Psoriasis

1. Psoriasis Georgia Skin and Cancer Clinic Chris Anderson ANP

2. What is Psoriasis? • Psoriasis is a chronic skin condition of unknown cause • Causes red/scaly patches • Usually lifelong/relapsing • Wide range of distribution • History: • Ancient condition; widely confused • Grouped with Leprosy at one time • Differentiated in 18th century by Dr. Ferdinand Von Hebra as psoriasis

3. The Many Faces of Psoriasis

18. Who has Psoriasis? • Often first seen ages 15-25 • 1/3 have a family history • 1-2 % of the world affected. • More common in Caucasians • Found equally in men and women. • Famous people with psoriasis: • Benjamin Franklin, Jerry Mathers, Art Garfunkel, John Updike

19. Pathophysiology • Epidermis has rapid accumulation of cells (accounts for the classic psoriatic lesion) • Lesions result from an increase in epidermal cell turnover. Transit time decreases from the normal 28 days to 2-3 days. • Most current therapies are directed at suppression of responsible T cells. www.psoriasis.or.id

20. Pathophysiology www.gene.com

21. Clinical Manifestations • Integument: • Silvery scale on an erythematous base • Auspitz’s sign • ***Koebner’s phenomenon • Arthritis: • 10-30% of patients • Pruritus: • Varies from asymptomatic to quite pruritic • Psychosocial problems: • Poor self-esteem • Exacerbating factors: • Stress, winter months (UV exposure) • Illness: Strep pharyngitis, HIV • Meds: anti-malarials, beta-blockers, lithium, interferon • Excessive alcohol consumption

22. Clinical Manifestations • KÖEBNER PHENOMENON • Lesions can appear in traumatized/damaged areas of skin Trauma Sun lamp burn Radiation

23. Wide range of distribution Can range from one small localized plaque to generalized exfoliative erythroderma Usually symmetrical Usually spares the face Distribution of Lesions www.aafp.org

24. Variations of Psoriasis

25. Localized psoriasis Scalp Psoriasis Generalized psoriasis Guttate psoriasis Psoriasis in children Palmoplantar psoriasis Psoriatic Nails Psoriatic Arthritis Inverse psoriasis Erythrodermic psoriasis (exfoliative dermatitis) Variations of Psoriasis

26. Localized psoriasis Scalp Psoriasis Generalized psoriasis Guttate psoriasis Palmoplantar psoriasis Psoriatic Nails Inverse psoriasis Psoriasis in children Variations of Psoriasis

27. Localized psoriasis Variations of Psoriasis

28. Localized Plaque Psoriasis • Basics • Mildest manifestation • Often an incidental finding • May consist of nail pitting or mild patches on elbows or knees. • Patient often unaware or not troubled

29. Localized Plaque Psoriasis • Diagnosis • Usually based on exam • Family history, aggravating factors and nail findings often helpful • Skin biopsy and fungal examinations can be performed

30. Localized psoriasis Scalp Psoriasis Variations of Psoriasis

31. Scalp Psoriasis • Basics • May involve the scalp alone or included other areas. • Plaques frequently hidden in the scalp or behind the ears. • Plaques often thick and well demarcated with a white scale. • Pruritus and scratching may exacerbate (Koebner’s) Psoriasis around hairline

32. Localized psoriasis Scalp Psoriasis Variations of Psoriasis Generalized psoriasis

33. Generalized Plaque Psoriasis • Basics • Can flare very quickly • May cover 20% to 80% of the body • Topical therapy alone becomes less effective • UV light treatment, systemic medications and/or biologics may be necessary

34. Localized psoriasis Scalp Psoriasis Generalized psoriasis Guttate Psoriasis Variations of Psoriasis

35. Guttate Psoriasis • Basics • Sudden onset of multiple raindrop shaped lesions. • Usually on trunk • Often the initial presentation in children/young adults. • Can follow group A beta-hemolytic strep pharyngitis. • DDx • Pityriasis Rosea, drug rash, secondary syphilis • Treatment • Abx therapy if positive ASO. • Consider traditional treatment for poor responders. www.psoriasis.org

36. Localized psoriasis Scalp Psoriasis Generalized psoriasis Guttate psoriasis Palmoplantar psoriasis Variations of Psoriasis

37. Psoriasis of the Palms and Soles • Basics • Hyperkeratotic type: • Well-demarcated plaques. • Koebner’s phenomenon? • Often cause pain, impairment of function, and embarrassment. • Pustular type: • Usually seen in adults • Yellow pustules (sterile) • DDx: • Contact dermatitis • Dishydrosis • Tinea

38. Psoriasis of the Palms and Soles • Treatment • Topicals are the first line • Class I TCS needed to penetrate thicker stratum corneum, often under occlusion. • Systemics or Biologics for poor responders

39. Localized psoriasis Scalp Psoriasis Generalized psoriasis Guttate psoriasis Palmoplantar psoriasis Psoriatic Nails Variations of Psoriasis

40. Psoriatic Nails • Basics • Nail involvement common. • Usually cosmetic condition only. • More common in patients with generalized psoriasis and psoriatic arthritis. • DDx: • Onychomycosis • Paronychia • Contact dermatitis www.psoriasis.org www.dartmouth.edu

41. Psoriatic Nails • Typical Nail Changes: • Pitting • Classic nail finding in psoriasis. • Produced by tiny punctate lesions that arise from the nail matrix and appear on the nail plate as it grows. • Onycholysis • Represents a separation of the nail plate from underlying pink nail bed. • “Oil Spots” • Orange-brown areas appearing under the nail plate. Presumably the result of psoriasis of the nail bed. • Subungual hyperkeratosis: • Buildup of scale beneath the nail plate. Onycholysis Pitting

42. Psoriatic Nails • Treatment is generally unrewarding, but some measures can be helpful: • Careful trimming and paring of the nails are recommended. • Topical steroids need to be directed toward the proximal fold (closer to matrix) • Intralesional steroids can be injected into the nail matrix • Consider systemic/biologic therapy based on the situation

43. Localized psoriasis Scalp Psoriasis Generalized psoriasis Guttate psoriasis Palmoplantar psoriasis Psoriatic Nails Variations of Psoriasis Inverse psoriasis

44. Inverse Psoriasis • Variation that occurs in flexural areas • Under breasts, axillary, gluteal cleft, anogenital • Koebner’s may play part • Often mistaken for candidal infection. Psoriasis.org Emedicinehealth.com

45. Localized psoriasis Scalp psoriasis Generalized psoriasis Guttate psoriasis Palmoplantar psoriasis Psoriatic nails Inverse psoriasis Variations of Psoriasis Psoriasis in Children

46. Psoriasis in Children • Basics • Begins before age 10 in 10% of those with psoriasis. • Early onset may predict more severe disease. • Often an associated family history. • May be difficult to distinguish from irritant/atopic dermatitis or cutaneous candidiasis. • May also present with typical plaques. • Requires intensive educational of the patient and family.

47. Infantile Psoriasis

49. Psoriasis in Children • Treatments: • Many of the treatments that are used in adults, such as Class I topical steroids, phototherapy, methotrexate, and retinoids, are generally avoided in children. • Low to medium potency topical steroids • Calcipotriene (Dovonex) • Keratolytics • Natural sunlight if available. • Some success with biologic therapy (off label??)

50. Management of Psoriasis