psoriasis

Psoriasis

• Meaning
• Greek psora to itch
• Arabic




























































30% nail psoriaisis

5% psoriatic arthritis

Objectives

• Discuss definition and epidemiology of psoriasis
• Explain causes and aggravating factors of psoriasis
• Describe clinical signs of psoriasis
• List topical and systemic treatment options including side effects

Psoriasis

• Psoriasis is a genetic, immunologically-mediated systemic disease primarily affecting skin and joints
• It is a chronic, incurable, debilitating disease that profoundly affects the quality of life of patients and their families.


How common is Psoriasis?
• 2% of population
• Racial variation
• Affects men and women equally
• Two age groups of onset
• Late teens to early 20s,

Aetiology

• Genetic,environmental and immunological
• Family history (30%)
• 70% concordance MZ twins
• 20 % DZ twins
• HLA - CW6

Aetiology 2- Environmental factors

• triggering factors :external factors may provoke psoriatic lesion
• a-Physical trauma (Koebner s phenomenon1872)
• b-infections strep tonsillitis
• viral HIV
• c-climate and sun lights
• d- stress
• e – drugs
• antimalarial B-bloker lithium
• withdrawal of systemic steroid


• Koebner’s phenomenon
• Production of the same lesion after trauma
• Lichen planus ,vitiligo viral warts behchet disease
• 25% of patients
• poor prognosis
• Reverse k phenomenon

Aetiology 3-immunological factors

• Evidence
• cyclosporin immunosupressor
• Bone marrow transplant of psoriatic donor
• activatedT lymphocyte increase no in dermis producing interluekin 12 and 17
• And tumor necrosis fator TNF


Pathogphysiology
• rapid turn over of cell proliferation of the basal cell layer
• excessive but controlled 3days
• two fold increase in proliferative cell population
• Immune system
• Increase activation of T cells

Histopathology

Histopathology

Histopathology

• Auspitz sign

• silvery scale
• Membrane like layer
• Pin point bleeding


Types of Psoriasis
• Chronic plaque psoriasis (90%)
• Palmoplantar psoriasis
• Flexural psoriasis
• Guttate psoriasis
• Erythrodermic psoriasis
• Pustular psoriasis

Chronic plaque psoriasis

Salmon pink patches
Well demarcated
Silvery scales

Symmetrical

Extensor surfaces

Clinical types 1-psoriasis vulgaris or chronic plaque psoriasis commonest .any age young ,extensor

Guttate psoriasis

Guttate psoriasis
More common in children / adolescents

Acute streptococcal infection

Rain drop-like lesions

Self-resolving (months)

May precede chronic psoriasis

Clinical types

• 2- Guttate ps children strept small papule red scaly
• treatment treat infection

Pustular psoriasis localized- Palmoplantar

Commoner in females

Adults

Assoc with smoking

? Distinct from ordinary psoriasis

Symmetrical

Pustular psoriasis - Generalised

Rare

Acute generalised pustular psoriasis (von Zumbusch)

Can occur with ordinary psoriasis

Precipitated by steroid withdrawal

Sheets of pustules, background erythema

May be systemically unwell

Clinical types 3-Pustular psoriasis
b-generalized trunk extremities nail palm sole toxic fever leucocytosis loss of appetite etretinate ,dapson

ErErythrodermic psoriasis

ythrodermic psoriasis
Erythroderma – more than 90% body surface area
Uncommon

Most likely preceding history of psoriasis

May not have other features psoriasis


May be systemically ill

Clinical types

• 4- Erythrodermic or Exfoliative psoriasis
• whole body face
• other causes of erythroderma eczema drugs malignancies ichthyosis
• metabolic changes :Hypoprotienemia , Iron deficiency anemia ,vitamins deficiency hypothermia hyperkinetic condition may lead to heart failure ,electrolyte disturbance

Erythrodermic or Exfoliative psoriasis

flexural pso axilla groin diffuse erythematous oozy affecting the vault differentiate from tinea active border clear vault +ve scraping

Psoriatic arthritis

• ½ have HLA B-27
• sero –ve RF ANF
• with or without skin lesions
• a- poly arthitis rheumatoid like
• b-Mono arthritis like pyogenic arthritis
• c-Axial skeleton ankyloing spondylitis like
• d Arthritis mutilans complete destruction of small joints of hand


psoriasis - Nails
Nail pitting
Onycholysis
Subungal hyperkeratosis


















• Prognosis
• Bad early onset +ve family history ,generalized, koebner +ve
• Good guttate reverse koebner

Management Psoriasis

• Education
• Topical treatment
• Phototherapy
• Systemic treatment

1st line: Topical treatment

• Emollients e.g. E45
• Vitamin D3 analogues (e.g.Calcipotriol)
• Topical corticosteroids
• Keratolytics e.g. 5% Salicylic acid
• Coal tar
• Dithranol (Short contact, dithrocream)

• Emollients

• Reduces scale and dryness
• Thick preparations can give folliculitis
•
• Vitamin D analogues
• Calcipotriol
• Irritation / hypercalcaemia
• Topical steroids
• Skin atrophy
• Coal tar
• Messy, folliculitis, irritation
• Dithranol
• Irritation, stains skin
First-line topical treatment – Chronic plaque psoriasis


2nd Line: Phototherapy
• UVB
• (narrowband UVB)
• UVA plus tablets (8 methoxypsoralen)
• = PUVA
• Side effects - Erythema / pruritis
• Nausea (PUVA)
• L/T – Skin cancer

• Admit, supportive treatment with careful monitoring of BP, temperature and urine output

Emollients and mild topical steroids

Consider systemic treatment

Management of erythrodermic psoriasis and

generalised pustular psoriasis

3rd Line: Systemic treatments

• Mode of Action
• Methotrexate
• Folic acid antagonist
• Selective inhibition of rapidly dividing cells
• Ciclosporin
• Suppression of T lymphocytes
• Blocks production of lymphokines
• Acitretin
• Vitamin A derivative
• Suppresses DNA synthesis and cell differentiation


• Side effects
• Methotrexate
• Teratogenicity, nausea and GI upset
• Liver fibrosis, marrow suppression
• LFT and CBP
• Ciclosporin
• Hypertrichosis, gym hypertrophy, tingling peripheries, carcinogenesis
• Hypertension, nephrotoxicity
• Blood pressure, blood urea serum creatinin
• Acitretin
• Teratogenic, dry skin and lips
• Hyperlipidaemia, hepatotoxicity
• Fasting lipids, LFTs

Biological therapy

Target t lymphocyte
Target TNF

Question 1

• What is the prevalence of psoriasis in the western world?
• 8%
• 15%
• 2%


Question 2
• What % of patients with psoriasis have a positive family history?
• 10%
• 30%
• 70%

Question 7

How could you treat Psoriasis on the face?

a. Mild steroid

b. Vitamin D analogues
c. Coal tar
d. Dithranol

Question 3

• What is the most common type of psoriasis?
• Chronic plaque psoriasis
• Palmoplantar psoriasis
• Flexural psoriasis
• Guttate psoriasis
• Pustular psoriasis