Psoriasis

DR.CHARVY PATEL
Defination
A chronic recurrent inflammatory disease of skin of
unknown origin characterized by well-circumscribed
erythematous , dry plaques of various size, covered
with mica-like scales.
 Pathogenesis:
Psoriasis results froma polygenic genetic disposition and an environmental trigger.
Its severity is believed to be genetically determined and several environmental factors are known to exacerbate it.
a. Activated T lymphocyte: appear to be important in all phases of the disease process (initiation, maintenance &
resolution) patient with psoriasis who undergo bone marrow transplantation from a healthy ones sometimes
experience long term remission
b. T- helper lymphocytes: migrate from blood vessels into skin, wher they interact with antigen – presenting cells
and then become activated into T-helper type- I phenotype, proliferate and release various cytokines which
attract and activate T-cytotoxic lymphocytes.
c. Interferon - α and tumor are released by immune cells further promoting inflammation and development of
psoriatic lesions.
d. Epidermal cells overlying the inflammatory process proliferate and twin over at four times the normal rate,
resulting in thickening of the epidermis with overlying scales.
In the upper epidermis proliferation of vessels occur.
Aetiology:
Genetic Factors: Identical twins have a concordance rate of
50-70%
There is a strong association with HLA, B13, B17, DR7.
Both HLA association and a family history of psoriasis are
more common in patients who develop the disease before
40 years of age.
Environmental Factors:
Attacks of psoriasis can be precipitated or
aggravated by stress, infection (streptococcal,
HIV) Pregnancy, Trauma, Drugs (chloroquine /
antimalarial, lithium), alcohol, tobacco,
smoking, sunlight.
Morphology
Psoriasis vulgaris (chronic plaque psoriasis) is the most common form.
The primary lesion is a plaque which is sharply marinated, indurated, erythematous (modified
by skin color)
The plaque surface is usually scaly and gentle scratching may produce a silvery appearance from
the lifting of numerous tiny scales.
Lifting larger scales may result in capillary bleeding (auspitz sign) because the elongated
cappilarries almost reach the skin surface.
Psoriatic plaque with well defined edge:
The Koebner’s phenomenon, in which psoriatic
lesions tend to develop at site of trauma (e.g a
surgical wound or a trivial scatch, abrasion or burn) is
a helpful diagnostic feature.
It also occurs in lichen planus but not in eczematous
dermatoses.
Variants:
1. Morphological :
Guttate Psoriasis: occurs in children and adolescents, small erythematous papules appear in
several guttate which clear within a week or evolve into plaque psoriasis.
Ruppoid psoriasis: Instead of scaling the surface of the plaques is covered by hard, thickened
firmly adherent keratin plaques.
Such lesion are classically seen in Reitee’s syndrome.
2. Modification by site:
Flexural Psoriasis: well defined erythematous lesions, mostly in elderly females in groins axilla,
inflammatory fold, vulva, gluteal cleft.
Scalp Psoriasis: Sharply defined indurated scaly plaques.
Scaling may be massive, especially in the occiput, may spread
to forehead and nape of the neck
Psoriasis of Palms and Soles: Bilateral, symmetrical, well
defined plaques, scales may be adherent unlike loose scales in
other parts
Nails :Pitting, nail plate thickening, subungual, hyperkeratosis,
onchylosis oil spots.
Joints : Arthritis types:
a. Asymmetrical oligo arthritis involving commonly joints of hand
and feet.
b. Distal interphalangeal arthritis
c. RA- like seronegative, symmetrical arthritis
d. Axial arthritis- spondylitis, sacroillitis and with or without
peripheral joint involvement.
e. Arthritis mutilans: severe deforming arthritis of finger.
Penile Psoriasis in uncircumcised male
No scaling on glans, lesions erythematous, well defined.
In circumcised males lesions similar to lesions at other sites.
Sign and symptoms:
A patchy rash that varies widely in how it looks from person to person, ranging from spots of
dandruff-like scaling to major eruptions over much of the body
Rashes that vary in color, tending to be shades of purple with gray scale on brown or Black skin
and pink or red with silver scale on white skin
Small scaling spots (commonly seen in children)
Dry, cracked skin that may bleed
Itching, burning or soreness
Cyclic rashes that flare for a few weeks or months and then subside
Types of Psoriasis
1. Plaque psoriasis. The most common type of psoriasis, plaque psoriasis
causes dry, itchy, raised skin patches (plaques) covered with scales. There may
be few or many. They usually appear on the elbows, knees, lower back and
scalp. The patches vary in color, depending on skin color. The affected skin might
heal with temporary changes in color (post inflammatory hyperpigmentation),
particularly on brown or Black skin.
Nail psoriasis. Psoriasis can affect fingernails and toenails,
causing pitting, abnormal nail growth and discoloration.
Psoriatic nails might loosen and separate from the nail bed
(onycholysis). Severe disease may cause the nail to crumble.
Guttate psoriasis. Guttate psoriasis primarily affects young
adults and children. It's usually triggered by a bacterial
infection such as strep throat. It's marked by small, drop-
shaped, scaling spots on the trunk, arms or legs.
Inverse psoriasis. Inverse psoriasis mainly affects the skin folds of
the groin, buttocks and breasts. It causes smooth patches of
inflamed skin that worsen with friction and sweating. Fungal
infections may trigger this type of psoriasis.
Pustular psoriasis. Pustular psoriasis, a rare type, causes
clearly defined pus-filled blisters. It can occur in widespread
patches or on small areas of the palms or soles.
Erythrodermic psoriasis. The least common type of
psoriasis, erythrodermic psoriasis can cover the entire body
with a peeling rash that can itch or burn intensely. It can be
short-lived (acute) or long-term (chronic).
Diagnosis
Examination skin, scalp and nails.
Small sample of skin (biopsy) for examination under a
microscope. This helps determine the type of psoriasis and
rule out other disorders.
Treatment
Psoriasis treatments aim to stop skin cells from growing so quickly and to remove scales. Options
include creams and ointments (topical therapy), light therapy (phototherapy), and oral or injected
medications.
Topical therapy
Corticosteroids. These drugs are the most frequently prescribed medications for treating mild to
moderate psoriasis. They are available as oils, ointments, creams, lotions, gels, foams, sprays and
shampoos. Mild corticosteroid ointments (hydrocortisone) are usually recommended for sensitive
areas, such as the face or skin folds, and for treating widespread patches. Topical corticosteroids
might be applied once a day during flares, and on alternate days or weekends during remission.
A stronger corticosteroid cream or ointment — triamcinolone (Trianex) or clobetasol (Cormax,
Temovate, others) — for smaller, less-sensitive or tougher-to-treat areas.
Long-term use or overuse of strong corticosteroids can thin the skin. Over time, topical
corticosteroids may stop working.
Vitamin D analogues. Synthetic forms of vitamin D — such as calcipotriene
(Dovonex, Sorilux) and calcitriol (Vectical) — slow skin cell growth. This type of
drug may be used alone or with topical corticosteroids. Calcitriol may cause less
irritation in sensitive areas. Calcipotriene and calcitriol are usually more
expensive than topical corticosteroids.
Retinoids. Tazarotene (Tazorac, Avage, others) is available as a gel or cream. It's
applied once or twice daily. The most common side effects are skin irritation and
increased sensitivity to light.
Tazarotene isn't recommended im pregnancy or breastfeeding.
Calcineurin inhibitors. Calcineurin inhibitors — such as tacrolimus
(Protopic) and pimecrolimus (Elidel) — calm the rash and reduce
scaly buildup. They can be especially helpful in areas of thin skin,
such as around the eyes, where steroid creams or retinoids are
irritating or harmful.
Calcineurin inhibitors contraindicated in pregnancy This drug is also
not intended for long-term use because of a potential increased risk
of skin cancer and lymphoma.
Salicylic acid. Salicylic acid shampoos and scalp solutions reduce the
scaling of scalp psoriasis. This may be used alone or with other
topical therapy, as it prepares the scalp to absorb the medication
more easily.
Anthralin. Anthralin is a tar cream that slows skin cell growth. It can
also remove scales and make skin smoother. It's not intended for use
on the face or genitals. Anthralin can irritate skin, and it stains almost
anything it touches. It's usually applied for a short time and then
washed off.