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PAPULOSQUAMOUS DISEASES

PAPULOSQUAMOUS DISEASES. Psoriasis Lichen planus Lichen nitidus Pityriasis rosea Pityriasis rubra pilaris Seborrheic dermatitis Pityriasis lichenoides et varioliformis acuta Parapsoriasis. PAPULOSQUAMOUS DISEASES (II). Psoriasis Seborrheic dermatitis. PSORIASIS.

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PAPULOSQUAMOUS DISEASES

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  1. PAPULOSQUAMOUS DISEASES • Psoriasis • Lichen planus • Lichen nitidus • Pityriasis rosea • Pityriasis rubra pilaris • Seborrheic dermatitis • Pityriasis lichenoides et varioliformis acuta • Parapsoriasis

  2. PAPULOSQUAMOUS DISEASES (II) • Psoriasis • Seborrheic dermatitis

  3. PSORIASIS Psoriasis is a common, genetically determined, inflammatory and hyperproliferative skin disease. Psoriasis is a hereditary disorder of skin with several clinical expressions. The most frequent type is psoriasis vulgaris, which occurs as chronic, recurring, scaling papules and plaques.

  4. CLASSIFICATION • Psoriasis vulgaris • Acute guttate • Chronic plaque • Inverse • Palmoplantar • Psoriatic erythroderma • Pustular psoriasis • Psoriatic arthritis

  5. PSORIASIS VULGARIS

  6. Epidemiology • Age of onset: May begin at any age. Uncommon < 10 years. Early: Peak incidence at 22.5 years of age (in children the mean age of onset is 8 years). Late: About age 55. • Sex: Equal incidence. • Race: Low incidence in West Africans, Japanese; very low incidence or absence in North and South American Indians. • Heredity: Polygenic trait. HLA-B13, B17, Bw57, HLA-Cw6 ( aerlier age of onset and with a positive family history) • Triggering Factors: Physical trauma (Koebner’s phenomenon), infections (acute streptococcal), stress, drugs ( glucocorticoids, lithium, antimalarials, interferon, beta-adrenergic blockers), heavy alcohol, smoking • Comorbid disease: Psoriatic arthritis, Crohn’s disease, cancer, depression, non-alcoholic fatty liver disease, metabolic syndrome (or components of it), cardiovascular disorders.

  7. Pathogenesis • A chronic inflammatory disorder with polygenic predisposition combined with triggering environmental factors such as trauma,infection, or medication. • Psoriasis is a T-lymphocyte-mediated autoimmune disease (mixed Th1 and Th17 disease). T cells and cytokines play a pivotale role ( overexpression of type 1 cytokines like IL-1, IL-6, IL-8, IL-12, IFN gamma and TNF alpha ) • The underlying pathophysiology involves epidermal proliferation and differentiation, angiogenesis and the cellular immune system. • Dysregulated interactions of innate and adaptive components of the immune system with resident cutaneous cell types. • 1) Cross-talk between innate (macrophages, mast cells, granulocytes) and adaptive immunity( Tcells) 2) Interleukin-23 / Th 17 axis 3) Effect on resident T cells of the skin (antimicrobial peptides, cytokines and chemokines secreted by keratinocytes act as chemoattractants for infiltrating immune cells) 4)Effect on vascular endothelial cells ( the inflammatory milieu leads to induction and activation of a range of pro-angiogenic factors – VEGF - , TNF alpha-governed pro-inflammatory environment in psoriatic skin induces endothelial adhesion molecules which facilitate the recruitement of circulating leucocytes in psoriatic skin.

  8. Physicalexamination • AcuteGuttateType:Eruption of smallsalmon-pinkpapules (guttate: Latin gutta, “drop”), withorwithoutscales, disseminated, generalized, mainly on theuppertrunk, stronglyassociatedwithstreptococcalthroatinfection, frequent in youngadultsandchildren • ChronicStable (plaque) Type:Sharplymarginated, dull-redplaqueswithlooselyadherent, lamelar, silvery-whitescales. Singlelesionorlesionslocalizedtooneormorepredilectionsites: elbows, knees, sacral-glutealregion, scalp, plm/soles. Sometimesonlyregionalinvolvement(scalp), oftengeneralized. • Special Sites • PalmsandSoles • Scalp • InversePsoriasis (perianal, genitaland body folds) • Nails: pitting, subungualhyperkeratosis, onycholysis, theoil spot (pathognomonic)

  9. Laboratory examinations • Dermatopathology • Culture: Throat culture

  10. Palmoplantar psoriasis • Chronic, relapsing eruption limited to palms and soles. Numerous very typical sterile, yellow, deep-seated pustules that evolve into dusky-red crusts. • Incidence: Low as compared to psoriasis vulgaris • Age of onset: 50 to 60 years. More common in females (4:1) • Symptoms: Stinging, burning, itching. Eruptions come and go, in waves. • Differential diagnosis: Tinea manus, tinea pedis, dyshidrotic eczema, contact dermatitis, HSV infection. • Course: Persistent for years and characterized by unexplained remissions and exacerbations.

  11. Generalized acute pustular psoriasis (Von Zumbusch) • This disorder can be a life-threatening medical problem with an abrupt onset. It starts with a burning fiery-red diffuse erythema that spreads in hours with pinpoint pustules appearing in clusters. Fever, weakness, severe malaise, fast pulse, leukocytosis, shedding of nails, hair loss, skin tenderness • Special types: Impetigo herpetiformis, acrodermatitis continua of Hallopeau

  12. Psoriatic arthritis • Rare before age 20 • Sero(-), “distal”, asymmetric oligoarthritis • Mutilating arthritis (bone erosion, osteolysis or ankylosis. • “Axial” (sacroiliac, hip, cervical) • Dactylitis (sausage fingers) • May be present (in 10% of patients) without any visible psoriasis • Often psoriatic involvement of fingertips and periungual skin • Massive nail involvement by psoriasis is frequent

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  14. Management (1) • Factors influencing selection of treatment: • Age • Type of psoriasis • Site and extent of involvement • Previous treatment • Associated medical disorders

  15. Management (2) • Localized psoriasis • Topical glucocorticoids • Intralesional triamcinolone acetonide • Topical anthralin • Topical vitamin D analogues( calcipotriene, 0.005%, ointment and cream) • Topical tacrolimus, 0.1% • Tazarotene ( a topical retinoid, 0.05 and 0.1% gel ) • Topical dithranol and coal tar • Topical PUVA, UVB • Salicylic acid • Moisturizing

  16. Management (3) • Generalizedpsoriasis • Narrow-Band UVB Phototherapy • Oral PUVA Photochemotherapy • Oral Retinoids • Methotrexate • Cyclosporine • Diet • MonoclonalAntibodiesandFusionProteins: Infliximab, Etanercept, Adalimumab, Ustekinumab (IL-12/23)

  17. GEOGRAPHIC TONGUE Also known as benign migratoryglossitis The condition usually presents as asymptomaticerythematouspatcheswithserpiginousborders, resembling a map. Theselesionscharacteristicallyhave a migratorynature.

  18. RELATED PHYSICAL FINDINGS • NAIL CHANGES IN PSORIASIS.

  19. GeneralizedPustular Psoriasis • is a distinctive characterized by acute variant of psoriasis. Attacks arefever that lasts several days and asudden generalized eruption of sterile pustules 2–3mm in diameter. • The pustules are disseminatedover the trunk and extremities, including thenail beds, palms, and soles. • The pustules usually ariseon highly erythematousskin, first as patchesand then becoming confluent as the diseasebecomes more severe.

  20. ERYTHRODERMIC PSORIASIS • generalizedform of the disease that affects all body sites,including the face, hands, feet, nails, trunk, and extremities • Erythemais the most prominentfeature, and scaling is different • Instead of thick, adherent, whitescale there is superficial scaling. • Psoriatic skin is often hypohidroticdue to occlusion of the sweat ducts

  21. INVERSE (FLEXURAL) PSORIASIS • lesionsmay be localized in the major skin folds,suchasthe axillae, the genito-crural region, and theneck. • Scalingis usually minimal or absent, and the lesions showa glossy sharply demarcated erythema, which is oftenlocalized to areas of skin-to-skin contact. • Sweating is impaired in affected areas.

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