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