Download MBBS Dermatology PPT 22 Psoriasis I Lecture Notes

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PSORIASIS

? A chronic disorder with polygenic predisposition
? Characterized by erythematous scaly papules and plaques;
? Sites: scalp, elbows, knees, hands, feet, trunk, and nails.

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? Triggering environmental factors: trauma, infection (streptococcal

sore throat), or medication.

? Severe forms like pustular psoriasis and erythrodermic psoriasis can

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occur

? Psoriatic arthritis : 10%?25% of patients

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Case 1: 21 year old

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History & Cutaneous examination

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History

Site

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Duration

Type of lesions

Morphology

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? Extensors

Seasonal variation

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? Primary

Colour

? Knees

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Joint pain

? Elbows

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? Papules

? Erythematous

Sore throat

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? Trunk

? Plaques

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? Hyperpigmented

Stress

? Scalp

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? Secondary lesion

? Size

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Alchohol

? Palms

? Scales

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? Margin

Smoking

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? Soles

HIV

? Flexures

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? Well defined

? Nails

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Nails

? Consistency

Systemic illness

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Palms

? Indurated

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Prior treatment

Soles
Scalp

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Mucosa
CHRONIC

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Red (`salmon pink'),sharply demarcated, indurated plaques

PLAQUE-

surmounted by `silvery white', micaceous scales

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TYPE

PSORIASIS

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Monomorphic and distributed relatively

symmetrically

?Clues to diagnosis

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Extensor surfaces of the limbs. over scalp, trunk

Nail findings

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Auspitz sign positive

HPE

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Grattage test & Auspitz sign

? Auspitz sign: Heinrich Auspitz (1835-86)

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? Grattage test - Scales in a psoriatic plaque can be accentuated by grating with a

glass slide

1. Gently scraping lesion with a glass slide accentuates the silvery scales (Grattage

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test positive). Scrape off all the scales

2. Continue to scrape the lesion ? glistening white adherent membrane

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(Burkley's membrane) appears

3. On removing the membrane, punctate bleeding points become visible

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HPE chronic plaque psoriasis

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? Hyperkeratosis and confluent parakeratosis
? Neutrophilic microabscesses in corneal layer/upper epidermis
? Hypogranulosis
? Regular acanthosis

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? Regular elongation of rete ridges called "squaredoff"rete ridges,
? Suprapapil ary thinning
? Dilated capillary loops in papillary dermis

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Munro's microabscess

Suprapapil ary thinning

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Hyperkeratosis,

parakeratosis

"squaredoff"rete ridges,

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Dilated capil ary loops

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Koebner phenomenon (isomorphic response)

? traumatic induction of psoriasis on

nonlesional skin

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? during flares of disease
? all-or-none phenomenon (i.e., if psoriasis

occurs at one site of injury it will occur at

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all sites of injury)

? occurs 7?14 days after injury
? Seen in upto 25% of patients

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Classification

Morphology / natural history based

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Chronic Plaque psoriasis

Site based

Acute guttate psoriasis

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`Unstable' psoriasis

Erythrodermic psoriasis

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Scalp psoriasis

Pustular psoriasis

Follicular psoriasis

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Atypical psoriasis

Sebopsoriasis

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Other specified forms

Flexural/inverse psoriasis

Genital psoriasis

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Linear and segmental

Verrucous

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Nonpustular palmoplantar

psoriasis

Elephanthine

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Nail psoriasis

Rupoid

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Psoriasis in childhood, old

Ostraceous

Mucosal lesions

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age

Ocular lesions

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Photoaggravated psoriasis

Druginduced/exacerbated

HIVinduced / exacerbated

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Case 2: 54 year old man

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Personal or family history of psoriasis

Psoriatic

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erythroderma

H/O withdrawal of drugs

Typical psoriatic plaques

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? Clues to diagnosis

Management options

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Large lamellar scales

Nail changes (oil-drop, pits, onycholysis)

Acitretin

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Cyclosporine A

PUVA, NB-UVB

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Arthritis

Methotrexate

Anti-TNF agents

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HPE typical changes of psoriasis

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Pustular psoriasis classification

Generalized

Localized

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1. Acute generalized (von Zumbusch).

1. Palmoplantar pustulosis.

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2. Subacute annular and circinate

2. Acrodermatitis continua of

Hallopeau

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? Acute generalized pustular psoriasis of pregnancy

(GPPP or impetigo herpetiformis).

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? Infantile and juvenile generalized pustular

Corticosteroids

psoriasis.

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withdrawal

Coal tar

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Infection

Pregnancy

Triggering factors

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Stress

Hypocalcaemia 14

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Case 4: 54 year old man

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Case 3: 54 year old man

Acute generalized (von Zumbusch).

Abrupt onset, high fever, malaise, burning in skin

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Fiery-red erythema topped by pinpoint sterile yellow

pustules

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Deleterious

Waves of fever and pustulation

germline

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Coalescing lesions > "lakes" of pus

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mutations

in IL36RN

Leukocytosis, elevated ESR or CRP, plasma albumin, calcium

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low.

Kogoj's spongiform pustules on HPE

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last trimester of pregnancy

GPPP

persist upto childbirth maybe beyond

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recurs in subsequent pregnancies

usually starts in the inguinogenital region

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High fever with severe constitutional symptoms

death due to cardiac or renal failure

stillbirth, neonatal death or fetal abnormalities

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Spongiform pustule of Kogoj

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Complications

Acanthotic epidermis

Hypocalcemia

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with Psoriasiform blunted rete ridges

Bacterial superinfection

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Sepsis

Dehydration

Neutrophils

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ARDS

infiltrating into

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epidermis

Management

Etretinate

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Methotrexate

Cyclosporine

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Infliximab

+ oral corticosteroids in GPPP

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Palmoplantar Pustulosis

Acrodermatitis continua of Hal opeau

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? Chronic relapsing eruption limited to

? acral pustule formation,

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palms and soles.

?

?

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subungual lakes of pus

Numerous sterile, yel ow, deep-seated

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pustules that evolve into dusky-red

? destruction of nail plates.

crusts.

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? permanent loss of nails and scarring.

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Guttate

Unstable

psoriasis

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psoriasis

Rule out

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H/o

Eruptive LP

withdrawal of systemic or

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P rosea

potent topical steroids,

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PLC

tar or dithranol,

Secondary syphilis

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Acute infection
hypocalcaemia
severe emotional upset

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Scalp psoriasis

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Flexural psoriasis

d/d Seborrheic dermatitis

d/d

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Tinea, candidiasis, intertrigo

Greasy yellowish scales

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Seborrheic dermatitis

Does not extend beyond hairline

Langerhans cell histiocytosis

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Hailey-Hailey disease

Ill defined areas of involment

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Nonpustular palmoplantar psoriasis

Topical PUVA

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Coal tar + Steroid

Acitretin Methotrexate

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Recalcitrant PPP ?

etanercept

Dd hyperkeratotic eczema

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Nail involvement increases with

Nail psoriasis

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Age

Duration

Extent

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Ps arthritis

Diagnostic techniques

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Dermoscopy

Videodermoscopy

Capil aroscopy

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Ultrasound

Optical coherence tomography

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Confocal laser scanning

microscopy (CLSM)

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PITS

?psoriatic suspected
? > 20 fingernail pits per person

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? >60 total pits per person

?Length of pit ?
length of time, matrix was affected
?Depth of pit

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involvement of intermediate + ventral

matrix + dorsal matrix

proximal nail

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matrix

psoriasis>>>

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parakeratotic

cel s in nail plate

>>> sloughed off

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>>> pits

Dogra A, Arora AK. Nail psoriasis: the journey so far. Indian J Dermatol. 2014;59(4):319-33

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Oil spot or Salmon patch

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.



focal nail bed

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parakeratosis >>

focal onycholysis >>

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serum and cel ular

debris accumulate and

become entrapped

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Dogra A, Arora AK. Nail psoriasis: the journey so far. Indian J Dermatol. 2014;59(4):319-33

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Dogra A, Arora AK. Nail psoriasis: the journey so far. Indian J Dermatol. 2014;59(4):319-33

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Co-morbidities in psoriasis

? Malignancy

? Autoimmune diseases

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? Nonalcoholic fatty liver disease

? Chronic obstructive pulmonary

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disease

? Obstructive sleep apnea

? Bone disease

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? Parkinsonism

? Psychosocial effect

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? Psychiatric disorders

? Alcohol abuse

? Smoking

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? Migraine

Higher disease severity

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and younger at diagnosis

have a higher risk

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Will it work?

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Mild plaque psoriasis <10% BSA

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without psoriatic arthritis

CONTRAINDICATIONS FOR COAL TAR

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FIRST LINE

Coal tar

? Unstable plaque psoriasis in a

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Dithranol

phase of progression

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Calcipotriol

? Pustular psoriasis

Potent steroid

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? Erythrodermic psoriasis

Salicylic acid

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Tazorotene

SECOND LINE

Local NB-UBV or PUVA

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Excimer laser

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Moderate to severe plaque psoriasis without

psoriatic arthritis

FIRST LINE

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NB-UBV or PUVA

SECOND LINE

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Acetretin

Apremilast

Ciclosporin

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Methotrexate

THIRD LINE

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Biologicals

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Moderate to severe plaque psoriasis with

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psoriatic arthritis

FIRST LINE

Apremilast

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Methotrexate

SECOND LINE

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Biologicals

THIRD LINE

Combination therapy

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Thank you

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