PSORIASIS VULGARIS

Key features
• It’s a chronic disorder that results from a
polygenic predisposition combined with
triggering factors, e.g. trauma, infections,
medications
• Sharply demarcated, scaly erythematous
plaques characterize the most common form of
psoriasis
• Most common sites of involvement : scalp,
elbows, knees, nails, hands, feet, trunk
 Key features

• Psoriatic arthritis is the major associated

systemic manifestations
• Underlying pathophysiology involves
epidermal proliferation and differentiation,
angiogenesis & cellular immune system
 Epidemiology & genetics
• Most frequent manifestation in children is guttate
psoriasis ff. streptococcal infec.

• Genetic factors:
• Psoriasis runs in some families
• HLA Studies
• The corresponding chromosomal region is called MHC
( on short arm of chr 6)
• Psoriasis is associated with several: HLA-B13, HLA B-17,
HLA B-37 & HLA-Bw 16, HLA-Cw6
 Introduction
• Psoriasis is a polygenic disease
• Various triggering factors may elicit a psoriatic
phenotype in predisposed individual
 Epidemiology and genetics
• Prevalence of the world’s population :2%
• Prevalence in Africa: 0.4-0.7%
• Psoriatic arthritis occurs in 5-30% of patients with
cutaneous psoriasis
• In general, the skin lesions appear before psoriatic
arthritis
10-15% of patients report arthritis first
Age of onset : any age from infancy
2 peaks in the age of onset: 20-30yrs; 50-60yrs
 Triggering factors
• External factors
• Elicitation of psoriatic lesions by injury to the
skin was described by Heinrich Koebner
• This phenomenon is observed in approx. 25%
of patients
• The lag time between the trauma and the
appearance of skin lesions is about 2-6wks
 Systemic triggering factors
• Infections:
• Esp. bacterial infections may induce or
aggravate psoriasis
• Commonest is strep. Infec. (esp. pharyngitis)
• HIV infec. may aggravate psoriasis. The
frequency of psoriasis is not increased in HIV-
positive patients
• the severity is rather greater in this population
 Systemic factors
• Endocrine factors
• Hypocalcemia triggers generalized pustular
psoriasis
• Pregnancy may alter disease activity
• Psychogenic stress:
• Drugs e.g. Li, beta-blockers, antimalarials
• Rapid tapers of corticosteroids can induce
pustular psoriasis
 Pathogenesis
• Both systemic and local factors are involved
• It is a T-lymphocyte-mediated autoimmune disease
• CD4+ cells interact with APCs, expressing MHC class II
antigens
• CD8+ cells interact with APCs, expressing MHC class I
antigens
• Activated T-lym produce 2 different patterns of cytokines:
• Th1 cells produce IL-2 & IFN-g
• Th2 cells produce IL-4, IL-5 & IL-10
• Psoriasis is a Th-1 dominant disease
 Pathogenesis
• Activated T-cells secrete cytokines which
• account for:
• epidermal proliferation(shortening of the cell cycle from 311
to 36h, resulting in 28 times the normal production of
epidermal cells)
• Epidermal differentiation
• Inflammation
• Cytokines from T-lym induces epidermal cells to produce IL-8
• IL-8 is chemotactic for neutrophils which accumulate in
psoriatic lesions as micropustules
 Clinical features
• Most common variant of psoriasis vulgaris is
chronic plaque psoriasis(cpp)
• Cpp is characterized by sharply demarcated
erythematous papule with silvery white scale
• Erythrodermic psoriasis: over 90% of the body
surface is involved
• Guttate psoriasis: small disseminated papules
& plaques
 Clinical features
• Classic findings: erythema, thickening, scale
• Erythema: due to elongated dilated capillaries
that are close to the skin surface
• Thickening: due to epidermal acanthosis
• Scales: due to abnormal keratinization
• Pruritus: during exacerbations
End result of clearing of the lesion is
postinflammatory hypo- or hyperpigmentation
 classification
• Psoriasis vulgaris psoriatic erythroderma
• Acute guttate pustular psoriasis
• Chronic plaque
• Inverse
• palmoplantar
 Chronic plaque psoriasis
• Fairly symmetric distribution of sharply
defined erythematous scaly plaques
• Sites of predilection: scalp, elbows, knees,
presacrum, hands, feet, genitalia
Psoriatic plaque: sharp demarcation and
silvery scales
Symmetrical distribution of psoriatic plaques
 Guttate psoriasis
• Common of psoriasis in children
• Often preceded by severe URTI usually by
Strep.
• Good prognosis in children- spontaneous
remission over weeks to months
• In adults it could become chronic
Guttate psoriasis
 Pustular variants
• Generalized pustular psoriasis
• Triggering factors: pregnancy, tapering of CS,
hypocalcemia, infections
Generalized pustular psoriasis
Annular pattern
Pustulosis of palms & soles
 Special localizations
• Scalp psoriasis: discrete lesions, tend to
advance to periphery of face, retroauricular
areas and upper neck
• Flexural psoriasis: shiny, pink to red, sharply
demarcated thin plaques, less scale
• Nail psoriasis: affects both nail matrix &
nailbed, pits in nails, “oil drops”, Splinter
haemorrhages, distal onycholysis, subungual
hyperkeratosis
 Psoriatic arthritis
• Occurs in 5-30% of patients with skin lesions
• Hallmark :erosive change, whilst serologies (e.g.
RF) remain negative
• Mono- & asymmetrical oligoarthritis ( both DIPs
and PIPs)
• Arthritis of DIPs
• Arthritis mutilans: shorter digits, wider and softer
due to osteolysis
• Spondylitis and sacroliitis
 Differential diagnosis
• Seborrhoeic dermatitis
• LSC
• intertrigo
 Treatment
• A repertoire of topical & systemic therapies
• Long-term management requires:
individualization of Tx, extent of disease,
potential side effects of medications
• Vitamin D3 analogues e.g. calcipotriol
• Active vit D3 inhibits epidermal proliferation,
induces normal differentiation, inhibits
neutrophil function
 Treatment
• Topical Corticosteroids esp. oint
• Dithranol
• Topical retinoids e.g. tazarotene
• To reduce thick scales of psoriatic plaques:
• Use of salt-water baths
• Topical salicylic acid
• Photo(chemo) therapy:
• Phototherapy with UVB
• Photochemotherapy with UVA (PUVA) ff. ingestion or
topical Tx with psoralen
 Treatment
• Methotrexate
• A premethotrexate assessment includes a
careful patient Hx, a complete physical
examination, and focused lab. Inves.
• E.g. of regimen is once a week, a single dose
on MTX is given orally.
• Cyclosporine 2-5mg/kg/day
• Systemic retinoids e.g. acitretin
 Treatment
• Fumarates
• Mycophenolate mofetil
•

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