Transcript Chronic plaque psoriasis?

Case report
The dermatology department of
Second Affiliated Hospital of
Kunming Medical University
Chief complaint
※Male，40-year-old
※Erythematous papules and scales on
elbows for 15 years
※Generalized itch
※Worsening over past 1 year
Present illness
※no obvious inciting trigger
no fever,no arthralgia and pustules
tried 'Piyanping' without relief
※developed red plaques on scalp and over
the body, associated with thick scales and
generalized itch
Present illness
※sought treatment at local hospital with resolution
of symptoms
recurrence of symptoms after cessation of
some drugs treatment
※ patient sought help at our hospital then.
patient denies loss of appetite and significant
weight loss.
Systemic examination:The life signs were
normal.The heart and lung、abdomen
examination were nomal.
Past history
※No diabetes and hypertension.
No history of contacting epidemic area ,situation
and diseases .
No history of food and drug allergy.
No past surgical history .
No recent travel history.
He had smoken about 20 years but no drinken.
Special examination
※Erythematous scales on trunk, limbs
plaques with white scales
irregular borders
polymorphic
nail pits
※absence of pustules
no joint swelling
no onycholysis
Clinical Differential Diagnosis
※seborrheic dermatitis
※pityriasis rosea
※planus lichen
※eczema
※Tinea corporis
※Lupus erythernatosus
※psoriasiform syphilis
Seborrheic dermatitis of the scalp:Diffuse
erythema and scaling of the scalp.
pityriasis rosea
Tinea corporis:Annular plaque with
scale on the extremity.
Laboratory test results
※blood count: PLT:64X10~9/L;total white
count,Hemoglobin etc are normol
※Biochemistry:ALB:34.6g/L;GGT:174U/L ALT
AST,Hepatitis B serology etc are normol
※Electrocardiogram: sinus rhythm, right
axis deviation
※Ultrasound of the liver and spleen etc are
normol.
Diagnosis
psoriasis vulgaris
(Chronic plaque psoriasis?)
※Psoriasis is a common, chronic, and recurrent
inflammatory disease of the skin charactenzed
by circumscribed, erythematous, dry, scaling
plaques of various sizes.The lesions are
usually covered by silvery white lamellar scale.
Epidemiology
The prevalence of psoriasis in
adults ranged from 0.91 to 8.5 percent,
and the prevalence of the disease in children ranged
from 0 to 2.1percent.
Geographic location appeared to influence the
likelihood of having psoriasis,disease prevalence
tended to increase with increasing distance from the
equator.
Although psoriasis can begin at any age, the
disease is less common in children than adults.
There seem to be two peaks for the age of onset
:one between the ages of 30 and 39 years and
another between the ages of 50 and 69 years.
The onset of psoriasis is at a mean age of 27
years, but the range is wide, from the neonatal
period to the 70s. Severe emotional stress tends
to aggravate psoriasis in almost half of those
studied
Etiology and pathogenesis
※The exact causes of psoriasis is not yet clear.
Now that psoriasis is genetic factors and
environmenta factors and other factors of
interaction between the complex genetic
diseases.
（1）heritability:
Patients with psoriasis often have relatives with
the disease, and the incidence typically
increases in successive generations.
Multifactorial inheritance is likely.
(2) environmental:
Only genetic factor is not enough to cause
disease, environmental factors played an
important role in inducing and aggravating
psoriasis.
Can trigger or worsen factors in patients with
psoriasis, mental tension and stress events,
trauma, infection, surgery, such as pregnancy,
smoking, and some drugs, including infection
was thought to be the important factors that
contributed to or aggravate psoriasis.
(3) Immune factors:
T-cells and cytokines play pivotal roles in the
pathophysiology of psoriasis. Overexpression of
type 1 cytokines，such as IL-2, IL-6, IL-8, IL-12,
IFN-r and TNF-ɑ, has been demonstrated, and
overexpression of IL-8 leads to the
accumulation of neutrophils.
Clinical manifestatations
Psoriasis occurs in a variety of clinical forms. The
major clinical categories include:
※Chronic plaque psoriasis
※Guttate psoriasis
※Pustular psoriasis
※Erythrodermic psoriasis
※Inverse psoriasis
※Nail psoriasis
(1) Chronic plaque psoriasis
Chronic plaque psoriasis is the most common variant of p
soriasis.Patients with chronic plaque type psoriasis usu
ally present with symmetrically distributed cutaneous pl
aques.The scalp, extensor elbows, knees, and back ar
e common sites for involvement.
The extent of involvement can rang from limited localized
disease to involvement of the majority of the body surfa
ce area. Involvement of intertriginous areas (inverse ps
oriasis), the ear canal,umbilicus, palms,soles,ornails al
so may be present.
The plaques are erythematous with sharply defi
ned margins that are raised above the surroundi
ng normal.
The Koebner phenomenon,which describes the
development of skin disease in sites of skin trau
ma,may
occur in patients with chronic plaque psoriasis.
Chronic plaque psoriasis:Multiple large plaques
with silver scale on the back.
(2) Guttate psoriasis
Guttate psoriasis is characterized by the abrupt
appearance of multiple small psoriatic
papules and plaques . The papules and plaques
of guttate psoriasis are usually less than 1 cm
in diameter (giving rise to the name guttate, whic
h means droplike). The trunk and proximal extremities are
the primary sites of involvement.
Guttate psoriasis typically occurs as an acute er
uption in a child or young adult with no previous
history of psoriasis.
Less commonly, a guttate psoriatic flare occurs i
n a patient with preexisting psoriasis. There is a
strong association between recent streptococcal
infection (usually pharyngitis) and guttate
psoriasis
Guttate psoriasis:Numerous erythematous, scaly
papules are present in this patient with guttate
psoriasis.
（3）Pustular psoriasis：
Reported causes of pustular psoriasis include pre
gnancy (impetigo herpetiformis), infection, and t
he withdrawal of oral glucocorticoids.
Pustular psoriasis is a form of psoriasis that can h
ave lifethreatening complications.
The most severe variant (the von Zumbusch type
of generalized pustular psoriasis) presents with
the acuteonset of widespread erythema, scaling,
and sheets of superficial pustules .
This form ofpsoriasis can be associated with mala
ise, fever, diarrhea, leukocytosis, and hypocalce
mia. Renal, hepatic,or respiratory abnormalities
and sepsis are potential complication.
Pustular psoriasis:Widespread erythematous
patches, desquamation, and pustules in pustular
psoriasis.
(4) Erythrodermic psoriasis
Erythrodermic psoriasis is an uncommon m
anifestation that may be acute or
chronic. It is characterized by generalized
erythema and scaling from head to toe .
Patients are at high risk for complications
related to loss of adequate barrier protectio
n such as infection(including sepsis) and
electrolyte abnormalities secondary to fluid
loss. Inpatient management involving
a dermatologist is frequently necessary.
Erythrodermic psoriasis:Diffuse erythema and
scale on the skin of a patient with erythrodermic
psoriasis.
(5) Inverse psoriasis
"Inverse psoriasis" refers to a presentation involving the intertriginous areas, including the inguinal, perineal, genital, intergluteal, axillary, or inframammary regions .
This presentation is called "inverse" since it is th
e reverse of the typical presentation on extenso
r surfaces. Thisvariant can easily be misdiagno
s-ed as a fungal or bacterial infection since ther
e is frequently no visible scaling.
Inverse psoriasis:Shiny, erythematous, well-
demarcated plaques in the axilla.
（6）Nail psoriasis
The prevalence of nail changes in psoriasis is
uncertain . Estimates of the prevalence of nail
psoriasis among individuals with psoriasis have
ranged from 10 to 81 percent, with an estimated
life time incidence ranging from 80 to 90
percent.
Nail psoriasis is most often noted after the onset
of cutaneous disease, but also may occur
concurrently or prior to the onset of cutaneous
psoriasis . Nail involvement may be the only
manifestation of psoriasis in 1 to 10 percent of
patients.
Nail pits in psoriasis:Numerous pits are present
on the nail of this patient with psoriasis.
Pathology
※HistoIogicalIy, all psoriasis is pustular. The
microscopic pustules include spongiform
intraepidermal pustules, and Munro
microabscesses within the stratum corneum.
※In early guttate lesions, focal parakeratosis is
noted withln the stratum corneum.
※The granular layer is absent focally,
corresponding to areas producing foci of
parakeratosis. In well-developed plaques,
there is regular epidermal acanthosis with
long,bulbous rete ridges, thinning over the
dermal papillae, and dilated capillaries within the
dermal papillae. The last two findings correlate
with the Ausprtz sign.
※The stratum corneum may be entirely
parakeratotic but still shows multiple small
neutrophilic microabscesses at varying levels.
※Spongiosis is typically scant except in the area
immediately surrounding collections of
neutrophils.
Treatment
Nonpharmacologic Therapy
•Sunbathing generally leads to improvement.
•Eliminate triggering factors (e.g., stress,
certain medications [e.g., lithium, betablockers, antimalarials]).
•Patients with psoriasis benefit from a daily
bath in warm water followed by application
of a cream or ointment moisturizer. Regular
use of an emollient moisturizer limits
evaporation of water from the skin and
allows the stratum corneum to rehydrate
itself.
General Rx
Therapeutic options vary according to the extent
of disease. Approximately 70% to 80% of all
patients can be treated adequately with topical
therapy.
•Patients with limited disease (<20% of the body)
can be treated with the following:
1.Topical steroids: disadvantages are brief
remissions, expense, and decreased effect
with continued use. Salicylic acid can be
compounded by pharmacist in concentrations
of 2% to 10% and used in combination with a
corticosteroid to decrease the amount of
scale.
2.Calcipotriene: a vitamin D analogue effective for
moderate plaque psoriasis. Adults should comb
the hair, apply solution to the lesions, and rub it
in, avoiding uninvolved skin. Disadvantages
include its cost and potential burning and skin
irritation. It should not be used concurrently with
salicylic acid because calcipotriene is
inactivated by the acidic nature of salicylic acid.
3.Tar products (Estar, LCD, Psorigel) can be used
overnight and are most effective when combined with
ultraviolet B (UVB) light (Goeckerman regimen).
4.Anthralin: useful for chronic plaques; can result in
purple-brown staining; best used with UVB light.
5.Retinoids such as tazarotene 0.05%, 0.1% cream or
gel, are effective in thinning plaques but are expensive
and can cause irritation.
6.Other useful measures include tape or occlusive
dressing, UVB and lubricating agents, and interlesional
steroids.
Therapeutic options for persons with
generalized disease (affecting >20% of the
body) and for those with inadequate
response to topical agents:
1.UVB light exposure three times a week: this
therapy does not require administration of a
systemic drug (unlike psoralen plus ultraviolet
A [PUVA])，but to be effective, it requires
removal of scale with keratolytic agents and
emollients.
2.Oral PUVA administered two to three times
weekly is effective for generalized disease. It is
often considered in patients for whom narrowband UVB therapy is ineffective. However, many
PUVA treatments are required, necessitating
frequent office visits, and it may be associated
with phototoxicity, such as erythema and
blistering, and increased risk of skin cancer.
•Systemic treatments include methotrexate 25
mg/wk for severe psoriasis. Etretinate (a
synthetic retinoid) is most effective for palmarplantar pustular psoriasis. Dose is 0.5 to 1
mg/kg/day. It can cause liver enzyme and lipid
abnormalities and is teratogenic.
·Cyclosporine is also effective in severe psoriasis;
however, relapses are common.
3.TNF inhibitors: Treatment with etanercept, a
tumor necrosis factor (TNF) antagonist, for
24 wk can also lead to a reduction in
severity of plaque psoriasis. Efalizumab, a
humanized monoclonal antibody that
inhibits the activation of T cells, has also
been reported to produce significant
improvement in plaque psoriasis treatment
period. Adalimumab—a fully human, antiTNF-alpha monoclonal antibody—has been
reported to be effective for joint and skin
manifestations of psoriasis.
Newer biologic agents in patients with
moderate to severe plaque psoriasis are
ustekinumab (an interleukin-12 and
interleukin-23 blocker), brodalumab, an
anti–interleukin-17 receptor antibody, and
briakinumab, a monoclonal antibody against
the p40 molecule shared by interleukin-12
and interleukin-23, which is overexpressed
in psoriatic skin lesions. Trials have shown
efficacy in the treatment of moderate-tosevere psoriasis.
Disposition
The course of psoriasis is chronic, and the
disease may be refractory to treatment.
Referral
•Dermatology referral is recommended in all
patients with generalized disease.
•Hospital admission may be necessary for severe
diffuse or poorly responsive psoriasis. The
Goeckerman regimen combines daily
application of tar with UVB exposure and can
result in prolonged remissions.
Thank you !
keywords
antimalarials 抗疟药
emollient [ɪ'mɒlɪənt] 润肤剂；软化剂
evaporation [ɪ,væpə'reɪʃən] n. 蒸发；消失
rehydrate [,riːhaɪ'dreɪt] vt. 再水化
Salicylic acid [,sælə'sɪlɪk]水杨酸；柳酸
Calcipotriene卡泊三醇
analogue ['ænəlɒg] n. 类似物；
concurrently [kən'kɝəntli] adv. 兼；同时发生地
Anthralin['ænθrəlin]n. 地蒽酚；蒽林
occlusive [ə'klu:siv, ɔ-] adj. 咬合的；闭塞
lubricating ['lʊbrɪ,ket] vi. 润滑；
psoralen['psɔrəlɪn] n. 补骨脂素
keywords
keratolytic[,kerə'tɒlɪtɪk] adj. 角质层分离的，促成
脱皮的
emollients [ɪ'mɒlɪənt] n. [药] 润肤剂；软化剂
necessitating [ni'sesiteitiŋ] v. 迫使（necessitate
的ing形式）
etretinate阿维A酯
teratogenic [,terətəu'dʒenik] adj. 产生畸形的；
畸形形成的
etanercept依那西普
antagonist [æn'tæg(ə)nɪst] [生化] 拮抗物
refractory [rɪ'frækt(ə)rɪ] adj. 难治的；难熔的；
不听话的