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Psoriasis lecture south yemen
1. Prepared by :- Dr Monther Fadel Nagi
Dermatology Resident
2. PSORIASIS
Definition
• Psoriasis is a chronic skin disorder characterized by
excessive proliferation of keratinocytes, resulting in
the formation of thickened scaly plaques, itching, and
inflammatory changes of the epidermis and dermis.
Clinical subtypes of psoriasis include guttate, pustular,
and arthritis variants
4. Etiology
• Unknown, but there is a strong genetic component and high
heritability. There are at least nine chromosomal loci with
linkage to psoriasis. These loci are called psoriasis
susceptibility 1 through 9 (PSORS1 through PSORS9). PSORS1
locus in the major histocompatibility complex (MHC) region on
chromosome 6 is considered the most important susceptibility
locus and is believed to account for 35% to 50% of the
heritability of the disease
• Familial clustering (genetic transmission with a dominant
mode with variable penetrants).
• One third of persons affected have a positive family history.
• A high prevalence of celiac disease has been noted in
patients with psoriasis.
5. Clinical Manifestation(s)
• Guttate psoriasis is generally preceded by
streptococcal pharyngitis and manifests with multiple,
droplike lesions on the extremities and the trunk
Some but not all patient will progress into
chronic plaque psoriasis.
6. Clinical Manifestation(s)
• Chronic plaque psoriasis generally manifests with
symmetric, sharply demarcated,erythromatous, silver-
scaled patches affecting primarily the intergluteal
folds, elbows, scalp, fingernails, toenails, and knees
This form accounts for 80% of psoriasis cases.
8. Clinical Manifestation(s)
• Pustular psoriasis may be generalized or focal and
can be associated with fever . Patients may move back
and forth between plaque and pustular morphologies.
9. Clinical Manifestation(s)
• Pruritus is variable. Soreness and bleeding may
occur.
• Joint involvement can result in sacroiliitis and
spondylitis.
• Psoriasis has an adverse effect on psychologic
and social functioning, with affected persons often
feeling stigmatized.
10. Physical Examination
• The primary psoriatic lesion is an erythematous papule topped by a
loosely adherent scale. Scraping the scale results in several bleeding
points (Auspitz sign).
• Nail involvement is common (pitting of the nail plate), resulting in
hyperkeratosis and onychodystrophy with
onycholysis.
16. TREATMENT
• Patients with psoriasis benefit from a daily bath
in warm water followed by application of a cream
or ointment moisturizer. Regular use of an
emollient moisturizer limits evaporation of water from
the skin and allows the stratum corneum to rehydrate
itself.
17. TREATMENT
• Therapeutic options vary according to the extent of
disease. Approximately 70% to 80% of all patients
can be treated adequately with topical therapy.
18. TREATMENT
• Patients with limited disease (<20% of the body)
-
be treated with the following:
• Topical steroids: disadvantages are brief remissions,
expense, and decreased effect with continued use.
Salicylic acid can be compounded by pharmacist in
concentrations of 2% to 10% and used in combination
with a corticosteroid to decrease the amount of scale.
19. TREATMENT
• Calcipotriene: a vitamin D analogue effective for
moderate plaque psoriasis.
Adults should comb the hair, apply solution to the lesions,
and rub it in, avoiding uninvolved skin. Disadvantages
include its cost and potential burning and skin irritation. It
should not be used concurrently with salicylic acid because
calcipotriene is inactivated by the acidic nature of salicylic
acid. Taclonex ointment is a combination of calcipotriene
and betamethasone dipropionate, a high-potency
corticosteroid. It is well tolerated and more effective than
either agent used alone but also much more expensive.
20. TREATMENT
• Tar products (Estar, LCD, Psorigel) can be used
overnight and are most effective when combined with
ultraviolet B (UVB) light (Goeckerman regimen).
• Anthralin: useful for chronic plaques; can result in
purple-brown staining; best used with UVB light.
• Retinoids such as tazarotene 0.05%, 0.1%, cream or
gel, are effective in thinning plaques but are expensive
and can cause irritation.
• Other useful measures include tape or occlusive
dressing, UVB and lubricating agents, and
intralesional steroids.
21. TREATMENT
• Therapeutic options for persons with generalized disease
(affecting >20% of the body) and for those with inadequate
response to topical agents
• UVB light exposure three times a week: this therapy does not
require administration of a systemic drug (unlike psoralen plus
ultraviolet A [PUVA]),
but to be effective, it requires removal of scale with keratolytic agents
and
emollients.
• Oral PUVA(Psoralen + ultraviolet light A) administered two to
three times weekly is effective for generalized disease. It is often
considered in patients for whom narrow-band UVB therapy is
ineffective. However, many PUVA treatments are required,
necessitating frequent office visits, and it may be associated with
phototoxicity, such as erythema and blistering, and increased risk of
skin cancer.
22. TREATMENT
• Systemic treatments include methotrexate 25
mg/week for severe psoriasis.
Etretinate (a synthetic retinoid) is most effective
for palmar-plantar, pustular psoriasis. The dose is 0.5
to 1 mg/kg/day. It can cause liver enzyme and lipid
abnormalities and is teratogenic.
23. TREATMENT
• Apremilast is a phosphodiesterase type-4 inhibitor
used in moderate to severe plaque psoriasis. Side
effects include diarrhea, nausea, headache, and
worsening depression.
• Cyclosporine is also effective in severe psoriasis;
however, relapses are common.
24. MODERN TREATMENT
• Chronic plaque psoriasis may be treated with
alefacept, a recombinant protein that selectively
targets T lymphocytes. Treatment with alefacept for 12
weeks (0.025, 0.075, or 0.150 mg/kg of body weight IV
weekly) may result in significant improvement. Some
patients also demonstrate a sustained clinical response
after the cessation of treatment. This medication is
very expensive (a 12-week course can cost >$8000).
25. MODERN TREATMENT
• TNF inhibitors: treatment with etanercept, a tumor
necrosis factor (TNF) antagonist, for 24 weeks can also lead
to a reduction in severity of plaque psoriasis. Efalizumab, a
humanized monoclonal antibody that inhibits the
activation of T cells, has also been reported to produce
significant improvement in plaque psoriasis treatment
period. Adalimumab—a fully human, anti-TNF-alpha
monoclonal antibody—has been reported to be effective
for joint and skin manifestations of psoriasis.
• Newer biologic agents in patients with moderate to
severe plaque psoriasis are
ustekinumab (an interleukin-
12 and interleukin-23 blocker)
