Full Answer Section

• Smoking: Smoking is linked to an increased risk and severity of psoriasis.
• Hormonal Changes: While less consistently reported, hormonal fluctuations may play a role in some individuals.

Different Clinical Types of Psoriasis:

• Plaque Psoriasis (Psoriasis Vulgaris): This is the most common type, characterized by raised, red patches (plaques) covered with silvery-white scales. These plaques commonly appear on the elbows, knees, scalp, and lower back, but can occur anywhere on the body. K.B. initially presented with this type and is now experiencing a generalized flare.
• Guttate Psoriasis: This type often appears as small, drop-like lesions scattered across the trunk, arms, and legs. It is frequently triggered by a streptococcal throat infection.
• Inverse Psoriasis: This type affects skin folds, such as the armpits, groin, under the breasts, and around the genitals. The lesions are typically smooth, red, and shiny, without the characteristic scale seen in plaque psoriasis. K.B.’s involvement in the groin area suggests this may be part of her current flare.
• Pustular Psoriasis: This less common form is characterized by widespread or localized areas of red skin with small, pus-filled bumps (pustules). There are several subtypes of pustular psoriasis.
• Erythrodermic Psoriasis: This is a rare and severe form where the entire body surface becomes red and inflamed, often with intense itching and pain. It can be life-threatening and requires immediate medical attention.
• Nail Psoriasis: This affects the fingernails and toenails, causing pitting, thickening, discoloration, and separation from the nail bed (onycholysis).
• Scalp Psoriasis: This can range from mild, fine scaling to thick, crusted plaques covering the entire scalp. It can occur alone or with other forms of psoriasis. K.B.’s scalp involvement is noted in her current flare.
• Psoriatic Arthritis: This is a chronic inflammatory arthritis that can occur in people with psoriasis. It causes pain, stiffness, and swelling in the joints. While not a skin manifestation, it’s an important associated condition.

2. There are several types of treatments for psoriasis, explain the different types and indicate which would be the most appropriate approach to treat this relapse episode for K.B. Also include non-pharmacological options and recommendations.

Psoriasis treatment aims to reduce inflammation, slow down the rapid production of skin cells, remove scales, and improve the overall appearance and comfort of the skin. Treatment approaches are often tailored to the severity, location, and type of psoriasis, as well as the patient’s response to previous therapies.

Types of Psoriasis Treatments:

• Topical Treatments: These are medications applied directly to the skin and are often the first-line treatment for mild to moderate psoriasis.
  • Corticosteroids: Reduce inflammation and itching. They come in various potencies, and high-potency corticosteroids were initially effective for K.B. However, prolonged use can lead to side effects like skin thinning and tachyphylaxis (reduced effectiveness).
  • Vitamin D Analogues (e.g., Calcipotriene, Calcitriol): Help slow down skin cell growth.
  • Topical Retinoids (e.g., Tazarotene): Normalize skin cell growth and reduce inflammation.
  • Calcineurin Inhibitors (e.g., Tacrolimus, Pimecrolimus): Primarily used for sensitive areas like the face and skin folds, they suppress the immune system locally.
  • Salicylic Acid: Helps to remove scales and soften thick plaques.
  • Coal Tar: Has anti-inflammatory and anti-scaling properties.
• Phototherapy (Light Therapy): This involves exposing the skin to specific wavelengths of ultraviolet (UV) light under medical supervision.
  • Ultraviolet B (UVB) Therapy: Narrowband UVB is often preferred.
  • Psoralen plus Ultraviolet A (PUVA): Involves taking a photosensitizing drug (psoralen) before UVA exposure.
  • Excimer Laser: Delivers targeted UVB to localized plaques.
• Systemic Medications: These are oral or injectable medications used for moderate to severe psoriasis or when topical treatments and phototherapy are insufficient.
  • Traditional Systemics:
    • Methotrexate: An immunosuppressant that reduces skin cell production and inflammation.
    • Cyclosporine: Another immunosuppressant, often used for short-term treatment of severe flares.
    • Acitretin: An oral retinoid that helps normalize skin cell growth. It is particularly useful for pustular psoriasis.
  • Biologics: These are protein-based drugs that target specific parts of the immune system involved in psoriasis. They are typically administered by injection or infusion and are highly effective for moderate to severe psoriasis. Examples include:
    • TNF-alpha inhibitors: Adalimumab, Etanercept, Infliximab, Certolizumab pegol.
    • IL-17 inhibitors: Secukinumab, Ixekizumab, Brodalumab.
    • IL-23 inhibitors: Guselkumab, Tildrakizumab, Risankizumab.
    • IL-12/23 inhibitor: Ustekinumab.
    • T-cell costimulation inhibitor: Abatacept.
  • Small Molecule Inhibitors: These are oral medications that target intracellular signaling pathways involved in inflammation. Examples include:
    • Apremilast: A phosphodiesterase 4 (PDE4) inhibitor.
    • Janus kinase (JAK) inhibitors: Tofacitinib (oral).
• Combination Therapy: Often, a combination of different treatment modalities (e.g., topical corticosteroids with vitamin D analogues, or systemic therapy with phototherapy) is used to achieve better results and manage side effects.

Most Appropriate Approach for K.B.’s Relapse:

Given that K.B.’s current flare-up is generalized and involves large areas, topical treatments alone are likely to be insufficient. Her previous good response to high-potency corticosteroids suggests that inflammation is a significant component of her psoriasis. However, the widespread nature of the current outbreak and the fact that she has relapsed after a period of remission indicate a need for a more aggressive approach.

The most appropriate initial approach for K.B. would likely involve systemic therapy, possibly in combination with topical treatments for localized areas and phototherapy if accessible and feasible.

• Systemic Medication: Considering the extent of her psoriasis, a biologic or a traditional systemic agent like methotrexate could be considered. Biologics are often preferred for their targeted action and generally favorable safety profile compared to traditional systemics, especially for long-term management. However, factors like cost, insurance coverage, and patient preference will play a role in the decision. A small molecule inhibitor like apremilast could also be an option, particularly if there are contraindications to other systemic agents.
• Topical Adjunctive Therapy: Topical corticosteroids of appropriate potency can be used for localized areas that may not respond as quickly to systemic therapy. Vitamin D analogues or calcineurin inhibitors can be used in sensitive areas like the groin and face.
• Phototherapy: If accessible, UVB phototherapy could be a valuable adjunct to systemic therapy, helping to reduce the overall disease burden.

The dermatologist will need to carefully evaluate K.B.’s medical history, previous treatments, lifestyle, and preferences to determine the most suitable systemic agent.

Non-Pharmacological Options and Recommendations:

• Emollients (Moisturizers): Regular use of thick, fragrance-free moisturizers is crucial to hydrate the skin, reduce dryness and scaling, and improve the effectiveness of other treatments.
• Gentle Skin Care: Avoiding harsh soaps, hot water, and aggressive scrubbing can help prevent irritation and further flare-ups.
• Stress Management: Techniques like yoga, meditation, deep breathing exercises, and counseling can help manage stress, a known trigger for psoriasis.
• Healthy Diet: While there’s no specific “psoriasis diet,” maintaining a balanced diet rich in fruits, vegetables, and omega-3 fatty acids may have overall health benefits. Limiting alcohol intake is generally recommended.
• Sun Exposure (with caution): Controlled, limited exposure to natural sunlight can sometimes improve psoriasis, but it’s essential to avoid sunburn by using sunscreen on unaffected skin and limiting exposure time.
• Oatmeal Baths: Soaking in lukewarm baths with colloidal oatmeal can help soothe itchy and inflamed skin.
• Psychological Support: Living with a chronic skin condition like psoriasis can be emotionally challenging. Support groups or counseling can be beneficial.

3. A medication review and reconciliation are always important in all patients, describe and specify why in this particular case is important to know what medications the patient is taking?

Medication review and reconciliation involve creating an accurate and complete list of a patient’s current medications, including prescription drugs, over-the-counter medications, vitamins, and supplements. This list is then compared to the physician’s orders to identify and resolve any discrepancies, such as duplications, omissions, incorrect dosages, or potential drug interactions.

In K.B.’s case, a thorough medication review is particularly important for several reasons:

• Drug-Induced Psoriasis: As mentioned earlier, certain medications (e.g., beta-blockers, lithium, antimalarials, some NSAIDs) can trigger or exacerbate psoriasis. It’s crucial to identify if K.B. is currently taking any such medications that might be contributing to her relapse. If so, the dermatologist may consider alternative medications in consultation with her primary care physician or other specialists.
• Potential Drug Interactions: If K.B. is started on a systemic treatment for her psoriasis, it’s essential to know all her other medications to avoid potential drug interactions that could reduce the efficacy of either treatment or increase the risk of side effects. For example, methotrexate can interact with certain NSAIDs and other medications.
• Impact on Treatment Decisions: K.B.’s current medication list might influence the choice of psoriasis treatment. For instance, if she has certain comorbidities being managed by specific medications, some psoriasis treatments might be contraindicated or require careful monitoring.
• Overall Health Context: Understanding all the medications K.B. is taking provides a broader picture of her overall health status and any underlying conditions that might affect her psoriasis or its treatment.
• Adherence and Understanding: Reviewing her medications can also help assess K.B.’s adherence to her current regimen and identify any potential barriers to medication use. It provides an opportunity to educate her about her medications and ensure she understands how to take them correctly.

4. What other manifestations could present a patient with Psoriasis?

Beyond the characteristic skin plaques, patients with psoriasis can experience a range of other manifestations:

• Nail Changes (Nail Psoriasis): As mentioned earlier, this can include pitting, thickening, discoloration (yellow-brown), crumbling, horizontal lines (Beau’s lines), and separation of the nail from the nail bed (onycholysis).
• Scalp Involvement: Ranging from mild dandruff-like scaling to thick, adherent plaques that can extend beyond the hairline. This can be itchy and cosmetically bothersome.
• Genital Psoriasis: Can occur on the penis, scrotum, vulva, and in the skin folds of the groin. It often appears as smooth, red patches without the typical scale. It can be itchy and cause discomfort.
• Oral Psoriasis: Less common, but can present as white or gray plaques on the tongue, gums, or inside the cheeks. It is usually asymptomatic.
• Eye Involvement: While less frequent than skin or joint involvement, psoriasis can affect the eyes, leading to conditions like conjunctivitis, blepharitis (inflammation of the eyelids), uveitis (inflammation of the middle layer of the eye), and dry eye.
• Psoriatic Arthritis: A chronic inflammatory arthritis that affects the joints. It can occur before, during, or after the onset of skin psoriasis. Common symptoms include joint pain, stiffness, swelling, and reduced range of motion. It can affect any joint but often involves the fingers, toes, spine, and sacroiliac joints.
• Metabolic Syndrome: Individuals with psoriasis, particularly severe psoriasis, have an increased risk of developing metabolic syndrome, a cluster of conditions including high blood pressure, high blood sugar, unhealthy cholesterol levels, and abdominal obesity, which increases the risk of heart disease, stroke, and type 2 diabetes.  
• Mental Health Issues: Psoriasis can significantly impact a person’s quality of life, leading to feelings of embarrassment, shame, anxiety, and depression.
• Increased Risk of Other Autoimmune Diseases: There is an association between psoriasis and an increased risk of other autoimmune conditions, such as Crohn’s disease, ulcerative colitis, and celiac disease.

C.J.’s Eye and Ear Issue

1. Based on the clinical manifestations presented on the case above, which would be your eyes diagnosis for C.J. Please name why you get to this diagnosis and document your rational.

Based on C.J.’s clinical manifestations, the most likely eye diagnosis is bacterial conjunctivitis.

Rationale:

• Crusty and Yellowish Discharge: This is a hallmark sign of bacterial conjunctivitis. The thick, purulent discharge is a result of bacterial infection and the inflammatory response.
• Bilateral Conjunctival Erythema: The redness of both eyes (bilateral) indicates inflammation of the conjunctiva, the clear membrane covering the white part of the eye and the inside of the eyelids. While other conditions can cause red eyes, the presence of yellowish discharge strongly points towards a bacterial etiology.
• Blurry Vision, Especially in the Morning, Improving After Clearing Discharge: The sticky discharge accumulating overnight can temporarily blur vision. Once the discharge is cleared, visual acuity returns to normal, suggesting the blurry vision is due to the physical obstruction rather than a more serious underlying eye condition affecting vision itself.

While allergic conjunctivitis can cause discharge, it is typically watery or stringy and associated with itching. Viral conjunctivitis often presents with watery discharge, a gritty sensation, and may be associated with systemic viral symptoms. Gonococcal and trachoma conjunctivitis are specific bacterial infections but often have distinct presentations or risk factors not mentioned in this case.

2. With no further information would you be able to name the probable etiology of the eye affection presented? Viral, bacterial, allergic, gonococcal, trachoma. Why and why not.

Based on the information provided, the most probable etiology of the eye affection is bacterial.

Why:

• The yellowish, crusty discharge is highly suggestive of a bacterial infection. Bacteria often produce a thick, purulent exudate.