Papulosquamous

 Pathogenesis: Overproduction of inflammatory cytokines (TNF-alpha,

IFN-gamma, IL-12, IL-17, IL-23) and stimulation of T cells.
ERYTHEMATOUS OR PURPLE PAPULES (OR PLAQUES) WITH SCALE - Streptococcal infections  trigger guttate subtype (usually in
children)
A. Psoriasis - HIV infection => trigger sudden onset widespread/severe psoriasis
(HALLMARK) Well-defined, salmon-colored papules and plaques with - Medications: lithium, beta-blocker, anti-malarials, NSAIDs
white to silvery scales. - Alcohol, smoking, metabolic syndrome
 Risk factors: Koebnerization, psychologic stress, medication, infection
Scalp Psoriasis vs. Tinea Capitis
 TC: kids + Lymphadenopathy
Associated features:
 Diagnosis: Clinical diagnosis (best initial test) and skin biopsy (most
- Auspitz sign: scales are scraped off  pinpoint bleeding accurate)
- Koebner phenomenon (eliciting lesions due to skin \
Acanthosis = epidermal hyperplasia
trauma)
Parakeratosis = retained nuclei
- Nail dystrophy: pitting, dystrophy, thickening and Neutrophilic collections in the stratum corneum (Munro’s microabscesses)
yellowish discoloration. ↑ stratum spinosum

 Treatment
 Distribution – Important!!! - First line: avoid smoking, avoid alcohol, stop triggering medicine,
- Elbows/knees weight loss, emollients
- Scalps and gluteal cleft - Mild = topical
- Nail Topicals steroids, topical vitamin D analogs (calcipotriene
- Peri-umbilical area cream), topical retinoids (tazarotene), topical calcineurin
- Palms and soles: thick scaly rash called keratoderma (thickening of inhibitors (tacrolimus), coal tar ointment, topical salicylic acid
epidermis) - Moderate to severe = systemics
-  entire body is possible (Erythrodermic Psoriasis) Phototherapy or PUVA
Oral immunosuppressives: methotrexate, cyclosporine, oral
 Systemic manifestations
retinoids
- Joint  Psoriatic arthritis
Oral apremilast (Otezla): selective inhibitor of the enzyme
o Always ask patients about joint symptoms to rule out
phosphodiesterase 4 (PDE4)
- Higher risk for: Cardiovascular disease, type 2 diabetes, metabolic
Injectable biologic medications: TNF-alpha inhibitors, Anti
disorder (obesity, hyperlipidemia).
interleukin agents
Psoriatic Arthritis Rupioid Psoriasis
Joint pain (improve with activity) + redness + “sausage digit” Thick oyster-shell rash
HIV patient

Erythrodermic Psoriasis
Solid redness covering >80% of body
Patients are severely ill: Fevers/chills, Electrolytes
abnormalities, Higher risk for infection, output heart failure Guttate Psoriasis
Kids
“Rain drop”
After a strep infection

Pustular Psoriasis
 exacerbated by withdrawal of steroids.
B. Lichen Planus (LP) Oral steroids, phototherapy, oral retinoids, systemic
(HALLMARK) Purple color + polygonal flat topped scaly papules immunosuppressive (methotrexate, mycophenolate mofetil)

Associated features:
- Very pruritic!
- Wickham’s striae = fine white reticulated lines overlying
papules or on mucosa
- Koebner phenomenon

 Distribution
- Symmetric

- Forearms/wrists, ankles
- Oral or genital mucosa
- Nails
- Scalp
- Can also be widespread.
 Diagnosis: clinical diagnosis (best initial) and skin biopsy (most accurate)
 Treatment
- First line: topical or intralesional steroids
- Second line:
Topical calcineurin inhibitors (tacrolimus, pimecrolimus)
C. Pityriasis Rosea (PR) – HHV6
(HALLMARK) A single “herald patch” (first) + rash over the trunk (later)

Pityriasis Rosea (PR) vs. Guttate Psoriasis

Clinically looks similar.
Both common in kids/teens/young adults
PR is acute, self-resolved

 Herald patch = Small round to oval pink scaly patches with central
“cigarette paper” appearance
 Prodrome of upper respiratory tract infection–like symptoms (fever,
headache, malaise, pharyngitis, lymphadenopathy)

 Diagnosis: Clinical diagnosis (best initial) + Skin biopsy (most accurate)

- Consider ruling out syphilis with RPR if patient is at risk
- Consider skin scraping for KOH to rule out tinea
 Treatment: Self-resolved
- Symptomatic relief with oral antihistamines, low potency
topical steroids
 Distribution: favors trunk along skin lines of cleavage = Christmas
tree pattern
D. Seborrheic Dermatitis – abnormal immune response Seborrheic Dermatitis in Infants
to Malassezia furfur yeast Cradle cap = adherent plaques across scalp with thick
yellow overlying scale
(HALLMARK) Distribution is key: sebaceous-rich areas and body folds Pink scaly patches in body folds and diaper area
- Scalp, ears, body folds of face, hair bearing areas of Resolves by 4th month.
face/chest/armpit/groin
 Clinical presentation:
- Erythematous patches with loose bran-like or greasy scale

- Color: pink (light skin), hypopigmented/hyperpigmented (dark skin)

- +/- Annular scaly patches can affect the edges of the face in dark
skin
- +/- Itching or burning
 Diagnosis: clinical diagnosis
 Treatment
- First line: topical antifungal cream or shampoo
- Second line: can add topical steroid for severe inflammatory
involvement of face/body