? A 50-year-old male patient
? Presents with a history of skin lesions x 34 years
? Red, itchy, scaly, lesions present all over the body & head
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? Lesions increase in summer but improve in winter? No joint pains
? On clinical examination: BSA: 15% apprx.; Erythematous, scaly,
sharply demarcated, plaques, present particularly over the extensor
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surfaces & scalp
? Palms & soles: largely spared
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D/D & D
? Type 1 hereditary, strongly HLA associated (particularly HLACw6),
early onset & more likely to be severe
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? Type 2 sporadic, HLA unrelated, of late onset & often mild
How to Quantify involvement
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PASI
? PASI ? 10
? Moderate
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Tests / Sign? Grattage test - Scales in a psoriatic plaque can be accentuated by
grating with a glass slide
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? Auspitz sign- 3 steps
? Step A: Gently scrape lesion with a glass slide - This accentuates the
silvery scales (Grattage test positive). Scrape off all the scales
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? Step B: Continue to scrape the lesion ? A glistening white adherent
membrane (Burkley's membrane) appears
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? Step C: On removing the membrane, punctate bleeding pointsbecome visible - positive Auspitz sign
How to treat this patient
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? Systemic antibiotics in psoriasis? Anti-Streptococcus medications ? may clear guttate attacks
? Diet in Psoriasis
? No clear evidence for / against oral zinc, fish oils, omega-3 fatty acids,
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turkey meat or diets low in tryptophan, protein or calories
? Some studies demonstrate celiac diseases associated-antibodies ?
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elimination of wheat from diet may bring long-term remissions? Treatment options
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Topical therapy
? Emollients - prevent & treat xerosis, decrease scaling
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? Moisturizing agents - cream bases, coconut / olive oil, white softparaffin & liquid paraffin mixtures etc.
Investigations
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? Systemic therapy? Why
? Initiation of systemic therapy - a shared decision between the patient
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& the clinician? Careful consideration of risk?benefit profiles of available treatments
? In general, systemic treatment indicated for - extensive disease not
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responsive to topical therapy or phototherapy; erythroderma;pustular psoriasis; psoriatic arthritis
? Impact of disease ? patient may opt for earlier systemic treatment
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? Logistics - e.g., inability to attend for regular phototherapy? Investigations:
? CBCs with ESR & PBF
? LFTs, RFTs, FBS/RBS, HBA1c, Urine R/E, M/E
? HBsAg, HCV, HIV-1 & 2
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? CXR-PA? Other investigations
Systemic Steroids
? When systemic steroid is given for 1st time, clearance of psoriasis is
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rapid but the disease eventually `breaks through', necessitating
progressive increases in dosage, with incidence of side effects
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? If withdrawal is attempted, psoriasis tends to relapse promptly & may`rebound'
? `Rebound' may take the form of widespread, eruptive psoriasis,
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erythrodermic psoriasis or generalized pustular psoriasis
? Systemic steroids should NEVER be used in the routine care of
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psoriasis? Psoriasis may remain labile & treatment resistant for many months
after the withdrawal
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? Oral or parenteral corticosteroids should generally be avoided? Used only when urgent control of complications is needed (e.g., acute
respiratory distress syndrome)
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? Or when other drugs are contraindicated for instance in pregnancy
? Shortterm effects of prednisolone (30?40 mg/day) may be good but
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serious relapses are liable to occur as the dosage is reduced unlessanother form of therapy (e.g., acitretin, TNFi) is given simultaneously
Counselling
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? Psoriasis ? a treatable but incurable disease? `Psoriasis is at all times and under all forms a very troublesome and,
often, an intractable disease, but it is rarely dangerous to life'?
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Wilson, 1842? `It is impossible to say, in any particular case, how long the disease
will last, whether a relapse will occur, or for what period of time the
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patient will remain free from psoriasis'? Hebra, 1868
? Patients' counseling ? paramount
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Papulosquamous Diseases? Psoriasis
? Pityriasis rosea
? Lichen planus
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? Erythroderma? Pityriasis lichenoides
? Pityriasis rubra pilaris
? Parapsoriasis
Erythroderma
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? Erythroderma is a morphological diagnosis characterized by
generalized erythema and scaling
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? Diffuse erythema and scaling of the skin involving more than 90% ofthe total body skin surface area
? Erythroderma is the term applied to any inflammatory skin disease
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that affects more than 90% of the body surface
Thank You
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