Psoriasis: Diagnosis and Management

Psoriasis: Diagnosis and Management

1. Psoriasis: Diagnosis and Management By Tatenda Chikwetu

2. Overview Epidemiology and pathophysiology Clinical presentation. Diagnosis M anagement

3. What Is Psoriasis? Inflammatory and hyperplastic disease of skin. Characterised by erythema and elevated scaly plaques. Chronic , relapsing condition. Course of disease often unpredictable.

4. Epidemiology Common skin disorder Prevalence variable: ~ 0.3–2.5% Prevalence equal in males and females Estimated incidence: ~ 60 per 100,000 per year

5. Psoriasis

6. Diagnosis Worsening of a long-term erythematous scaly area. Sudden onset of many small areas of scaly redness. Pain (especially in erythrodermic psoriasis). Pruritus (especially in eruptive, guttate psoriasis). Afebrile (except in pustular or erythrodermic psoriasis, in which the patient may have high fever). Dystrophic nails, which may resemble onychomycosis . Long-term, steroid-responsive rash with recent presentation of joint pain. Joint pain (psoriatic arthritis) without any visible skin findings Conjunctivitis or blepharitis .

7. S ymptoms

8. Onset Mean age: ~ 23–37 years Current theory: 2 distinct peaks with possible genetic associations Early onset (16–22 years) More severe and extensive More likely to have affected first-degree family member Late onset (57–60 years) Milder form Affected first-degree family members nearly absent

9. Genetic Influence Evidence suggests strong genetic association Studies of monozygotic twins show concordance for psoriasis (e.g. 64% in a Danish Study) Multiple susceptibility loci have been identified Disease expression likely result of genetic and environmental factors

10. Common Trigger Factors For Psoriasis Infections (e.g. streptococcal, viral) Skin trauma (Koebner phenomenon) Psychological stress Drugs (e.g. lithium, beta blockers) Sunburn Metabolic factors (e.g. calcium deficiency) Hormonal factors (e.g. pregnancy)

11. Impact Of Disease Concerns that it will worsen Depression Feeling embarrassed Feeling unattractive

12. Common Sites Affected By Psoriasis Can affect any part of the body – typically scalp, elbow, knees and sacrum Extent of disease varies

13. Types Of Psoriasis Chronic plaque Guttate Flexural Erythrodermic Pustular Localised and generalised Local forms Palmoplantar Scalp Nail (psoriatic onychodystrophy )

14. Clinical Presentation: Classic Psoriasis Well-defined and sharply demarcated Round/oval-shaped lesions Usually symmetrical Erythematous , Raised plaques Covered by white, silvery scales

15. Chronic Plaque Psoriasis Most common type – affects approximately 85% Features pink, well-defined plaques with silvery scale Lesions may be single or numerous Plaques may involve large areas of skin Classically affects elbows,knees , buttocks and scalp

16. Guttate Psoriasis Numerous and small lesions ~ 1 cm diameter Pink with less scale than plaque psoriasis Commonly found on trunk and proximal limbs Typically seen in individuals < 30 years Often preceded by an upper respiratory tract streptococcal infection

17. Flexural Psoriasis Lesions in skin folds articularly groin, gluteal cleft, axillae and submammary regions Often minimal or absent scaling May cause diagnostic difficulty when genital or perianal region is affected in isolation

18. Erythrodermic Psoriasis Generalised erythema covering entire skin surface May evolve slowly from chronic plaque psoriasis or appear as eruptive phenomenon Patients may become febrile, hypo/ hyperthermic and dehydrated Complications include cardiac failure , infections, malabsorption and anaemia Relatively uncommon

19. Other Forms Pustular Psoriasis Palmoplantar Psoriasis Scalp Psoriasis Nail Psoriasis

20. Psoriatic Arthritis Approximately 5–20% have associated arthritis Five major patterns of psoriatic arthritis: Distal interphalangeal involvement Symmetrical polyarthritis Psoriatic spondylarthropathy Arthritis mutilans Oligoarticular , asymmetrical arthritis Clinical expressions often overlap

21. Diagnosing Psoriasis Other dermatological disorders can resemble psoriasis Diagnosed clinically according to appearance, distribution , history of lesions and family history Important to consider non- cutaneous complications Heart problems Arthritis

22. Differential Diagnosis

23. Lacks symmetrical lesions Presence of peripheral scale and central clearing Tinea corporis

24. Discoid eczema Individualised patches more pruritic than psoriasis Lack silvery scale Less vivid colour than psoriasis

25. Tinea Manuum Ringworm of hands Fine powdery scale, particularly involving palms and palmar creases Usually asymmetrical

26. Managing Psoriasis Before starting treatment. Establish relationship of trust with patient. Provide patient with information. Emphasise benign nature of disease. Explain that psoriasis tends to be chronic and recurrent.

27. Treatment Options For Psoriasis Stepwise approach is advised Treatments include: General measures and topical therapy Phototherapy Systemic and biological therapies Combination therapies : may reduce toxicity and improve outcomes

28. Drug Options Topical corticosteroids ( eg , triamcinolone acetonide 0.025-0.1% cream, betamethasone 0.025-0.1% cream Ophthalmic corticosteroids ( eg , prednisolone acetate 1% ophthalmic, dexamethasone ophthalmic) IM corticosteroids ( eg , triamcinolone ): Intralesional corticosteroids: Useful for resistant plaques and for the treatment of psoriatic nails Coal tar 0.5-33% Keratolytic agents ( eg , anthralin , urea): Use of these medications may facilitate more direct steroid contact with the skin Artificial tears

29. Drug Options Vitamin D analogs ( eg , calcitriol ointment, calcipotriene , calcipotriene and betamethasone topical ointment) Topical retinoids ( eg , tazarotene aqueous gel and cream 0.05% and 0.1%) Antimetabolites ( eg , methotrexate ) Immunomodulators ( eg , tacrolimus topical 0.1%, cyclosporine, alefacept , ustekinumab ) TNF inhibitors ( eg , infliximab , etanercept , adalimumab ) Phosphodiesterase-4 inhibitors ( eg , apremilast ) Interleukin inhibitors ( eg , ustekinumab , secukinumab , ixekizumab , brodalumab )

30. Topical Therapies Approximately 70% of patients with mild-to-moderate psoriasis can be managed with topical therapies alone Tailor to needs of patient Potency , delivery vehicle and patient motivation may affect compliance Application may be time-consuming for patients

31. Topical Therapies: Emollients Include aqueous cream, sorbolene cream, white soft paraffin and wool fats When used regularly they can: alleviate pruritus reduce scale enhance penetration of concomitant topical therapy hydrate dry and cracked skin

32. Topical Therapies: Keratolytics Over-the-counter products include: Salicylic acid Urea Help dissolve keratin to soften and lift psoriasis scales May enhance penetration of other actives

33. Topical Therapies: Coal Tar Help reduce inflammation and pruritus May induce longer remissions. Use limited by distinctive smell and ability to stain clothing and skin. May cause local skin irritation

34. Other Topical DITHRANOL - Anti-proliferative properties TAZAROTENE - Topical synthetic retinoid CALCIPOTRIOL - Synthetic vitamin D analogue Reverses abnormal keratinocyte changes

35. Topical Therapies: Corticosteroids Possess anti-inflammatory, antiproliferative and immunomodulatory properties Reduce superficial inflammation within plaques Potency choice depends on disease severity, location and patient preference.

36. Topical Therapies: Corticosteroids Adverse effects associated with long-term use include : Skin atrophy and telangiectasia Hypopigmentation Striae Rapid relapse or rebound on stopping therapy Precipitation of pustular psoriasis Pituitary-adrenal axis suppression through significant systemic absorption (rare)

37. Other Therapies Phototherapy Systemic therapies Methotreaxate Cyclospirin Biological agent Target immune system Tumour necrosis factor-alpha inhibitors Etanercept Adalimumab Infliximab Interleukin (IL-12 and IL-32) inhibitor Ustekinumab

38. Summary Psoriasis is a lifelong condition . Chronic, inflammatory disease of skin T-cell mediated disorder Classic presentation characterised by red, scaly plaques. Gets worse over time Individuals will often experience flares and remissions throughout their lives. Controlling the signs and symptoms typically requires lifelong therapy

39. Summary Management should address both medical and psychological aspects There is currently no cure but various treatments can help to control the symptoms. Most effective agents for severe psoriasis carry an increased risk of skin cancers, lymphoma and liver disease. Treatments include topical therapy, phototherapy, systemic therapy and biological agents