Psoriasis

Psoriasis is a skin condition that causes red, flaky, crusty patches of skin covered with silvery scales. These patches normally appear on your elbows, knees, scalp and lower back, but can appear anywhere on your body. Most people are only affected with small patches. In some cases, the patches can be itchy or sore.

1. Psoriasis an overview Presented by Ayaat A. Kadhum

2. What is psoriasis? Psoriasis is a chronic lifelong skin inflammatory disorder. Characterized by the formation of well-defined raised erythematous plaques. Accompanied with silvery white scales depends on lesion type ,that preferentially localize on the extensor surfaces. Anyone can get psoriasis. It occurs mostly in adults, but children can also get it Psoriasis is not contagious. Ayaat Alobaidy

3. Prevalence According to current studies, more than 8 million Americans have psoriasis. 125 million people worldwide—2 to 3 percent of the total population—have psoriasis, according to the World Psoriasis Day consortium. An estimated 30 percent of people with psoriasis also develop psoriatic arthritis. Psoriasis prevalence in African Americans is 1.9 percent compared to 3.6 percent of Caucasians. Psoriasis is likely to be under-diagnosed among African-Americans and other individuals with skin of color due to differences in clinical presentation.   In Iraq the incidence of psoriasis is 1.8% of overall skin disease cases. Ayaat Alobaidy

4. Ayaat Alobaidy

5. Psoriasis and Skin Color Psoriasis can affect persons of any race; however, epidemiologic studies have shown a higher prevalence in western European and Scandinavian populations. In these groups, 1.5-3% of the population is affected by the disease. Psoriasis is found more frequently in white (3.6 percent) than in African American (1.9 percent) and Hispanic (1.6 percent) populations.However, these numbers may not paint the full picture, as psoriasis may be more readily identified in people with lighter skin and it is sometimes misidentified in people with darker skin tones. Across skin types, many features present similarly, such as the symmetrical distribution of psoriasis on the body and well-circumscribed nature of psoriasis plaques. Differences do exist and are important to recognize, such as “the red color or erythema that is typically seen with psoriasis on light skin often appears more purple or brown in darker skin types. Sometimes the scale that accompanies psoriasis is so thick that it is difficult to appreciate that underlying color of the plaque itself. Nevertheless, psoriasis remains a common condition across skin types and races/ethnicities. Ayaat Alobaidy

6. Ayaat Alobaidy

7. Common Comorbidities in Patients with Psoriasis Depression: Prevalence is up to 60 percent : may improve with treatment of psoriasis. Immune-mediated inflammatory conditions : Risk of Crohn's disease or ulcerative colitis is 3.8 to 7.5 times greater in persons with psoriasis; reported increased risk of psoriasis in persons with a family history of multiple sclerosis. Malignancy : Risk of lymphoma is increased 1.3- to 3.0-fold in persons with psoriasis; risk of squamous cell carcinoma is increased 14-fold in white patients after 250 or more psoralen plus ultraviolet A treatments. Metabolic syndrome, obesity : Increased prevalence in hospitalized patients with psoriasis. Myocardial infarction : Increased risk persists after controlling for major cardiovascular risk factors. Ayaat Alobaidy

8. Safety Considerations for Biologic Therapies in Patients with Psoriasis Demyelinating disorders. Exacerbation of cardiac failure. Hepatic dysfunction. Infections, including tuberculosis (Activation of latent tuberculosis or new infection). Lupus-like syndrome. Risk of nonmelanoma skin cancer, lymphoma, and solid-organ cancer. Ayaat Alobaidy

9.   What are the causes of psoriasis? Ayaat Alobaidy

10. Immunopathogenic mechanisms in psoriasis The exact cause is unknown, however researches believe heredity, environment and immune system also play a role in psoriasis. Occasionally, psoriasis is provoked by drugs such as lithium, chloroquine and hydroxy chloroquine , beta-blockers, non-steroidal anti-inflammatory drugs, and angiotensin converting enzyme (ACE) inhibitors. As psoriasis is a common T-lymphocyte mediated inflammatory skin disease and is being an immune-mediated disorder (immunosuppressant medications can clear psoriasis plaques) in which the excessive reproduction of skin psoriasis — types, causes and medication cells are secondary factors produced by the immune system. Ayaat Alobaidy

11. Role of T Cell in Psoriasis T cells become active, migrate to the dermis and trigger the release of cytokines which cause inflammation and the rapid production of skin cells. It is not known what initiates the activation of the T cells. That work initially pointed towards a major role of T lymphocytes as inducers of the disease phenotype and the pathogenic contribution of this cell type has now been tested through clinical studies of more than a dozen immune modifying biological agents in patients with psoriasis . Ayaat Alobaidy

12. Types of Psoriasis 1. Psoriasis Vulgaris: (chronic plaque psoriasis), is the most common type. Well defined lesions and range from a few millimeters to many centimeters in diameter. Pink or red with large, centrally adherent, silvery-white, polygonal scales. Symmetrical sites on the elbows, knees, lower back and scalp are sites of predilection . Ayaat Alobaidy

13. Types of Psoriasis 2. Guttate Psoriasis: Small drop-like papules. often occurs acutely after an event such as drug exposure, or illness such as streptococcal pharyngitis . More commonly seen in children and adolescents. Ayaat Alobaidy

14. Types of Psoriasis 3. Erythrodermic Psoriasis: A very rare type of psoriasis. It only affects about 3 percent of people with psoriasis, but it can be very serious. This variant of psoriasis is characterized by generalized erythema and scaling. its onset can be gradual or acute. Ayaat Alobaidy

15. Types of Psoriasis 4. Pustular Psoriasis : Is a rare and severe form of psoriasis that involves widespread inflammation of the skin and small white or yellow pus-filled blisters or pustules. Affects less than 5% of all psoriasis patients and there are two types of pustular psoriasis: 1- Localized pustular psoriasis 2- Generalized Pustular Psoriasis Ayaat Alobaidy

16. Types of Psoriasis 5. Plaque psoriasis : Is the most common form of psoriasis. 80-90 percent of people with psoriasis experience plaque psoriasis. Plaques appear as raised, inflamed and scaly patches of skin that may also be itchy and painful Ayaat Alobaidy

17. Types of Psoriasis 6.Inverse psoriasis: Sometimes called hidden psoriasis or intertriginous psoriasis, a form of psoriasis that affects skin folds. Inverse psoriasis can occur under arms, under a woman’s breasts, or in the groin or inner thigh area. Ayaat Alobaidy

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19. Psoriasis severity determination Several factors go into determining whether psoriasis is mild, moderate, or severe, including: Body Surface Area: The 1% Hand Test: One of the most important factors is how much of the body is covered by psoriasis. Dermatologist or the patient can use their hand to estimate this. One hand covers roughly 1% of the body’s surface area. Intensity of Symptoms: Dermatologists will look at the intensity of symptoms to help determine severity. If the plaques and scales are especially thick, red, scaly, or itchy, that can contribute to psoriasis being more severe. Psoriasis Location:Having symptoms in places that have a greater impact on life can also play a role in severity. For example, on face where it can be more embarrassing, or in folds of skin that are constantly irritated. Personal Impact: The non-physical impact of psoriasis can also contribute to severity. This could include emotional well-being, day-to-day activities, and relationships with others. Ayaat Alobaidy

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22. General approach for treatment of psoriasis Treatment goals include improvement of skin, nail, and joint lesions plus enhanced quality of life.  Treatment must be individualized to incorporate patient preferences and the potential benefits and adverse effects of therapies. Consultation with a dermatologist may be warranted for patients with severe disease that requires systemic therapy. Ayaat Alobaidy

23. General and Topical management Assurance explanation of disease. Aviodance of precipitating factor. Control of secondary infection. Topical management Highly potent steroids: Clobetasol Propionate;dose depends upon severity of patient. Salicylic acid and Vitamin D analogue: calcipotriol. Topical methotraxate Topical retinoids: tazarotene. Dithranol Topical PUVA Ayaat Alobaidy

24. Ayaat Alobaidy

25. Specific management Methotraxate: Dose: 2.5 mg or 5 mg 12hrly, 3 doses in a week for 3-12 months with folic acid supplementation. Duration of treatment depends on patient's condition. systemic retinoids: Acitrectin. antibiotic, antifungal. Photo chemotherapy: Psoralen and ultraviolet A. During giving methotrexate & during treatment: - complete blood count - liver function test - renal function test must be done. Methotrexate is contra-indicated in pregnancy. Never prescribe systemic steroid in psoriasis because it flares up the condition. Ayaat Alobaidy

26. Foods that help fight inflammation Ayaat Alobaidy

27. Psoriasis Triggers Many people who are predisposed to psoriasis may be free of symptoms for years until the disease is triggered by some environmental factor. Common psoriasis triggers include: Infections, such as strep throat or skin infections Weather, especially cold, dry conditions Injury to the skin, such as a cut or scrape, a bug bite, or a severe sunburn Stress Smoking and exposure to secondhand smoke Heavy alcohol consumption Certain medications — including lithium, high blood pressure medications and antimalarial drugs Rapid withdrawal of oral or systemic corticosteroids Ayaat Alobaidy

28. Medications may trigger Psoriasis The following have all been linked to psoriasis: lithium beta-blockers Tetracycline Non-steroidal anti-inflammatory drugs (NSAIDs) malaria drugs Ayaat Alobaidy

29. Foods that can contribute to inflammation Ayaat Alobaidy

30. Risk group : Ayaat Alobaidy

31. Risk group : Anyone can develop psoriasis. About a third of instances begin in the pediatric years. These factors can increase the risk: Family history: The condition runs in families. Having one parent with psoriasis increases therisk of getting the disease, and having two parents with psoriasis increases the risk even more. Stress: Because stress can impact the immune system, high stress levels may increase the risk of psoriasis. Smoking: Smoking tobacco not only increases the risk of psoriasis but also may increase the severity of the disease. Smoking may also play a role in the initial development of the disease. Ayaat Alobaidy

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33. Diagnosis Routine investigation of the disease through : Clinical checkup should be firstly done and diagnosis of psoriasis according to appearance, distribution, history of lesions and family history . CBC – Normocytic normochromic Anaemia ESR – Increased level RBS Urine examination Chest X-ray Skin biopsy Investigation of the secondary bacterial infection accompanied with psoriasis. Ayaat Alobaidy

34. Complications People with psoriasis are of greater risk of developing other conditions, including: Psoriatic arthritis, which causes pain, stiffness and swelling in and around the joints Eye conditions, such as conjunctivitis, blepharitis and uveitis Obesity and Type 2 diabetes High blood pressure and Cardiovascular disease Other autoimmune diseases, such as celiac disease, sclerosis and the inflammatory bowel disease called Crohn's disease Mental health conditions, such as low self-esteem and depression Ayaat Alobaidy

35. Secondary infections complicating skin lesions The link between psoriasis and infection is probably explained by the superantigen theory, Superantigens  ( SAgs ) are a class of  antigens  that result in excessive activation of the immune system. Specifically it causes non-specific activation of T-cells resulting in polyclonal T cell activation and massive cytokine release. So that superantigens are the products of bacteria, viruses, or fungi, which can bypass normal immunological pathway and cause powerful stimulation to the immune system. The most common problem is secondary aerobic and anaerobic bacterial invaders complicate psoriatic lesions. Ayaat Alobaidy

36. Which type of bacteria can we detect ? As previously mentioned both aerobic and anaerobic bacteria can be detect among infected lesions in psoriasis patients. Recent studies showed that Staphylococcus aureus and group A - haemolytic streptococci were the most prevalent aerobes and were isolated from all body sites. In contrast, organisms that reside in the mucous membranes close to the lesions predominated in infections next to these membranes. Proteus  spp , Staphylococcus  epidermidis , Pseudomonas  aeruginosa , Bacillus spp.  Enteric bacteria were primarily isolated from children, E. coli and Enterococcus  fecalis .  Anaerobic bacteria represented by  Propionobacter  spp.,  Fusarium  spp. & Clostridium  perfrinens Ayaat Alobaidy

37. References Zohra Zaidi, Sean W. Lanigan , Dermatology in Clinical Practice, Springer- Verlag London Limited 2010. Informa - DM, Lines PI, Services PI, Immunisation T, Travel N, Network H, et al. Medicines information services. England. 2014;979. Lafi , S., Hasan , A., Al- Alowssi , M. Secondary Bacterial Infections Complicating Psoriasis. Egyptian Academic Journal of Biological Sciences, G. Microbiology, 2010; 2(2): 37-42. doi : 10.21608/eajbsg.2010.16706 Rachakonda TD, Schupp CW, Armstrong AW. Psoriasis prevalence among adults in the United States. Journal of the American Academy of Dermatology. 2014;70(3):512-516. Mease PJ, Gladman DD, Papp KA, et al. Prevalence of rheumatologist-diagnosed psoriatic arthritis in patients with psoriasis in European/North American dermatology clinics. Journal of the American Academy of Dermatology. 2013;69(5):729-735.

38. References Rachakonda TD, Schupp CW, Armstrong AW. Psoriasis prevalence among adults in the Unite States. J Am Acad Dermatol . 2014;70(3):512-516. doi:10.1016 / j.jaad.2013.11.01 . Gottlieb A, Korman NJ, Gordon KB, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 2. Psoriatic arthritis: overview and guidelines of care for treatment with an emphasis on the biologics.  J Am Acad Dermatol . 2008;58(5):851–864. Alexis AF, Blackcloud P. Psoriasis in skin of color: epidemiology, genetics, clinical presentation, and treatment nuances. J Clin Aesthet Dermatol . 2014;7(11):16-24. Drugdexsystem .  http:// thomsonreuters.com /products_services/healthcare/healthcare_products/a-z/ drugdex_system / . Accessed May 8, 2012.

39. References Menter A, Gottlieb A, Feldman SR, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 1. Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics.  J Am Acad Dermatol . 2008;58(5):826–850. Kimball AB, Gladman D, Gelfand JM, et al. National Psoriasis Foundation clinical consensus on psoriasis comorbidities and recommendations for screening.  J Am Acad Dermatol . 2008;58(6):1031–1042. Menter A, Gottlieb A, Feldman SR, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 1. Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics.  J Am Acad Dermatol . 2008;58(5):826–850. Al Samarai , A. G. M. (2009). Prevalence of skin diseases in Iraq: a community based study. International Journal of Dermatology, 48(7), 734–739.