Psoriasis

chronic scaling disease that has polygenic determinants as well as environmental triggering factors

1. PSORIASIS HABAKUK LARRY OMONDI

2. Definition Comes from a Greek word meaning “ITCHING” An inflammatory autoimmune papulosquamous eruption on skin increased epidermal proliferation resulting in accumulation of stratum corneum . *Chronic, Benign, Non-contagious Predilection, extensor aspects of limbs, scalp

3. What causes it? Unknown Interplay of: Genetics Immune system Environment

4. Complex disorder Immune system Genes Environment

5. A complex genetic disorder - Possible genetic error in mitotic control - 1/3 have a family history of psoriasis Immune System : Activation of lymphocytes -increase in inflammatory mediators -growth of skin cell speed up

6. Genetic Basis for Psoriasis FATHER MOTHER One parents affected  ¼ (25%) of children will get it

7. Genetic Basis for Psoriasis FATHER MOTHER Two parents affected  2/4 (50%) of children will get it

8. Environment Infections Stress Changes in climate, such as cold weather Skin injuries, such as burns Certain medications lithium, beta blockers, anti-malarial drugs, and non-steroidal anti-inflammatory drugs such as ibuprofen

9. Body involvement The scalp, knees, elbows and torso The nails, palms, soles, genitals and face Symmetrically = the same place on the right and left sides of the body

10. Epidemiology

11. Cont… Family history Occur at any age Most common in people in their 20s and 40-50s. Males=females

12. Classification Discoid/Plaque psoriasis Most common Affects mostly: elbows, knees, gluteal cleft, scalp, ears Symmetrical Nails may be pitted and/or thickened

13. Psoriatic plaque

14. Psoriatic Knee

15. Psoriatic scalp

16. Characteristics Well demarcated Thickened Deep red plaques Surmounted by silvery scales Vary in size small(1-2cm) to large (entire extensor surface)

17. Eruptive/ Guttate psoriasis Most frequently in children Follows a beta hemolytic streptococcal pharyngeal infection

18. Guttate psoriasis

19. Characteristics Red Oval/round Scaly plaques Upto 1cm in diameter Mostly on trunk and proximal limbs

20. Pustular psoriasis Localised / generalised Localised esp on Palms and soles Can be annular in children Fever and malaise are common Also follows withdrawals from steroids

21. Localised Palm Plantar

22. Generalised

23. Cont… Palmoplantar pustulosis -common in adults -manifests as crops of sterile yellow pustules -0.1-0.5cm -on palms and soles - involute to red brown macules and scaling Erythematous plaques studded with pastules appear at any site and become confluent

24. 4. Erythrodermic psoriasis Also exfoliative psoriasis/ redman syndrome Results from: Pustular psoriasis Triggered by infection Overtreatment by tar Sudden withdrawal of corticosteroids Pts at risk of: fluid & protein loss, poor temp control and infection

25. Erythrodermic psoriasis Widespread, Generalized erythema and scaling

26. 5. Rupioid Psoriasis - Grossly hyperkeratonic plaques Rupia - very scaly, heaped up and secondarily infected psoriatic lesion

27. 6. Inverse, flexural psoriasis Affects the flexural areas Lesions are moist and without scales Common in old people Sites mostly affected are: Areola Groin Beneath breast

28. Beneath Breasts

29. Signs and Symptoms Pruritus Well demacated lesions Silvery scale on red plaques Knee-elbow-scalp distribution Glans penis/vulva may be affected Positive AUSPITZ sign(underlying pinpoints of bleeding following scrapping) Psoriatics often have pink/red intergluteal fold

30. 8. Köbner Phenomenon

31. 9. Stippled nails and pitting and onycholysis

32. 10. Psoriatic Arthritis- Affects mostly IP joints sparing MC joints

33. Essentials of Diagnosis Silvery scales on bright red plaques Well demarcated plaques Nail findings- pitting and onycholysis Mild itching Psoriatic arthritis

34. Investigations FH- inc. leucocytes and ESR Urine- Uric acid increases in 10-20% Severe cases- anemia:B12, B9 and Fe deficiency Biopsy- Parakeratosis , hyperkeratosis, Epidermal hyperplasia Histology- Elongated rete ridges, inflamatory cells( perivascular ), munro microabsesses

35. Histology

36. Cont…

37. DDx Tinea cruris Candidiasis Seborrheic dermatitis Pityriasis rosea Onychomycosis Eczema

38. THERAPY

39. Treatment Is aimed at reducing cell turnover, underlying inflammatory process and depends on the areas of the body affected Current treatment also aims at altering the immune response

40. Treatment cont….. Available options are: 1. Topical Emolient -decrease fissuring, cracking and scalling . Forms- acqueous cream, urea cream Tar – is the mainstay & available in rural areas. E,g coal tar Sulpur salycylate -scalp psoriasis(emulsion)

41. d) Dithranol - E( Topical Calcipotriol ( Vit . D3 derivative)-indicated for chronic plaque psoriasis f) topical Steroids – are useful for flexural and scalp Various preparations are available

42. Topical treatment cont….. Available preparations of steroids include: Betacort – (Bet. valerate 0.05%) mod. potent Glovate – ( Clob . Prop. 0.05%) very potent Combinations eg Betasalic , Fucivate & Bulkot Mixi Cream/ oint ( Beclomet . Dipro . 0.025% plus Clotrm . 1% & Gentamy . 0.1%)

43. Treatment cont…… Other adjuvant topical drugs include: Keratolytics eg Salicylic acid, Benzoic acid urea, etc Emollients eg Vaselline , Xamana jelly, etc 2. Other measures – control of itching – use antihistamines Cetrizine ( Zycet ) Tabs, Syrup Steramine ( Betamet . 0.25mg & Dexchlorpheniramine 2mg)

44. Adjuvant treatment For secondary infections-systemic or topical antibiotics eg Dynocin , Cloxacillin , Cephalexin , etc Topical include Fucimin (Sod. Fucidate 2%), Silver Sulphadiazine , combined like Bulkot Mixi or Fucivate , etc

45. Treatment cont….. Systemic - used for very severe and extensive forms of psoriasis. Methotrexate – 10-25mg IM/IV once weekly Azathioprine – 2mg/Kg P.O. Hydroxyurea Acitracin ( Retinoids )-0.5-1mg/kg/day Cyclosporin -A – also used for suppression of organ rejection-3mg/kg/day PUVA – photochemical therapy