Psoriasis

Psoriasis

1. Psoriasis. Valmiki Seecheran. Y5 MBBS. Family Medicine Rotation | Dr. Adams.

2. Objectives. To have a brief overview of the background of psoriasis. To understand the signs and symptoms. To understand the various causes. To understand the mechanism. To understand the various types of work up. To understand the management.

3. Background. ‘’Psoriasis vulgaris’’ Psoriasis is a chronic, noncontagious, multisystem, inflammatory disorder.  Skin lesions vary from localized patches to entire body coverage. Affects 2-4% of general population. Occur at any age. Commonly in 15-25 years. M-F – 1:1. 5 types – plaque*, guttate , inverse, pustular and erythrodermic .

4. Signs & Symptoms.

5. Plaque psoriasis. 85-90% of people with psoriasis. Raised areas of inflamed skin covered with silvery-white scaly skin. Elbows, knees, scalp & back. Uncontrolled plaque psoriasis -> psoriatic eythroderma . Severe itching, swelling and pain. Often occurs from abrupt withdrawal of glucorticosteroids . Fatal – affects the function of skin – temperature and barrier functions.

6. Pustular psoriasis. Raised bumps filled with noninfectious pus. Skin around the pustules is red and tender. Usually localized to hands and feet - palmoplantar pustulosis . Generalized pustular psoriasis (von Zumbusch ) – rare psoriasis during pregnancy. Annular pustular psoriasis – rare form. Seen during childhood.

7. Inverse psoriasis. Flexural psoriasis. Smooth, inflamed patches of skin. Affects skin folds – around genitals, armpits, overweight patients ( panniculus ), intergluteal cleft and under breasts.

8. Guttate psoriasis. Numerous small, scaly, red/pink, ‘teardrop’ shaped lesions. Primarily appears on the trunk but also limbs and scalp. Usually preceded by a streptococcal infection – streptococcal pharyngitis.

9. Other. Seborrheic-like psoriasis – red plaques with greasy scales usually on scalp, forehead, skin folds close to the nose, around mouth and trunk. Psoriatic arthritis – painful inflammation of joints and connective tissue – fingers and toes – sausage shaped – dactylitis . Can also affect hip, knees, spine and sacroiliac joint. 30% psoriasis affect individuals will develop psoriatic arthritis.

10. Medical signs Other than clinical presentation. Auspitz’s sign – pinpoint bleeding when scale is removed. Koebner phenomenon – psoriatic skin lesions induced by trauma. Itching and pain localized to papules/ plaques.

11. Auspitz vs Koebner .

12. Causes. Genetics 1/3 psoriasis patients report a family history. PSORS1 to PSORS9. Lifestyle Chronic infections, stress, climate (temperate countries). HIV Advanced HIV. More severe in patients with HIV along with psoriatic arthritis. Medication Beta blockers, calcium channel blockers, statins, NSAIDS, Lithium, terbinafine , steroid withdrawal.

13. Mechanism. Hyperproliferation of the keratinocytes in the epidermis, with an increase in the epidermal cell turnover rate.  Skin cells are replaced every 3-5 days in psoriasis rather than the usual 28-30 days. Inflammatory cascade involving dendritic cells, macrophages & T-cells -> Premature maturation of kertainocytes .

14. Diagnosis. Clinical presentation! Scaly, erythematous plaques, papules, patches – painful + itchy. DDx – discoid eczema, seborrheic eczema. Skin biopsy – histological – stratum granulosum layer often missing or severely decreased – prematuration .

15. Treatment. Topical agents. Corticosteroids – continuously 8 weeks. Moisturizers – Calcipotriol & coal tar. Phototherapy. 311-313 nanometers. UV-B lamps. UV-A tanning beds. PUVA. Systemic agents – methotrexate, ciclosporin , retinoids . – immune suppressants & regulate epithelial cell growth. Alternatives- Sea baths – balneotherapy & fish oils.

16. Prognosis. Most people experience mild lesions that can be treated with topical therapies. - ve impact on quality of life – physical, aesthetic discomfort. Linked with low self esteem & depression. Increased risk of diabetes & HTN, Crohn’s disease & Ulcerative colitis.