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Psoriasis

Psoriasis

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Published by: Rasmieh Al-amer on Mar 25, 2011
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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
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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 O R M A L STRATUM CORNEUM STRATUM GRANULOSUM STRATUM SPINOSUM P Disorganized S O Neutrophil R accumulation I A S Immaturity I S Proliferation STRATUM BASALE DERMIS 6 .

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However. smoking .Associated factors The precise cause of psoriasis is still unknown. ‡ Genetic Factors: . viral. alcohol.30% of people with psoriasis have had psoriasis in family .Prescription Drugs. chemical injury . obesity. and sometimes an obvious environmental trigger. HIV .Mechanical.Infections: Strep. hormonal.Autosomal dominant inheritance ‡ Nongenetic Factors: . stress. there is often a genetic predisposition. endocrine. ultraviolet.

Irregular thickening of the epidermis. 3 . Parakeratosis (nuclei retained in the horny layer).Histology ‡ The main changes are the following 1 . but thinning over dermal papillae is apparent clinically when bleeding is caused by scratching and the removal of scales (Auspitz s sign). 5 . . 2 . 4 . T-lymphocyte infiltrate in upper dermis. Dilated and tortuous capillary loops in the dermal papillae. Polymorphonuclear leucocyte microabscesses (described originally by Munro).

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 .

raised patches with silvery scales ‡ Symmetric ‡ Pruritic/ Painful ‡ Pitting Nails ‡ Arthritis in 10-20% of patients .Clinical Presentation ‡ Erythematous.

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Common Patterns Plaque psoriasis (The most common form) Nail psoriasis (causes pitting. affects <30 yrs old) Pustular psoriasis Erythrodermic psoriasis (The least common type of psoriasis) Psoriatic arthritis(In addition to inflamed. abnormal nail growth and discoloration) Scalp psoriasis Inverse psoriasis Guttate psoriasis (triggered by a bacterial infection such as strep throat. psoriatic arthritis causes pitted. scaly skin. discolored nails and the swollen. painful joints that are typical of arthritis) .

leads to inflammatory eye conditions (e. It generally develops quickly. conjunctivitis). You may notice flakes of dead skin in your hair or on your shoulders. You may have a single outbreak that goes away on its own. especially if you have ongoing respiratory infections. it can cause stiffness and progressive joint damage may lead to permanent deformity. It's more common in overweight people and is worsened by friction and sweating. It's marked by small. water-drop-shaped sores on your trunk. Although the disease usually isn't as crippling as other forms of arthritis. The sores are covered by a fine scale and aren't as thick as typical plaques are.Plaque The plaques itch or may be painful and can occur anywhere on your body. with pus-filled blisters appearing just hours after your skin becomes red and tender. or by another type of psoriasis that's poorly controlled. You may have just a few plaques or many. by corticosteroids and other medications. severe itching and fatigue. chills. Psoriatic nails may become loose and separate from the nail bed (onycholysis). Generalized pustular psoriasis can also cause fever. It may be triggered by severe sunburn. Nail Scalp Guttate Inverse Pustular Erythrodermi c arthritis . especially after scratching your scalp. legs and scalp. Symptoms range from mild to severe. causes smooth patches of red.g. The blisters dry within a day or two but may reappear every few days or weeks. or you may have repeated episodes. inflamed skin. arms. Severe cases may cause the nail to crumble. the skin around your joints may crack and bleed. including your genitals and the soft tissue inside your mouth. and in severe cases.

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In patients with spondylitis and sacroiliitis there is a strong correlation with the presence of HLA-B27.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. .

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 .

‡ Seborrhoeic eczema ‡ ‡ ‡ ‡ Scalp involvement is more diffuse and less lumpy. There may be signs of seborrhoeic eczema elsewhere. . tend to run along rib lines. Lesions are usually confined to the upper trunk. Intervening areas of normal scalp skin are unusual. extensor aspects of elbows and knees but rather the trunk and proximal parts of the extremities. lack candle grease scaling. Scaling is of collaret type and a herald plaque may precede the rash. are oval rather than round. Flexural plaques are less well defined and more exudative.‡ Discoid eczema ‡ ‡ Lesions are less well defined and may be exudative or crusted. ‡ Pityriasis rosea ‡ ‡ ‡ ‡ This may be confused with guttate psoriasis the lesions. such as in the eyebrows. and may be extremely itchy. nasolabial folds or on the chest. Lesions do not favour scalp.

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patchy alopecia. arcuate. The scaly lesions are brownish and characteristically the palms and soles are involved.‡ Secondary syphilis ‡ ‡ ‡ There is usually a history of a primary chancre. condylomata lata and lymphadenopathy complete the picture. Uninvolved nails are common. ‡ Cutaneous T-cell lymphoma ‡ ‡ The lesions. are not in typical locations and are often annular. . Oral changes. which tend to persist. 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. Pitting is not seen and nails tend to be crumbly and discoloured at their free edge. reniform or show bizarre outlines.

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4 Radiology and tests for rheumatoid factor are helpful in assessing arthritis.Investigations 1 Biopsy is seldom necessary. 3 Skin scrapings and nail clippings may be required to exclude tinea. 2 Throat swabbing for -haemolytic streptococci is needed in guttate psoriasis. .

Treatment .

thereby reducing inflammation and plaque formation. Remove scale and smooth the skin. Treatment plan Topical treatment Light therapy Oral medications . 2.Treatment ‡ Psoriasis treatments aim to: 1. Interrupt the cycle that causes an increased production of skin cells. which is particularly true of topical treatments that you apply to your skin.

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

such as your face or skin folds. To minimize side effects and to increase effectiveness. for persistent plaques on your hands or feet. They slow cell turnover by suppressing the immune system. Low-potency corticosteroid ointments are usually recommended for sensitive areas. Medicated foams and scalp solutions are available to treat psoriasis patches on the scalp. Stronger corticosteroid ointment for small areas of your skin. topical corticosteroids are generally used on active outbreaks until they're under control.Topical corticosteroids ‡ ‡ The most frequently prescribed medications for treating mild to moderate psoriasis. and for treating widespread patches of damaged skin. or when other treatments have failed. ‡ ‡ ‡ ‡ . which reduces inflammation and relieves associated itching.

Calcipotriene (Dovonex) is a prescription cream. Anthralin ‡ This medication is believed to normalize DNA activity in skin cells. Anthralin (Dritho-Scalp) can also remove scale.Vitamin D analogues ‡ These synthetic forms of vitamin D slow down the growth of skin cells. 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. countertops and bedding. . ‡ However. including skin. anthralin stains virtually anything it touches. clothing. 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 is sometimes used in combination with ultraviolet light. making the skin smoother.

your doctor needs to know if you're pregnant or intend to become pregnant if you're using tazarotene. ‡ Like other vitamin A derivatives. so sunscreen should be applied while using the medication. it normalizes DNA activity in skin cells and may decrease inflammation. ‡ Although the risk of birth defects is far lower for topical retinoids than for oral retinoids. Avage) was developed specifically for the treatment of psoriasis.Topical Retinoids ‡ These are commonly used to treat acne and sun-damaged skin. . It may also increase sensitivity to sunlight. but tazarotene (Tazorac. ‡ The most common side effect is skin irritation.

calcineurin inhibitors (tacrolimus and pimecrolimus) are only approved for the treatment of atopic dermatitis. which in turn reduces inflammation and plaque buildup. They may be especially helpful in areas of thin skin. The most common side effect is skin irritation. ‡ ‡ ‡ ‡ .Calcineurin inhibitors ‡ Currently. 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. where steroid creams or retinoids are too irritating or may cause harmful effects. such as around the eyes. Calcineurin inhibitors are not recommended for long-term or continuous use because of a potential increased risk of skin cancer and lymphoma.

such as topical corticosteroids or coal tar. ‡ It reduces scaling. Salicylic acid promotes sloughing of dead skin cells and reduces scaling. coal tar is probably the oldest treatment for psoriasis. to increase its effectiveness. ‡ Coal tar has few known side effects. Coal tar ‡ A thick. black byproduct of the manufacture of petroleum products and coal. stains clothing and bedding. but it's messy. ‡ Coal tar is available in over-the-counter shampoos. and has a strong odor. creams and oils.Salicylic acid ‡ ‡ ‡ Available over-the-counter . Sometimes it's combined with other medications. itching and inflammation. Salicylic acid is available in medicated shampoos and scalp solutions to treat scalp psoriasis. ‡ Exactly how it works isn't known. .

. Moisturizers in an ointment base are usually more effective than are lighter creams and lotions. but they can reduce itching and scaling and can help combat the dryness that results from other therapies. moisturizing creams won't heal psoriasis.Moisturizers ‡ By themselves.

. 4. 3. 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.Light therapy (phototherapy) ‡ As the name suggests. UVB phototherapy Narrowband UVB therapy Photochemotherapy. or psoralen plus ultraviolet A (PUVA). Excimer laser Combination light therapy 1. 6. 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. 2. Sunlight. 5.

‡ Short-term side effects may include redness.Sunlight ‡ Ultraviolet (UV) light is a wavelength of light in a range too short for the human eye to see. ‡ UVB phototherapy. UVB phototherapy ‡ Controlled doses of UVB light from an artificial light source may improve mild to moderate psoriasis symptoms. Using a moisturizer may help decrease these side effects. but intense sun exposure can worsen symptoms and cause skin damage. When exposed to UV rays in sunlight or artificial light. widespread psoriasis and psoriasis that resists topical treatments. ‡ Daily exposures to small amounts of sunlight may improve psoriasis. can be used to treat single patches. the activated T cells in the skin die. This slows skin cell turnover and reduces scaling and inflammation. . also called broadband UVB. itching and dry skin.

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narrowband UVB therapy may be more effective than broadband UVB treatment. UVA light penetrates deeper into the skin than does UVB light. the most serious form of skin cancer. or psoralen plus ultraviolet A (PUVA). It's usually administered two or three times a week until the skin improves. . Narrowband UVB therapy may cause more severe and longer lasting burns.Narrowband UVB therapy ‡ ‡ ‡ A newer type of psoriasis treatment. burning and itching. ‡ ‡ ‡ ‡ ‡ ‡ Photochemotherapy involves taking a light-sensitizing medication (psoralen) before exposure to UVA light. freckles and increased risk of skin cancer. Short-term side effects include nausea. including melanoma. Long-term side effects include dry and wrinkled skin. then maintenance may require only weekly sessions. This more aggressive treatment consistently improves skin and is often used for more severe cases of psoriasis. headache. PUVA involves two or three treatments a week for a prescribed number of weeks. and psoralen makes the skin more responsive to UVA exposure. Photochemotherapy.

called the Goeckerman treatment. A controlled beam of UVB light of a specific wavelength is directed to the psoriasis plaques to control scaling and inflammation. the Ingram regimen. Excimer laser therapy requires fewer sessions than does traditional phototherapy because more powerful UVB light is used. Combination light therapy Combining UV light with other treatments such as retinoids frequently improves phototherapy's effectiveness. Another method. treats only the involved skin. Side effects can include redness and blistering. 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. used for mild to moderate psoriasis. The two therapies together are more effective than either alone because coal tar makes skin more receptive to UVB light.Excimer laser ‡ ‡ ‡ ‡ ‡ This form of light therapy. Some doctors give UVB treatment in conjunction with coal tar. . Combination therapies are often used after other phototherapy options are ineffective.

Because of severe side effects. 4. 3. 2. some of these medications are used for just brief periods of time and may be alternated with other forms of treatment. 5. 1.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. . Retinoids Methotrexate Cyclosporine Hydroxyurea Immunomodulator drugs (biologics).

women must avoid pregnancy for at least three years after taking the medication. itching and hair loss. ‡ Side effects may include dryness of the skin and mucous membranes. . ‡ And because retinoids such as acitretin (Soriatane) can cause severe birth defects.Retinoids ‡ Related to vitamin A. ‡ Signs and symptoms usually return once therapy is discontinued. this group of drugs may reduce the production of skin cells if you have severe psoriasis that doesn't respond to other therapies.

When used for long periods it can cause a number of serious side effects. loss of appetite and fatigue. but may cause upset stomach. including severe liver damage and decreased production of red and white blood cells and platelets.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 unlike the stronger drugs it can be combined with phototherapy. ‡ It should not be taken by women who are pregnant.Cyclosporine ‡ Cyclosporine suppresses the immune system and is similar to methotrexate in effectiveness. ‡ Cyclosporine also makes you more susceptible to kidney problems and high blood pressure the risk increases with higher dosages and longterm therapy. ‡ Possible side effects include anemia and a decrease in WBCs and platelets. Hydroxyurea ‡ This medication isn't as effective as cyclosporine or methotrexate. including cancer. ‡ Like other immunosuppressant drugs. cyclosporine increases your risk of infection and other health problems.

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. ‡ They include alefacept (Amevive). . infliximab (Remicade) and ustekinumab (Stelara). ‡ Although they're derived from natural sources rather than chemical ones. ‡ Biologics work by blocking interactions between certain immune system cells. etanercept (Enbrel). ‡ Several immunomodulator drugs are approved for the treatment of moderate to severe psoriasis. ‡ These drugs are given by intravenous infusion. they must be used with caution because they have strong effects on the immune system and may cause life-threatening infections.Immunomodulator drugs (biologics).

6. time. 2. NEVER use systemic steroids. Avoid the long-term use of potent or very potent topical corticosteroids. . 4. NEVER promise a permanent cure. but be ENCOURAGING. mess and risk of systemic therapy to general health. 3. Discuss a treatment plan with the patient. cost. Do NOT aggravate eruptive psoriasis. Consider disability. The treatment MUST NOT be worse than the disease.Treatment considerations 1 . 5.

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