Transcript File

Psoriasis
• Psoriasis is a non-infectious, chronic
inflammatory disease of skin, characterized by
well defined erythematous plaques with silvery
scale.
• Occurs mostly over extensor surfaces and
scalp.
Characteristic Lesion of Psoriasis!
• Histopathology
– Increased epidermal cell proliferation due to
:increased growth fraction,shorten epidermal
turnover time normal 60 to10 days
– Thickening of the epidermis(acanthosis)with
suprapapilary thinning responsible for the Ausitz sign)
– Retention of nuclei by keratinocytes (parakeratosis)
– Collection of polymorphs in the epidermis forming
micro a microabscesses
– Tortuous and dilated blood vessels
– Inflammatory infiltrate primarily of lymphocytes in
the upper dermis
– Prolifilation of fibroblast
Precipitating factors!
• Trauma
 Appears in areas of skin damage like scratches or surgical
wounds (Koebner phenomenon)
• Infection
 Preceded by β-hemolytic streptococcal throat infection
(Guttate),HIV
• Sunlight
 Rarely, ultraviolet radiation may worsen psoriasis
• Drugs
 Antimalarials, β-blockers and lithium- worsens psoriasis
 Stopping systemic steroids- rebound of psoriasis
• Emotion
 Anxiety precipitates some exacerbations
cause and Pathogenesis!
• The exact cause is still unknown
• T-cell mediated inflammatory disease
– Epidermal hyperproliferation secondary to activation
of immune system
– Altered maturation of skin
– Inflammatory cell infiltrate with neutrophilic and lymphocytic
predominance.
– Vascular changes
• Cause: Excessive number of germinative cells
entering the cell cycle rather than by a decrease
in cell cycle time.
• The turnover is greatly shortened, to less than 10
days as compared to a normal turnover period of
60 days
Associated Factors
• Genetic Factors:
- 30% of people with psoriasis have had
psoriasis in family
• Nongenetic Factors:
- Mechanical, ultraviolet, chemical injury
- Infections: Strep, viral, HIV
- Prescription Drugs, stress, endocrine,
hormonal, obesity, alcohol, smoking
GENETICS
• Affected Parent Chance of developing
• 1 of the parent affected
15%
• Both are affected
50%
• If one sibling already has the disease
The chance still goes higher
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The risk of those with HLA-Cw6 genotype developing
psoriasis is 10-20 times more than those without it.
• Psoriasis occurs in 2% of the world’s
population.
• Highest in Caucasians
• In Africans, African-Americans and Asiansbetween 0.4% and 0.7%
• Equal frequency in males and females
• May occur at any age- from infancy to the 10th
decade of life. Mostly occurs at the age of 10
or more.
Prevalence!
• Two-thirds of patients have mild disease
• One-third have moderate to severe disease
• Early onset (prior to age 15)
– Associated with more severe disease
– More likely to have a positive family history
• Life-long disease
– Remitting and relapsing unpredictably
– Spontaneous remissions of up to 5 years have been
reported in approximately 5% of patients
Sharply demarcated erythematous
plaque with silvery white scale
Commonly affected sites
Presentation pattern of psoriasis
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Plaque
Guttate
Flexural psoriasis
Localised forms
Generalized pustular
Nail involment
erythroderma
Differntial diagnosis
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Drug eruption,lichen planus
Pityriasis rosea
Candidiasis of flexures
Hyperkeratotic
eczema,sebhorric
dermatitis.
• Fungal infection of nail
plaque
• Well defined,discoid plaques
• Involves elbow,knees,scalp hair margin,sacrum
• Plaques are red covered by waxy white scales
which when removed leaves bleeding point
known as ausptiz sign.
• Plaques 2cm to several cm and may be itchy.
Chronic plaque psoriasis
guttae
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Acute ,symetrical eruption of drop like lesion
Commonly over the trunk and limbs
Most common in young adults
May follow a streptococcal throat infection.
Guttae psoriasis
flexural
• Common sites are axillae,sub-mammary area
and natal cleft,
• Plaques are smooth and glazed.
• Common in elderly.
Localized forms
• Palmoplantar pustulosis
– yellow to brown colored sterile pustules on palm
and soles.
– common in middle age females
– Common in ciggarete smokers.
• Scalp psoriasis:
Can be confused with dandruff but are better
demarcated and more thickly scaled.
• Napkin psoriasis:
– seen in infant in the nappy area
– Lesion are well defined psoriasiform eruption are
seen.
Generalized pustular
• Rare but life threatening
• Sheets of small sterile yellowish pustules
appear on erythematous background and
spreads rapidly
• Acute onset
• Fever , malaise and pt.requires hospital
admission.
• The skin initially becomes fiery red and tender.
• Constitutional signs and symptoms, such as headache,
fever, chills, arthralgia, malaise, anorexia, and nausea
is present.
• Within hours, clusters of nonfollicular, superficial 2
to 3mm pustules may appear.
• The most common sites of involvement are the
flexural and anogenital areas. Less often, facial
lesions may also occur.
• Pustules may occur on the tongue and subungually,
resulting in dysphasia and nail shedding respectively.
These pustules coalesce within 1 day to form
flakes of pus that dry and desquamate in sheets
Smooth erythematous surface is left on which
new crops of pustules appear.
These episodes of pustulation may occur for days
to weeks, thereby causing the patient severe
discomfort and exhaustion.
A telogen effluvium type of hair loss may develop
in 2-3 months.
Upon remission of the pustular component, most
systemic symptoms disappear; however, the
patient may be in an erythrodermic state or may
have residual lesions of psoriasis vulgaris.
• Other symptoms and signs
– Fever
– Dehydration
– Itching
– Weight loss
– Muscle Weakness and fatigue
– Fast heart rate
– More severe complications may include breathing
difficulties, low blood calcium levels, pneumonia,
congestive heart failure and hepatitis.
– Seeking immediate dermatologic care for this
condition is important.
Generalised pustular
Causes
The following have reportedly triggered an eruption:
• Withdrawal of systemic steroids
• Drugs like lithium, phenylbutazone, oxyphenbutazone,
trazodone, penicillin, iodine, hydroxychloroquine, calcipotriol,
interferon-alpha, and recombinant interferon-beta injection
• Strong, irritating topicals, including tar, anthralin, steroids
under occlusion, and zinc pyrithione in shampoo
• Infections
• Sunlight or phototherapy
• Cholestatic jaundice
• Hypocalcemia
• Idiopathic in many patients
Treatment
• Generalized pustular psoriasis is treated by:
• Placing dressings soaked in a mixture of
aluminum acetate and water over the affected
areas.
• Topical steroids may also be used.
• Severe cases may require acitretin,
methotrexate, or cyclosporine.
Nail involvement
• Affects the nail matrix or nail bed
• Commonest change ;thimble pitting followed
by oncholysis(separation of distal edge of nail
from nail bed)
• Adjacent to onycholysis salmon pink
discoloration is seen .
• Subungal hyperkeratosis
• Associated with psoriatic arthopathy.
Psoriasis of nails
Complication of psoriasis
Psoriatic arthropathy
Occurs in about 5% cases.
• Four forms:
1. Distal arthritis:Mostly causes swelling of interphalangeal
joints of hand and feet,sometimes causing flexion
deformity. Sausage like swelling of digits may occur.
2. Rheumatoid like arthritis:mimics rheumatoid arthropathy
with polyarthopathy,but is less symmetrical and R.F factor
is negative.
3. Mutilans arthritis:erosion develop in small bones of hand
and feet,sometimes in the spine. The bones may be
dissolved giving severe deformity.
4. Ankylosing spondylitits
Fixed flexion deformity of distal
interphalangeal joints following
arthropathy.
Rheumatoid-like changes associated
with severe
psoriasis of hands.
Erythrodermic psoriasis
• Also known as generalised exfoliative
dermatitis.
• Any inflammatory dermatosis that involves all
or nearly all skin surface.
pathophysiology
• Acute
• Chronic
Acute form:Odema of epidermis and dermis is
prominent and is inflitrated by inflammatory
cells.
Chronic form: There is lenghtening of rete
ridges and thickening of epidermis.
causes
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Eczema (40%)
Psoriasis(25%)
Lymphoma(15%)
Drug eruption(10%)
Pityriasis rubra pilaris(1%)
Unknown(8%)
Erythrodermic psoriasis may be precipitated
by:
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Infections
Low calcium
Withdrawal of oral corticosteroids (prednisone)
Withdrawal of excessive use of strong topical corticosteroids
Strong coal tar preparations
Certain medications including lithium, antimalarials
• It is a dermatological emergency
• Common in male and middle aged and elderly.
• Often developd suddenly especially when
associated with leukemia or eczema.
• A patchy erythema develops which spreads all
over the body within 12-48 hours and
accompanied by pyrexia ,malaise,shivering .
• After 2-6 days scaling appears and the skin
appears hot, red dry and thickened.
• The exfoliation of skin is continous and
copious.scalp and body hair is lost .nail become
thickened and is shed.
• Pigmentary changes occur and those with a dark
skin hypopigmentaion is seen.
complications
• Cardiac failure
• Hypothermia:failure to sweat and excess heat
loss.
• Dehydration
• Hypoalbuminaemia:protein loss in exfoliated
scales.
• Cutaneous oedema:hypoalbuminaemia.
Management
• Inpatient treatment essential .
• Nursed in a warm room at a steady
temperature.(30-32degree)
• Pulse,BP,temperature and fluid balance should
be monitored regularly.
• Tropical steroid and bland cream are main stay
of treatment.
• Systemic steroid are life saving in emergency
cases.
Treatment of psoriasis
• Explanations and reassurances must be given
to the patients or the parents.
• Information leaflets help to reinforce verbal
advice.
• At present there is no cure for psoriasis; all
treatments are suppressive and aimed at either
inducing a remission or making the condition
more tolerable. However, spontaneous
remissions will occur in 50% of patients.
Local Therapies
1. Topical Corticosteroids
2. Topical Vitamin D3 Analogues
3. Topical Retinoids
4. Photo(chemo)therapy
Systemic Therapies
1. Oral
2. Parenteral
Topical corticosteroids
• High potency and Super potent topical steroids
• These include
– Fluocinonide (cream, ointment, gel)
– Betamethasone dipropionate cream
– Clobetasol propionate (cream, ointment, gel, foam,
lotion)
– Diflorasone diacetate ointment
– Betamethasone dipropionate ointment
Topical corticosteroids
Side effects associated with use
 Skin atrophy
 Burning and stinging
 Suppression of the hypothalamic-pituitary-adrenal
(HPA) axis
This may occur after 2 weeks of use with certain topical
corticosteroids
Topical Vitamin D3
Analogues
 Prototype for this group is
calcipotriene
 3 formulations – cream, ointment,
and scalp solution
 Former two are approved for
plaque psoriasis
 Latter for moderate to severe
psoriasis of the scalp
Topical Vitamin D3
Analogues
Side effects associated
with use
 Cutaneous
Burning
Stinging
Pruritis
Skin irritation
Tingling of the skin
Ultraviolet B (UVB)
• Treatment is time
consuming
– 2-3 visits/week for
several months
• Side effect – possibility
of experiencing an acute
sunburn reaction
Photo(chemo)therapy
• Two types of phototherapy
– Ultraviolet B (UVB)
– Ultraviolet A + psoralen (PUVA)
PUVA
• Consists of ingestion or
topical treatment with a
psoralen followed by
UVA
• Usually reserved for
severe, disabling psoriasis
• Time consuming – 2-3
visits/wk; at least 6 weeks
• Precautions
– Patients must be protected
from further UV light for
24 hours post treatment
• Side effects with oral
psoralen
– Nausea
– Dizziness
– Headache
• Side effects with PUVA
– Early
• Pruritus
– Late
• Skin damage
• Increased risk for skin
cancer, particularly
squamous cell (SCC) and
after 200 - 250 treatments,
increased risk for
melanoma
Systemic Therapies
• Oral
– Methotrexate
– Cyclosporine
– Oral retinoids (acitretin)
• Parenteral
– Amevive (alefacept)
– Raptiva (efalizimab)
– Enbrel (etanercept)
• Methotrexate :Folic acid
antagonist
• Usually reserved for
severe, recalcitrant,
disabling psoriasis
• Maximum improvement
can be expected after 8 12 weeks
Side effects:
• Acute or chronic
hepatotoxicity
• Hepatic cirrhosis
• Leukopenia
• Thrombocytopenia
• Anemia, including aplastic
anemia
• Rarely, interstitial
pneumonitis
• Stomatitis
• Nausea/vomiting
• Alopecia
• Photosensitivity
• Burning of skin lesions
Parenteral Therapy
Amevive
• Immunosuppressive
dimeric fusion protein
• Indicated for the
treatment of adult
patients with moderate to
severe chronic plaque
psoriasis
• With 12 weeks of therapy,
a disease state of clear or
almost clear was achieved
by 11% (via IV) and 14%
(via IM) of patients,
respectively
• Dose dependent
reduction in circulating
CD4+ and CD8+ T
lymphocytes
– Should not be
administered to patients
with low CD4+ counts
– CD4+ counts must be
monitored before and
weekly throughout
therapy
Oral retinoid
• Oral retinoid approved for
the treatment of severe
psoriasis in adults
• Significant improvement
can be achieved with 8
weeks of therapy
• Those associated with
retinoid therapy
– Cheilitis
– Alopecia
– Skin peeling
– Dry skin
– Pruritus
– Rhinitis
– Xeropthalmia
– Arthralgia
• Increase risk of malignancies
– Skin cancer – BCC and SCC
– Lymphoma
• Serious infections requiring hospitalization
• Risk of reactivation of chronic, latent
infections
• Hypersensitivity reactions