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Case Presentation…… Dr. Aravindakshan. G. K.
A 35 year man CC of itching of whole skin of about 12 years. The skin appears like as whitish scaly lesions got aggravated by sun exposure, night and during sleep. He also complaints of right knee joint pain since 3 months got aggravated from rising from seat, walking and ameliorated by rubbing and lying on bed.
On enquiry complaints started as lesions on knee joint as pustules and scaly lesions on anterior part of leg, scalp, hands and face. PMH suggests about allopathic treatment but only temporary relief. PH suggests about bronchial asthma from childhood, before 1 year as hepatomegaly.
FH suggests about mother died due to D.M & H.T. O/E, pulse rate: 78/min. resp. rate: 18/min. B.P: 98/68 mm of Hg. mild pallor. H.S: S1 long and dull, S2 normal.
Psychic features as indecsessive, use abuse words, disappointed when others say wrong about him, desires solitude. Regional features as scaly eruptions as whole body, nails in all toes as yellowish tiny pittings and kollionychia.He also has palilalia and slurring of speech.
Other investigations report as on colourdoppler study as mitral valve and tricupsid valve reguritation.
Individualistic features as 1. scrapping with knife. 2. always wants to be neat. 3. worries about little matters. 4. worries about his family. 5. when anger use abuse words.
Medicine prescribed as Ars. Alb 0/6 / 1D. the remaining days as SL..
Diagnosed as Psoriasis • A papulosquamous disorder….
Definition….. • It is a chronic inflammatory skin disorder clinically characterized by well defined erythematous, sharply demarcated papules and rounded plaques, covered by silvery scale and a chronic fluctuating course.
The patches are most common on the knees, elbows, scalp, tailbone, and back, but they may be anywhere on the body (including the fingernails, palms, and soles of the feet).
Psoriasis is not contagious. The exact cause of psoriasis is not known, but the body's natural defense system (immune system) is believed to be involved. The condition tends to run in families
Doctors believe that the immune system is a factor in the development of psoriasis. This is because increased numbers of white blood cells are present between the abnormal layers of skin and because psoriasis responds to drugs that suppress the immune system.
The patches (called plaques) are made up of dead skin cells that form thick layers. The body replaces normal skin cells every 28 days, but in psoriasis, skin cells are replaced every 3 to 6 days.
The histological changes of psoriasis are two key pathophysiological features. • The keratinocyteshyperproliferate with a grossly increased mitotic index and an abnormal pattern of differentiation, leading to the retention of nuclei in the stratum corneum, not normally present as the stratum corneum cells are dead. • There is a large inflammatory cell infiltrate.
The T-cell infiltrates in psoriasis have a non-random patterns of migration including CD8+T cells present in the epidermis, and CD4+ T cells in the dermis. Besides T cells, other immu-nocyte subsets include increased numbers of neutrophils, dermal dendritic cells, macro-phages, and mast cells.
Especially in chronic plaque lesions, a marked epidermal thickening is observed This thickening is a result of hyperplasia of basal and suprabasalkeratinocytes. At the same time, abnormal keratinocyte differentiation with marked PARAKERATOSIS (nuclei in the stratum corneum)and an absent granular layer is demonstrated.
Neutrophilsinvade the epidermis and accumulate as small spongiform Kogoj pustules or migrate up to the stratum corneum forming Munro’smicroabscesses. • Munro’s microabscesses are found only inparakeratotic areas of the epidermis. • Infiltration of neutrophils is striking in pustular and in guttate psoriasis.
The number of epidermal lymphocytes of the psoriatic lesion is significantly increased and comprises both CD8+ (killer) T lymphocytes and CD4+ (helper) T lymphocytes, • Langerhanscellsand a macrophage subpopulation called non-Langerhansdendritic cells represent the epidermal dendritic cells. • In psoriasis, fully mature Langerhans cells are increased in number and have enhanced antigen-presenting capacity due to overexpression of HLA class II molecules
Neoangiogenesis is characteristic of psoriatic plaque formation, and in lesional skin increased numbers of dilated, tortuous vesselsare thus encountered. • Indeed, a four-fold increase in endothelium of the superficial, but not of the deeper, microvasculature in lesional skin is reported
Psoriasis vulgaris Also known as "plaque psoriasis," it is the type that affects 80% to 90% of people with the disease. Psoriasis vulgaris can be recognized by the presence of raised, red, scaly patches (or "plaques"), usually on the elbows, knees, scalp, chest, nails, and lower back and associated with fever, malaise, diarrhea, and arthralgias. These may vary in size. The scales may be thick and silvery.
Guttate psoriasis This form is less common; only about 10% of patients have this type. Guttate psoriasis often appears after someone suffers from strep throat. It commonly starts in childhood or adolescence with the sudden appearance of drop-sized patches (guttate means drop-like). • These lesions may spread to cover large areas of the upper body, legs, arms, and scalp.
Pustular psoriasis • This is a rare form of psoriasis. It may be localized (usually appears on the palms of the hands and the soles of the feet), or generalized over the entire body. Localized pustular psoriasis can be quite painful, making it difficult to use your hands or walk normally. Most commonly, skin becomes red and swollen, with small, pus-filled pimples that dry to form brown dots; some people may have scaly patches
Inverse psoriasis • This form is also called skin-fold, flexural, or genital psoriasis, because smooth, red, dry patches often occur in the folds of the skin (known as flexures). Inverse psoriasis may concentrate in the genital area, as well as under the breasts and in the armpits, and is more common in people who are overweight. It is characterized by increased sensitivity to friction and sweating. The affected skin can cause great discomfort, and this can make sexual relations difficult.
Erythrodermic psoriasis • Also known as exfoliative psoriasis, this is a form of psoriasis that covers almost the entire body. It is characterized by severe redness and scaling, which is often accompanied by itching and pain. Because symptoms are so widespread over the body, this form can be extremely serious.
Erythrodermic psoriasis can cause the body temperature to fluctuate, especially in extremely hot or cold weather. It can also complicate heart disease and cause heart failure, because the heart rate may accelerate due to increased blood flow to the inflamed skin
Psoriatic arthritis: a related condition • Psoriatic arthritis is an arthritic condition— a condition related to the joints. The most common symptoms are inflammatory arthritis, and dry, scaly, thick, and inflamed skin. However, the skin symptoms and the arthritis symptoms frequently appear at different times, often years apart, so their connection may not be obvious
Psoriatic arthritis usually involves the joints of the hands and feet, knees, and ankles, which can become painful, swollen, hot, red, and stiff. Pain and stiffness can also develop in the lower back, buttocks, neck, and upper back. Psoriasis skin symptoms may include pitting and ridges in the fingernails and toenails. Nearly one quarter of people with psoriasis have psoriatic arthritis.
Symptoms…… Tiny areas of bleeding when skin scales are picked or scraped off (Auspitz's sign). • Mild scaling to thick, crusted plaques on the scalp. • Itching, especially during sudden flare-ups or when the psoriasis patches are in body folds, such as under the breasts or the buttocks. • Nail disorders. Nail disorders are common, especially in severe psoriasis.
Nail symptoms include: Tiny pits in the nails (not found with fungal nail infections). • Yellowish discoloration of the toenails and possibly the fingernails. • Separation of the end of the nail from the nail bed. • Less often, a buildup of skin debris under the nails
Differential Diagnosis….. SECONDARY SYPHILIS.
