Download MBBS Dermatology PPT 22 Psoriasis I Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Dermatology PPT 22 Psoriasis I Lecture Notes


Psoriasis -I

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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.
? Triggering environmental factors: trauma, infection (streptococcal

sore throat), or medication.

? Severe forms like pustular psoriasis and erythrodermic psoriasis can

occur

? Psoriatic arthritis : 10%?25% of patients

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Case 1: 21 year old

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History & Cutaneous examination

History

Site

Duration

Type of lesions

Morphology

? Extensors

Seasonal variation

? Primary

Colour

? Knees

Joint pain

? Elbows

? Papules

? Erythematous

Sore throat

? Trunk

? Plaques

? Hyperpigmented

Stress

? Scalp

? Secondary lesion

? Size

Alchohol

? Palms

? Scales

? Margin

Smoking

? Soles

HIV

? Flexures

? Well defined

? Nails

Nails

? Consistency

Systemic illness

Palms

? Indurated

Prior treatment

Soles
Scalp

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Mucosa
CHRONIC

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

PLAQUE-

surmounted by `silvery white', micaceous scales

TYPE

PSORIASIS

Monomorphic and distributed relatively

symmetrically

?Clues to diagnosis

Extensor surfaces of the limbs. over scalp, trunk

Nail findings

Auspitz sign positive

HPE

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Grattage test & Auspitz sign

? Auspitz sign: Heinrich Auspitz (1835-86)

? 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

test positive). Scrape off all the scales

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

(Burkley's membrane) appears

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

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HPE chronic plaque psoriasis

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

Hyperkeratosis,

parakeratosis

"squaredoff"rete ridges,

Dilated capil ary loops

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Koebner phenomenon (isomorphic response)

? traumatic induction of psoriasis on

nonlesional skin

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

occurs at one site of injury it will occur at

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

Chronic Plaque psoriasis

Site based

Acute guttate psoriasis

`Unstable' psoriasis

Erythrodermic psoriasis

Scalp psoriasis

Pustular psoriasis

Follicular psoriasis

Atypical psoriasis

Sebopsoriasis

Other specified forms

Flexural/inverse psoriasis

Genital psoriasis

Linear and segmental

Verrucous

Nonpustular palmoplantar

psoriasis

Elephanthine

Nail psoriasis

Rupoid

Psoriasis in childhood, old

Ostraceous

Mucosal lesions

age

Ocular lesions

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

erythroderma

H/O withdrawal of drugs

Typical psoriatic plaques

? Clues to diagnosis

Management options

Large lamellar scales

Nail changes (oil-drop, pits, onycholysis)

Acitretin

Cyclosporine A

PUVA, NB-UVB

Arthritis

Methotrexate

Anti-TNF agents

HPE typical changes of psoriasis

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Pustular psoriasis classification

Generalized

Localized

1. Acute generalized (von Zumbusch).

1. Palmoplantar pustulosis.

2. Subacute annular and circinate

2. Acrodermatitis continua of

Hallopeau

? Acute generalized pustular psoriasis of pregnancy

(GPPP or impetigo herpetiformis).

? Infantile and juvenile generalized pustular

Corticosteroids

psoriasis.

withdrawal

Coal tar

Infection

Pregnancy

Triggering factors

Stress

Hypocalcaemia 14




Case 4: 54 year old man

Case 3: 54 year old man

Acute generalized (von Zumbusch).

Abrupt onset, high fever, malaise, burning in skin

Fiery-red erythema topped by pinpoint sterile yellow

pustules

Deleterious

Waves of fever and pustulation

germline



Coalescing lesions > "lakes" of pus

mutations

in IL36RN

Leukocytosis, elevated ESR or CRP, plasma albumin, calcium

low.

Kogoj's spongiform pustules on HPE

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last trimester of pregnancy

GPPP

persist upto childbirth maybe beyond

recurs in subsequent pregnancies

usually starts in the inguinogenital region

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

Complications

Acanthotic epidermis

Hypocalcemia

with Psoriasiform blunted rete ridges

Bacterial superinfection

Sepsis

Dehydration

Neutrophils

ARDS

infiltrating into

epidermis

Management

Etretinate

Methotrexate

Cyclosporine

Infliximab

+ oral corticosteroids in GPPP

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Palmoplantar Pustulosis

Acrodermatitis continua of Hal opeau

? Chronic relapsing eruption limited to

? acral pustule formation,

palms and soles.

?

?

subungual lakes of pus

Numerous sterile, yel ow, deep-seated

pustules that evolve into dusky-red

? destruction of nail plates.

crusts.

? permanent loss of nails and scarring.

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Guttate

Unstable

psoriasis

psoriasis

Rule out

H/o

Eruptive LP

withdrawal of systemic or

P rosea

potent topical steroids,

PLC

tar or dithranol,

Secondary syphilis

Acute infection
hypocalcaemia
severe emotional upset

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Scalp psoriasis

Flexural psoriasis

d/d Seborrheic dermatitis

d/d

Tinea, candidiasis, intertrigo

Greasy yellowish scales

Seborrheic dermatitis

Does not extend beyond hairline

Langerhans cell histiocytosis

Hailey-Hailey disease

Ill defined areas of involment

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Nonpustular palmoplantar psoriasis

Topical PUVA

Coal tar + Steroid

Acitretin Methotrexate

Recalcitrant PPP ?

etanercept

Dd hyperkeratotic eczema



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Nail involvement increases with

Nail psoriasis

Age

Duration

Extent

Ps arthritis

Diagnostic techniques

Dermoscopy

Videodermoscopy

Capil aroscopy

Ultrasound

Optical coherence tomography

Confocal laser scanning

microscopy (CLSM)

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PITS

?psoriatic suspected
? > 20 fingernail pits per person
? >60 total pits per person

?Length of pit ?
length of time, matrix was affected
?Depth of pit
involvement of intermediate + ventral

matrix + dorsal matrix

proximal nail

matrix

psoriasis>>>

parakeratotic

cel s in nail plate

>>> sloughed off

>>> 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

.



focal nail bed

parakeratosis >>

focal onycholysis >>

serum and cel ular

debris accumulate and

become entrapped

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

? Nonalcoholic fatty liver disease

? Chronic obstructive pulmonary

disease

? Obstructive sleep apnea

? Bone disease

? Parkinsonism

? Psychosocial effect

? Psychiatric disorders

? Alcohol abuse

? Smoking

? Migraine

Higher disease severity

and younger at diagnosis

have a higher risk

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Will it work?????

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Mild plaque psoriasis <10% BSA

without psoriatic arthritis

CONTRAINDICATIONS FOR COAL TAR

FIRST LINE

Coal tar

? Unstable plaque psoriasis in a

Dithranol

phase of progression

Calcipotriol

? Pustular psoriasis

Potent steroid

? Erythrodermic psoriasis

Salicylic acid

Tazorotene

SECOND LINE

Local NB-UBV or PUVA

Excimer laser

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Moderate to severe plaque psoriasis without

psoriatic arthritis

FIRST LINE

NB-UBV or PUVA

SECOND LINE

Acetretin

Apremilast

Ciclosporin

Methotrexate

THIRD LINE

Biologicals

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Moderate to severe plaque psoriasis with

psoriatic arthritis

FIRST LINE

Apremilast

Methotrexate

SECOND LINE

Biologicals

THIRD LINE

Combination therapy

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Thank you

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This post was last modified on 07 April 2022