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Psoriasis

Psoriasis. Definition.

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Psoriasis

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  1. Psoriasis

  2. Definition • Psoriasis is a common, chronic, disfiguring, inflammatory and proliferative condition of the skin; in which both genetic and environmental influences play a critical role characterised by red, scaly, sharply demarcated indurated plaques of various sizes, particularly over extensor surfaces and scalp.

  3. Aetiopathogenesis • Genetic predisposition: HLA-B13, B17, and Cw6 • Epidermal hyperproliferation • Antigen driven activation of autoreactive T-cells • Angiogenesis • Multifactorial inheritance • Overexpression of Th1 cytokines such as IL 2, IL 6, IL 8, IL 12, INF - γ, TNF α

  4. Trigger factors • Trauma (Koebner phenomenon): Mechanical, chemical, radiation trauma. • Infections: Streptococcus, HIV • Stress • Alcohol and smoking • Metabolic factors: pregnancy, hypocalcemia • Sunlight: usually beneficial but in some may cause exacerbation

  5. Trigger factors Drugs: Beta-blockers NSAIDS ACE inhibitors Lithium Antimalarials Terbinafine Calcium channel blockers Captopril Withdrawal of corticosteroids

  6. Patient Profile • Sex: Adults (M=F) but in adolescents (F>M) • Age: 2 peak age ranges 1st peak : 16-22 years 2nd peak: 57-60 years • Earlier age of onset: Female sex Positive family history • 3-fold higher risk in siblings of patients with onset before 15 years of age

  7. History • Patients give H/O Prominent itchy, red areas with increased skin scaling and peeling. • New lesions appearing at sites of injury/trauma to the skin (Koebner phenomenon) • Actual clearance of lesions following trauma to the skin (Reverse Koebner phenomenon) • Exacerbation in winter, improvement in summer • Significant joint pain, stiffness, deformity in 10-20%

  8. Morphology • Classical Lesion: Erythematous, round to oval well defined scaly plaques with sharply demarcated borders • Scales: Psoriatic plaques typically have a dry, thin, silvery-white or micaceous scale. • Sites: Elbows, knees, extensors of extremities, scalp & sacral region in a symmetric pattern. Palms/ soles involved commonly

  9. CLASSICAL PSORIASIS

  10. Morphology • Auspitz sign: Removing the scale reveals a smooth, red, glossy membrane with tiny punctate bleeding points • Grattage test: On grattage, characteristic coherence of scales seen as if one scratches a wax candle(‘signe de la tache de bougie)

  11. Morphology • Koebner’s phenomenon Linear distribution of the plaques seen along scratch marks or at sites of trauma • Woronoff‘s ring Psoriatic plaques occasionally appear to be immediately encircled by a paler peripheral zone.

  12. Morphological Types • Chronic plaque psoriasis: plaques with less scaling • Follicular psoriasis: follicular papules. • Linear psoriasis: linear arrangement of plaques • Annular/ figurate psoriasis: ring shaped or other patterns. • Rupoid, elephantine and ostraceous psoriasis

  13. CHRONIC PLAQUE PSORIASIS

  14. ANNULAR PSORIASIS

  15. Morphological Types • Guttate psoriasis: Common in children , good prognosis • Pustular psoriasis: Crops of pustules based on erythema • Localised / generalised • Impetigo herpetiformis • Erythrodermic psoriasis: 16-24% of all cases of exfoliative dermatitis

  16. GUTTATE PSORIASIS

  17. GUTTATE PSORIASIS

  18. PUSTULAR PSORIASIS

  19. PUSTULAR PSORIASIS

  20. ERYTHRODERMIC PSORIASIS

  21. Distributional Variation • Scalp psoriasis • Palmoplantar psoriasis • Nail psoriasis: pitting, onycholysis, subungual hyperkeratosis, or the oil-drop sign. (25-50%) • Mucosal psoriasis • Inverse psoriasis: • spares the typical extensor surfaces • affects intertriginous (i.e, axillae, inguinal folds, inframammary creases) areas with minimal scaling.

  22. SCALP PSORIASIS

  23. PALMOPLANTAR PSORIASIS

  24. PALMOPLANTAR PSORIASIS

  25. NAIL PSORIASIS

  26. INVERSE PSORIASIS

  27. Psoriasis in children and in HIV Psoriasis in children: • Plaques not as thick as in adults, less scaly • Diaper area in infants, flexural areas in children • Face involvement more common than in adults Psoriasis in HIV: • Acute onset • Severe flares • Poor prognosis

  28. Psoriatic arthritis • Seen in 5-10% of psoriatic patients • Types: 1. Classic (16%)-DIP joint involvement 2. Oligoarticular (70%) 3. Rheumatoid type(15%) 4. Psoriatic spondylitis (5%) 5. Arthtritismutilans (5%) Contd…

  29. Psoriatic arthritis Associations: • Tenosynovitis • Enthesitis • Osteolysis • New bone formation • Joint fibrosis & ankylosis

  30. Complicated psoriasis • Erythrodermic psoriasis • Generalisedpustular psoriasis • Psoriatic arthritis

  31. Histopathology Skin biopsy findings: • Parakeratosis • Microabscesses of Munro in the horny layer • Absence of granular layer • Regular elongation of rete ridges (camel-foot shaped) • Suprapapillary thinning of st.malpighii • Spongiform pustules of Kogoj • Dilated and tortuous capillaries in dermal papillae • Superficial perivascular inflammatory infiltrate

  32. HISTOPATHOLOGY

  33. Differential diagnosis • Nummular eczema • Tineacorporis • Lichen planus • Secondary syphilis • Pityriasisrosea • Drug eruption • Candidiasis • Tineaunguium • Seborrheic dermatitis

  34. ECZEMA

  35. SECONDARY SYPHILIS

  36. TINEA CORPORIS

  37. TINEA CORPORIS

  38. Treatment General measures: • Counselling regarding the natural course of the disease • Weigh reduction in obese patients. • Avoidance of trauma or irritating agents. • Reduce intake of alcoholic beverages. • Reduce emotional stress • Sunlight and sea bathing improve psoriasis except in photosensitive

  39. Topical therapy • Emollients: white soft paraffin & liquid paraffin • Corticosteroids: Potent steroids like fluocinoloneacetonide, betamethasonedipropionate or clobetasol propionate • 5-10% Coal tar: for stable but resistant plaques • 0.1-1% dithranol: for few stable, thick, resistant plaques Contd…

  40. Topical therapy • Keratolytics & humectants: as adjuvantseg. Salicylic acid 3-10%, urea 10-20% • Calcipotriene • Tazarotene • Macrolactams (calcineurin inhibitors): Tacrolimus & Pimecrolimus.

  41. Response to topical therapy • Effects of topical therapy evident in 2-3 weeks • Clearing of scale is usually observed first, followed by flattening of the treated plaques • Resolution of erythema may take 6-8 weeks

  42. Phototherapy 1. Extensive and widespread disease 2. Resistance to topical therapy

  43. PUVA photochemotherapy (PUVA) • Combined use of a photosensitizing drug methoxsalen (8-methoxypsoralens) with UVA irradiation (320-400 nm) • Mechanism of action: 1. Interferes with DNA synthesis → decrease cellular proliferation 2. Induces apoptosis of cutaneous lymphocytes (localized immunosuppression).

  44. Method of administering PUVA • 0.6mg/kg of 8-MOP(methoxypsoralen) given 2 hrs before irradiation • Initial dose of UVA is 2-5 J/cm2 with exposure time of 5 mins • PUVA administered 2-3 times per week in an outpatient setting. • Every week UVA dose increased by 20% and exposure time by 5 mins • Maintenance treatments every 2-4 weeks until remission • Relief with 20-30 treatments

  45. Side Effects • Nausea, pruritus, burning sensation. • Long-term complications • photo damage to the skin • skin cancer

  46. UVB phototherapy • Irradiation with light of wavelength 290-320 nm • Effective for moderate to severe psoriasis • Usually combined with one or more topical treatments like tar or anthralin • Narrow-band UVB phototherapy • Use of a fluorescent bulb with a narrow emission spectrum that peaks at 311 nm (UVB spectrum, 290-320 nm). • More effective than broadband UVB for the treatment of plaque-type psoriasis

  47. Systemic Agents Indications: • Resistant to both topical treatment and phototherapy • Active psoriatic arthritis. • Physically, psychologically, socially or economically disabling disease • Steroids: only used in life threatening situations like erythrodermic & pustular psoriasis. • Cyclosporin: Immune modulator • Used in erythrodermic & resistant psoriasis • Limitations: expensive & nephrotoxic and hypertensive

  48. Systemic Agents • Methotrexate: • Three doses of 2.5-5 mg orally 12 hrly or 7.5-15 mg single dose; administered every week. • Contraindicated in hepatic & renal diseases. Close monitoring of blood counts & hepatic function essential. • Acitretin: • For widespread psoriasis; combination with PUVA reduces total cumulative dose of UV irradiation • Contraindicated in pregnancy & women of child bearing age

  49. Biological therapies Selective, immunologically directed intervention at key steps in the pathogenesis of the disease. Mechanism of action: • Inhibits the initial cytokine release and Langerhans cell migration • Targets activated T cells, prevents further T-cell activation, and eliminates pathologic T cells; • Inhibits proinflammatory cytokines, such as TNF

  50. Biological therapies Indications: • Severe, recalcitrant cases • Psoriatic arthritis Mode of administration: • Intravenous, Subcutaneous Biological agents: • Efalizumab (Raptiva) • Etanercept (Enbrel ) • Infliximab (Remicade)

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