Lecture 1 – Psoriasis

Definition – chronic relapsing skin disease characterized by inflammation

mediated by cytokines released from T-cells which result in hyperproliferation
of keratinocytes what macroscopically presents as desquamating papules

A patient can have different types of psoriasis simultaneously or in one

lifetime.

Affects 2-4% of the

The is a risk of psoriasis in people with vitamin D synthesis deficiency therefore

its more common in Nordic countries.

- 3 fold increase of risk of psoriasis in monozytotic twins

- 55 fold increase of risk of psoriatic arthritis in relatives of psoriatic
arthritis patients
- 19 fold increase of risk of psoriasis in relatives of psoriatic arthritis
patients
- CARD 14 is a scaffold protein which activates nuclear factor NF kB
activation of this leads to proinflammatory cytokines like IL 8 and CCL 20
which leads to chemotaxis
Its polygenic but we also see epigenetic factors. Based on studies, we know
that the risk of having a first degree relative with psoriasis is a bit higher for
father than mothers. If there were no epigenetics facts the risk should be 50%.

Diagnosis of Psoriasis
Skin lesions – clinical appearance and skin biopsy

Psoriatic arthritis
- Screening tools
o Psoriasis Epidemiology Screening Tool (PEST)
o Psoriatic Arthritis Screen and Evaluation Tool (PASE)
o Toronto Psoriatic Arthritis Screen (ToPAS)
- Imaging diagnsotics
o USG, MRI
o RTG
- Biochemical tests
o RF, CRP

Therapeutic goals
- Treatment goal is a reduction in PASI (psoriasis Area and Severity Index)
>- 75% and DLQI below 5 as compared to disease severity at the time of
treatment initiation within 16 weeks.
DLQI score 0-1 = no effect at all on patient's life DLQI score
of 2-5 = small effect on patient's life, DLQI score of 6-10 =
moderate effect on patient's life, DLQI score of 11-20 = very
large effect on patient's life, DLQI score of 21-30 =
extremely large effect on patient's life.

Therapeutic guidelines:

In case of benign psoriasis,

- the recommended first line therapy removing scaling, vitamin D analogs
with glycocorticosteroids …..
- second line, high potency glycocorticosteroids topically, …., coltar …

In moderate to severe,
- methotrexat 15-25 milligrams per week
- cyclosporine is not recommended just suggested
 - Fumarates in induction of remission but not available in all euorpean
countries
- Acitretin only in second line therapy and not in patients of child bearing
age
- “Biologics” only in patients with contraindications or lack of
effectiveness (biologics only target specific parts of the immune system)

Koebnerization - the emergence of new psoriatic lesions in the healthy skin

regions following an injury/trauma to psoriatic patients

- Psoriasis in the area of previous herpes zoster – isotopic sign of Wolf

(Wolf's isotopic response is defined as the appearance of a new skin
disease at site of a previous, already healed, unrelated disease.)
- Streptococcal pharyngitis is a risk factor for psoriasis
- Antiobiotics and aggravation of psoriasis vulgaris or pustulitis (not sure
if there is a cause)
- Relation between psoriasis and psychological stress
- Psoriasis and circadian rhythm


Th17 cell differentiation is regulated by the circadian clock

- Not enough scientific evidence that alcohol increases the risk of
appearance of psoriasis but there was strong evidence between alcohol
consumption and severity of psoriasis
- Smoking is a risk factor of psoriasis
- Marijuana leads to free oxygen radicals but cannabionoids limit
proliferation of keratinocytes and induce change of methylation and
acetylation of histones in T lymphocytes leading to reduction of T1 and
increase in T2. Cannabinoids also have antipruritic activity.