Psoriasis

1. Psoriasis

2. Psoriasis is a non-infectious, chronic inflammatory disease of skin, characterized by well defined erythematous plaques with silvery scale. • Occurs mostly over extensor surfaces and scalp.

3. Characteristic Lesion of Psoriasis!

4. Histopathology • Increased epidermal cell proliferation due to :increased growth fraction,shorten epidermal turnover time normal 60 to10 days • Thickening of the epidermis(acanthosis)with suprapapilary thinning responsible for the Ausitz sign) • Retention of nuclei by keratinocytes (parakeratosis) • Collection of polymorphs in the epidermis forming micro a microabscesses • Tortuous and dilated blood vessels • Inflammatory infiltrate primarily of lymphocytes in the upper dermis • Prolifilation of fibroblast

5. Precipitating factors! • Trauma • Appears in areas of skin damage like scratches or surgical wounds (Koebner phenomenon) • Infection • Preceded by β-hemolytic streptococcal throat infection (Guttate),HIV • Sunlight • Rarely, ultraviolet radiation may worsen psoriasis • Drugs • Antimalarials, β-blockers and lithium- worsens psoriasis • Stopping systemic steroids- rebound of psoriasis • Emotion • Anxiety precipitates some exacerbations

6. cause and Pathogenesis! • The exact cause is still unknown • T-cell mediated inflammatory disease • Epidermal hyperproliferation secondary to activation of immune system • Altered maturation of skin • Inflammatory cell infiltrate with neutrophilic and lymphocytic predominance. • Vascular changes • Cause: Excessive number of germinative cells entering the cell cycle rather than by a decrease in cell cycle time. • The turnover is greatly shortened, to less than 10 days as compared to a normal turnover period of 60 days

7. Associated Factors • Genetic Factors: - 30% of people with psoriasis have had psoriasis in family • Nongenetic Factors: - Mechanical, ultraviolet, chemical injury - Infections: Strep, viral, HIV - Prescription Drugs, stress, endocrine, hormonal, obesity, alcohol, smoking

8. GENETICS • Affected Parent Chance of developing • 1 of the parent affected 15% • Both are affected 50% • If one sibling already has the disease The chance still goes higher • The risk of those with HLA-Cw6 genotype developing psoriasis is 10-20 times more than those without it.

9. Psoriasis occurs in 2% of the world’s population. • Highest in Caucasians • In Africans, African-Americans and Asians- between 0.4% and 0.7% • Equal frequency in males and females • May occur at any age- from infancy to the 10th decade of life. Mostly occurs at the age of 10 or more.

10. Prevalence! • Two-thirds of patients have mild disease • One-third have moderate to severe disease • Early onset (prior to age 15) • Associated with more severe disease • More likely to have a positive family history • Life-long disease • Remitting and relapsing unpredictably • Spontaneous remissions of up to 5 years have been reported in approximately 5% of patients

11. Sharply demarcated erythematous plaque with silvery white scale

12. Commonly affected sites

13. Presentation pattern of psoriasis Differntial diagnosis Drug eruption,lichen planus Pityriasis rosea Candidiasis of flexures Hyperkeratotic eczema,sebhorric dermatitis. Fungal infection of nail • Plaque • Guttate • Flexural psoriasis • Localised forms • Generalized pustular • Nail involment • erythroderma

14. plaque • Well defined,discoid plaques • Involves elbow,knees,scalp hair margin,sacrum • Plaques are red covered by waxy white scales which when removed leaves bleeding point known as ausptiz sign. • Plaques 2cm to several cm and may be itchy.

15. Chronic plaque psoriasis

16. guttae • Acute ,symetrical eruption of drop like lesion • Commonly over the trunk and limbs • Most common in young adults • May follow a streptococcal throat infection.

17. Guttae psoriasis

18. flexural • Common sites are axillae,sub-mammary area and natal cleft, • Plaques are smooth and glazed. • Common in elderly.

19. Localized forms • Palmoplantarpustulosis • yellow to brown colored sterile pustules on palm and soles. • common in middle age females • Common in ciggarete smokers. • Scalp psoriasis: Can be confused with dandruff but are better demarcated and more thickly scaled. • Napkin psoriasis: • seen in infant in the nappy area • Lesion are well defined psoriasiform eruption are seen.

20. Generalized pustular • Rare but life threatening • Sheets of small sterile yellowish pustules appear on erythematous background and spreads rapidly • Acute onset • Fever , malaise and pt.requires hospital admission.

21. The skin initially becomes fiery red and tender. • Constitutional signs and symptoms, such as headache, fever, chills, arthralgia, malaise, anorexia, and nausea is present. • Within hours, clusters of nonfollicular, superficial 2 to 3mm pustules may appear. • The most common sites of involvement are the flexural and anogenital areas. Less often, facial lesions may also occur. • Pustules may occur on the tongue and subungually, resulting in dysphasia and nail shedding respectively.

22. These pustules coalesce within 1 day to form flakes of pus that dry and desquamate in sheets • Smooth erythematous surface is left on which new crops of pustules appear. • These episodes of pustulation may occur for days to weeks, thereby causing the patient severe discomfort and exhaustion. • A telogen effluvium type of hair loss may develop in 2-3 months. • Upon remission of the pustular component, most systemic symptoms disappear; however, the patient may be in an erythrodermic state or may have residual lesions of psoriasis vulgaris.

23. Other symptoms and signs • Fever • Dehydration • Itching • Weight loss • Muscle Weakness and fatigue • Fast heart rate • More severe complications may include breathing difficulties, low blood calcium levels, pneumonia, congestive heart failure and hepatitis.  • Seeking immediate dermatologic care for this condition is important.

24. Generalised pustular

25. Causes The following have reportedly triggered an eruption: • Withdrawal of systemic steroids • Drugs like lithium, phenylbutazone, oxyphenbutazone, trazodone, penicillin, iodine, hydroxychloroquine, calcipotriol, interferon-alpha, and recombinant interferon-beta injection • Strong, irritating topicals, including tar, anthralin, steroids under occlusion, and zinc pyrithione in shampoo • Infections • Sunlight or phototherapy • Cholestatic jaundice • Hypocalcemia • Idiopathic in many patients

26. Treatment • Generalized pustular psoriasis is treated by: • Placing dressings soaked in a mixture of aluminum acetate and water over the affected areas. • Topical steroids may also be used. • Severe cases may require acitretin, methotrexate, or cyclosporine.

27. Nail involvement • Affects the nail matrix or nail bed • Commonest change ;thimble pitting followed by oncholysis(separation of distal edge of nail from nail bed) • Adjacent to onycholysis salmon pink discoloration is seen . • Subungal hyperkeratosis • Associated with psoriatic arthopathy.

28. Psoriasis of nails

29. Complication of psoriasis

30. Psoriatic arthropathy Occurs in about 5% cases. • Four forms: • Distal arthritis:Mostly causes swelling of interphalangeal joints of hand and feet,sometimes causing flexion deformity. Sausage like swelling of digits may occur. • Rheumatoid like arthritis:mimics rheumatoid arthropathy with polyarthopathy,but is less symmetrical and R.F factor is negative. • Mutilansarthritis:erosion develop in small bones of hand and feet,sometimes in the spine. The bones may be dissolved giving severe deformity. • Ankylosingspondylitits

31. Fixed flexion deformity of distal interphalangeal joints following arthropathy.

32. Rheumatoid-like changes associated with severepsoriasis of hands.

33. Erythrodermic psoriasis • Also known as generalised exfoliative dermatitis. • Any inflammatory dermatosis that involves all or nearly all skin surface.

35. pathophysiology • Acute • Chronic Acute form:Odema of epidermis and dermis is prominent and is inflitrated by inflammatory cells. Chronic form: There is lenghtening of rete ridges and thickening of epidermis.

36. causes • Eczema (40%) • Psoriasis(25%) • Lymphoma(15%) • Drug eruption(10%) • Pityriasis rubra pilaris(1%) • Unknown(8%)

37. Erythrodermic psoriasis may be precipitated by: • Infections • Low calcium • Withdrawal of oral corticosteroids (prednisone) • Withdrawal of excessive use of strong topical corticosteroids • Strong coal tar preparations • Certain medications including lithium, antimalarials

38. It is a dermatological emergency • Common in male and middle aged and elderly. • Often developd suddenly especially when associated with leukemia or eczema. • A patchy erythema develops which spreads all over the body within 12-48 hours and accompanied by pyrexia ,malaise,shivering . • After 2-6 days scaling appears and the skin appears hot, red dry and thickened. • The exfoliation of skin is continous and copious.scalp and body hair is lost .nail become thickened and is shed. • Pigmentary changes occur and those with a dark skin hypopigmentaion is seen.

39. complications • Cardiac failure • Hypothermia:failure to sweat and excess heat loss. • Dehydration • Hypoalbuminaemia:protein loss in exfoliated scales. • Cutaneous oedema:hypoalbuminaemia.

40. Management • Inpatient treatment essential . • Nursed in a warm room at a steady temperature.(30-32degree) • Pulse,BP,temperature and fluid balance should be monitored regularly. • Tropical steroid and bland cream are main stay of treatment. • Systemic steroid are life saving in emergency cases.

41. Treatment of psoriasis • Explanations and reassurances must be given to the patients or the parents. • Information leaflets help to reinforce verbal advice. • At present there is no cure for psoriasis; all treatments are suppressive and aimed at either inducing a remission or making the condition more tolerable. However, spontaneous remissions will occur in 50% of patients.

42. Local Therapies • Topical Corticosteroids • Topical Vitamin D3 Analogues • Topical Retinoids • Photo(chemo)therapy Systemic Therapies • Oral • Parenteral

43. Topical corticosteroids • High potency and Super potent topical steroids • These include • Fluocinonide (cream, ointment, gel) • Betamethasone dipropionate cream • Clobetasol propionate (cream, ointment, gel, foam, lotion) • Diflorasone diacetate ointment • Betamethasone dipropionate ointment

44. Topical corticosteroids • Side effects associated with use • Skin atrophy • Burning and stinging • Suppression of the hypothalamic-pituitary-adrenal (HPA) axis • This may occur after 2 weeks of use with certain topical corticosteroids

45. Topical Vitamin D3 Analogues • Prototype for this group is calcipotriene • 3 formulations – cream, ointment, and scalp solution • Former two are approved for plaque psoriasis • Latter for moderate to severe psoriasis of the scalp Topical Vitamin D3 Analogues • Side effects associated with use • Cutaneous • Burning • Stinging • Pruritis • Skin irritation • Tingling of the skin

46. Ultraviolet B (UVB) • Treatment is time consuming • 2-3 visits/week for several months • Side effect – possibility of experiencing an acute sunburn reaction

47. Photo(chemo)therapy • Two types of phototherapy • Ultraviolet B (UVB) • Ultraviolet A + psoralen (PUVA)

48. PUVA • Consists of ingestion or topical treatment with a psoralen followed by UVA • Usually reserved for severe, disabling psoriasis • Time consuming – 2-3 visits/wk; at least 6 weeks • Precautions • Patients must be protected from further UV light for 24 hours post treatment • Side effects with oral psoralen • Nausea • Dizziness • Headache • Side effects with PUVA • Early • Pruritus • Late • Skin damage • Increased risk for skin cancer, particularly squamous cell (SCC) and after 200 - 250 treatments, increased risk for melanoma

49. Systemic Therapies • Oral • Methotrexate • Cyclosporine • Oral retinoids (acitretin) • Parenteral • Amevive (alefacept) • Raptiva (efalizimab) • Enbrel (etanercept)

50. Methotrexate:Folic acid antagonist • Usually reserved for severe, recalcitrant, disabling psoriasis • Maximum improvement can be expected after 8 -12 weeks Side effects: • Acute or chronic hepatotoxicity • Hepatic cirrhosis • Leukopenia • Thrombocytopenia • Anemia, including aplastic anemia • Rarely, interstitial pneumonitis • Stomatitis • Nausea/vomiting • Alopecia • Photosensitivity • Burning of skin lesions