Psoriasis & Psoriatic Arthritis

Dr Prathibha J P
 Psoriasis
• Chronic progressive, inflammatory disorder of
the Skin and Joints
• Fingernails and toenails are also affected
• Individuals with psoriasis may suffer from
depression and low self-esteem
 Aetiopathogenisis
• Not Known
• Multifactorial inheritance
• Genetic predisposition:
HLA-B13, B17, and Cw6
• Epidermal hyperproliferation
• Angiogenesis
• Overexpression of Th1 cytokines such as IL 2, IL 6, IL 8,
IL 12, INF - γ, TNF α
• Skin cells replicate at an extremely rapid rate.
• New skin cells are produced about eight times
faster than normal--over several days instead
of a month.
• Forming thick patches, or plaques, of red sores
(lesions) covered with flaky, silvery-white dead
skin cells (scales)
• Sex: Adults (M=F) but in adolescents (F>M)
• Age: 2 peak age ranges
1st peak : 16-22 years
2nd peak: 57-60 years
• Earlier age of onset: Positive family history
 Triggering factor
• Trauma: Mechanical, Chemical
• Infections: Streptococcus, HIV
• Stress
• Excessive alcohol consumption
• Smoking
• Metabolic Factors: Pregnancy, hypocalcemia
• Drugs - lithium, Beta-blockers, ACE inhibitors,
Antimalarials, Captopril, Withdrawal of
corticosteroids
 Psoriasis
• Classical Lesion: Erythematous, round to oval well
defined scaly plaques with sharply demarcated
borders
• Scales: Psoriatic plaques typically have a dry, thin,
silvery-white or micaceous scale.
• Sites: Elbows, knees, extensors of extremities, scalp
& sacral region in a symmetric pattern.
• Palms/ soles involved commonly
• New lesions appearing at sites of
injury/trauma to the skin (Koebner
phenomenon)
• Exacerbation in winter, improvement in
summer
• Significant joint pain, stiffness, deformity in 10-
20%
• Auspitz sign:
Removing the scale reveals a smooth, red,
glossy membrane with tiny punctate bleeding
points
• Koebner’s phenomenon
Linear distribution of the plaques seen along
scratch marks or at sites of trauma
Auzpits sign Koebner’s phenomena
 Morphological types
• Chronic plaque psoriasis: plaques with less scaling
• Guttate psoriasis: Common in children , good prognosis
• Pustular psoriasis: Crops of pustules based on erythema
– Localised / generalised
– Impetigo herpetiformis(Pregnancy asso., Psoriasis)
• Erythrodermic psoriasis: 16-24% of all cases of exfoliative
dermatitis
• Linear psoriasis: linear arrangement of plaques
 Distributional variation
• Scalp psoriasis
• Palmoplantar psoriasis
• Nail psoriasis: pitting, onycholysis, subungual
hyperkeratosis, or the oil-drop sign. (25-50%)
• Inverse psoriasis/Flexural Psoriasis:
– spares the typical extensor surfaces

– affects intertriginous (i.e, axillae, inguinal folds,

inframammary creases) areas with minimal scaling.
Guttate Psoriasis
Pustular Psoriasis
Impetigo Herpetiformis
Erythrodermic Psoriasis
Linear Psoriasis
Scalp Psoriasis
Inverse/Flexural Psoriasis
Palmoplantar Psoriasis
 Nail Psoriasis
• Psoriasis can affect both fingernails and
toenails. Commonly seen in fingernails
• Skin + nail involvement 50%.
• In psoriatic arthritis this may rise to 80%.
• Fingernails are more often involved than
toenails.
• For many people, nail psoriasis is often mild
and causes few problem
 Common changes in Nail psoriasis
• Pitting of the nails – the surface of the nail develops small
pits(Thimble Nails)>20 pits/nail
• Onycholysis – the nail becomes detached from the underlying nail bed
• Subungual hyperkeratosis – a chalky substance accumulates under
the nail. The nail becomes raised and can become tender
• Discolouration – yellow brown discoloration of nail
• Oil drop/ Salmon Patch - red discoloration in nail bed proximal to
onycholysis
• Bues Lines – Transverse ridges on nail
• Psoriatic inflammation nail Matrix – nail crumpling
• Splinter haemorrhages
• Red lunula
Oil drop sign Subungual hyperkeratosis
 Nail Psoriasis
Pitting of nails Crumpling of nails
 Clinical Presentation
• 60 – 70%: Skin psoriasis
• 15%: Psoriatic arthritis
• 15%: Skin and arthritis diagnosed at same time
Psoriatic Arthritis
 Psoriatic Arthritis
• Chronic progressive, inflammatory disorder of the
joints
– Characterized by osteolysis and bony proliferation
• Males and females are equally affected
• Usually seronegative for Rheumatoid Factor
• Classified with HLA-B27-associated
spondyloarthropathies
• PsA can range from mild nondestructive disease to a
severely rapid and destructive arthropathy
 Psoriatic Arthritis
• Seen in 5-10% of psoriatic patients
• Types:
1. Classic (16%)-DIP joint involvement
2. Oligoarticular (70%)< 5joints, asymmetric
3. Rheumatoid type(15%)>5joints, symmetric
4. Psoriatic spondylitis (5%)
5. Arthritis mutilans (5%)
• Enthesitis (inflammation at site of tendon
insertion)
• Tenosynovitis (inflammation of tendon and its
enveloping sheath)
• Dactylitis or “sausage digit”
• Morning stiffness lasting >30 min in 50% of
patients
• Ridging, pitting of nails, onycholysis
• Dactylitis noted in >40% of patients
• Eye inflammation (conjunctivitis, iritis, or
uveitis)
 Extra articular findings
• Skin - psoriasis
• Nails - pits and onycholysis
• Pitting edema - often asymmetrical
• Ocular inflammation - conjunctivitis, iritis
• Inflammatory Bowel disease
Hallmark of Ps A
 Radiological findings
• Narrowed joint space and condylar erosions
• Reactive subperiosteal new bone
formation(juxta-articular)
• Pencil in cup apperance
 Differentials
• Rheumatoid Arthritis
• Reactive arthritis
• Ankylosing Spondylitis
 How to diagnose Ps A
• No diagnostic laboratory testing
• Radiologically:
– erosive changes and new bone formation in distal
joints
– Fluffy periostitis and new bone formation at sites
of enthesitis
– “pencil in cup” appearance
 CASPAR Criteria for Diagnosis PsA
• Inflammatory articular disease (joint, spine, or
entheseal)
• With 3 points from following categories:
− Psoriasis: current (2), history (1), family history (1)
− Nail dystrophy (1)
− Negative rheumatoid factor (1)
− Dactylitis: current (1), history (1) recorded by a rheumatologist
− Radiographs: (hand/foot) evidence of juxta-articular new bone
formation
• Specificity 98.7%, Sensitivity 91.4%
Features of PsA
 Treatment
• NSAIDs if disease is mild.
• PT, OT, splinting devices
• If erosive disease, treat aggressively with
DMARDs (MTX, Sulfasalazine, CsA).
• Early referral to rheumatology for initiation of
DMARDs to prevent progression
 Prognosis
• 20% of patients have a severe an debilitating
form of arthritis
• progression of clinical damage occurs in a
majority of patients
• radiologic changes occur over time despite
treatment
Thank You