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Psoriasis

  • Thought to be an autoimmune skin disease with inherited genetic predisposition & immunological triggers
  • PSORS1 on chromosome 21 within MHC has been identified
  • HLA-CW6 in 60%; HLA -B17, -CW6, -DR4 & -DR7 a/w psoriatic arthropathy
  • Immunological stimuli (eg. B-hemolytic streptococci & drugs (eg. antimalarials))
  • Alcohol increases incidence and makes it more intractable
  • Smoking is a/w palmoplantar pustulosis

Clinical

Features

  • Nails
  • Koebners phenomenon
  • Auspitz sign

when the scale of psoriasis is gently scraped it comes off easily, revealing dilated blood vessels underneath (will bleed)

  • Localised forms
  • Generalised Pustular
  • Rare but serious and even life threatening
  • Sheets of small, sterile yellowish pustules develop on an erthematous background and may spread rapidly. Pustules may coalesce into lakes of pus
  • Onset is acute
  • Patient is unwell with high, swinging fever and leukocytosis
  • Patient may die often of secondary infection

Management

Topical

Systemic

  • Phototherapy & Photochemotherapy

Thank you!

http://exposed-film.co.uk/about-exposed/the-film

  • Vitamin D Analogues
  • In mild/moderate chronic plaque psoriasis
  • Calcipotriol (Dovonex) up to 100g/week BD, scalp preparation
  • Tacalcitol (Curatoderm) ointment up to 35g/week OD on scalp & face
  • calcitriol (Silkis)
  • Often used in alternation with topical steroid or in combination with UVB or PUVA therapy
  • Adv: do not smell/stain, easy to apply & no risk of skin atrophy
  • Disadv: skin irritation, possible hypercalcaemia if exceeds maximum dose

UVB

  • Topical Corticosteroids
  • 290 – 320 nm given 3 times a week
  • Can be given to children or pregnant women
  • Combined with other topical agents
  • Main SE: acute sunburn & increased long-term risk of skin cancer
  • For face, genitalia, flexures and for stubborn plaques on hands, feet & scalp
  • Potent ones should not be applied to the face
  • Adv: clean, non irritant, easy to use
  • Disavd: skin atrophy, induction of acne/dermatitis, atypical fungal infection, systemic absorption, tachyplaxis

Psoralen plus UVA (PUVA)

  • Coal tar preperations
  • 8-methoxypsoralen PO before UVA (320 – 400nm)
  • Causes cross-linkage in DNA, inhibits cell division & suppresses cell-mediated immunity
  • Immediate SE: pruritus, nausea, mild erythema
  • Long term: increased risk of skin cancer, premature skin ageing, cataracts (use UVA-opaque sunglasses for 24h after taking psoralen
  • Useful in inpatient care eg: combined with UVB (Goeckerman regiment)
  • Outpatient: refined tar (1 -10%)in cream or lotion base eg: Alphosyl, Carbo-Dome, Exorex
  • Suitable for chronic plaque psoriasis/ guttate psoriasis after the acute phase
  • Adv: safe, act by inhibiting DNA synthesis
  • Disadv: smelly and messy
  • Methotrexate
  • Ditranol (Anthralin)
  • Folate antagonist
  • May have anti-inflammatory + immune modulatory effects
  • Given once a week PO in single dose (7.5 – 15 mg)
  • Prior: liver, kidney, bone marrow functions must be assessed
  • Improvement is within 2 – 4 weeks
  • C/I: liver disease, alcoholism, acute infection
  • After administration, liver function is monitored either with serum procollagen III aminopeptide or liver biopsy

Inpatient

  • Adv: antimitotic efect
  • Disadv: irritant to normal skin, stains on skin, hair, linen, clothes & bathtubs -->  purple- brown colour

  • usually used with Lassar’s paste (zinc & salicyclic acid paste)
  • Applied to plaques initially 0.1%, up to 2%
  • Surrounding skin is prepared with bland preparation eg: white soft paraffin.
  • Treated area is covered with tube gauze
  • Ingram regimen: combined with daily tar bath & UVB. Psoriasis usually clears within 3/52

  • Dithranol is applied 30 min each day in stable plaque psoriasis
  • Wash off with shower
  • Dithrocream (0.1% - 2%)
  • Retinoids

Outpatient

  • Vitamin A derivative acitretin (Neotigason) – effective in pustular psoriasis & thinning hyperkeratotic plaques
  • May be used with topical agents or UVB or PUVA
  • Minor SE: dry mucosa, itching, peeling of skin
  • Serious SE: hyperostosis, abnormal LF, hyperlipidaemia, teratogenicity
  • Retinoids
  • Ciclosporin
  • Topical: tazarotene(0.05% & 0.1% Zorac gel)
  • Effective for chronic plaque psoriasis
  • May irritate, often used in alternation with topical steroid
  • Neoral, an immunosuppressant is effective in severe psoriasis.
  • Inhibits T-lymphocyte activation & IL-2 production
  • SE: dose-dependent reversible nephrotoxicity. BP & kidney function are monitored during treatment
  • Risk of skin cancers or lymphoma. Avoid concomitant UV treatment
  • Keratolytics & Scalp preparations
  • Others
  • Oedema
  • Hydroxyurea: does not affect liver function but suppresses bone marrow
  • Fumaric acid esters are effective in some cases
  • Other biologic agents are expensive
  • 5% salicyclic acid ointment: hyperkeratotic psoriasis of palms & soles
  • 3% salicyclic acid in cream base: scalp psoriasis applied daily or once in 2-3 days, combined with a tar-containing shampoo eg: Alphosyl, Capasal, Polytar, T/Gel).
  • Coconut oil compound eg Cocois also helps scaly scalps

due to inflammatory polymorphs infiltrating the epidermis

  • Plaques

Well-defined raised areas of psoriasis

  • Heat Loss
  • Scaling

May be very prominent

Plaques appear thickened with masses of adherent and shedding waxy appearance

Scratching produces waxy appearance - tache de bougie

due to widespread dilated cutaneous blood vessels

Redness of affected skin very marked, especially at flexures.

Erythrodermic psoriasis - >90% of body surface

  • Erythema

Commonly seen in palmoplantar psoriasis where deep-seated pustules are dominant features.

Rarely on trunks and limbs (unstable psoriasis)

  • Pustules
  • Hyperkeratosis

Normal - keratinocytes migrate from basal layer of epidermis to surface in

23 days

Psoriasis - process takes 3-5 days => thickened skin due to scaling

Lifting of the nail plate off the nail bed

due to abnormal nail adhesion

usually manifests as a white/salmon patch on the nail plate

  • Onycholysis
  • Subungal hyperkeratosis

accumulation of chalky-looking material under the nail

due to excessive proliferation of the nail bed (can => onycholysis)

  • Pitting

very small depression in the nail plate

result from parakeratotic cells being lost from the nail surface

Complications

  • Beau's Lines

Transverse lines on the nail plate

due to intermittent inflammation of the nail bed leading to transient arrest in nail growth

due to leakage of blood from dilated tortuous capillaries

  • Splinter hemorrhages

at site of trauma

Depending on the type and location of the psoriasis and how widespread the disease is, psoriasis can cause complications. These include:

pruritus, fissuring, bleeding of lesions

  • Physical
  • Systemic
  • in generalized pustular or erythrodermic psoriasis:
  • fever, weight loss
  • congestive heart failure (due to increased cutaneous blood flow)
  • fluid/electrolyte imbalance
  • hypoalbuminemia, low iron, hyperuricemia
  • Emotional/Psychological
  • patients with psoriasis often feel stigmatized and socially isolated
  • loss of self-esteem
  • depression
  • costs of medication
  • time away from work
  • Economical

Aetiology

  • Psoriatic arthritis
  • 5-10% of patients with psoriasis will have psoriatic arthritis;
  • seronegative (RF), association with HLA-B27
  • asymmetric peripheral joint involvement (most common)
  • symmetric peripheral joint involvement (resembles rheumatoid arthritis)
  • axial disease (resembles ankylosing spondylitis)
  • arthritis mutilans (uncommon)

Chronic, non-infectious, inflammatory

dermatosis characterised by well-demarcated

erythematous plaques topped by silvery scales

Increased T-cell activity in skin

Types

Increased levels of proinflammatory cytokines in psoriatic lesions (esp. gamma-INF and TNF-alpha

Increases keratinocyte proliferation

+

Induces SKALP/elafin gene

marker for abnormal keratinocyte differentiation, hyperproliferative epidermis and increased inflammation

  • Most common pattern
  • Single or multiple well defined,raised disc shaped plaques involving the elbows, knees, scalp hair margin or sacrum
  • Plaques usually red and covered by waxy white scales. If detached, may leave a bleeding points (Auspitz sign)
  • Classical Plaque
  • An acute symmetrical eruption of “drop like” lesions with little scale in the early stage, usually on the trunk and limbs
  • Mostly occurs in adolescents or young adults
  • May follow a streptococcal infection

References

  • Buxton PK, Morris-Jones R. "ABC of Dermatology". BMJ books; Wiley-Blackwell; 5th edition; 2009.
  • Gawkerodger. "Dermatology: An Illustrated Colour Text". Churchill Livingstone; Elsevier; 4th edition; 2008.
  • http://www.mims.co.uk/news/882277/Psoriasis/
  • Guttate Psoriasis
  • Affects the axillae, submammary areas, umbilicus, groin and natal cleft
  • Plaques are smooth,often glazed and itchy
  • Mostly found in elderly
  • Flexural Psoriasis

Epidemiology

characterized by yellow to brown coloured sterile pustules on the palms and soles. Most common in middle aged woman who are cigarette smokers

  • Palmoplantar Pustulosis

uncommon indolent type of pustulosis affecting the digits and nails.

  • Acrodermatitis of Hallopeau

very common, indeed scalp may be affected alone. May be confused with dandruff + seborrhoiec dermatitis but is generally better demarcated and more thickly scaled

  • Scalp psoriasis

well defined psoriasiform eruption in the nappy area of infants. Few develop true psoriasis later in life

  • Napkin psoriasis
  • Affects 3% of the Malaysian Population
  • partly hereditary and partly brought on by trigger factors in the environment (stress, certain infections, drugs, physical injury)
  • individuals between the ages of 15 and 35, but can develop at any age. Approximately 10-15 percent of those with psoriasis get it before age ten.
  • Unusual for children under the age of 8.
  • Equal sex distribution
  • Psoriasis affects the matrix or nail bed in 25-50% of cases
  • 2 common findings: pitting and onycholysis
  • Frequently associated with psoriatic arthropathy
  • Treatment is difficult
  • Nail involvement

Dermatological Society of Malaysia: http://www.dermatology.org.my/overview_psoriasis.html

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