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  1. 1. The Non Infectious, Chronic, Inflammatory “Itching Condition” Presented By: Siddharth Shankar Nath
  2. 2. Introduction Psoriasis is an immune mediated, non contagious skin disorder. It has no known cause. It is controllable but not curable. Course of disease often unpredictable It is a mistake of immune system that makes faulty signal which leads to overproduction of skin cell.
  3. 3.  It is characterized by well defined Erythematous plaques with large, adherent, silvery scales Term first used (along with “lepra”) by Hippocrates (460-377 B.C.) in Corpus Hippocraticum Von Hebra first to distinguish psoriasis from leprosy in 1841.
  4. 4. Types Plaque (Most Popular) Guttate Flexural (Inverse) Pustular Erythrodermic Others Like Nail, Palm, Scalp
  5. 5. Affected Location Scalp (80%) Elbows (78%) Legs (74%) Kness (57%) Nails (10-55%) Gluteal cleft Palms/Soles (12&)
  6. 6. Symptoms Of Psoriasis Most frequentlyexperienced symptoms Scaling 94 Itching 79 Skin redness 71 Tightness of skin 31 Bleeding 29 Burning sensation 21 Fatigue 19 Other 5 0 10 20 30 40 50 60 70 80 90 100
  7. 7. Common Triggers Factors ForPsoriasis 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) Smoking & Taking AlchoDrinking
  8. 8. 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
  9. 9. 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
  10. 10. Flexural Psoriasis Lesions in skin folds Particularly 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
  11. 11. Pustular Psoriasis Two forms: Localised form More common Presents as deep-seated lesions with multiple small pustules on palms and soles Generalised form Uncommon Associated with fever and widespread pustules across inflamed body surface
  12. 12. 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, malabsorp tion and anaemia Relatively uncommon
  13. 13. Nail Psoriasis May be present in patients with any type of psoriasis Can take several forms: Pitting: discrete, well- circumscribed depressions on nail surface Subungual hyperkeratosis: silvery white crusting under free edge of nail with some thickening of nail plate Onycholysis: nail separates from nail bed at free edge ‘Oil-drop sign’: pink/red colour change on nail surface
  14. 14. Palm Psoriasis Can be hyperkeratotic or pustular May mimic dermatitis – look for psoriatic manifestations elsewhere to aid diagnosis Possibly aggravated by trauma
  15. 15. Scalp Psoriasis Varies from minor scaling with erythema to thick hyperkeratotic plaques May extend beyond hairline Patient scratching may produce asymmetric plaques
  16. 16. Difference Between normal SkinPsoriasis Skin N O R M A L PSORIASIS
  17. 17. Treatments Tropical Phototherapy Systemic Climotherapy
  18. 18. Tropical Sunlight  Dithranol Corticosteroids  Tazarotene Calcipotrience Coal tar Moisturizes Bath solution Salicylic acid Emollient Keratolytics
  19. 19. Phototherapy UVB photo therapy PUVA (ultraviolet A) (UVA)
  20. 20. Systemic Methotrexate Cyclosporine Hydroxyurea Retionoids Antibiotics
  21. 21. Climotherapy For decades, people have claimed that visiting the Dead Sea in Israel is a powerful treatment for psoriasis. The sun and water, which is 10 times saltier than the ocean, are believed to be a healing combination. It may sound like a myth, but scientific evidence suggests this form of climatotherapy works. In studies, 80% to 90% of patients improved after visiting the Dead Sea. Almost half saw their rash disappear for the next several months.
  22. 22. Treatment Facts Approximately 70% of patients with mild-to-moderate psoriasis can be managed with topical therapies alone Mometasone Fuorate, Halobetasole, Clobetasole Propionate, desoximetasone, methotrexate, tazarotene , cyclosporine, fluocinonide are the major molecule used for Psoriasis treatment.
  23. 23. Corticosteroids Level of Potency Corticosteroid Commercial ProductsUltra-high Halobetasol propionate Ultravate crm/oint Clobetasol propionate Temovate crm/oint Betamethasone dipropionate Diprolene oint Diflorasone diacetate Psorcon ointHigh Halcinonide Halog crm Amcinonide Cylocort oint Betamethasone dipropionate Diprolene AF crm Mometasone furoate Elocon oint Diflorasone diacetate Florone oint Fluocinonide Lidex crm,gel,oint Desoximetasone Topicort crm,oint,gelMild to high Halcinonide Halog oint,crm,soln Triamcinolone acetonide Aristocort A oint Betamethasone dipropionate Diprosone crm Fluocinonide Lidex-E crm
  24. 24. CorticosteroidsLevel of Potency Corticosteroid Commercial ProductsMild Hydrocortisone valerate Westcort Triamcinolone acetonide Kenalog crm and oint Flurandrenolide Cordran oint Mometasone furoate Elocon crm Fluocinolone acetonide Synalar ointLow to mild Hydrocortisone valerate Westcort crm Triamcinolone acetonide Kenalog crm and oint Flurandrenolide Cordran crm Betamethasone dipropionate Diprosone lotion Hydrocortisone butyrate Locoid crm Flucolone acetonide Synalar crmLow Alclometasone dipropionate Aclovate crm and oint Betamethasone valerate Valisone lotion Fluocinolone acetonide Synalar soln and crm Hydrocortisone, dexamethasone, prednisolone, methylprednisolone
  25. 25. Corticosteroids Ointments: helps hydrate; good for dry, hyperkeratotic, scaly lesions Cream: for use on all areas, useful for infected lesions Solutions: for scalp psoriasis, often contain alcohols which can be painful with open lesions
  26. 26. Corticosteroids Adverse Effects: (esp. with occlusion)  Systemic absorption  Dermal atrophy  Telangiectasis  Ecchymoses  Peri-orbital acne  Poor wound healing  Pyogenic infections
  27. 27. Calcitriol 1. Increase cellular differentiation 2. Inhibits cellular proliferation Adverse Effects:  Hypercalcemia  Hypercalciuria  Mild calcitriol intoxication: renal stones  Not for long term use, therefore analogues were developed
  28. 28. Retinoids Vitamin A derivatives MOA: 1. Normalization of abnormal keratinocyte differentiation 2. Reduction in keratinocyte proliferation 3. Reduction in inflammation
  29. 29. Oral Retinoids  Etretinate & Acitretin (Soriatane®)  Second generation retinoids  For pustular and erythrodermic psoriasis  Etretinate withdrawn from US market- 1998  Acitretin= active metabolite of etretinate  Reserved for treatment of severe forms of psoriasis due to side effects.
  30. 30. Summary Chronic, inflammatory disease of skin. T-cell mediated disorder . Classic presentation characterised by red, scaly plaques. Management should address both medical and psychological aspects. Treatments include topical therapy, phototherapy, systemic therapy and biological agents.
  31. 31. Psoriasis Organization National Psoriasis  Directory of doctors Foundation (NPF):-  Assistance on insurance issues Established as patient  Driving research for better support group in treatments and control Portland, OR in 1968  Encourage all of your The best information patients to join about psoriasis, psoriatic arthritis, and treatments Psoriasis Advance magazine, 6 issues per year Support and encouragement through an online community of thousands
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