Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Dermatology PPT 1 Pbl Papulosquamous Diseases Lecture Notes
PBL ? Papulosquamous
Diseases
The Problem
? 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
? 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
surfaces & scalp
? Palms & soles: largely spared
D/D & D
? Type 1 hereditary, strongly HLA associated (particularly HLACw6),
early onset & more likely to be severe
? Type 2 sporadic, HLA unrelated, of late onset & often mild
How to Quantify involvement
PASI
? PASI ? 10
? Moderate
Tests / Sign
? Grattage test - Scales in a psoriatic plaque can be accentuated by
grating with a glass slide
? 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
? Step B: Continue to scrape the lesion ? A glistening white adherent
membrane (Burkley's membrane) appears
? Step C: On removing the membrane, punctate bleeding points
become visible - positive Auspitz sign
How to treat this patient
? 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,
turkey meat or diets low in tryptophan, protein or calories
? Some studies demonstrate celiac diseases associated-antibodies ?
elimination of wheat from diet may bring long-term remissions
? Treatment options
Topical therapy
? Emollients - prevent & treat xerosis, decrease scaling
? Moisturizing agents - cream bases, coconut / olive oil, white soft
paraffin & liquid paraffin mixtures etc.
Investigations
? Systemic therapy
? Why
? Initiation of systemic therapy - a shared decision between the patient
& the clinician
? Careful consideration of risk?benefit profiles of available treatments
? In general, systemic treatment indicated for - extensive disease not
responsive to topical therapy or phototherapy; erythroderma;
pustular psoriasis; psoriatic arthritis
? Impact of disease ? patient may opt for earlier systemic treatment
? 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
? CXR-PA
? Other investigations
Systemic Steroids
? When systemic steroid is given for 1st time, clearance of psoriasis is
rapid but the disease eventually `breaks through', necessitating
progressive increases in dosage, with incidence of side effects
? If withdrawal is attempted, psoriasis tends to relapse promptly & may
`rebound'
? `Rebound' may take the form of widespread, eruptive psoriasis,
erythrodermic psoriasis or generalized pustular psoriasis
? Systemic steroids should NEVER be used in the routine care of
psoriasis
? Psoriasis may remain labile & treatment resistant for many months
after the withdrawal
? Oral or parenteral corticosteroids should generally be avoided
? Used only when urgent control of complications is needed (e.g., acute
respiratory distress syndrome)
? Or when other drugs are contraindicated for instance in pregnancy
? Shortterm effects of prednisolone (30?40 mg/day) may be good but
serious relapses are liable to occur as the dosage is reduced unless
another form of therapy (e.g., acitretin, TNFi) is given simultaneously
Counselling
? 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'?
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
patient will remain free from psoriasis'? Hebra, 1868
? Patients' counseling ? paramount
Papulosquamous Diseases
? Psoriasis
? Pityriasis rosea
? Lichen planus
? Erythroderma
? Pityriasis lichenoides
? Pityriasis rubra pilaris
? Parapsoriasis
Erythroderma
? Erythroderma is a morphological diagnosis characterized by
generalized erythema and scaling
? Diffuse erythema and scaling of the skin involving more than 90% of
the total body skin surface area
? Erythroderma is the term applied to any inflammatory skin disease
that affects more than 90% of the body surface
Thank You
This post was last modified on 07 April 2022