ACUTE PHASE REACTANTS

ERYTHROCYTE SEDIMENTATION RATE (ESR):

Indirect msr of inflammation

dep. on red cell neg. charges

Inc. w/ age

C-REACTIVE PROTEIN:

Direct msr of inflammation

Rapid change

AUTOANTIBODIES NAMED AFTER PTS.

anti-Sm (SLE)

anti-Jo-1 (MYOSITIS)

anti-Ro (NEONATAL LUPUS & FATAL ♥ BLOCK, CROSSES PLACENTA)

AUTOANTIBODIES NAMED BY DISEASE

anti-Scl-70 (SCLERODERMA)

Rheumatoid Factor (RA)

anti-SS-A (SJOREN'S)

AUTOANTIBODIES NAMED BY ANTIGEN

anti-histidyl-transfer-RNA synthetase (Jo-1, myositis)

anti-topoisomerase-1 (Scl-70, scleroderma)

anti-cyclic citrullinated protein (CCP, RA 95% SPECIFIC)

anti-nuclear antibodies (ANA, anti-DNA = LUPUS)

Pts. must have 4 out 7 Criteria:

Morning Stiffness ≥ 1 hr

Swelling in 3+ joints

Swelling in Hand Joints

Symmetric Joint Swelling

Erosions or Decalcifications on X-ray

Rheumatoid Nodules

Abnormal Serum RF

SHARED EPITOPE OF RA

RA IMMUNE PATHOGENESIS

Antigen (presented by APC/Bcells) > T-cells

IL-1 & IL-6 induced

Inflammation & Joint Destruction

Metalloproteases destroy Collagen in joints

Pre-osteoblast turns into Osteoclast in RANK binds to RANKL > Bone Destruction

RHEUMATOID FACTOR

Antibody binds to Fc portion of IgG or IgM

Only ~80% pts w/ RA have RF (NOT very sensitive or specific)

CHARACTERSITICS OF RA

PIP & MCP involvement (Spares DIP)

Symmetric Disease

*Rhumatoid Erosion (degradation of cartilage ) hallmark

Deformities:

Ulnar Deviation

Swan Neck (hyperextension of PIP)

Flexsion of PIP

Foot & Hip involvement

Atlanto-axial

RA's EXTRA-ARTICULAR MANIFESTATIONS

Subcutaneous Nodules (elbow)

Sjogren's Syndrome:

Xerostomia, xeropthalmia, salivary & lacrimal lymphoid follicles

Felty's Syndrome

Splenomegaly, pancytopenia, leg ulcers

Pleuropulmonary Disease:

Effusions, interstitial lung disease, lung nodules

Episcleritis, scleritis, scleromalacia

Vasculitis

NEW CRITERIA FOR RA DX

Need a Score ≥6/10:

Joint Involvement

Serology

Acute Phase Reactants

Duration

TMT of RA

NSAIDS

Glucocorticoids

DMARDs

Biologic DMARDs

TNF antagonist: Entanercept, Infliximab, Adalimumab

IL-1 Rec. Antagonist: Anakinra

B-cell Depletion: Rituximab

IL-6 Antagonist: Toclizumab

Co-Stimulation Inhibitors: Abatacept

SKIN LAYERS

Epidermis (thickest on palms & soles)

Dermis(thickest on back)

Subcutis

EPIDERMIS

Layers:

Stratum Corneum

Stratum Granulosum

Stratum Spinosum

Stratum Basale

EPIDERMIS

Cell Types:

KERATINOCYTE: Pincipal cell (in all 4 layers), ECTODERMAL orgin, cytoskeleton: keratin & actin filaments; synthesizes intercellular lamellar bodies & keratohyline granules; 30 days to be shed. D/O: Lamellar Ichthyosis, Ichthyosis vulgairs, Harlequin fetus, Epidermolysis bullosa simplex, atopic dematitis, BCC & SSC

MELANOCYTE: Pigment producing, NEURAL CREST orgin, btw basal cells; Melanosomes produced in golgi (skin color); Melanin produced by tyrosinase. D/O: Piebaldism, Oculocutaneous albinism, Vitiligo, Melanoma

EPIDERMIS

Cell Types:

LANGERHANS: Dendrititc cells, CD1+, Birbeck graunules, BONE MARROW dervied, chief APC of epiermis. D/O: Histiocytosis X, Allergic contact dermatitis

MERKEL: NEURAL CREST origin; slow adapting type I mechanoreceptors; on high tactile sensitivity sites (palms, scalp, soles, mucosa); Cytokeratin 20 marker. D/O: Merkel cell carcinoma

DERMAL-EPIDERMAL JUNCTION (DJE)

Components:

Hemidesmosomes: connects basal layer to BM

Lamina Lucida: electron lucent zone; anchoring filaments made of laminin 5 & 6 and integrins

Lamina Densa: electron dense zone; laminin 5 & type IV collagen; attachment for hemidesmosomes

Sublamina Densa: anchoring fibrils (type VII collagen) anchor epidermis to dermis

D/O: Bullous Pemphigoid, Epidermolysis Bullosa, Dermatitis Herpetiformis, Porphysia Cutanea Tarda

DERMIS

Fibroblast: syn procollagen; secretes elastic fibers

Collagen: structural protein; ~80% total dry weigh; Collagen I most abundant; tensile strength. D/O: Osteogenesis Imperfecta, Ehler's danlos, Epdemolysis, Bullosa Acquisita

Elastic Fibers: Stretch & recoil; secreted by fibroblasts; elastin protein core surrounded by microfibril mesh. D/O: Cutis laxa, Marfan's syndrome, Pseudoxanthoma elasticum

Mast Cells: role in allergy & anaphylaxis & wound healing; Bone Marrow dervied (CD34+). IgE(FcεRI) receptor; granules contain: heparin, histamine, tryptase, serine protease, eicosanoids, cytokines & plt. activating factor. D/O: Solitary mastocyoma, Mastocytosis, Urticaria Pigmentosa

SKIN APPENDAGES

Eccrine Gland: composed of Acrosyringium, Duct, & Spiral secretory gland; most abundant in palms, soles, forehead & axillae; cholinergic innervations: heat & emotional stress. D/O: Miliaria, Hyperhydrosis, Anhidrotic/Hypohydrotic Ectodermal Dysplasia

Appocrine Gland: Coiled secretory gland in dermis &subcutaneous fat; found in axillae, anogenital region, periumbilical, nipples, vermilion border of lip; secretes by decapitation; swear is milky & odorless. D/O: Fox-Fordyce, Bromhidorosis (b.o) & Chomhidrosis

Sebaceous Gland: always associated w/ hair follicles; holocrine secretion; sebum: wax esters, triglycerides, FFA, & squalene; abundant in face & scalp. D/O: Hidradenitis suppurative, Acne, Folliculitis Decalvans, Dissecting Cellulitis

SKIN APPENDAGES

Hair Follice: only permanently regenerating organ; Infundibulum(uppermost), Isthmus (btw sebaceous duct & insertion of erector pili), Hair bulb (inferior). Round hair shaft = straight hair. Oval hari shaft = curly hair. Dark hair: large melanosomes produe eumelanin; Light hair: smaller ovoid melanosomes produce pheomelanin; Red hair: spherical melanosomes produle pheomelanin; Grey hair: dec. # melanosomes; White hair: absence of melanin. Phases of growth: Anagen (growing 2-6 yrs), Catagen (transitional 2-3 wks), Telogen (resting 3 mths) D/O: Anagen effluvium (chemotherapy), Telogen effluvium (Post partum, post surgical, crash diet, syphillis, heavy metal exposure, vit. deficiency or toxicity)

Nail Unit: Matrix, Lunula, Nail Plate, Nail bed, Nail folds.Growth:  Fingernails ~3mm/mth; Toenails ~1mm/mth. D/O: Beau's lines, psoriatic pitting, koilocychia, Terry's nails (liver disease), Lindsey's nails (kidney disease), habit tick deformity

PRIMARY CUTANEOUS LESIONS

MACULE/PATCH (>1cm): flat i.e cafe-au-lait spot, freckle, junctional nevus, atopic dermatitis, vitiligo

PAPULE/PLAQUE (>1cm): elevated lesion i.e. BCC, skin tags, psoriasis, urticaria, melanoma, lichen planus, sle, pityriasis rosea, cutaneous T-cell lymphoma

NODULE: circumscribed, elevated >1cm, deeper dermal component. i.e. BCC, Kaposi's sarcoma, melanoma, wart, SCC, hemangioma

TUMOR: large nodule exophytic

PUSTULE: collection of leukocytes & serum ie. acne, folliculitis, impetigo, herpes, candidiasis

WHEAL: edematous, red/pale plaque i.e. hives, dermographism, insect bites, urticarial vasculitis, early bullous pemphigoid

VESICLE: 'blister' collection of clear/yellow fluid 1 cm i.e. contact dermatitis, herpes, erythema, pemphigus vulgaris, epidermolysis bullosa

BULLA: collection of >1cm fluid; can be hemorrhagic

SECONDARY CUTANEOUS LESIONS

Scale: "flakes": abnl keratinization & shedding i.e. xerosis, ichthyosis, psoriasis (silvery), eczema/dermatitis, seborrheic dermatitis, tinea

Crusts: scab: dried serum & cellular debris i.e. Impetigo (honey colored), tinea capitis, insect bits, prurigo nodularis

Erosion: focal loss of epidermis/ no scar. ie. candidiasis, herpes simplex, eczema, Toxic epidermal necrolysis/ Stevens Johnson

Ulcers: loss of epidermis & dermis/ scar i.e. pressure ulcer, ischemic, neoplasms, pyoderma gangrenosus, factitial

Fissure: linear loss of epi & dermis i.e. xerosis, eczema, psoriasis, contact dermitits, palmoplantar keratoderma

Atrophy: depression in skin i.e. aging, dermatomyosisits, discoid SLE, morphea

Excoriation: erosion due to scratching

Lichenification: thickened epidermis dure to scratching/ rubbing i.e. eczema, lichen simplex chronicus, neurodermatitis

SPECIAL LESIONS

Comedo: plug of sebaceous/keratinous material in follicle i.e. acne, favre racouchot, nevuss comedonicus

Cyst: circums. papule/nodule w/ punctum i.e. epidermal inclusion cyst, pilar cyst, pilonidal cyst

Burrow: narrow, elevated tortuos channel by parasite i.e. scabies, cutaneous larva migrans

Petechia: circums deposit of blood (flat) i.e. Henoch Schonlein Purpura, vasculiits, Rocky Mt. spotted fever, solar pupura (age related)

Purpura: circums extravasation of blood >.5cm  may be palpable

Telangiectasia: dilated superficial blood vessels "spider veins" i.e. rosacea, cirrhosis, SLE, scleroderma, steroid atropy

PATTERNS & DISTRIBUTION

Annular/ Arcuate: ring shaped i.e. tinea corporis, subacute SLE

Discrete: distinctly separate lesions i.e. psoriasis, lichen planus, discoid lupus

Clustered: grouped together

Confluent: lesions run together

Dermatomal/Zosteriform: in a dermatome i.e. herpes zoster

Follicular: around follicles i.e. folliculitis

Guttate: drop-like papules i.e. psoriasis, roseola

Serpiginous: snake like i.e. scabies

Scariatiniform: like scarlet fever i.e. viral exanthum, drug eruption

Morbilliforms: like measles (same as above)

Satellite lesion: small papuls around larger plaque i.e. candida dermatitis

Target lestion: concentric cirlces i.e. erythema, stevens johnson, leukocytoclastic vasculitis

Koebner Phenomenon: lesions in areas of trauma i.e psoriasis, lichen planus/niditus, flat warts

Reticular: Net like i.e. 5th diease (erythema infectiosum) livedo reticularis, erythema ab igne

ANKLE PAIN

LATERAL: Lateral ankle sprain

H/E: Inversion of foot w/ acute lateral pain/swelling. Tenderness to palpation. Pain w/ passive inversion & active eversion

Imaging: X-ray if Ottawa rules met

Tmt: RICE

MEDIAL: Deltoid ligament sprain (don't miss high ankle sprain)

H/E: Eversion of foot w/ medial pain

Imagin: X-ray if Ottawa rules met

Tmt: RICE

POSTERIOR: Achilles Tendonitis

H/E: Heal pain &/or morning stiffness. Examine w/ ankle dorsiflexed w/ flex/ext of knee & arches

Imaging: lateral wt-bearing heal radiograph

Tmt: Acute: RICE, NSAIDS & heal lifts. Chronic: surgery

Achilles Rupture

H/E: acute onset, "gap" can be palpated along back of  leg. Inability to plantarflex

Imaging: non if gap felt; MRI

Tmt: boxer boot for high risk pts; surgery for athletes

HIP PAIN

Anterior:

Osteoarthritis: Pain w/ activity, slow progression, reduced ROM. Tmt: analgesics, moist heat, muscle strength exercise, joint replacement

Meralgia Parathetica: Numbness in ant. thigh, tight clothing, obesity, constant flextion at hip all inc. risk. Tmt: reassurance, weight loss, loose clothing, can refer for nerve block

Lateral:

Trochanteric Bursitis: Uable to lay on side at night, pain crossing legs, tenderness over trochanter. Tmt: avoid direct pressure, stretches, steroid injection into bursa. Correct any gain abnormality

Posterior:

Sacroliitis: Pain in upper buttock, tenderness to palpationover sacroiliac joint. pain w/ Patricks test. Tmt: correct gait abnormaility. Sacroiliac belt. Physical therapy. Anti-inflammatory meds, moist heat

Anterolateral:

Hip Fracture: hx of trauma, osteoporosis. Unable to bear weight. Intolerance to passive rotation of hip. Needs Surgery.

OTTAWA KNEE RULE

OBTAIN X-RAYS ONLY IF:

Pt ≥ 55 years

Isolated tenderness of patella

Tenderness at head of fibula

Inability to flex the knee to 90 deg

Inability to bear weight

ANTERIOR KNEE PAIN

PATELLOFEMORAL PAIN SYN: Pain when climbing stairs, rising from a chair. Retropatellar pain, pain w/ compression of patella on femur. Plain film. Tmt: PT for quad strength, analgesics, brace

PREPATELLAR BURSITIS: Hx of kneeling, swelling on top of patella, ROM of knee preserved. Tmt: Aspiration for etiology, compression, anti-inflamm, avoid direct pressure

LATERAL KNEE PAIN

OA/ MENISCAL TEAR/ LCL STRAIN

ILIOTIBIAL BAND SYN: Runners (running on uneven surfaces) burning pain. Tmt: RICE, good shoes, anti-inflamm meds, run on even ground

POSTERIOR KNEE PAIN

KNEE EFFUSION

SEPTIC ARTHRITIS: Aucte onset, warm painful esp w/ movement of joint, erythema. Joint Aspiration. Tmt: Antibiots & joint wahout by Ortho

GOUT/PSEUDOGOUT: Self limited episodes of warm, exquistely tender swollen knee, restricted ROM during flare. MRI. Ortho eval

LIGAMENTOUS TEAR: Rapid swelling, trauma, instability of knee. MRI. Ortho eval

MENISCAL TEAR: Swelling occurs slowly over hrs, loking, joint line tenderness. MRI. Tmt: if no locking: RICE, brace & PT; if locking: Ortho eval

FOOT PAIN

CAUSES OF LIMP IN PEDIATRIC POPULATION

INFECTION

INFLAMMATORY

TRAUMA

STRUCTURAL ABNORMALITIES

ASEPTIC NECROSIS

APOPHYSITIS

LIMP DUE TO INFECTION

SEPTIC ARTHRITIS:Infants : spread from osteomyelitis. Irritable & pseudoparalysis; Child: isolated infxn; Adolescent: systemic (gonococcus). Febrile & ill appearing. Knee & hip most commonly involved. Preceding trauma or URI. PE: Effusion , warmth, tenderness of joint, pain on ROM. Studies: ESR & WBCs elevated. Imaging: plain radiographs: joint effusion

OSTEOMYELITIS: infxn of medullary bone spreads to bony cortex; hematogenous spread; hx of trauma, Lower extremities & Staph a. most common. Low grade fever & limp; children <5. PE: severe localized tenderness. Studies: + blood culture; elevated ESR/CRP. Imaging: bone scans + as early as 24-48 hrs

MYOSITIS: immune mediated process or invasion of viral particles (Influenza A/B). Severe muscle pain, calf musc. most affected. Stiff legged gait. Resolves w/in days. Studies: elevated serum creatine kinase (renal failure common)

LIMP DUE TO INFLAMMATION

TRANSIENT SYNOVITIS/TOXIC SYNOVITIS: follows URI, most common cause of hip pain, antalgic gait, non-ill appearing, pt. hold hip flexed, abducted & externally rotated. Must exclude hip infx; yellow, non-purulent fluid. Serial radiographs to eval dev. of avascular hip necrosis

JUVENILE IDIOPATHIC ARTHRITIS: autoimmune rxn leads to synovial hypertrophy & chronic joint inflammation (<16 yrs). Systemic: >2wks hx joint pain; high spiking fever Inc. ESR, salmon pink macular rash, hepatosplenomegaly, lymphadenopathy. Polyarticular: males (knees, wrists, ankles) >4 joints, RF+, small joints, symmetrical, nodules. Pauciarticular: females, <5 joints, ANA+, asymmetrical, iridocyclitis, large wt bearing joints.

REACTIVE ARTHRITIS: after infxn. Microorganism not recovered, but associated w/ diarrheal illness (Yersinia, Salmonella, Chlamydia & Campylobacter)

ACUTE RHEUATIC FEVER: follows group A strep pharyngitis. Migratory arthritis, carditis, erythema marginaturm , subcut. nodules. PE: inflammation affects several joints (migratory pattern). Studies: GAS infxn. Sterile joint fluid. Plain radiographs: joint effusion

HENOCH-SCHONLEIN PURPURA: small vessel vasculitis (follows URI). Purpuric cutaneous rash of ankles, buttocks & elbows, migratory polyarthritis, periorbital edema. Studies: hematuria, proteinuria

LIMP DUE TO TRAUMA

TODDLERS FRACTURE: distal half of tibia, child < 8yrs, child refuses to bear wt; AP films; faint luncent ablique line crossing the distal tibia

STRESS FRACTURE: due to repetitive loading, child w/ new or Inc. sport activity; most frequent: proximal tibia> fibula> pars intraarticularis> femur

CHILD ABUSE: rare cause, suspect if child < 3yrs, and if hx doesn't fit injury

LIMP DUE TO STRUCTURAL ABNORMALITIES

SLIPPED CAPITAL FEMORAL EPIPHYSIS: slips posteriorly; obese males (8-15 yrs); ill defined acute hip pain, knee pain & antalgic limp. PE: impaired internal rotation, restricted hip flexion. "ice cream fell off the cone" on AP films

DEVELOPMENTAL DYSPLASIA OF HIP: instability of hip joint due to abnormal shape of acetabalum. Infant: laxity of hip joint; Child: Trendelenburg limp. PE: +Ortalani/Barlow (hip click or clunk). +Trendelenburg pelvic tilt test. Hip ultrasound in infants; plain radiograpsh in children show lateral & superior positioning of ossified portion of femoral head & neck

LIMP DUE TO ASEPTIC NECROSIS

LIMP DUE TO APOPHYSITIS

Degenerative changes in epiphyseal ossification center (lower extremities) during rapid growth.

OSGOOD SCHLATTER: overuse injury of tibial tuberosity in active individuals. Anterior knee pain (9-14 yr boys). PE: tenderness to palpation & prominence of tibial tuberosity. Pain reproduced when extending knee against resistance, squatting

SEVER DISEASE: affects insertion of Achilles tendon due to repetitive micro trauma. 9-11 yrs bilateral heel pain/toe walking gait. PE: tender calceneal apophysis w/ compression

KOHLER DISEASE: unilateral foot ain (2-9 yr) PE: tender over tarsal navicular; Plain radiographs small, denser navicular

FREIBERG DISEASE: apophysitis of 2nd/ 3rd/or 4th metatarsal. Dull aching paoin (adolescent girls). Tender plantar surface of involved metatarsal head. Plain x-ray metatarsal smaller & dense.

UPPER EXTREMITY LIMB PAIN DUE TO: CLAVICLE FRACTURE

Fall on shoulder, direct injury, or FOOSH

Affected arm held in cradeled position

PE: obvious deformity, crepitus, shoulder drop

Imaging: fracture middle third most common (indicative of pathologic process)

UPPER EXTREMITY LIMB PAIN DUE TO:NURSEMAID'S ELBOW

Radial head subluxation (1-4 yr). Injury due to sudden forceful traction to the pronated forearm w/ elbow in extension. Annular ligament slips over head of the radius & slides into radiohumeral joint. Child doesn't use affected arm & holds it close to bocy in extension w/ forearm pronated.

PE: focal tenderness/swelling

UPPER EXTREMITY LIMB PAIN DUE TO: BRACHIAL PLESUS PALSIES

Path: birth trauma, shoulder dystocia, diabetic mother, & breech

Upper BPP (Erb's Palsy): injury to C4,5,6. Adduction, internal rotation of affected arm>>loss of elbow extension

Total BPP (Erb-Duchenne-Klumpke's): injury to C5-T1 (entire plexus). Total flaccid paralysis

Type III (Klumpke palsy): injury to C8, T1. Paralysis of intricnsic muscles of hand, flexors of wrist/fingers > "claw hand" can have Horner's synd

TYPES OF CHILD ABUSE

PHYSICAL ABUSE

SEXUAL ABUSE

EMOTIONAL ABUSE

PHYSICAL NEGLECT

MEDICAL NEGLECT

EDUCATIONAL NEGLECT

FACTITIOUS ILLNESS (MUNCHHAUSEN SYN BY PROXY)

"Those who don't cruise rarely bruise"

Bruises in fleshy or protected parts (i.e. inner thighs, abdomen, upper arms) are suspicious.

Patterned bruises

What are types of inflicted burns and where do they tend to occur?

Occur in younger children

Immersion burns: stocking-glove burns w/out nearby splash burns

Splash burns: to resemble accidental burns

Object burns: distinguishable by shape; cigarette burns common

posterior rib fracture

spinal processes fractures

classic metaphyseal lesions (bucket-handle, chip or corner fractures)

scapular fracture

sternum fractures

Adult is angry or out of control

Intention is to inflict pain

Punishment involves anywhere other than clothed buttocks or backs of thighs

Leaves marks > than a few mins

Object is used (belt, cord, paddle..)

Sexual Abuse Victims

• ~80% females (9 yrs)
• 2/3 of victims aboused more than once (half for more than a year)
• Male victims are younger and likely to become sexual offenders

• 98% male
• An adult the child/teen knows
• ~85% family member
• Physically abusive to adult parnet
• Likely to use illicit drugs or alcohol

Most commonly diagnosed STI's in sexually abused victims?

HPV (condyloma acuminata)

Chlamydia Trachomatis

Neisseria gonorrhea

Treatment of STDs

1. Gonorrhea/chlamydia/trichomonas: Doxycycline or Azithormycin; Cefixime or Ceftriaxone; Metronidazole (Chlamydia)

2. Pregnancy: confirm beta HCG-; Plan B + Phenergan

3. Genital Herpes Simplex Virus: Acyclovir

4. Syphilis: Benzathine Pen G (or Tetra/Doxycycline)

5. HPV: Podophyllin, cryotherapy, TCA, surgical excision, observation

Epidemiology: White, males, late adolescence to early adulthood

Path: HLA-B27 genetic association

Clinical Features: Enthesitis, Sacrolilits, Peripheral joint involvement (hips,knees, ankles, MTPs, shoulders), Eye involvement

Dx: Symmetrical sacroilitis

Tmt: Non-pharmalogical; NSAIDS, glucocorticoids, Methotrexate & sulfasalazine, Biologic agenst, Surgery

Epidemiology: male:female equal; 35-50 yr; Psoriasisi precesed arthritis in 67% cases

Joint involvement: Asymmetric oligoarticular disease; DIP predominant, arthritis mutilans, symmetric polyarthritis, axial involvement

Clinical Features: Dactylitis (Sausage digits), tenosynovitis, enthesitis, arthritis, extra-articular: skin, nails, eyes disease

Dx: Caspar Criteria:  evidence of psoriasis, psoriatic nail dystrophy (pitting), Negative RF

Radiographs: asymmetric sacroilitis, DIP involvement, pencil in a cup deformity, ray distribution, acroosteolysis

Tmt: Derm referral; NSAIDS, glucocorticoids, DMARDS, Biologic agenst, Surgery

Epidemiology: Onset 20-40 yrs; GU: Males; GI: equal M:F

Organisms: Enteric: Salmonella, shigella, yersinia, campylobacter, clostridium; Urogenital: Chlamydia, mycoplama genitalum, ureaplasma urealyticum; URI: B-hemolytic strep; chlamydia pneumoniae

Clinical Features: Can't see, can't pee, can't climb a tree

Dx: Symmetrical sacroilitis

Tmt:  NSAIDS, glucocorticoids, DMARDS, antibiotics Biologic agents

Poor prognosis: hip arthritis, dactylitis, poor NSAID response, +HLA-B27, heel pain

Bowel Diseases Associated: IBD, Infectious gastroenteritis, Whipple's, Celica, Intestinal bypass arthritis

Feaures: Axial> independent of gut inflammation (symmetric sacroilitis). Peripheral> relation btw gut diseasee & flares

Tmt: Non-pharmalogical; NSAIDS, Peripheral: control gut inflammation, glucocorticoids injections, Biologic agenst, DMARDs; Axial: local glucocorticoid injections as necessary, DMARDS, Biologics

Erythamous plaques, with "silver" scales on elbows, knees, scalp & gluteal cleft

Types: Plaque, Guttate, Pustular, Inverse, Erythrodermic, Palmoplantar & Psoriatic Arthritis

Path: both polygenic & envmt factors. Can appear as Koebner phenomenon,esp following B-heme Strep infxn.

Dx: biopsy