11. Psoriasis.
• Definition.
• Psoriasis is a complex , chronic , multifactorial ,
inflammatory disease that involves hyper
proliferation of the heratinocytes in the epidermis ,
with an increase in the epidermal cell turnover
rate. It is an immune-mediated disease (a disease
with an unclear cause that is characterized by
inflammation caused by dysfunction of the immune
system ) that causes inflammation in the body.
There may be visible signs of the inflammation such
as raised plaques (plaques may look different for
different skin types) and scales on the skin.
12. • This occurs because the overactive immune system
speeds up skin cell growth. Normal skin cells
completely grow and shed (fall off) in a month. With
psoriasis , skin cells do this in only three or four days.
Instead of shedding , the skin cells pile up on the
surface of the skin. Some people report that psoriasis
plaques itch, burn and sting. Plaques and scales may
appear on any part of the body , although they are
commonly found on the elbows , knees and scalp.
• Inflammation caused by psoriasis can impact other
organs and tissues in the body . People with psoriasis
may also experience other health conditions.
13. • This occurs because the overactive immune system speeds up
skin cell growth. Normal skin cells completely grow and shed
(fall off) in a mouth. With psoriasis , skin cells do this in only
three or four days.Instead of shedding , the skin cells pile up
on the surface of the skin. Some people report that psoriasis
plaques itch , burn and sting. Plaques and scales may appear
on any part of the body , although they are commonly found
on the elbows , knees and scalp.
• Inflammation caused by psoriasis can impact other organs and
tissues in the body. People with psoriasis may also experience
other health conditions. One in three people with psoriasis
may also develop proriatric arthritis. Psoriasis often goes
undiagnosed , particularly in its milder forms. However, it's
important to treat Psoriasis early on to help avoid permanent
joint damage.
14. Clinical Manifestations.
• Signs and symptoms of psoriasis may include the
following.
• Worsening of a long term erthematous scaly area.
• Sudden onset of many small areas of scaly redness
• Recent streptococcal throat infection , viral
infection , immunization, use of antimalarial drug
or trauma
• Pain (especially in erythrodermic psoriasis and in
some cases of traumitized plaques or in the joints
affected by psoriatic arthritis)
15. • 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
16. Etiology.
• a. Immune system :
• Immune system is body's defence against disease
and it helps fight infection. One of the main types
of cell used by the immune system is called a T-cell
. T-cells normally travel through the body to detect
and fight invading germs, such as bacteria . But in
people with psoriasis , they start to attack healthy
skin cells by mistake. This causes the deepest layer
of skin to produce new skin cells more quickly than
usual , triggering the immune system to produce
more T-cells . IT's not known what exactly causes
this problem with the immune system , although
17. • Genetics :
• If psoriasis runs in family , so one may be more
likely to psoriasis if a close relative suffers with the
condition , but the exact role genetics plays in
psoriasis is unclear. Research has shown that many
different genes are linked to the development of
psoriasis and it's likely that different combinations
of genes may make people more vulnerable to the
condition.
18. • Psoriasis triggers : Many people's psoriasis
symptoms start or get worse because of a certain
event , called a trigger . Knowing your triggers may
help , you avoid a flare up . Common psoriasis
triggers include :
• An injury to your skin , such as cut , scrape , insect
bite or sunburn - this is called the Koebner
response
• Drinking excessive amounts of alcohol
• Smoking
• Stress
19. • Throat infections - In some people , usually children
and yung adults , a form of psoriasis called guttate
psoriasis develops after a streptococcal throat
infection , but most people who have srteptococcal
throat infections don't develop psoriasis
• Other immune disorders , such as HIV , which cause
psoriasis to flare up or appear for the first time
20. • Classification of Psoriasis :
• Common types of psoriasis includes the following:
• Plaque Psoriasis
• Guttate Psoriasis
• Pustular Psoriasis
• Inverse Psoriasis
• Nail Psoriasis
• Psoriatic Arthritis
21. • Chronic stationary psoriasis (psoriasis vulgaris) :
Most common type of psoriasis , involves the scalp
, extensor surfaces , gentials , umbilicus and
lumbosacral and retro auricular regions.
• Plaque psoriasis : Most commonly affects the
extensor surfaces of the knees , elbows , scalp and
trunk
• Guttate psoriasis : Presents predominantly on the
trunk , frequently appears suddenly , 2-3 weeks
after an upper respiratory tract infection with
group A beta-heamolytic streptococci , this variant
is more likely to itch , sometimes severly.
22. • Inverse psoriasis : Presents on the palms and soles
or diffusely over the body
• Erythrodermic psoriasis : Typically encompasses
nearly the entire body surface area with red skin
and a diffuse , fine , peeling scale
• Scalp psoriasis: Affects approximately 50% of
patients
• Nails psoriasis : May be indistinguishable from , and
more prone to developing , onychomycosis
• Psoriatic arthritis : Affects approximately
10-30% of those with skin sympotms , usually in the
23. • Napkin psoriasis : Presence of psoriasis in children's
diaper region
• Linear psoriasis : Psoriasis that occurs within a
dermatome
24. • Pathysiology of psoriasis :
• Stress , Genetic , Autoimmune Reaction and
Medication Cause - Hyperactive of T-cells -
Epidermis Infiltration and Keratinocyte proliferation
-Deregulated inflammatory process - Large
production of various (Cytokines Interferron ,
interleukin -12) - Superficial Blood Vessel Dilated
and Vascular Engorgement - Epidermal Hyperplasia
and Improper cell maturation - Fails to release
adequate lipids which lead to flaking , Scaling
presentation of psoriasis lesion- silver scaling of
skin
25. • Pharmacological Management of psoriasis :
• Treatments are determined by the type and
severity of your psoriasis and the area of skin
affected. Physician will start with a mild treatment ,
such as topical creams applied to the skin and then
move on to stronger treaments if necessary .
• A wide range of treatments are available for
psoriasis , but identfying the most effective one can
be difficult.
26. • Treatments fall into 3 categories :
• Topical - creams and ointments applied to skin
• Phototherapy - Skin is exposed to certain types of
ultraviolet light
• Systemic - oral and injected medications that work
throughout the entire body
• Different types of treatment are often used in
combination .
• The various trearments for psoriasis are outlined
below :
• Topical corticosteroids : (e.g. triamcolone acetonide
27. • Opthalmic corticosteroids (e.g. predinosolone
acetate 1 % opthalmic , dexamethasone opthalmic )
• Intramuscular corticosteroids (e.g. triamcinolone ) :
Requires caution because that patient may have a
significant flare as the medication wears off , 3
months should elapse between injections
• Intralesioinal corticosteroids : May be useful for
resistant plaques and for the treatment of psoriatic
nails
• Coal tar 0.5 -33%
• Keratolytic agents (anthralin , urea) : use of these
29. • Transition from conventional systemic therapy to a
biologic agent , either directly or with an overlap if
transitioning is needed due to lack of efficacy or
with a treatment-free interval if transitioning is
needed for safety reasons
• Combination therapy
• Continuous therapy for patients receiving biologic
agents
• Switching biologic agents : if due to lack of efficacy ,
perform without a washout period , if for safety
reasons , a treatment free interval may required.
30. • Combinations of multiple agents : (e.g.
methotrexate and a biologic) are necessay in some
patients but the long-term safety and optimal
laboratory monitoring have yet to be defined.
• Other therapies :
• Management of psoriasis may also involve the
following nondrug therapies.
• Light therapy with solar or ultraviolet radiation
• Stress reduction
• Biofeedback
• Climotherapy
31. • Punctual occlusions and ocular lubricants :
• For Kerato-conjutivitis sicca
• Bandage contact lens : To retard corneal melting.
• Surgical option - Ocular manifestations such as
trichiasis and cicatricial ectropion usually require
surgical treatment . Progression of corneal melting ,
inflammation and vascularisation may require
lamellar or penetrating keratoplasty.
32. Eczema.
Definition.
Eczema is a general term for rash-like skin conditions
. The most common type of eczema is called atopic
dermatitis . Eczema is often very itchy . When you
scratch it , your skin becomes red and inflamed
(puffy). Eczema is most in babies but also affects
children and adults.
Atopic dermatitis is a chronic skin conditions . It is
caused by an allergic reaction.It is the most common
type of eczema.''Atopic'' describes an inherited
tendency to develop dermatitis, asthma and hay
fever. Dermatitis means that the skin is red and itchy.
33. Clinical Manifestation of Eczema.
• Atopic dermatitis (eczema) signs and symptoms
vary widely from person to person and include :
• Dry skin
• Itching , which may be severe , especially at night.
• Red to brownish-gray patches ,especially on the
hands , feet , ankles , wrist , neck , upper chest ,
eyelids inside the blend of the elbows and knees ,
and infants , the face and scalp
• Small , raised bumps , which may leak fluid and
crust over when scratched
• Thickened ,cracked , scaly skin
34. Etiology.
• Eczema is a polyetiological disease with complex
pathogenesis , where the main role is played by
allergic factors, affecting the organisms with
changed reactivity of the central and vegetative
nervous systems
• Genetic factor - In very rare cases , eczema is
caused by inherited mutations in a single gene.
• Psychological Factor - There is a brain-skin barrier .
Anger , emotional stress , depression, anxiety ,
tiredness , tension and low self esteem can cause
eczema.
35. • Endocrine turbulence.
• Hormonal fluctuations are reflected on the skin.
Aggravation during menstruation can be the cause
of eczema.
• Metabolize disorder - Eczema can be linked with
the metabolic syndrome and can increase risk of
cardio-vascular disease.
• Ingested allergen- Eczema comes and goes over
time . Allergens such as dust mites (Staphylococcus
aureus) , moulds , scurf , inhale pollen and food like
fish or shrimp can worsen the situation.
36. Classification of Eczema-Eczema
can be classified as-
• Contact Dermatitis.
• Contact dermatitis is an inflammatory reaction of
the skin to physical , chemical or biologic agents
.The epidermis is damaged by repeated physical
and chemical irritations
• Contact dermatitis may be due to irritants and
allergens
• The eruptions begin when the causative agent
contacts the skin. Acute phase includes itching ,
burning and erythema followed by edema and
oozing . In subacute phase , these vesicular
changes are less marked , and they alternate with
37. • Atopic Dermatitis .
• AD is a chronic , highly pruritic , eczematous skin
disease that follows patient from very early stage
i.e. childhood to puberty and sometimes adulthood
too.
• It is a state in which exuberant production of IgE
occurs as a response to common environmental
allergens.
• It can be hereditary and run in the family members.
• Common symptoms are dry and scaly skin , itchy
rash particularly on head and scalp , neck , buttocks
38. • Other factors can be climatic factors , anxiety ,
temperature , humidity , irritants and allergens .
• The patient with AD usually develops other atopic
disease like asthma , hay fever or food allergies.
• Seborrhoeic Dermatitis :
• Seborrhoeic Dermatitis commonly occurs in hairy
areas of the skin characteristic greasy yellowish
scales
• It causes redness on light skin , and light patches on
darker skin
• It is also called dandruff , cradle cap , seborrhea,
39. • Napkin Dermatitis.
• It is commonly known as nappy rash. It is an irritant
contact dermatitis caused by the interaction of
several factors.
• Particularly it involves the prolonged contact of the
skin with urine or faeces , which makes the skin
more prone to disruption through friction with the
napkin .
• Its best treatment is to keep the baby's skin clean
and dry . A mild hydrocortisone cream or antifungal
cream can be applied.
40. Pathophysiology of Eczema.
• There are two phases.
• Acute phase - In acute stage , the fluid escapes
from dilated dermal blood vessels to produce
edema in epidermis . This collects into tiny vesicles
or blisters , particularly where the skin is thick , as
on the palms and soles . These vescicles coalesce
into larger blisters. It may lead to rupture onto the
skin surface where skin is thinner and cause
exudation and crushing.
• It is characterized by progression through number
of diseases . Red , hot , swollen and itchy skin along
with papules , tiny blisters , scaling and exudation
41. • Chronic phase -
• The chronic stage shows less edema and
vesiculation and more thickening of the epidermis
and horny layers ,produced by prolonged rubbing
and scratching by the surface.
• In addition to features listed in acute eczema ,
chronic eczema may show dries skin , becoming
scalier and painful fissures.
• These both stages are accompanied by a heavy
inflammatory cell infiltration of dermis and
epidermis.
42. Pharmacological Management of
Eczema.
• The objective of management is to rest the
involved skin and protect it from further damage .
Local irritant should be removed and soap is not
generally used until healing occurs.
• Moisturizing - Emollients soften the skin and
reduce itching . For best effects oils such as
petroleum jelly can be used and creams or lotions.
• Itch releif -
• Application of anti-itch medication or calamine
lotion to the affected area and avoiding scractching
43. • Corticosteroids -
• The application of topical steroids is very effective .
Ointments are employed for dry or lichenified skin ,
creams or weeping skin or body folds and lotions.
• Immuno modulators -
• The drugs with antiinflammatory properties are
used. They regulate the local immune response of
the skin.
44. • Antibiotics - Up to 30 % of Atopic eczema is due to
bacteria . The use of oral antibiotics can be
effective.
• Anti-fungal Agents - Anti-fungal creams may help
with the infection which is available over the
counter .
• Immunosuppressants - They help to stop the itch-
scratch cycle of eczema and allow the skin to heal.
45. • Oral retinoid - The patients unresponsive to potent
topical corticosteroids are prescribed oral retinoid
(Alitretinoin)
• Non-Pharmacological treatment includes -
• Light therapy-
• Ultraviloet therapy - Ultraviolet light therapy
(phototherapy ) with PUVA (psoralens plus
ultraviolet A radiation) or combinations of UVA and
UVB
• Diet - Anti-inflammatory diet can be helpful in
treating eczema . Such diet involves fruits ,
46. • Traditional remedies -
• Traditional remedies such as chinese herbal tea ,
application of calendula cream which heals skin
inflammation , burns and cuts .
• Managing mental and emotional state -
Psychological support can help in eczema
management.
47. Scabies.
• Scabies is derived from latin word ''scabrere'' which
means to scratch.
• Scabies is an itchy skin condition caused by a tiny
burrowing mite called Sarcoptesscabiei which and
produce small red bumps.
• The mites live in the folds and narrow cracks of the
skin. Common mite sites include :
• Folds in between the fingers and toes
• Bends at the wrists
• Area around the belt shine
• Bends at the knees
48. • Intense itching occurs in the area where the mite
burrows. The urge to scratch mau be especially
strong at night.
• Scabies is cotagious and can spread quickly through
close physical contact in a family , child care group ,
school class , nursing home or prison.
49. • Clinical Manifestations.
• Inflamatory response , generalized pruritus
• Erythematous skin
• Pimple like rash or burrows between the common
sites of infection
• Intense itching mostly at night
• Sores on the body caused by scratching . Sores can
sometimes become infected with bacteria
50. • Etiology and pathophysiology.
• Scabies usually is transmitted by direct contact with
an affected individual.
• In classic scabies infection, typically 10-15 mites
(range , 3-50) live on the host .Little evidence of
infection exists during the first month (range , 2-6
weeks ) but after 4 weeks and with subsequent
infections, a delayed type IV hypersensitivity
reaction to mites , eggs and scybala (feces) occurs.
51. • The time required to induce immunity in primary
infestations probably accounts for the 4 week
asymptomatic latent period . While reinfestation,
the sensitized individual may develop a rapid
reaction (within hours).
• The resultant skin eruption and its associated
intense Pruritus are the hallmarks of classic
scabies.
52. • Pharmacological Treatment.
• The medications used for the treatment of scabies
are known as scabicides that target both mites and
their eggs and is only available by prescription.
• Historically it was treated with topical application
of 5 % of Sulphur but not in use nowadays.
• Prescription option include as :
• 5 % Permethrin cream : Commonly used and safe
for children as well as for pregnant woman.
• 10 % Crotamition lotion or cream
53. • 10% Sulphur ointment
• 1 % Lindane lotion
• 25 % Benzyl benzoate
• Keratolytic topical cream alone or in combination
with benzyl benzoate treatment.
• Anti-parasitic agents such as Ivermectin
• Other treatment includes :
• Antihistamines
• Antibodies
• Steroidal creams
54. • Calamine lotion
• 1 % permethrin i.e. Nix
• Sulphur soaps and creams
• Non pharmacological management includes -
• Educate patient about personal hygiene specially
hand washing
• Increase awareness and surveillance for scabies
• Use disinfectant sprays , including those that
contain permethrin on surfaces and clothing
55. • Apply rubbing alcohol or Lysol to kill bugs on hard
surfaces
• Wash clothes and bed linens in hot water and dry
on a hot cycle
• If you don't have access to hot water , place the
items in plastic bags and store them away from
home for five to seven days
• Wash pets with a pet-specific solution such as
sulfur concentrate pet dip
• Sprinkle borax on carpets . Many grocery stores and
department stores rent out steam cleaners at a
56. • Replacing mattress or use a zippered cover without
removing it for a few weeks.
• Putting all stuffed toys or unwashable fabrics in a
sealed bag for a few weeks and the scabies will die
off.
