Psoriasis Dr. M. Arif - PowerPoint Presentation

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Psoriasis

Dr. M.

Arif

Abid

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Psoriasis DescriptionInflammatory, common, chronic, genodermatosis which appears to be due abnormal t lymphocytes function

may be affected Skin, nails and joints forms.There are several distinct clinical type The most common presentation is scaly plaques on the elbows, knees, and scalp,

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3- 4 days

28

days

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History Prevalence worldwide estimated at 1-3% of the population. Etiology is not completely understood.

There are known inherited genetic factors and several established environmental triggers Men and women are equally affected. First-degree relatives are at increased risk of developing psoriasis.

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History onset at any age,peaks

during 20s and again in late 50s. A Early onset of generalized psoriasis implies a less stable, more severe chronic clinical course. Once expressed, psoriasis is likely to follow a relentless, waxing and waning course Extent and severity of disease varies widely Environmental factors, including treatment, influence the course and severity.

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Exacerbating factors human immunodeficiency virus infection physical trauma (Koebner phenomenon) infections(Streptococcus and Candida)

drugs:Ithiumbeta-blockersantimalaria corticosteroid withdrawalwinter season. The psychosocial impact can be severe.

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Clinical PresentationsVariations in the morphology of psoriasis

• Chronic plaque psoriasis• Guttate psoriasis (acute eruptive psoriasis)• Pustular psoriasis• Erythrodermic psoriasis

• Light-sensitive psoriasis

• HIV-induced psoriasis

•

Keratoderma

blennorrhagicum (Reiter syndrome)Variations in the location of psoriasis• Scalp psoriasis

• Psoriasis of the palms and soles

• Pustular psoriasis of the palms and soles

• Pustular psoriasis of the digits

• Psoriasis

inversus

(psoriasis of flexural areas)

• Psoriasis of the penis and Reiter syndrome• Nail psoriasis• Psoriatic arthritis

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Skin Findings Plaque Psoriasis The most common presentation.

Red, sharply defined, scaling papules that coalesce to form stable, round to oval plaques. It typically involves extensor extremities(elbows and knees), scalp, and sacrum

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Skin Findings…

Plaque Psoriasis …Face, palms and soles are not typically involved in this form. The deep rich red color is a characteristic feature presenting uniformly across the untreated lesion. The scale is adherent silvery white and reveals bleeding points when removed(the Auspitz sign).

Scale may become extremely dense, especially on the scalp

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Guttate Psoriasis This is an unstable form, associated with sudden appearance of

innumerable monomorphic 2-5 mm psoriasiform papules on the trunk with silvery scale. It is often associated with group A streptococcal pharyngitis, viral infections and-less often with systemic steroid withdrawal.

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Localized Pustular Psoriasis(Palmoplantar Pustulosis) This chronic recurrent form has been associated with tobacco use

. Small sterile pustules evolve from a red base on palms and soles. Pustules do not rupture but turn rusty brown and scaly as they reach the surface; they are often quite painful.

Nail involvement is common

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. Inverse(Inter triginous) PsoriasisAn uncommon form occurring in flexural or

intertriginous areas such as the groin, axillac and under the breasts, There are smooth, red and sharply defined plaques with a macerated surface, often with odor.

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Generalized Pustular Psoriasis An uncommon severe form requiring immediate medical attention.

It may be associated with fever and tenderness. Affected patients complain of chills and malaise. It may be drug related. Sterile pustules are regional or generalized, and often occur in waves with advancing pustules followed by thin desquamation and a new wave of pustules.

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Erythrodermic Psoriasis This uncommon severe form requires immediate medical attention.

There is total body redness with chills and skin painIt may be drug related.

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Nail Disease Clinical findings vary and are related to the specific areas of nail matrix involvement. Matrix:

Pitting results from involvement of the;

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Nail Disease Nail matrix involvement and/or involvement of underlying nail bed onycholysis

(separation of nail from nail bed), subungual debris oil drop sign

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Joint Disease Several distinct clinical patterns, all of which are rheumatoid factor negative.

The asymmetric oligoarthritis is the most common hose with psoriatic arthritis

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Joint Disease The distal interphalangeal affects 10% of patients with psoriatic arthritis often with local nail changes

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Joint Disease Symmetric polyarthritis is similar to rheumatoid arthritis in presentation.

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Joint Disease The mutilating type affects 5% of patients with psoriatic arthritis, it has onset.

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Joint Disease The spinal type affects 20% of patients with psoriatic arthritis and is debilitating

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Differential Diagnosis Seborrheic dermatitis involves the face more often than psoriasis, but is not mutually exclusive on the scalp Dyshidrotic eczema(hand/foot) is more vesicular than localized pustular psoriasis

Tinea capitis(scalp) and onychomycosis(nails) should be excluded with a potassium hydroxide exam

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Treatment The three categories of treatment: topical

therapy phototherapy systemic therapy-may be combined or alternated

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Topical Therapy Topical Tar Preparations(OTC) These are available in lotions, ointments foams and shampoos. They are relatively inexpensive, and may be compounded with topical They may cause irritation, odor, and staining of clothing

Calcipotriene and Calcipotriol They are vitamin D3 preparations which can be applied every day or twice daily as tolerated in amounts up to 100g per

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Treament…. Topical Steroids Topical steroids(group I-V) as monotherapy give fast but temporary

relief Use group I-V topical steroids(applied at a different time of day These are the best agents for reducing inflammation and itching

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Scalp Treatment oil(apply to entire scalp at bedtime, cover with a shower cap and wash out the following morning). Repeat for 5-10 days. This treatment removes scale and controls inflammation.

Hot olive oil turbans and manual scale debridement might work for very thick scaleSteroid gels or steroid foams penetrate through hair and into scale. Calcipotriene in combination with solution bethametasone dipropionate

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Topical Nail Treatment Nails are difficult to treat so the physician's goal is to provide symptomatic/cosmetic relief. Topical

calcipotriene solution, clobetasol solution and tazarotene gel may be helpful if applied to the posterior nail fold area; this requires months of Intra lesional triamcinolone injected

into the nail bed is painful to administer but often provides temporary improvement.

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Phototherapy UVB therapy Ultraviolet B This is a very effective treatment;

ultraviolet light may be used in combination with topical treatment.A minority of patients do not respond, and even fewer will get worse.Ultraviolet B is typically given 3-5 per week.PUVA therapy

Psoralin

+ UVA

2 hours

After taking 0.6mg/kg 8 methoxy

psoralin patient exposed to UVA source

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Systemic therapy Systemic therapy is complicated and best managed by a dermatologist. Rotational

Therapy A rotational approach to therapy minimizes long-term toxic effects from any one therapy and allows effective long-term management. Methotrexate Methotrexate is effective in unstable erythrodermic, generalized pustular psoriasis and extensive chronic plaque disease

.

Work up to a dose of 12.5-22.5 mg weekly.

Give folic acid 1 mg daily, but not on methotrexate day.

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Systemic therapy …Acitretin Highly

effective for generalized pustular and Erythrodermic psoriasis, moderately effective for palmoplantar psoriasis. Useful in combination with psoralen plus ultraviolet A and ultraviolet B.

(

RePUVA

)

Start at 10-25 mg/day as a single dose.

Side effects are similar to those of isotretinoin, which limits treatment for many patients they include: Teratogenicity, dry skin, sticky skin, myalgias,

arthralgias

,

pseudotumor

cerebri

, depression, hair loss, hepatitis, pancreatitis or increased

cholesterol/triglycerides

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Seborrheic dermatitis

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DescriptionSeborrheic dermatitis is a common, chronic, inflammatory papulosquamous

disease. It has been proposed that Pityrosporum oval yeast is the cause.

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HistoryAll ages can be affected. Infants and adults

There are tow distinct clinical presentations:Infantile seborrheic dermatitis Adult seborrheic dermatitis It has greater severity and is more difficult to control in patients with neurologic disease(e.g. head trauma, Parkinson's disease, stroke) and in patients with human immunodeficiency virus infection.

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Skin Findings The papules are moist, transparent to yellow, greasy and scaling, among coalescing red patches and plaques

Usually favors areas where the concentration of sebaceous glands is maximal: the scalp margins central face presternal

areas

.

Pityrosporum yeast grows favorably in these areas of oil production.

Characteristic locations are the: eyebrows, base of eyelashes nasolabial folds

paranasal

skin

and external ear canals.

May affect flexural skin including the postauricular, inguinal, and

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Pediatric Considerations(cradle cap) Infants (Cradle Cap)

Infants commonly develop a greasy adherent scale on the vertex of the scalp. Minor amounts of scale are easily removed by frequent shampooing with products containing sulfur

, salicylic acid, or

both.

Scale

may accumulate and become thick and adherent over much of the scalp and may be

accompanied by inflammation and Secondary infection can occur.It began from 2 month and continue untel 6 to 9 months

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Treatment Adults tend to have a chronic course with seasonal

remissions and exacerbations Flares are precipitated by stress, fatigue, and climate changes. Mild to moderate facial seborrheic dermatitis may respond well to topical antifungals such as ketoconazole cream.

Daily

facial

washing with antidandruff shampoo

or soaps containing zinc pyrithione(ZNP) or selenium

sulfide is effective. Group VI or VII topical steroid creams or lotions hydrocortisone applied twice daily for several days may be required periodically for control.

Mild to moderate

scalp involvement

is best managed with frequent and extended shampooing with antidandruff shampoos

,

Effective formulations may contain

ketoconazole, ciclopirox, coal tar, salicylic acid, selenium

sulfide,

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Antifungal therapy includes :ketoconazole 200mg every day

fluconazole 150 mg every day, or itraconazole 200 mg every day for 1 or 2 weeks.Indicated for sever un responsive to shampoo and topical steriodes seborrheic dermatitis

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Pityriasis Rosea

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DescriptionCommon, self limited, usually asymptomatic, clinically distinctive papulosquamous eruption.

Seasonal clustering of cases in the community are often noted

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HistoryMore than 75% of patients are between

10 and 35 years of age. Many patients report a mild prodrome or upper respiratory illness within a month of onset The first lesion herald patch, appears suddenly

and asymptomatically

, often on the chest or back.

The lesion is an oval plaque of 1-2 cm in diameter, which develops a thin

collarette of residual scale inside the border 1-2 weeks later numerous similar but smaller lesions begin to appear Reach a maximum number within 2 weeks while the herald patch is still present.

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HistoryLesions usually clear spontaneously in 4-12 weeks without scarring, although

postinflammatory pigmentary changes may take months to resolve in darker- skinned people.Seasonal cases in the spring and fall within the community suggest a viral etiology, though this has not been confirmed Limited outbreaks have occurred in close quarters such as fraternity houses and military barracks.

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Skin Findings Early lesions are broad-based papules

subsequently develop a thin collarette of scale the center of the papule desquamates.Lesions are salmon colored on Caucasian skin and

dark brown

on African-American skin

.

lesions are typically confined to the trunk

and proximal extremities often concentrated on the lower abdomen.

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The long axis of the oval lesions is reminiscent oriented along skin branches, pine tree when fully developed. most cases of pytirsis

rosea are clinically distinct may seem obvious,Atypical cases do occur and may be confused with other disorders.

Skin Findings

…

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Lichen Planus

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DescriptionAn uncommon, inflammatory papulosquamous disorder of unknown etiology

Skin, nails, hair and mucous membranes may be affected.

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HistoryRare in children aged under 5 years more common in women 10%

of patients have a positive family history Course is variable and unpredictable in all types Itching is variable, most often intermittent, and

instable

Can

occur

abruptly as generalized diseasc

may be secondary to a drug Severe oral lichen planus may degenerate to squamous cell carcinoma(in 3% of cases)

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Skin Findings

The primary lesion is a 2-10mm flat topped papule with an irregular, angulated border

(purple

polygonal papules).

New lesions are pink

but over time they become purple and sharply defined Surface shows a lacy reticulated pattern of whitish lines(Wickham's striae) New lesions may develop in areas of injury(the Koebner phenomenon)

There are several clinical

forms

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Papular Lichen Planus The most common clinical presentation

. Papules are located on the flexor surfaces of the wrists and forearms, the ankles and the lumbar region.

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Hypertrophic Lichen Planus Lesions that persist become thicker and darker red in color Most often they are on the shins.

Papules aggregate into different patterns. Vesicles or bullae may appear Persistent brown staining develops after the lesions resolve.

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Follicular Lichen Planus Follicular based on the scalp Permanent

hair loss with associate marked scarring (scarring alopecia).

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Mucosal Lichen Planus Most common form is the non-erosiv with a white lacy pattern

. The erosive form is painful with beefy desquamation. Oral lesions primarily involve the buccal mucosa and lateral edge of the tongue. This may extend to involve the mucosal lip but rarely extends beyond the vermillion border.

The penis and vulva may be involved, with intense itching and burning, marked mucosal fragility, and erythema.

Secondary

candidiasis occurs frequently, likely as a side effect of topical treatment.

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Nail Involvement Nail changes may be present in the absence of skin findings.

There are proximal to distal linear depressions in the nail plate ( longitudinal ridging) Inflammation of the matrix results adhesion of the proximal nail fold to scarred matrix to form a pterygium (scar)

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TreatmentSedating antihistamines(hydroxyzine 10-25 mg every 4 hours) for pruritus. Group

I or II topical steroids twice daily as initial topical treatment for localized disease.Intralesional triamcinolone acetonide ( 5-10 mg/mL) for hypertrophic lesions. Prednisone for generalized skin or erosive mucosal involvement; a 4-week course starting at 1 mg/kg/day and gradual decrease of the dosage.

Retinoids(

Acitretin

) 1

mg/kg/day,

cyclosporine(5-6 mg kg/day may be considered for severe recalcitrant forms of lichen planus. Tacrolimus 0.1% ointment twice daily has been used with some success for erosive oral lesions.

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Treatment …Corticosteroids(fluocinonide, fluocinolone actinide, triamcinolone acetonide in an adhesive base(Orabase) for initial treatment for oral lesions, applied directly to the lesions.

Prednisolone tablets, the active form of prednisone; 5 mg tablet dissolved in the mouth. Swish and swallow

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Any question?

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Thanks