PSORIASIS

Diagnosis and management

Dr.Md. Shshidul Islam

Assistant professor
Dermatology & VD, CBMC’B
OVERVIEW 2

1. Epidemiology and pathophysiology

2. Clinical presentation

3. Diagnosing psoriasis

4. Managing psoriasis

5. Case studies
WHAT IS PSORIASIS? 3

– Inflammatory and hyperplastic

disease of skin
– Characterised by erythema and
elevated scaly plaques
– Chronic, relapsing condition
– Course of disease often
unpredictable

.
SYMPTOMS OF PSORIASIS 4

Most frequently
experienced symptoms

Adapted from Krueger G et al. Arch Dermatol 2001; 137: 280–4.

 SOCIAL IMPACT OF PSORIASIS 5

Psoriasis mistaken
as contagious 57

48
Psoriasis mistaken for other
disease

Trouble receiving equal

treatment in service 40
establishments (e.g. hair
salons,
public pools)
0 10 20 30 40 50 60
Percentage of respondentswith severe psoriasis (n = 502)

Adapted from Krueger G et al. Arch Dermatol 2001; 137: 280–4.

PSORIASIS AFFECTS EMOTIONAL STATE 6
 EPIDEMIOLOGY 7

• Common skin disorder

• Prevalence variable: ~ 0.3–2.5%

• Prevalence equal in males and females

• Estimated incidence: ~ 60 per 100,000 per year

AGE OF ONSET 8

• Mean age: ~ 23–37 years

• Current theory:
2 distinct peaks with possible genetic associations
– Early onset (16–22 years)
• More severe and extensive
• More likely to have affected first-degree family member
– Late onset (57–60 years)
• Milder form
• Affected first-degree family members nearly absent
GENETIC INFLUENCE 9

• Evidence suggests strong genetic association

– Studies of monozygotic twins show concordance
for psoriasis (e.g. 64% in a Danish Study)

– Multiple susceptibility loci have been identified

• Disease expression
– likely result of genetic and environmental factors
 COMMON TRIGGER FACTORS FOR PSORIASIS 10

• Infections (e.g. streptococcal, viral)

• Skin trauma (Koebner phenomenon)

• Psychological stress

• Drugs (e.g. lithium, beta blockers)

• Sunburn

• Metabolic factors (e.g. calcium deficiency)

• Hormonal factors (e.g. pregnancy)

PSORIASIS IS A T-CELLMEDIATED, 11
AUTOIMMUNE DISEASE1

Current hypothesis:

– Unknown skin antigens stimulate immune response

• Antigen-specific memory T-cells are primary mediators

• Leads to impaired differentiation and
hyperproliferation of keratinocytes
CLINICAL PRESENTATION: 12
CLASSIC PSORIASIS
– Well-defined and
sharply demarcated
– Round/oval-shaped
lesions
– Usually
symmetrical
– Erythematous,
raised plaques
– Covered by white,
silvery scales
COMMON SITES 13
AFFECTED BY PSORIASIS
• Can affect any part
of the body –
typically scalp,
elbow, knees and
sacrum

• Extent of disease
varies

1
TYPES OF PSORIASIS 14

• Chronic plaque • Pustular

• Guttate – Localised and generalised

• Flexural • Local forms

– Palmoplantar
• Erythrodermic
– Scalp
– Nail (psoriatic
onychodystrophy)
 CHRONIC PLAQUE PSORIASIS 15

– Most common type – affects

approximately 85%
– Features pink, well-defined
plaques with silvery scale
– Lesions may be single or
numerous
– Plaques may involve large
areas of skin
– Classically affects elbows,
knees, buttocks and scalp
CHRONIC PLAQUE PSORIASIS 16
CHRONIC PLAQUE PSORIASIS 17
CHRONIC PLAQUE PSORIASIS 18
CHRONIC PLAQUE PSORIASIS 19
 GUTTATE PSORIASIS 20

– Numerous and small lesions

– ~ 1 cm diameter
– Pink with less scale than
plaque psoriasis
– Commonly found on trunk
and proximal limbs
– Typically seen in individuals
< 30 years
– Often preceded by an upper
respiratory tract
streptococcal infection

1.
 FLEXURAL PSORIASIS 21

– Lesions in skin folds

articularly groin,
gluteal cleft, axillae and
submammary regions
– Often minimal or
absent scaling
– May cause diagnostic
difficulty when genital
or perianal region is
affected in isolation

1
 ERYTHRODERMIC PSORIASIS 22

– Generalised erythema
covering entire skin surface
– May evolve slowly from
chronic plaque psoriasis or
appear as eruptive
phenomenon
– Patients may become febrile,
hypo/hyperthermic and
dehydrated
– Complications include cardiac
failure, infections,
malabsorption and anaemia
– Relatively uncommon
 PUSTULAR PSORIASIS 23

– Two forms:
• Localised form
• More common
• Presents as deep-seated
lesions with multiple small
pustules on palms and soles
• Generalised form
• Uncommo Associated with
fever and widespread
pustules across the body
• inflamed body surface
 PALMOPLANTAR PSORIASIS 24

– Can be hyperkeratotic
or pustular
– May mimic dermatitis –
look for psoriatic
manifestations
elsewhere to aid
diagnosis
– Possibly aggravated by
trauma
 SCALP PSORIASIS 25

– Varies from minor

scaling with erythema
to thick hyperkeratotic
plaques
– May extend beyond
hairline
– Patient scratching may
produce asymmetric
plaques
 NAIL PSORIASIS 26

– May be present in patients with

any type of psoriasis
– Can take several forms:
• Pitting: discrete, well-
circumscribed depressions on
nail surface
• Subungual hyperkeratosis:
silvery white crusting under
free edge of nail with some
thickening of nail plate
• Onycholysis: nail separates
from nail bed at free edge
• ‘Oil-drop sign’: pink/red colour
change on nail surface
NAIL PSORIASIS 27
NAIL PSORIASIS 28
NAIL PSORIASIS 29
 PSORIATIC ARTHRITIS 30

– Approximately 5–20%
have associated arthritis
– Five major patterns of
psoriatic arthritis:
• Distal interphalangeal
involvement
• Symmetrical polyarthritis
• Psoriatic spondylarthropathy
• Arthritis mutilans
• Oligoarticular, asymmetrical
arthritis
– Clinical expressions often
overlap
DIAGNOSING PSORIASIS 31

• Other dermatological disorders

can resemble psoriasis

• Diagnosed clinically according to appearance,

distribution, history of lesions and family history

• Important to consider non-cutaneous complications

 DIFFERENTIAL DIAGNOSIS 32

• Localised patches/plaques • Flexural

– Tinea – Tinea
– Eczema – Eczema
– Superficial basal cell – Candidiasis
carcinoma and Bowen’s – Seborrhoeic dermatitis
disease
– Seborrhoeic dermatitis • Erythrodermic
– Cutaneous T-cell lymphoma – Eczema
(mycosis fungoides) – Cutaneous T-cell lymphoma
– Pityriasis rubra pilaris
• Guttate – Lichen planus
– Pityriasis rosea – Drug
– Drug eruption
– Secondary syphilis • Palmoplantar
– Tinea
 LOCALISED PATCHES/PLAQUES 33

 Tinea corporis
• Affects body
• Lacks
symmetrical
lesions
• Presence of
peripheral scale
and central
clearing Tinea coporis Psoriasis

.
 LOCALISED PATCHES/PLAQUES 34

– Discoid eczema
• Individualised patches
more pruritic than
psoriasis
• Lack silvery scale
• Less vivid colour than
psoriasis

Discoid eczema Psoriasis

1.
 LOCALISED PATCHES/PLAQUES 35

– Superficial basal
cellcarcinoma/Bowen’
s disease
• Asymmetrical lesions,
either single or few in
number
• Perform biopsy if
lesions resistant to
topical psoriasis Bowen’s disease Psoriasis
treatment, or to confirm
diagnosis
 LOCALISED PATCHES/PLAQUES 36

– Seborrhoeic dermatitis
• Characterised by yellowish
scaling and erythema
– Localised to many of the
same areas as psoriasis
• Diffuse scaling differs from
sharply defined psoriasis
plaques
• Affects furrows of face
(facial psoriasis is generally
restricted to hairline)
Dermatitis
Psoriasis
 LOCALISED PATCHES/PLAQUES 37

– Cutaneous T-cell lymphoma

(mycosis fungoides)
• Red, discoid lesions
• Asymmetrical and less scaly than
psoriasis
• Lesions may present with fine
atrophy and be resistant to
antipsoriatic therapy
• Biopsy to confirm diagnosis

Mycosis fungoides

Psoriasis
 GUTTATE PSORIASIS 38

– Pityriasis rosea
• Difficult to distinguish from acute
guttate psoriasis
• Presents first as single large patch,
progresses to a truncal rash of
multiple red scaly plaques
(‘Christmas tree’ distribution)
• Resolves over 8–12 weeks

< Psoriasis ^ Pityriasis rosea

1
 GUTTATE PSORIASIS 39

– Secondary syphilis
• Search for characteristic primary
syphilitic lesion, lymphadenopathy,
and lesions of face, palm and soles
• Conduct serology and skin biopsies
to confirm

< Psoriasis ^ Secondary syphilis

1
FLEXURAL PSORIASIS 40

– Tinea cruris
• Affects groin area
• Characterised by central clearing
with advancing edge
• Non-silvery lesion with fine
scale, particularly at periphery
• Lesion frequently extends more
on left side

< Psoriasis ^ Tinea cruris

1
FLEXURAL PSORIASIS 41

– Atopic eczema
• Often associated with asthma
and hay fever
• Lacks classic psoriatic nail
involvement and sharply
demarcated scaly plaques

< Psoriasis ^ Atopic eczema

1.
 FLEXURAL PSORIASIS 42

– Candidiasis
• Characteristic
peripheral pustules and
scaling differ to
psoriasis
• Yeast cultures are
diagnostic

– Seborrhoeic dermatits

Flexural psoriasis

1
 PALMOPLANTAR PSORIASIS 43

– Tinea manum
• Ringworm of hands
• Fine powdery scale,
particularly involving
palms and palmar
creases
• Usually asymmetrical

Tinea corporis Psoriasis

1.
 PALMOPLANTAR PSORIASIS 44

– Hand and foot eczema

• Hyperkeratotic forms
difficult to distinguish
from psoriasis
• Biopsies can assist
diagnosis
• Look for history of
atopy, a lack of psoriasis
Eczema
elsewhere on body, and
evidence of eczema
elsewhere on skin Psoriasis
 PALMOPLANTAR PSORIASIS 45

– Pompholyx of palms
and soles (dishydrotic
eczema)
• Presents as clear vesicles
– contrast to
white/yellow pustules in
pustular psoriasis
• Accompanied by intense Eczema
pruritus

Psoriasis
DETERMINING PSORIASIS SEVERITY 46

• Psoriasis Area and Severity Index (PASI)

– Score indicates severity of disease at a given time
– Single number that considers severity of lesions and
extent of disease across four major body sites (head,
trunk, upper limbs and lower limbs)
– Score ranges from 0 (no disease) to 72 (maximal
disease)
MANAGING PSORIASIS 47

• Before starting treatment

– Establish relationship of trust with patient
– Provide patient with information
• Emphasise benign nature of disease
• Explain that psoriasis tends to be chronic and
recurrent
MANAGING PSORIASIS 48

• Determine clinical setting before

selecting treatment, considering
– Disease pattern, severity and extent
– Sites of disease
– Coexistent medical conditions
– Patient’s perception of disease severity
– Time commitments and treatment expense
– Previous treatments for psoriasis
MANAGING PSORIASIS 49

• Goals of management
– Tailor management to individual and address both
medical and psychological aspects
– Improve quality of life
– Achieve long-term remission and disease control
– Minimise drug toxicity
– Evaluate and monitor efficacy and suitability of
individual treatments
– Remain flexible and respond to changing needs
TREATMENT OPTIONS FOR PSORIASIS 50

• Stepwise approach is advised

• Treatments include:
– General measures and topical therapy
– Phototherapy
– Systemic and biological therapies

• Combination therapies : may

reduce toxicity and improve outcomes
TREATING PSORIASIS: 51
GENERAL MEASURES

• Reduce/eliminate potential trigger

factors:
– Stress
– Smoking
– Alcohol
– Trauma
– Drugs
– Infections

1
TOPICAL THERAPIES 52

• Approximately 70% of patients with

mild-to-moderate psoriasis can be managed
with topical therapies alone

• Tailor to needs of patient

• Potency, delivery vehicle and patient

motivation may affect compliance

• Application may be time-consuming for patients

TOPICAL THERAPIES: 53
EMOLLIENTS

• Include aqueous cream, sorbolene cream, white soft

paraffin and wool fats

• Regular use can:

– alleviate pruritus
– reduce scale
– enhance penetration of concomitant topical therapy
– hydrate dry and cracked skin

• Soap should be avoided

.
TOPICAL THERAPIES: 54
KERATOLYTICS

• Over-the-counter products include:

– Salicylic acid
– Urea

• Help dissolve keratin to soften

and lift psoriasis scales

• May enhance penetration of other actives

1
TOPICAL THERAPIES: 55
COAL TAR

• Help reduce inflammation and pruritus

• May induce longer remissions

• Use limited by distinctive smell

and ability to stain clothing and skin

• May cause local skin irritation

TOPICAL THERAPIES: 56
DITHRANOL

• Anti-proliferative properties

• Particularly effective in thick plaque psoriasis

• Initiate therapy at very low concentrations

– can burn skin

• Not suitable for face, flexures or genitals

• Stains clothes permanently

and skin temporarily
TOPICAL THERAPIES: 57
TAZAROTENE

• Topical synthetic retinoid

• For treatment of chronic plaque psoriasis

• Applied once daily in evening

• Commonly causes local irritation

1
TOPICAL THERAPIES: 58
CORTICOSTEROIDS

• Possess anti-inflammatory, antiproliferative and

immunomodulatory properties

• Reduce superficial inflammation within plaques

• Potency choice depends on disease severity,

location and patient preference

1
TOPICAL THERAPIES: 59
CORTICOSTEROIDS

• Adverse effects associated

with long-term use include:
– Skin atrophy and telangiectasia
– Hypopigmentation
– Striae
– Rapid relapse or rebound on stopping therapy
– Precipitation of pustular psoriasis
– Pituitary-adrenal axis suppression through significant systemic
absorption (rare)
TOPICAL THERAPIES: 60
CALCIPOTRIOL (DAIVONEX®)

• Synthetic vitamin D analogue

• For chronic plaque-type psoriasis

• Reverses abnormal keratinocyte changes by:

– Inducing differentiation
– Suppressing proliferation of keratinocytes
TOPICAL THERAPIES: 61
CALCIPOTRIOL (DAIVONEX®)

• Response may require 4–6 weeks

• Adverse effects include erythema and irritation

TOPICAL THERAPIES: CALCIPOTRIOL/BETAMETHASONE 62
DIPROPIONATE OINTMENT (DAIVOBET®)

• For plaque-type psoriasis

• Combination of calcipotriol and a potent topical

corticosteroid (betamethasone dipropionate)
– Stable formulation for both actives

• Provides rapid, effective psoriasis control

TOPICAL THERAPIES: CALCIPOTRIOL/BETAMETHASONE 63
DIPROPIONATE OINTMENT (DAIVOBET®)

– Combination of calcipotriol and betamethasone dipropionate in

Daivobet is more effective than either active constituent used alone
• 39.2% mean reduction in PASI score after 1 week

.
TOPICAL THERAPIES: CALCIPOTRIOL/BETAMETHASONE 64
DIPROPIONATE OINTMENT (DAIVOBET®)

• Once-daily treatment with the

potential to improve compliance

• Can be used intermittently in 4-weekly cycles with

Daivonex® used in between for maintenance

• Most common adverse events include pruritus, rash and

burning sensation

1
TOPICAL THERAPIES: CALCIPOTRIOL/BETAMETHASONE 65
DIPROPIONATE GEL

• Newly TGA approved product not yet available in

Australia
• Specially formulated for the scalp

• Provides rapid, effective control of scalp psoriasis

– More effective than treatment with individual actives alone
– 53.2% (more than half) of patients had absent or
very mild disease after just two weeks of gel application

• Once-daily formulation may

encourage compliance
OTHER THERAPIES 66

• Phototherapy

• Systemic therapies

• Biological agents
PHOTOTHERAPY 67

• For psoriasis resistant to topical therapy and covering >

10% of body surface area

• Immunomodulatory and anti-inflammatory effects

• Three main types of phototherapy:
– Broadband UVB
– Narrowband UVB
– PUVA (administration of psoralen before UVAexposure)

• Treatment usually administered 2–3 times/week

1
SYSTEMIC THERAPIES 68

• Reserved for patients with widespread

or severe psoriasis

• Potentially serious adverse effects

and drug interactions

• Many require PBS authority

prescription from dermatologist
SYSTEMIC THERAPIES: 69
METHOTREXATE

• Most commonly used systemic

treatment for psoriasis

• Slows epidermal cell proliferation

and acts as immunosuppressant

• Closely monitor kidney, liver and

bone-marrow function

• Perform PASI score before starting treatment

SYSTEMIC THERAPIES: 70
CYCLOSPORIN

• Immunosuppressive agent

• For patients with severe psoriasis

that is refractory to other treatments

• Requires ongoing monitoring of

blood elements, and renal and liver function

1
SYSTEMIC THERAPIES: 71
ACITRETIN

• Oral retinoid

• For treatment of all forms of severe psoriasis

• Once-daily oral therapy

• Teratogenic – pregnancy must be avoided

BIOLOGICAL AGENTS 72

• Proteins derived from living organisms that

exert pharmacological actions

• For adults with moderate-to-severe chronic

plaque-type psoriasis who are candidates for
phototherapy or systemic therapy

• Most administered sub-cutaneously

BIOLOGICAL AGENTS 73

• Target key parts of immune system

that drive psoriasis

• Biological agents include:

– Tumour necrosis factor-alpha inhibitors
• Etanercept
• Adalimumab
• Infliximab
– Interleukin (IL-12 and IL-32) inhibitor
• Ustekinumab
CASE STUDY 1 74

• ((insert image of condition))

• ((insert information under headings below))

• Presentation
• Clinical examination
• Diagnosis
• Management
• ((Diagnosis and management can appear on following
screen as ‘builds’ after audience discussion, if
preferred))
CASE STUDY 2 75

• ((insert image of presenting condition))

• ((insert information under headings below))

• Presentation
• Clinical examination
• Diagnosis
• Management
• ((Diagnosis and management can appear on following
screen as ‘builds’ after audience discussion, if
preferred))
DIAGNOSIS AND MANAGEMENT OF 76
PSORIASIS: SUMMARY

• Chronic, inflammatory disease of skin

• T-cell mediated disorder
• Classic presentation characterised by red, scaly
plaques
• Management should address both medical and
psychological aspects
• Treatments include topical therapy, phototherapy,
systemic therapy and biological agents
 77

THANK
YOU
ALL