Title: GZ / The Grenz Zone Season 1 / Ep 4/5
Tags: GZ DermnetNZ

Q: What is the likely diagnosis in a patient with joint pain/stiffness in the hands, especially in the DIP joints (pictured below)?
[...]
A: Psoriatic arthritis

Q: What vitamin deficiency results from methotrexate use?
[...]
A: Folate (B_9)

Q: [drug] = reversed with [drug]
A: Methotrexate; leucovorin "rescue"
Back Extra: Bypasses DHF-reductase, which is blocked

Q: Von Zumbusch is a form of [...] psoriasis that is often associated with [...] withdrawal
A: pustular; steroid

Bleeding time affected by: 5 G’s (garlic, ginsing, ginger, green tea, gingko), as well as fish oil, vitamin E, saw palmetto, St. John’s wort

Name the general types of psoriasis
Guttate
Palmoplantar
Inverse
Erythrodermic
Pustular
Back Extra: Pustular special subtypes
- Impetigo herpetiformis (occurs in pregnancy)
- -  Von Zumbusch (generalized, rapid onset, associated with
systemic steroid withdrawal)

Q: The following are genetic predispositions to developing psoraisis upon activation by a trigger
[...]
HLA-[a/w 90% of early onset, 50% late onset cases]
HLA-[...]
A: PSORS1; Cw6; B27 – associated with sacroiliitis & pustular Psoriasis
Back Extra: More complex even than that, but these are the big players

Triggers for psoriasis can be remembered with the mnemonic SICK LAB -
Stress/Smoking
Infection (Group A Step, URI)
hypoCalcemia
Koebnerization – 25% of pt’s, takes 2-6 weeks
Lithium
Antimalarials/ACEI/Alcohol
Beta blockers
Other meds such as CCB’s, NSAIDS, TNF-alpha inhibitors

Histology of psoriasis
- Confluent parakeratosis
- Munro’s microabscesses – collections of neutrophils in 
stratum corneum, aka
“neuts in the horn”
- Decreased or absent granular layer
- Regular acanthosis with thinning over dermal papilla, which contain dilated
capillaries

Th17 cells: stimulated by IL-12 and IL-23 and themselves release IL-17, IL-22, and TNF-α

Th_1 cells: stimulated by IL-12 and promote CD8 T cells to produce IFN-γ, IL-2, IL-6, IL-8, IL-12

Q: Th2 cells: stimulated by IL-[...] and produce IL-[anti-inflammatory cytokine which inhibits Th1 cells]
A: 4; 10

Q: What is the only irreversible side effect of topical corticosteroids (TCS)?
[...]
A: Striae
Back Extra: The rest should improve after tapering

Q: Cyclosporine MOA:
[...]
A: Complexes w/ cyclophilin to inhibit calcineurin and reduce IL-2 production

Q: Methotrexate MOA:
[...]
A: Inhibits dihydrofolate reductase (DHFR)

Q: Methotrexate
Testing indicated for high cumulative doses (≥ 1.5–4 g), particularly for patients with preexisting liver disease, alcohol abuse, hepatitis C, psoriasis, or those who did not receive folic acid supplementation
[...]
A: Liver biopsy

Some lab values get “BULKed up” on cyclosporine
HyperBilirubinemia
HyperUricemia ( gout),
HyperLipidemia
HyperKalemia

Q: Which psoriasis drug blocks PDE-4, and is useful because there is no lab monitoring required
[...]
A: Apremilast

Q: Which psoriasis drug has a shown asociation with depression and weight loss?
[...]
A: Apremilast

Q: What are the 4 main TNF-α inhibitors used to tx psoriasis?
[...]
A: Adalimumab, Etancercept, Infliximab, certolizumab

Q: What are the 3 main IL-17 inhibitors used to tx psoriasis?
[neutralize(s) IL-17A]
[antagonize(s) the IL-17 receptor]
A: Ixekizumab and secukinumab; Brodalumab

Q: What are the main advantages to use IL-17 inhibitors to tx psoriasis?
[...]
A: Act quickly
Back Extra: ie quick and good

Q: Which TNF-α inhibitor is given IV?
[...]
A: Infliximab
Back Extra: Infliximab = IV

Ustekinumab is a fully human monoclonal IgG1 antibody directed against the common p40 subunit of IL-12 and IL-23

Nail changes associatied with psoriasis include onycholysis, irregular pitting, oil spots, splinter hemorrhages, and subungual hyperkeratosis

Q: What are two ways to determine the body surface area that is affected by psoriasis (and other skin conditions)
[...]
[...]
A: Rule of 9's; 1 palm of patient (including fingers) = 1% BSA

List the 5 types of psoriatic arthritis
Oligoarthritis (w/ swelling and tenosynovitis of hands)
Asymmetric DIP with nail damage
Rheumatoid arthritis-like
Arthritis mutilans
Ankylosing spondylitis
Back Extra: More likely if nails and scalp affected, often presents with morning stiffness >30-45 minutes

Q: Features of psoriatic arthritis may include [...], which describes inflammation at a tendon insertion site, and [...], which is the swelling of finger(s) ("sausage digit")
A: enthesitis; dactylitis
Back Extra: Enthesitis seen in 20% of patients, classically affects achilles
Dactylitis seen in 15-30% of patients (below)

Acitretin may be especially useful in the treatment of pustular, palmoplantar, or erythrodermic psoriasis
Contraindications include pregnancy, childbearing age not on contraception, severe liver or kidney disease, or excess alcohol use

Q: Which drug used to treat psoriasis (among other conditions) may result in gingival hyperplasia, hypertrichosis and gout as side effects?
[...]
A: Cyclosporine

Q: When using the PASI (psoriasis area and severity index), what does a PASI-75 mean?
[...]
A: 75% reduction in PASI score
Back Extra: Score 0-72 based on BSA and 0-4 score for lesion erythema, induration, and desquamation/scale
Can calculate easily using Grappa app

Q: Guselkumab (Tremfya), Tildrakizumab (Ilumya) and Risankizumab (Skyrizi) MOA: blocks [...] subunit on [...] only
A: p19; IL-23

Q: What are some additional screening options to take into consideration with TNF-alpha inhibitors for psoriasis patients?
[...]
[...]
A: CHF; Demylelinating disease (multiple sclerosis/Guillan-Barre syndrome)