ULEP, ALYSSA JANE G.

PSORIASIS
VALENCIA, MARY KATHLEEN E.
PSORIASIS

• Chronic inflammatory disorder of the skin and joints

• The usual presentation is with well-demarcated red plaques with an
overlying scale
• Prevalence: Estimated 1% and 3% in Europe and North America
AETIOLOGY

• Combination of genetic and environmental factors

• In most cases, there is a genetic disposition and up to 70% of
patients report a family history of psoriasis
PRECIPITATING FACTORS

Infections
• Have been implicated as riggers for psoriasis
• Streptococcal infections, pharyngitis, frequently precede the onset of
guttate psoriasis
• HIV infection can aggravate psoriasis
PRECIPITATING FACTORS

Drugs
• Can exacerbate or induce psoriasis in predisposed individuals
• Most common causative agents is lithium, b-blockers, anti-malarials,
non-steroidal inflammatory drugs, tetracycline and rapid withdrawal
of systemic corticosteroids
PRECIPITATING FACTORS

Alcohol and Smoking

• Psoriasis is associated with high rates of alcoholism due to the
psychological stresses of the disease
• Smoking is strongly associated with palmoplantar psoriasis. Up to
95% of patient with this variant are smokers at disease onset
• Smoking cessation must be addressed due to the improvement in
disease status and associated risk reduction of ischemic heart disease
 PRECIPITATING FACTORS
Emotional Stress
• Anectodal observations is an important trigger factor for psoriasis
• Psychological distress and depression can cause as a consquence of
posriasis
Koebner Phenomenon
• Psoriatic lesions which occurs at site of injury to the skin such as cut,
burn, scratch or surgical scar
 PATHOLOGY & CLINICAL FEATURES
CLINICAL FEATURES OF PSORIASIS
• Well-demarcated
• Erythematous scaly plaques
COMMON SITES AFFECTED
• Scalp
• Buttocks
• Elbows
• Knees
• Nails
 PATHOLOGY & CLINICAL FEATURES
HISTOLOGICALLY
• Acanthosis (epidermis is thickened)
• Hyperkeratosis (thickened upper horny layer)
• Thick & scaly skin due to increased epidermal turnover
• Differentiation of cells through the epidermis terminating in the keratin
horny layer normally takes up to 40 days
• Epidermal turnover in psoriatic skin maybe as rapid as 7 days
 PATHOLOGY & CLINICAL FEATURES
HISTOLOGICALLY
• In the dermis, capillaries are dilated, turtous and closer to the surface of
the skin
• This explains Auspitz’s sign which is the appearance of pin point bleeding
after scrapping off psoriasis scales
 CLINICAL TYPES
• PSORIASIS VULGARIS
• GUTTATE PSORIASIS
• SCALP PSORIASIS
• PSORIATIC NAIL DISEASE
• PALMOPLANTAR PSORIASIS
• FLEXULAR PSORIASIS
• ERYTHODERMIC PSORIASIS
• GENERALISED PUSTULAR PSORIASIS
• PSORIATIC AROPATHY
 PSORIASIS VULGARIS
• Also known as chronic plaque psoriasis
• Most common variant
• Can occur at any age but most often begins at young adulthood and has
a chronic relapsing course
• Typical psoriatic lesion is a red, sharply demarcated plaque with
overlying silvery scale
• Distribution is symmetrical in elbows and knees also the sacrum, nails
and scalp are affected
• Treatment is aimed at management rather than cure
PSORIASIS VULGARIS
GUTTATE PSORIASIS

• More commonly seen in children and young adults

• Characterised by widespread scaly eruption small ‘tear drop-like’
scaly plaques
• Often acute and can appear 10-14 days after a streptococcal upper
respiratory tract infection
• Topical treatment and UVB (ULTRAVIOLET B) therapy are effective
• May be the first manifestation of psoriasis in predisposed
individuals
GUTTATE PSORIASIS
 SCALP PSORIASIS
• Involvement of the scalp may be the only manifestation, but may also
occur in psoriasis vulgaris
• Appears as scaly demarcated plaques extending to
the hairline
and around
the ears
• Hair loss
is rare
 PSORIATIC NAIL DISEASE
• Nails are frequently affected
• In small proportion, nails are the only area affected
• Nail pitting, nail ridging, onycholysis (seperation of the nail form the nail
bed)
• Hyperkeratosis under the nail and complete nail destruction
• Treatment: Methotraxate
PSORIATIC NAIL DISEASE
 PALMOPLANTAR PSORIASIS
• Sites are palms and soles
• There is sharp demarcation in involved areas
• It can take two forms:
Inflamed hyperkeratotic fissured skin which can be very painful
Sterile pustules on an erythematous base which dry to leave small brown
macules
• Pustular form is common in smokers
PALMOPLANTAR PSORIASIS
FLEXULAR PSORIASIS

• Occurs in axillae, groin, submammary areas and genitalia, tend to

be clearly demarcated
• Due to friction and moisture within skin folds, lesions differ in
apperance from classical psoriasis and tend to be red and glazed
rather than scaly
• Secondary infection: Candida are common
FLEXULAR PSORIASIS (AXILLA)
• AlsoERYTHRODERMIC PSORIASIS
known as exfoliative psoriasis, severe potentially life-threatening
condition in which more than 90% of the body surface is red and scaly
• Consequence of either eczema psoriasis
• Skin function is impaired, patient suffer dehydration, electrolyte
imbalance, temperature, dysregulation and serious secondary infection
• Bland emollients such as white soft paraffin and mild to moderate
topical steroid should be used
ERYTHRODERMIC PSORIASIS
GENERALISED PUSTULAR PSORIASIS

• Acute, unstable form of psoriasis manifesting as widespread sheets

of tiny sterile pustules on an erythematous base
• Patient is usually systematically unwell with fever and general
malaise
• Oral steroids must be avoided for the management
GENERALISED PUSTULAR PSORIASIS
PSORIATIC ARTHROPATHY
• Approximately 25% patients suffer with and associated arthropathy
• Five patterns:
 Monoarthopathy (nflammation of one joint at a time)
 Rheumatoid arthritis like
 Osteoarthritis like
 Sacroiliitis like
 Arthritis mulitans (extremely severe form of chronic rheumatoid or
psoriatic arthritis characterized by resorption of bones)
• Treatment: Methotrexate, Biological agents with actions against TNFα
SIGNS AND SYMPTOMS OF PSORIASIS
• red, raised, inflamed patches of skin.
• whitish-silver scales or plaques on the red patches.
• dry skin that may crack and bleed.
• soreness around patches.
• itching and burning sensations around patches.
• thick, pitted nails.
• painful, swollen joints
REFERENCE: https://www.healthline.com/health/psoriasis
 TREATMENT
TOPICAL THERAPY
• Vitamin D analogues- inihibit keratinocyte differentiation and production
Calcipotriol most commonly prescribed
• Steroids- topical steroids are cosmetically acceptable and ready to apply
The use of potent steroids on large areas of psoriasis is associated with risks of
local atrophy and systemic absorption
In general, very potent steroids should be avoided
 TREATMENT
TOPICAL THERAPY
• Coal tar
Along with dithranol, coal tar is one of the oldest topical treatments for psoriasis
Has anti-inflammatory, anti-bacterial, anti-pruritic and antimitotic effect
Limitation of tar are irritation of delicate skin sites, odour and temporary staining
of skin and clothing
• Dithranol-synthetic anthracene derivative which has an anti-priliferative and anti-
inflammatory effect in skin
• Salicyclic acid-useful to reduce scale, can be mixed with coal tar, steroid and urea
 LABORATORY TEST
• TOPICAL RETINOIDS
• Less effective than Vitamin D analogues
• Irritation is possible side effect
 LABORATORY TEST
TOPICAL TREATMENT OF PSORIASIS AT SPECIAL SITES
SCALP
Tar shampoo is effective in mild scalp psoriasis
Coconut oil compounds, peanut oil, and greasy emollient with salicyclic
acid can be used as descaling agents
Topical steroid can be applied for inflammatory disease
 LABORATORY TEST
TOPICAL TREATMENT OF PSORIASIS AT SPECIAL SITES
GENITALS
Genital regions are prone to irritation and mild to moderate topical
steroids can be used
NAILS
• Before treatment of psoriasis, fungal infections of the nails should be
excluded
• Systemic therapy is preferred
 LABORATORY TEST
PHOTOTHERAPHY
Narrow band UVB (ULTRA VIOLET B 311-313 nm) is preferable to broadband
UVB (290-320 nm) due to increased safety and reduced risk of burning
PUVA (PSORALEN& ULTRAVIOLET A LIGHT)
Psoralens are drug that are activated by long wave ultraviolet light (320-
400nm), thereby interfering with DNA synthesis and reducing epidermal
turnover
PUVA UVB
LABORATORY TESTS

SYSTEMIC THERAPY
Indicated in severe widespread psoriasis, intolerant relapsing after
topical therapy and phototherapy
• PASI (PSOSRIASIS AREA AND SEVERITY INDEX)
• DLQI (Dermatology Quality of Life)
Commonly prescribed in psoriasis include methotrexate, acitretin
and ciclosporin
BIOLOGIC THERAPY

• Biologics are drugs desired to block specific molecular steps

imoortant in immune mediated disease
• Have been used succesfully in rheumatoud arthiritis, inflammatory
bowel disease and are now licensed for used in chronic plaque
psoriasis
TNF ALPHA ANTAGONIST
TNF ALPHA ANTAGONIST
REFERENCE

Clinical Pharmacy and Therapeutics by Roger Walker and Cate

Whittlesea (Fifth Edition) 2012