Transcript Psoriasis

ECZEMAS
Cecilia T. Roxas-Rosete, FPDS
Consultant, Section of Dermatology
The Medical City Hospital
ECZEMA
-Inflammatory
-Greek
Skin Disorder
word ek – zeo “to boil or
bubble over”
Erythema
Papules
Vesicles
Pustules
Oozing
Crusts
Scales
Regression
Progression
Healing
Chronic eczema
Acute Eczema
Series 2007
A PEODG and SP Dermatology Exclusive
Chronic Eczema
Series 2007
A PEODG and SP Dermatology Exclusive
EPIDEMIOLOGY



Atopic dermatitis (AD) is a chronically
relapsing skin disorder that arises
most commonly during early infancy,
childhood or adolescence
Usually begins before age 6 months
Remits spontaneously in 65% of
affected children before age 10 years
EPIDEMIOLOGY:
1)
2)
3)
STAGES
Infantile – 2 months to 2
yrs.
Childhood – 2 to 10 yrs.
Adulthood
ETIOLOGY &
PATHOGENESIS

Unknown

Triggered by an interplay of factors
1. Genetic
2. Immunologic
3. Environmental
Hanifin &Rajka’s Diagnostic Criteria
for Atopic Dermatitis
Must have > 3 major criteria & > 3
minor criteria
Major Criteria:




Pruritus
Personal or family history of atopic disorders
(asthma, atopic eczema, allergic rhinitis)
Chronic or chronically relapsing course
Typical distribution and morphology
> infants: facial and extensor involvement
> children & adults: flexural lichenification
and linearity
Hanifin & Rajka’s Diagnostic Criteria
for Atopic Dermatitis
Minor Criteria:







Xerosis
Icthyosis/keratosis pilaris/palmar hyperlinearity
Type I skin test reactivity
Elevated serum IgE
Early age at onset
Tendency to skin infection (Staph aureus & HS
I)
Hand / foot dermatitis
Hanifin & Rajka’s Diagnostic
Criteria for Atopic Dermatitis
Minor Criteria:





Nipple eczema
Cheilitis / conjunctivitis / keratoconus / ant.
subscapular cataracts
Dennie-Morgan fold
Orbital darkening
Pityriasis alba
Hanifin & Rajka’s Diagnostic
Criteria for Atopic Dermatitis
Minor Criteria:






Itch when sweating
Intolerance to wool and lipid solvents
Food intolerance
Perifollicular accentuation
White dermographism / delayed blanching
Course influenced by
environmental/emotional factors
Triggering Factors in Atopic
Dermatitis







Contact irritants and allergens
Aeroallergens – house dust mites,pollens
and molds
Foods – egg, milk, peanuts, fish, wheat and
shellfish
Microbial organisms – Staph. aureus, URTI,
Candida
Hormones
Stress
Climate
SEBORRHEIC
DERMATITIS






common chronic skin disorder
infants / adults
often assoc with increased sebum
production (seborrhea) of face & scalp
2-5% of the population
affects males > females
often assoc with HIV (85%),
parkinsonism
Etiology – Inflammatory Rx to yeast
(Pityrosporum Ovale)
Sites: Face, ears, scalp, upper trunk
Infants – Cradle Cap
Adults – Dandruff (scalp, eyebrows)
Skin: “greasy” yellowish scales on a red
base
Seborrheic
Dermatitis
Nummular Eczema




discrete coin-shaped pruritic lesion
erythematous, vesicular, crusted
patches
assoc with emotional stress
sites – legs, arms, dorsum of hands
Dyshidrotic
eczema
Lichen simplex
chronicus
CONTACT DERMATITIS




Any pruritic skin disorder that results
when a particular substance comes in
contact with the skin
Inflammation of the skin with
spongiosis or intercellular edema of the
epidermis
A common cause of occupational
disability
A form of extrinsic eczema
Contact Dermatitis:
Prevalence




General population: 1.5% - 5.4%
Important cause of disability in
occupational and personal life
Accounts for about 20% of all
dermatological consultations
Accounts for majority of all occupational
skin diseases
2 Types (Contact
Dermatitis)
1.
Irritant CD – Skin reaction resulting from
exposure to an offending agent.
- immediate Rx
- Acids, alkali, detergents
2. Allergic CD – results from repeated
exposure to an allergen or compound due
to DELAYED hypersensitivity RX
- 7-10 days
IRRITANT CONTACT
DERMATITIS




Severity of the reaction is related to the
amount and duration of exposure to the
irritant.
Most cases are acute in onset - symptoms
develop within seconds of exposure.
Prolonged exposure to a low-level irritant
(soap, water) can lead to chronic ICD.
Most common site: hand.
Irritant Contact Dermatitis:
Mild Irritant (Acute)
Irritant Contact Dermatitis:
Mild Irritant (Chronic)
Irritant Contact Dermatitis:
Strong irritant
ALLERGIC CONTACT
DERMATITIS (ACD)
 Due
to repeated exposure
to a substance to which the
individual is sensitized
 A cell-mediated type IV
delayed hypersensitivity
reaction






Series 2007
Application of contact allergens (Ag)
Release of cytokines by keratinocytes,
Langerhans cells and other cells within
the skin
Cytokines activate Langerhans cells
which uptake the antigen and emigrate
into the regional lymph nodes
During this process, the Langerhans
cells mature into dendritic cells; the
antigen is processed, re-expressed on
the surface and finally presented to
naïve T cells in the regional lymph
node
Upon appropriate antigen
presentation, T cells bearing the
appropriate T cell receptor clonally
expand and become effector T cells.
Effector T cells recirculate into the
periphery where they may later meet
the antigen again.
A PEODG and SP Dermatology Exclusive
Common Allergens In the
General Population
1.
2.
3.
4.
5.
NACDG 1998
Nickel
Fragrances
Neomycin
Balsam of Peru
Thimerosal
1.
2.
3.
4.
5.
PCDSG 2000
Nickel
Potassium
Dichromate
Fragrance Mix
Cobalt
Paraben Mix
ACD: Nickel
ACD: Nickel
ACD: Nickel
ACD: Fragrance
ACD: Colorant in Toothpaste
ACD: Fragrance in Deodorant
Common Occupational
Allergens







Rubber accelerating chemicals (thiuram)
Biocides (formaldehydes)
Hairdressing chemicals
Resin – acrylates
Chromates
Plant allergens
Latex
ACD: Rubber
ACD due to contact with acrylates
Series 2007
A PEODG and SP Dermatology Exclusive
ACD: Chromate
Patch Test


Only objective diagnostic tool for the
definitive diagnosis of allergic contact
dermatitis
May aid in differentiating ACD from
ICD
Patch Test: Technique
1.
Test substances appropriately
diluted. Standardized kits
available.
Some Common Allergens Used
in Patch Testing






Nickel - Jewelry
Balsam of Peru - Perfumes, citrus fruits
Dichromate - Cement, leather, matches
Paraphenylenediamine - Hair dyes, clothing
Rubber chemicals - Shoes, clothing, gloves
Colophony - Sticking plasters
Some Common Allergens Used
in Patch Testing






Benzocaine - Topical anaesthetics
Neomycin - Topical medicaments
Parabens - Preservatives in cosmetics,
creams
Epoxy resins - Glues
Formaldehyde - Clothing, cosmetics, paper
Wool alcohol - Lanolin, cosmetics, creams
Patch Test: Technique
2. Apply the patch to the upper or mid back.
Leave the patch in place and keep dry for
2 days before removing.
Patch Test: Technique
3. Read tests:
– a) The same day that patches are
removed
– b) One additional reading 3, 4, or 7
days after test initially applied
Patch Test: Technique
4.
Grade test reactions according to
intensity:
0 = no reaction
doubtful = minimal erythema
(+) = erythema w/ papules
(++) = erythema,papules,vesicles
(+++) = erythema, bullae
(++) REACTION
(+++) REACTION
Patch Test: Technique
5. Relate relevance of positive reactions
to clinical dermatitis cautiously. Careful
history and review of skin exposures
must establish significance
Photocontact eczema




Require exposure to sunlight following
topical application of certain chemicals
Long wave UVA – action spectrum
Topical photosensitizers – PPD in hair dyes,
PABA esters in sunscreening agents,
halogenated salicylates in soaps and
cosmetics & topical sulfonamides
Topical photoirritants – psoralens in
perfumes
PSORIASIS
Cecilia Roxas-Rosete, MD, FPDS
Consultant, Section of Dermatology
The Medical City Hospital
Psoriasis
EPIDEMIOLOGY
 Age of onset: 20 to 50 y/o
 Sex: M=F
 Heredity: Polygenic
 Pathogenesis: Alteration of the cell
kinetics of keratinocytes
Psoriasis
PHYSICAL FINDINGS
Psoriasis Vulgaris
 Most common
 Erythematous welldefined papules &
plaques with large
amounts of silvery
white scales
 Sites: scalp,
elbows,knees, lumbar
area
Psoriasis
Psoriasis
Auspitz Sign
Psoriasis
Psoriasis
Psoriasis
Psoriasis
Psoriasis
Psoriasis
Physical Findings
Eruptive (Guttate)
Psoriasis
 0.5cm-1.0cm lesions
 Young adults
 Streptococcal throat
infection
Psoriasis
PHYSICAL FINDINGS
Psoriasis geographica
 ‘land map”
Psoriasis
PHYSICAL FINDINGS
Annular Psoriasis
 Partial central clearing
resulting in ring-like
lesions
Psoriasis
PHYSICAL FINDINGS
Psoriasis inversa
 Flexural psoriasis
 Localized in skin folds
Psoriasis
PHYSICAL FINDINGS
Psoriatic Erythroderma
(Exfoliative Dermatitis)
 All body sites
 Prominent erythema
 May represent
generalized Koebner’s
phenomenon
Psoriasis
PHYSICAL FINDINGS
Pustular Psoriasis
 Pustular psoriasis of
von Zumbusch
 Pus are sterile
Psoriasis
TRIGGER FACTORS
A. Physical trauma: Koebner’s
Phenomenon
 various traumatic insult to skin
 30%-50% of psoriasis patients give
history of koebner’s
Psoriasis
Koebner’s Phenomenon
Psoriasis
TRIGGER FACTORS
B. Infection
 15%-76% report history of infection
 E.g. Streptococcal throat infection
- guttate psoriasis
HIV
- 2.5% develop psoriasis
Psoriasis
TRIGGER FACTORS
C. Stress
 30%-40% adult cases
 90% in children
Psoriasis
TRIGGER FACTORS
D. Drugs
 Corticosteroids – may cause flare-ups
 Lithium
 Beta-Adrenergic blockers, ACE
inhibitors
 Anitmalarials
 Aspirin
Psoriasis
SYSTEMIC ASSOCIATIONS
Psoriatic arthropathy is the only
recognized non-cutaneous
manifestation
 Classified as one of the seronegative
spondyloarthropathies

Psoriasis
SYSTEMIC ASSOCIATIONS
 Psoriatic Arthritis
Psoriasis
SYSTEMIC ASSOCIATIONS
 Arthritis mutilans – 5%
Psoriasis
SYSTEMIC ASSOCIATIONS
Genetically determined autoimmune
disease – 5%-8%
 (+) HLA-B27 linkage in 20% of
psoriatic arthropathies

frequency of ulcerative colitis in
psoriasis patients

Psoriasis
SYSTEMIC ASSOCIATIONS
 Metabolic syndrome:
> heart disease (high blood pressure)
> stroke
> diabetes (insulin resistance)
> excessive body fat around waist
(obesity)
> dyslipidemia ( low HDL,
high triglyceride)
THANK
YOU