 Pathogenesis: Overproduction of inflammatory cytokines (TNF-alpha,

Papulosquamous IFN-gamma, IL-12, IL-17, IL-23) and stimulation of T cells.

ERYTHEMATOUS OR PURPLE PAPULES (OR PLAQUES ) WITH SCALE
A. Psoriasis
(HALLMARK) Well-defined, salmon-colored papules and plaques with
white to silvery scales.
Associated features:
- Auspitz sign: scales are scraped off  pinpoint bleeding
- Koebner phenomenon (eliciting lesions due to skin
trauma)
- Nail dystrophy: pitting, dystrophy, thickening and
yellowish discoloration.
- Streptococcal infections  trigger guttate subtype (usually in
children)
- HIV infection => trigger sudden onset widespread/severe psoriasis
- Medications: lithium, beta-blocker, anti-malarials, NSAIDs
- Alcohol, smoking, metabolic syndrome
 Risk factors: Koebnerization, psychologic stress, medication, infection
Scalp Psoriasis vs. Tinea Capitis
 TC: kids + Lymphadenopathy
 Diagnosis: Clinical diagnosis (best initial test) and skin biopsy (most
accurate)
\
Acanthosis = epidermal hyperplasia
Parakeratosis = retained nuclei
Neutrophilic collections in the stratum corneum (Munro’s microabscesses)
↑ stratum spinosum

 Treatment
- First line: avoid smoking, avoid alcohol, stop triggering medicine,
 Distribution – Important!!!
weight loss, emollients
- Elbows/knees
- Mild = topical
- Scalps and gluteal cleft
Topicals steroids, topical vitamin D analogs (calcipotriene
- Nail
cream), topical retinoids (tazarotene), topical calcineurin
- Peri-umbilical area
inhibitors (tacrolimus), coal tar ointment, topical salicylic acid
- Palms and soles: thick scaly rash called keratoderma (thickening of
- Moderate to severe = systemics
epidermis)
Phototherapy or PUVA
-  entire body is possible (Erythrodermic Psoriasis)
Oral immunosuppressives: methotrexate, cyclosporine, oral
 Systemic manifestations
retinoids
- Joint  Psoriatic arthritis Oral apremilast (Otezla): selective inhibitor of the enzyme
o Always ask patients about joint symptoms to rule out phosphodiesterase 4 (PDE4)
- Higher risk for: Cardiovascular disease, type 2 diabetes, metabolic Injectable biologic medications: TNF-alpha inhibitors, Anti
disorder (obesity, hyperlipidemia). interleukin agents
Psoriatic Arthritis Rupioid Psoriasis
Joint pain (improve with activity) + redness + “sausage digit” Thick oyster-shell rash
HIV patient

Erythrodermic Psoriasis
Solid redness covering >80% of body
Patients are severely ill: Fevers/chills, Electrolytes
abnormalities, Higher risk for infection, output heart failure Guttate Psoriasis
Kids
“Rain drop”
After a strep infection

Pustular Psoriasis
→ exacerbated by withdrawal of steroids.
B. Lichen Planus (LP) Oral steroids, phototherapy, oral retinoids, systemic
immunosuppressive (methotrexate, mycophenolate mofetil)
(HALLMARK) Purple color + polygonal flat topped scaly papules

Associated features:
- Very pruritic!
- Wickham’s striae = fine white reticulated lines overlying
papules or on mucosa
- Koebner phenomenon

 Distribution
- Symmetric

- Forearms/wrists, ankles
- Oral or genital mucosa
- Nails
- Scalp
- Can also be widespread.
 Diagnosis: clinical diagnosis (best initial) and skin biopsy (most accurate)
 Treatment
- First line: topical or intralesional steroids
- Second line:
Topical calcineurin inhibitors (tacrolimus, pimecrolimus)
C. Pityriasis Rosea (PR) – HHV6  Diagnosis: Clinical diagnosis (best initial) + Skin biopsy (most accurate)
(HALLMARK) A single “herald patch” (first) + rash over the trunk (later) - Consider ruling out syphilis with RPR if patient is at risk
- Consider skin scraping for KOH to rule out tinea
Pityriasis Rosea (PR) vs. Guttate Psoriasis  Treatment: Self-resolved
Clinically looks similar. - Symptomatic relief with oral antihistamines, low potency
Both common in kids/teens/young adults
topical steroids
PR is acute, self-resolved

 Herald patch = Small round to oval pink scaly patches with central
“cigarette paper” appearance
 Prodrome of upper respiratory tract infection–like symptoms (fever,
headache, malaise, pharyngitis, lymphadenopathy)

 Distribution: favors trunk along skin lines of cleavage = Christmas

tree pattern
D. Seborrheic Dermatitis – abnormal immune response to Seborrheic Dermatitis in Infants
Cradle cap = adherent plaques across scalp with thick
Malassezia furfur yeast yellow overlying scale
(HALLMARK) Distribution is key: sebaceous-rich areas and body folds Pink scaly patches in body folds and diaper area
- Scalp, ears, body folds of face, hair bearing areas of Resolves by 4th month.
face/chest/armpit/groin
 Clinical presentation:
- Erythematous patches with loose bran-like or greasy scale

- Color: pink (light skin), hypopigmented/hyperpigmented (dark skin)

- +/- Annular scaly patches can affect the edges of the face in dark
skin
- +/- Itching or burning
 Diagnosis: clinical diagnosis
 Treatment
- First line: topical antifungal cream or shampoo
- Second line: can add topical steroid for severe inflammatory
involvement of face/body