunctivitis is the most frequent complaint
  • Syndrome has been attributed to many different agents such as Shigella flexneri, Salmonella spp., yersinia spp., Ureaplasma urealyticum, Borrelia burgdorferi, Cryptosporidia, and Campylobacter fetus
  • May be responsible for the infectious enteritis that precedes onset in a small percentage of patients
  • In cases that follow an infection of the genitourinary tract, Chlamydia trachomatis may be associated
HLA-B27 positivity is present in 80% of cases of Reiter’s syndrome
  • This rises to 90 to 100% in patients with accompanying sacroiliitis, uveitis, or aortitis
  • May be caused by abnormalities in the production and elicitation of immune mediators or T cells
laboratory findings
Laboratory findings
  • No specific changes are characteristic of this syndrome
  • A leukocytosis of 10, 000 to 20, 000/mm3 and an elevated sed rate are the most consistent findings
  • Identical to psoriasis
differential diagnosis121
Differential diagnosis
  • May be confused with rheumatoid arthritis, ankylosing spondylitis, gout, psoriatic arthritis, gonococcal arthritis, acute rheumatic fever, chronic mucocutaneous candidiasis, and serum sickness
  • Usually mucocutaneous lesions are self limited and clear within a few months
  • Topical steroids are helpful
  • NSAIDs for the joint disease
  • Methotrexate for severe disease
  • Cyclosporine
  • Acitretin
The course is characterized by exacerbations and remission in about on third of patients
  • A chronic deforming arthritis occurs in a bout 20% of patients, with significant disability resulting, chiefly from foot deformities
subcorneal pustular dermatosis sneddon wilkinson disease
Subcorneal pustular dermatosis(Sneddon-Wilkinson Disease)
  • Chronic pustular disease which occurs chiefly in middle-aged women.
  • Pustules are superficial and arranged in annular and serpiginous patterns, especially on the abdomen, axillae and groins
  • Sometimes vesicles are present
  • Cultures from pustules are sterile
  • Oral lesions are rare
  • Some cases occur in association with and IgA monoclonal gammopathy
subcorneal pustular dermatosis sneddon wilkinson disease125
Subcorneal pustular dermatosis(Sneddon-Wilkinson Disease)
  • Dapsone appears to be effective in most cases
  • Sulfapyridine
  • Acitretin
  • Narrow band UVB
  • Corticosteroids, colchicine, and TCN with niacinamide
  • Without treatment this is a chronic condition with remissions of variable duration
eosinophilic pustular folliculitis
Eosinophilic pustular folliculitis
  • Also referred to as sterile eosinophilic pustulosis
  • Five times more common in males
  • Peak age of onset in the third decade, although a number of pediatric cases have been reported
  • Characterized by pruritic, follicular papulopustules arranged in groups
  • Plaques may form
eosinophilic pustular folliculitis127
Eosinophilic pustular folliculitis
  • Distribution is usually asymmetrical, with the face, trunk, and upper extremities most often afflicted
  • Cause is unknown, however, numerous studies have implicated chemotactic substances, ICAM-1, and cyclooxygenase-generated metabolites
  • Typical course is one of spontaneous remissions and exacerbations lasting from a few months to several years
eosinophilic pustular folliculitis128
Eosinophilic pustular folliculitis
  • Dapsone or systemic steroids are the treatment of choice
  • Success with intralesional steroids, clofazimine, minocycline, isotretinoin, UVB therapy, indomethacin, colchicine, cyclosporine, and cetirizine
  • Must be distinguished from HIV-associated EF
eosinophilic pustular folliculitis129
Eosinophilic pustular folliculitis
  • Another variant has been described that occurs early in childhood
  • Patients develop sterile pustules and papules preferentially over the scalp and; however, scattered clusters of pustules may occur over the trunk and extremities
  • High-potency topical steroids are the treatment of choice
  • Recurrent exacerbations and remissions usually occur with spontaneous remission