Psoriasis

FOR HEALTH OFFICER

STUDENTS
SOLOMON H ( MD, DVR )
Introduction
Greek word
◦ Psora: “itch”
◦ -sis: “action, condition”
“Itchy condition”
A common, chronic, disfiguring,
inflammatory and proliferative
condition of the skin
A polygenic disease with various
triggering factors
Characterised by red, scaly, sharply
demarcated, indurated plaques, present
particularly over extensor surfaces and
scalp

+/- Itching

Morphologic variations exist

30% of patients have joint involvement

Epidemiology
2% prevalence in the world
◦ US & Canada ~ 4.6% - 4.7%
◦ Africa ~ 0.4% - 0.7%
Any age: Infancy – 8th decade of life
◦ 20 – 30 years
◦ 50 – 60 years
◦ Children ~ 0.5% -1.1% ~ Guttate type
◦ Age < 40 accounts for 75% of the cases
Slight female preponderance
Etiopathogenesis
Triggering factors
Trauma
◦ Koebner phenomenon ~ 25% of cases
◦ 2-6weeks after the history of trauma
◦ Previous dermatoses
◦ Physical, chemical, electrical injury
◦ Koebner & reverse koebner phneomenon
Infections
◦ Streptococcal infection
◦ RVI
Sunlight
◦ Sweden ~ 5.5% of study group ~ Strong
sunlight
Drugs
◦ Lithium, Antimalarials, NSAIDs, ACEI, β-
blockers, Rapid tapering of steroids
Endocrine
◦ Pregnancy
◦ Hypocalcaemia
Psychogenic
◦ UK ~ 60% of patients reported exacerbation,
worsening & resistance to treatment due to
stress
Obesity, alcohol & smoking
◦ Exacerbation & resistance to treatment
Clinical features
Many morphologic variants exist
Hallmarks:
◦ Erythema
◦ Thickening
◦ Scale
◦ +/- Itching
Size varies between pin point to 20cm
Usually well demarcated with pinpoint
bleeding upon removal of the scale ~
Autzpit sign
Chronic plaque psoriasis
Erythematous, scaly plaques
Symmetric distribution
More over extensor areas
Limited – extensive
30% of patients have genital
involvement
Months – years
+/- periods of remission
Guttate psoriasis
2% of patients
Common in children
Preceding history of
URTI ~ 66%
↑ AntisteptolysinO titer
Excellent prognosis in children
May become chronic in adults
Rupioid, elephantine and ostraceous
psoriasis
plaques associated with gross
hyperkeratosis
◦ Rupoid: cone-shaped lesions
◦ Elephantine: large plaques
◦ Ostraceous: ring-like hyperkeratotic lesion
with a concave surface
Erythrodermic psoriasis
Generalized erythema and scaling
Gradual or acute
Gradual: chronic lesions evolve to
exfoliation, mild treatment = good
prognosis
Acute: Sudden & unexpected, febrile &
ill, whole skin involved, severe itching,
intolerant to treatment, frequent relapse
Pustular psoriasis
3 types
◦ Generalized pustular psoriasis
◦ Pustulosis of the palms and soles
◦ Acrodermatitis continua of hallopeau
Generalized pustular psoriasis
Erythema & sterile pustules on c/f
Neutrophils on Hx
4 patterns: Von Zumbush, Annular,
Exanthematic & Localized patterns
RF: Pregnancy, rapid tapering of steroids,
hypocalcaemia, infections and topical
irritants

Pustulosis of the palms & soles

Yellow to brown

macules, sterile
pustules, and
erythematous plaques
Localized & chronic
RF: Infection, smoking
Acrodermatitis Continua of Hallopeau
Rare
Pustules on distal portion of fingers, toes,
even nail bed
Ends with scaling & crust formation
Special locations
Scalp psoriasis
Common site,
well defined,
discrete lesions
Asbestos like
+/- attachment to
the scalp hairs
= Pitrysiasis amantacia
Telogen effluvium may occur
Flexural psoriasis
Shiny pink to red, sharply demarcated
thin plaques
Less scale +/- fissure
Axillae, inguinal crease,
intergluteal cleft,
inframamary region,
retroauricular folds
Also called
inverse psoriasis
Penis
solitary patch on the glans of the
uncircumcised male
Lacks scales, but its colour and well-
defined edge are usually distinctive
Palm and sole psoriasis
typical scaly patches on which a fi ne
silvery scale
sharply defined edge at the wrist or
forearm
Oral mucosa
Migratory annular erythematous lesion
Commonly on the tongue
Similar to geographic tongue
Common in generalized pustular psoriasis
Nail psoriasis
10-80% of patients
Finger nails > toe nails
Increased risk of psoriatic arthritis
Can affect the nail matrix, nail bed, even
capillaries
Psoriatic arthritis
5-30% of patients
10-15% have arthritis symptoms even
before skin manifestations
Hallmark: erosive changes years after
periarticular inflammation
5 types:
1. Mono & assymetric oligoarthritis
2. Arthritis of DIP
3. RA-like arthritis
4. Arthritis mutilans
5. Spondylitis & sacrolitis
Ocular lesions
◦ Blepharitis, conjunctivitis, keratitis, xerosis,
symblepharon and trichiasis have been
recorded.
◦ Chronic uveitis has been found particularly in
patients with psoriatic arthritis
Diagnosis
 Mainly clinical

 Biopsy can be done when the diagnosis is doubtful; in

atypical cases

 Laboratory abnormalities in psoriasis are usually not

specific & may not be found in all patients.

 Imaging studies particularly in pts with psoriatic

arthritis
Management

Severity of psoriasis can be classified as :

◦ Mild < 10% BSA
◦ Moderate > 10% BSA
◦ Severe > 30% BSA
Mild to Moderate - Topical
Moderate to severe - Systemic therapy
 Photo(chemo) therapy
Topical treatments
 Emollients
 Keratolytics
 Topical Corticosteroids
 Vitamin D analogues
 Tar
 Anthralin
 Retinoids
 Topical Immunomodulators
Phototherapy
 MOA

◦ selective depletion of T cells, esp those residing in

the epidermis-----involve apoptosis
◦ shift from a Th1 immune response towards Th2
response in the lesional skin.

Includes ---
 Ultravioletlight B (UVB)
 Psoralen + UVA (PUVA)
 Laser Treatments
 Sunlight
Systemic treatments
Methotrexate
Systemic Retinoids
Cyclosporine
Systemic Steroids
Biologics
Scalp Psoriasis
Tar lotions/gels/ shampoo
SA+oil
Topical steroid +SA
 dithranol cream
 Corticosteroid scalp applications
Coal tar+SA+oil
Calcipotriol scalp solution
 Nail Psoriasis
Local triamcinolone injections
Topical retinoids
PUVA photochemotherapy
Cyclosporine
Acitretin
MTX
Biologics
THANK YOU