Psoriasis

Objectives
• Identify the pathogenic factors for development of
psoriasis

• Identify the cause of Psoriasis

• List the clinical features of psoriasis

• Describe the progressive management of the clinical

features of psoriasis

• List the options of Psoriasis treatment

 Background

• Epidemiology
– Age
– Gender
– Genetic
– Scandinavian/European descent
• Risk Factors
3
 Psoriasis
“an inherited disease”
If you have psoriasis, what is the risk to:

• Your unrelated neighbor? About 2%

• Your sibling? 15-20%
• Your identical twin? 65-70%
• Your child? 16%-50%
 Psoriasis
• T-cell mediated inflammatory disease

– Epidermal hyperproliferation secondary to activation of

immune system

– Altered maturation of skin (turning over 6 times normal)

– Inflammation

– Vascular changes
N P Disorganized
O STRATUM
CORNEUM
S
R O Neutrophil
STRATUM
M GRANULOSUM
R accumulation
A I
L STRATUM A
SPINOSUM
S Immaturity
I
S Proliferation
STRATUM
BASALE

DERMIS
6
7
 Associated factors
The precise cause of psoriasis is still unknown. However, there is often
a genetic predisposition, and sometimes an obvious environmental
trigger.

• Genetic Factors:
- 30% of people with psoriasis have had psoriasis in family
- Autosomal dominant inheritance

• Nongenetic Factors:

- Mechanical, ultraviolet, chemical injury

- Infections: Strep, viral, HIV
- Prescription Drugs, stress, endocrine, hormonal, obesity, alcohol,
smoking
 Histology
• The main changes are the following

1 . Parakeratosis (nuclei retained in the horny layer).

2 . Irregular thickening of the epidermis, but thinning over dermal papillae

is apparent clinically when bleeding is caused by scratching and the
removal of scales (Auspitz’s sign).

3 . Polymorphonuclear leucocyte microabscesses (described originally by

Munro).

4 . Dilated and tortuous capillary loops in the dermal papillae.

5 . T-lymphocyte infiltrate in upper dermis.

 Genetics and Pathogenesis
• Psoriasis and the Immune System
– The major histocompatibility complex (MHC)
• Short arm of chromosome 6
– Histocompatibility Antigens (HLA)
• HLA-Cw6
• HLA-B13, -B17, -B37, -Bw16
– T-lymphocyte-mediated mechanism
 Clinical Presentation
• Erythematous, raised patches with silvery
scales
• Symmetric

• Pruritic/ Painful

• Pitting Nails

• Arthritis in 10-20% of patients

12
Common Patterns
Plaque psoriasis (The most common form)

Nail psoriasis (causes pitting, abnormal nail growth and discoloration)

Scalp psoriasis

Inverse psoriasis
Guttate psoriasis (triggered by a bacterial infection such as strep throat, affects
<30 yrs old)

Pustular psoriasis

Erythrodermic psoriasis (The least common type of psoriasis)

Psoriatic arthritis(In addition to inflamed, scaly skin, psoriatic arthritis causes pitted,
discolored nails and the swollen, painful joints that are typical of arthritis)
Plaque The plaques itch or may be painful and can occur anywhere on your body, including
your genitals and the soft tissue inside your mouth. You may have just a few plaques or
many, and in severe cases, the skin around your joints may crack and bleed.

Nail Psoriatic nails may become loose and separate from the nail bed (onycholysis). Severe
cases may cause the nail to crumble.

Scalp You may notice flakes of dead skin in your hair or on your shoulders, especially after
scratching your scalp.
Guttate It's marked by small, water-drop-shaped sores on your trunk, arms, legs and scalp. The
sores are covered by a fine scale and aren't as thick as typical plaques are. You may
have a single outbreak that goes away on its own, or you may have repeated episodes,
especially if you have ongoing respiratory infections.

Inverse causes smooth patches of red, inflamed skin. It's more common in overweight people
and is worsened by friction and sweating.

Pustular It generally develops quickly, with pus-filled blisters appearing just hours after your skin
becomes red and tender. The blisters dry within a day or two but may reappear every
few days or weeks. Generalized pustular psoriasis can also cause fever, chills, severe
itching and fatigue.

Erythrodermi It may be triggered by severe sunburn, by corticosteroids and other medications, or by

c another type of psoriasis that's poorly controlled.

arthritis leads to inflammatory eye conditions (e.g. conjunctivitis), Symptoms range from mild to
severe. Although the disease usually isn't as crippling as other forms of arthritis, it can
cause stiffness and progressive joint damage may lead to permanent deformity.
 Complications
• Psoriatic arthropathy:

 Arthritis occurs in about 5% of psoriatics.

 Distal arthritis involves the terminal interphalangeal joints of the toes and
fingers

 Other patterns include involvement of a single large

Joint

 Tests for rheumatoid factor are negative and nodules are absent.

In patients with spondylitis and sacroiliitis there is a

strong correlation with the presence of HLA-B27.
Fixed flexion deformity of distal interphalangeal
joints following arthropathy
 Differential diagnosis
Discoid eczema
Seborrhoeic eczema
Pityriasis rosea
Secondary syphilis
Cutaneous T-cell lymphoma
Tinea unguium
• Discoid eczema
• Lesions are less well defined and may be exudative or crusted, lack ‘candle grease’ scaling,
and may be extremely itchy.
• Lesions do not favour scalp, extensor aspects of elbows and knees but rather the trunk and
proximal parts of the extremities.

• Seborrhoeic eczema
• Scalp involvement is more diffuse and less lumpy.
• Intervening areas of normal scalp skin are unusual.
• Flexural plaques are less well defined and more exudative.
• There may be signs of seborrhoeic eczema elsewhere, such as in the eyebrows, nasolabial
folds or on the chest.

• Pityriasis rosea
• This may be confused with guttate psoriasis
• the lesions, are oval rather than round, tend to run along rib lines.
• Scaling is of collaret type and a herald plaque may precede the rash.
• Lesions are usually confined to the upper trunk.
• Secondary syphilis
• There is usually a history of a primary chancre.
• The scaly lesions are brownish and characteristically the palms and soles are involved.
• Oral changes, patchy alopecia, condylomata lata and lymphadenopathy complete the
picture.

• Cutaneous T-cell lymphoma

• The lesions, which tend to persist, are not in typical locations and are often annular,
arcuate, reniform or show bizarre outlines.
• Atrophy may be present and individual lesions may vary in their thickness.

• Tinea unguium
• This is often confused with nail psoriasis but is more asymmetrical and there may be
obvious tinea of neighbouring skin.
• Uninvolved nails are common.
• Pitting is not seen and nails tend to be crumbly and discoloured at their free edge.
 Investigations

1 Biopsy is seldom necessary.

2 Throat swabbing for β-haemolytic streptococci is

needed in guttate psoriasis.

3 Skin scrapings and nail clippings may be required

to exclude tinea.

4 Radiology and tests for rheumatoid factor are helpful in

assessing arthritis.
Treatment
 Treatment
• Psoriasis treatments aim to:
1. Interrupt the cycle that causes an increased production of skin
cells, thereby reducing inflammation and plaque formation.

2. Remove scale and smooth the skin, which is particularly true of

topical treatments that you apply to your skin.
Treatment plan

Topical treatment Light therapy Oral medications

 topical
• Used alone, creams and ointments that you apply to your skin can effectively treat
mild to moderate psoriasis. When the disease is more severe, creams are likely to
be combined with oral medications or light therapy. Topical psoriasis treatments
include:
1. Topical corticosteroids
2. Vitamin D analogues
3. Anthralin
4. Topical retinoids
5. Calcineurin inhibitors
6. Salicylic acid
7. Coal tar
8. Moisturizers
 Topical corticosteroids
• The most frequently prescribed medications for treating mild to moderate
psoriasis.

• They slow cell turnover by suppressing the immune system, which reduces
inflammation and relieves associated itching.

• Low-potency corticosteroid ointments are usually recommended for sensitive areas,

such as your face or skin folds, and for treating widespread patches of damaged skin.

• Stronger corticosteroid ointment for small areas of your skin, for persistent plaques
on your hands or feet, or when other treatments have failed.

• Medicated foams and scalp solutions are available to treat psoriasis patches on the
scalp.

• To minimize side effects and to increase effectiveness, topical corticosteroids are

generally used on active outbreaks until they're under control.
 Vitamin D analogues
• These synthetic forms of vitamin D slow down the growth of skin cells.
Calcipotriene (Dovonex) is a prescription cream, ointment or solution containing
a vitamin D analogue that may be used alone to treat mild to moderate psoriasis
or in combination with other topical medications or phototherapy.

Anthralin
• This medication is believed to normalize DNA activity in skin cells.
Anthralin (Dritho-Scalp) can also remove scale, making the skin smoother.
• However, anthralin stains virtually anything it touches, including skin,
clothing, countertops and bedding. For that reason doctors often
recommend short-contact treatment — allowing the cream to stay on
your skin for a brief time before washing it off.
• Anthralin is sometimes used in combination with ultraviolet light.
 Topical Retinoids
• These are commonly used to treat acne and sun-damaged skin, but
tazarotene (Tazorac, Avage) was developed specifically for the
treatment of psoriasis.
• Like other vitamin A derivatives, it normalizes DNA activity in skin
cells and may decrease inflammation.
• The most common side effect is skin irritation. It may also increase
sensitivity to sunlight, so sunscreen should be applied while using
the medication.
• Although the risk of birth defects is far lower for topical retinoids
than for oral retinoids, your doctor needs to know if you're
pregnant or intend to become pregnant if you're using tazarotene.
 Calcineurin inhibitors
• Currently, calcineurin inhibitors (tacrolimus and pimecrolimus) are only approved
for the treatment of atopic dermatitis, but studies have shown them to be
effective at times in the treatment of psoriasis as well.

• Calcineurin inhibitors are thought to disrupt the activation of T cells, which in turn
reduces inflammation and plaque buildup.

• The most common side effect is skin irritation.

• Calcineurin inhibitors are not recommended for long-term or continuous use

because of a potential increased risk of skin cancer and lymphoma.

• They may be especially helpful in areas of thin skin, such as around the eyes,
where steroid creams or retinoids are too irritating or may cause harmful effects.
 Salicylic acid
• Available over-the-counter .
• Salicylic acid promotes sloughing of dead skin cells and reduces scaling. Sometimes it's
combined with other medications, such as topical corticosteroids or coal tar, to increase its
effectiveness.
• Salicylic acid is available in medicated shampoos and scalp solutions to treat scalp
psoriasis.

Coal tar
• A thick, black byproduct of the manufacture of petroleum products and coal, coal
tar is probably the oldest treatment for psoriasis.
• It reduces scaling, itching and inflammation.
• Exactly how it works isn't known.
• Coal tar has few known side effects, but it's messy, stains clothing and bedding,
and has a strong odor.
• Coal tar is available in over-the-counter shampoos, creams and oils.
 Moisturizers
• By themselves, moisturizing creams won't heal psoriasis, but they
can reduce itching and scaling and can help combat the dryness
that results from other therapies. Moisturizers in an ointment base
are usually more effective than are lighter creams and lotions.
 Light therapy (phototherapy)

• As the name suggests, this psoriasis treatment uses natural or artificial ultraviolet
light. The simplest and easiest form of phototherapy involves exposing your skin to
controlled amounts of natural sunlight. Other forms of light therapy include the
use of artificial ultraviolet A (UVA) or ultraviolet B (UVB) light either alone or in
combination with medications.

1. Sunlight.
2. UVB phototherapy
3. Narrowband UVB therapy
4. Photochemotherapy, or psoralen plus ultraviolet A (PUVA).
5. Excimer laser
6. Combination light therapy
 Sunlight
• Ultraviolet (UV) light is a wavelength of light in a range too short for the human
eye to see. When exposed to UV rays in sunlight or artificial light, the activated
T cells in the skin die. This slows skin cell turnover and reduces scaling and
inflammation.
• Daily exposures to small amounts of sunlight may improve psoriasis, but
intense sun exposure can worsen symptoms and cause skin damage.

UVB phototherapy
• Controlled doses of UVB light from an artificial light source may improve
mild to moderate psoriasis symptoms.
• UVB phototherapy, also called broadband UVB, can be used to treat
single patches, widespread psoriasis and psoriasis that resists topical
treatments.
• Short-term side effects may include redness, itching and dry skin. Using
a moisturizer may help decrease these side effects.
 Narrowband UVB therapy
• A newer type of psoriasis treatment, narrowband UVB therapy may be more effective than broadband
UVB treatment.
• It's usually administered two or three times a week until the skin improves, then maintenance may
require only weekly sessions.
• Narrowband UVB therapy may cause more severe and longer lasting burns.

Photochemotherapy, or psoralen plus

ultraviolet A (PUVA).
• Photochemotherapy involves taking a light-sensitizing medication (psoralen) before exposure
to UVA light.
• UVA light penetrates deeper into the skin than does UVB light, and psoralen makes the skin
more responsive to UVA exposure.
• This more aggressive treatment consistently improves skin and is often used for more severe
cases of psoriasis.
• PUVA involves two or three treatments a week for a prescribed number of weeks.
• Short-term side effects include nausea, headache, burning and itching.
• Long-term side effects include dry and wrinkled skin, freckles and increased risk of skin
cancer, including melanoma, the most serious form of skin cancer.
 Excimer laser
• This form of light therapy, used for mild to moderate psoriasis.
• treats only the involved skin.
• A controlled beam of UVB light of a specific wavelength is directed to the psoriasis plaques to
control scaling and inflammation.
• Excimer laser therapy requires fewer sessions than does traditional phototherapy because
more powerful UVB light is used.
• Side effects can include redness and blistering.

Combination light therapy

Combining UV light with other treatments such as retinoids frequently improves

phototherapy's effectiveness.
Combination therapies are often used after other phototherapy options are ineffective.
Some doctors give UVB treatment in conjunction with coal tar, called the Goeckerman
treatment. The two therapies together are more effective than either alone because
coal tar makes skin more receptive to UVB light.
Another method, the Ingram regimen, combines UVB therapy with a coal tar bath and
an anthralin-salicylic acid paste that's left on your skin for several hours or overnight.
 Oral or injected medications
• If you have severe psoriasis or it's resistant to other types of treatment, your
doctor may prescribe oral or injected drugs. Because of severe side effects, some
of these medications are used for just brief periods of time and may be alternated
with other forms of treatment.

1. Retinoids
2. Methotrexate
3. Cyclosporine
4. Hydroxyurea
5. Immunomodulator drugs (biologics).
 Retinoids
• Related to vitamin A, this group of drugs may reduce the
production of skin cells if you have severe psoriasis that doesn't
respond to other therapies.

• Signs and symptoms usually return once therapy is discontinued.

• Side effects may include dryness of the skin and mucous

membranes, itching and hair loss.

• And because retinoids such as acitretin (Soriatane) can cause severe

birth defects, women must avoid pregnancy for at least three years
after taking the medication.
 Methotrexate
• Taken orally, methotrexate helps psoriasis by decreasing the
production of skin cells and suppressing inflammation. It may
also slow the progression of psoriatic arthritis in some people.
Methotrexate is generally well tolerated in low doses, but may
cause upset stomach, loss of appetite and fatigue. When used
for long periods it can cause a number of serious side effects,
including severe liver damage and decreased production of red
and white blood cells and platelets.
 Cyclosporine
• Cyclosporine suppresses the immune system and is similar to methotrexate in
effectiveness.
• Like other immunosuppressant drugs, cyclosporine increases your risk of
infection and other health problems, including cancer.
• Cyclosporine also makes you more susceptible to kidney problems and high
blood pressure — the risk increases with higher dosages and long-term therapy.

Hydroxyurea
• This medication isn't as effective as cyclosporine or methotrexate, but
unlike the stronger drugs it can be combined with phototherapy.
• Possible side effects include anemia and a decrease in WBCs and
platelets.
• It should not be taken by women who are pregnant.
 Immunomodulator drugs (biologics).
• Several immunomodulator drugs are approved for the treatment of
moderate to severe psoriasis.
• They include alefacept (Amevive), etanercept (Enbrel), infliximab
(Remicade) and ustekinumab (Stelara).
• These drugs are given by intravenous infusion, intramuscular injection
or subcutaneous injection and are usually used for people who have
failed to respond to traditional therapy or who have associated
psoriatic arthritis.
• Biologics work by blocking interactions between certain immune
system cells.
• Although they're derived from natural sources rather than chemical
ones, they must be used with caution because they have strong effects
on the immune system and may cause life-threatening infections.
 Treatment considerations
1 . Discuss a treatment plan with the patient.
Consider disability, cost, time, mess and risk of systemic therapy to
general health.

2. The treatment MUST NOT be worse than the disease.

3. Do NOT aggravate eruptive psoriasis.

4. NEVER use systemic steroids.

5. Avoid the long-term use of potent or very potent topical

corticosteroids.

6. NEVER promise a permanent cure, but be ENCOURAGING.