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Psoriasis

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Isabel Allsop

on 5 May 2016

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Transcript of Psoriasis

Psoriasis
Palmoplantar
Flexural Psoriasis
Commonly around the groin, under breasts, umbilicus, around the genitalia
Shiny and smooth appearance
May appear like dermatitis but is more defined
Secondary infection with candida
Guttate
Chronic Plaque
Most common presentation- 90%
Large flat areas (plaques) of psoriasis with typical silvery scale
Often accompanied by scalp and nail psoriasis
May be localised (e.g. extensor surfaces, elbows and knees) or generalised (involving scalp, trunk and limbs).
Divided into small plaque and large plaque psoriasis
Large Plaque
What is psoriasis?
Immune mediated inflammatory disease
"Hyperproliferation of epidermal keratinocytes with inflammation of the epidermis and dermis"
Usually presents with symmetrically distributed, red, scaly plaques with well-defined edges
(Very brief) Histology
Plaques have an epidermal proliferation rate of 8-10 days rather than the usual 50-75 days
Who Gets Psoriasis?
2% of the population, men and women equally
Caucasians particularly affected
Peak onset at 15–25 years and 50–60 years
HLA- Cw6 associated with early onset psoriasis and guttate psoriasis
Linked to other health conditions, including inflammatory arthritis, inflammatory bowel disease (especially Crohn disease), uveitis and celiac disease
Types of Psoriasis
Chronic Plaque
Palmoplantar Psoriasis
Flexural Psoriasis
Guttate Psoriasis
Erythrodermic Psoriasis
Pustular Psoriasis
Erythrodermic Psoriasis
Management Overview
Large plaque psoriasis describes thick, well-demarcated, red plaques with silvery scale. This type of psoriasis often has early onset (<40 years) and may be associated with metabolic syndrome. There's often a family history of psoriasis. It can be quite resistant to treatment.
Small Plaque
Small plaque psoriasis often presents with numerous lesions a few millimetres to a few centimetres in diameter. The plaques are thinner, pinkish in colour and have a fine scale. They may be well-defined or merge with surrounding skin. Family history is less common. Although it may arise at any age, small plaque psoriasis often arises in those over than 40 years of age. This type of psoriasis often responds well to phototherapy.
Management of Chronic Plaque
Topicals
Emollients for itching- E45
1st line: potent corticosteroid + vitamin D analogue once daily
Betnovate + calcipotriol
NICE guidelines 2012
2nd Line: vitamin D analogue twice daily
No improvement after 8-12 weeks
3rd line:
Potent corticosteroid applied twice daily for up to 4 weeks
Coal tar preparation applied once or twice daily
Dithranol
Koebner Phenomenon
Objectives
Be familiar with the different clinical presentations of psoriasis

List the systemic complications of severe psoriasis

List at least 5 possible aggravating factors for psoriasis

Know the various topical treatment options for psoriasis and be able to discuss the risk and benefit of each treatment, Coal tar, Dithranol, Vitamin D analogues, Topical steroids and Topical retinoids

Know the various second line treatment options for psoriasis and be able to discuss the risk and benefit of each treatment, Phototherapy, Acitretin (an oral retinoid), Methotrexate and Cyclosporin

Know how to write a prescription for topical treatments

Understand the difficulties, physical and psychological, experienced by patients with psoriasis
Presents as partially or completely red, dry and thickened skin, often with deep painful cracks (fissures). The skin changes tend to have a sharp border, and are often symmetrical, ie similar distribution on both palms and/or both soles. Associated with smoking.
Looks very similar to contact dermatitis.....
Check the history!
Family history of Psoriasis, other areas of psoriasis
Any contact with irritants- are they a hairdresser for example?
May need skin scrapings to rule out fungal infection
Management- Hard to Treat
Topicals
1. Emollients
2.
Very potent
corticosteroids- Dermovate
3. Salicylic acid for very thick plaques
(Consider psoralen (oral or topical) with local ultraviolet A (PUVA) irradiation)
Improving general lifestyle can help in managing palmoplantar- quitting smoking, regular exercise
Palmoplantar psoriasis is more commonly associated with
psoriatic nail dystrophy
and
psoriatic arthritis
, compared to other psoriasis
Very rare form of psoriasis, occurring once in 3% of psoriasis sufferers during their lifetime. Presenting as severe redness and shedding of skin over a large area of the body.
Exfoliation often occurs in large "sheets" instead of smaller scales
It is a life threatening condition, affecting more than 90% of the body.
May be precipitated by:
Infections
Low calcium
Withdrawal of oral corticosteroids (prednisone)
Withdrawal of excessive use of strong topical corticosteroids
Strong coal tar preparations
Certain medications including lithium, antimalarials and interleukin II
Excessive alcohol consumption
Complications include:
Dehydration
Heart failure
Infection
Hypothermia
Protein loss and malnutrition
Oedema (swelling), particularly of lower legs
Death
Management
Hospitalisation
Supportive treatments
Treat complication (antibiotics)
Methotrexate/ Ciclosporin
Usually affecting the trunk and upper arms
May follow a streptococcal infection of the throat
Usually children and young adults
May resolve spontaneously
Management
Topical emollient
Mild steroid
Coal tar
Calcipitrol
Consider Phototherapy
Treat underlying infection!
Management
Topicals
Weak topical steroids, combination with thrush treatment if necessary
Hydrocortisone or canesten
Calcitriol-
vitamin D analogue

Avoid strong steroids, dithranol, salicylic acid and coal tar- irritation and skin thinning
Topicals
Emollients
Vitamin D analogue- calcitriol
Steroids

Thick plaques- salicylic acid or dithranol- Chronic plaque palmoplantar

Phototherapy
If topical treatment fails to resolve the psoriasis

UVB Narrowband
short exposure times with high intensity
2-5 times per week therapy
Theraputic wave lengths only
Fewer risks than PUVA
Risks:
Skin cancer and aging
PUVA
Photochemotherapy
8-methoxypsoralen + UVA exposure
UVB not used with psoralens as the wave lengths fail to activate
More risks compared to UVB narrowband and only slightly more effective
Risks:
Phototoxic erythema
Pruritis
Nausea
Skin aging and cancer
Systemic

Severe palmoplantar psoriasis may need systemic treatment:
PUVA
Methotrexate
Biologics (may trigger palmoplantar pustulosis)
Systemic therapy
3rd Line treatment

Methotrexate
Moderate to severe psoriasis
Effects in 6-8 weeks, maximum effects at 5-6 months
Live damage
No alcohol
Avoid in pregnancy
Ciclosporin
Short term to stabilise disease
Monitoring: BP, FBC, LFTs, creatinine
Acitretin
oral retinoid (vitamin-A derivative)
slows proliferation epithelial cells
Severe psoriasis
Pustular psoriasis, erythrodermic psoriasis, palmoplantar pustulosis
Teratogenic - contraception for two years after treatment has finished
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