LICHEN PLANUS LICHEN NITIDUS PITYRIASIS RUBRA PILARIS PITYRIASIS ROSEA PSORIASIS PSORALENS SPONGIFORM PUSTUKES OF KOGOJ MUNROES MICROABSCESS WICHAM'S STRIAE KOEBNER PHENOMENON AUSPITZ SIGN MAX JOSEPH SPACE PHOTOTHERAPY PSORIATIC ARTHRITIS 20 NAIL SYNDROME LICHEN PLANOPILARIS HERALD PATCH

1. PAPULOSQUAMOUS
DISORDERS
TONY SCARIA 2010
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2. PAPULOSQUAMOUS DISORDERS
• LICHEN PLANUS
• PSORIASIS
• PITYRIASIS ROSEA
• PITYRIASIS RUBRA PILARIS
• SEBORRHIC DERMATITIS
• 2* SYPHILIS
• DRUG RAECTION
• REITER DISEASE
• ECZEMA
• TINEA TONY SCARIA 2010
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3. Psoriasis
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4. Psoriasis
• c/c inflammatory skin disorder characterised by erythematous
,sharply demarcated papules and round plaques, covered by silvery
mica like scales (d/t air trapped in b/w)
• Absent scaling in flexures and glans
• Variably pruritic
• In 2nd and 3rd decade
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5. • HLACW6  JUVENILE PSORIASIS
• HLAB27  PSORIATIC ARTHRITIS
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6. Sites
• Extensor aspect of elbows
• Knees
• Scalp
• Hand
• Sacral area
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7. Psoriasis
• Etiology
• HLA CW6 B13/17/37
• Positive family history (>50%)
• Worsen in winter
• Increased epidermal proliferation (4days ) psoriasis
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8. Aggravating factors
• Septic focus
• Emotional stress
• Cold
• Injury
• Trauma
• Drugs
• Beta-blockers, NSAIDS (ibuprofen), ACE inhibitors, Lithium, Antimalarials,
Terbinafine
• Calcium channel blockers ,Captopril
• Withdrawal of corticosteroidsTONY SCARIA 2010
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9. Histology
• Acanthosis
• Nuclei in stratum corneum
• Parakeratosis
• Prolifn of stratum spinosum
• Microabscess
• In stratum spinosum
• Spongiform pustules of Kogoj
• In stratum corneum
• Munroes microabscess
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10. T Cell mediated
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11. TONY SCARIA 2010
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12. • Squirting papillae
• Migration of neutrophils
out of dilated capillaries
• Suprapapillary thinning
• Stratum granulosa
• Edematous dermal
papillae
• Exaggeration of rete
pattern
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13. TONY SCARIA 2010
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14. Morphology
• Auspitz sign:
Removing the scale reveals a smooth, red, glossy membrane ( bulkeleys membrane )
with tiny punctate bleeding points
• Grattage test:
On grattage, mica like scales appear
• Candle grease sign:
• characteristic coherence of scales seen as if one scratches a wax candle(‘signe de la
tache de bougie) TONY SCARIA 2010
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15. Auspitz sign  d/t suprapapillary thinning
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16. Koebner /isomorphic phenomenon
• Traumatized areas (scratching,wounds,suture)develop somorphic
lesions in patients with cutaneous d/s
• psoriasis
• lichen planus
• Vitiligo
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17. Linear distribution of the plaques seen along
scratch marks or at sites of trauma
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18. Koebner phenomenon
• Vitiligo
• Lichen planus
• Lichen nitidus
• Psoriasis
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19. Reverse koebner
• Healing of lesion at the site of trauma (cryotherapy)
• Psoriasis
• Granuloma annualre
Pseudo – koebenrs
Seen in infectious diseases like warts ,pyoderma gangrenosum ,molluscum contagiousum
d/t spread of infective agent to new site ,
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20. KOEBNER
PHENOMENEON
• DEVELOPMENT OF
LESION ALONG
LINES OF
TRAUMA(7-14 DAYS
AFTER TRAUMA)
• D/T CYTOKINES
• PSORIASIS
• LICHEN PLANUS
• VITILIGO
• LICHEN NITIDUS
PSEUDOKOEBNER
PHENOMENON
• ALONG LINES OF
TRAUMA D/T VIRUS
INOCULATION
• MOLLUSCUM
CONTAGIOSUSM
• VERRUCA
VULGARIS
REVERSE KOEBNER
• ABSENC EOF
LESION ALONG
LINES OF TRAUMA
• PSORIASIS
INVERSE KOEBNER
• SUBSIDENCE OF
LESION AFTER
TRAUMA
• GRANULOMA
ANNULARIS
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21. • Woronoff‘s ring
Psoriatic plaques occasionally appear to be immediately encircled by a paler halo
Woronoff‘s ring
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22. Nail signs in psoriasis  high incidence of
psoriatic arthropathy
• Pitting in nail matrix  mc nail
change
• >10 pits = psoriasis
• Nail plate thickening
• Onycholysis
• Separation of nail plate from nail bed
• Oil spot sign  most
characteristic aka salmon patch
• Brownish disclorn of nail plate
• Subungal hyperkeratosis 
thickenend nail bed TONY SCARIA 2010
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23. Oil drop sign  most specific
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24. Nail pitting is also seen in
• Alopecia areata
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25. SURROUNDED BY RING
OF WARNOFF
(HYPOPIGMENTED)
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26. Classification
• Non pustular
• Chronic stable placque
• Guttate
• Erythrodermic
• Inverse
• Regional (scalp,palmoplantar)
• Rupoid ,
• elephantine and
• ostraceous
• Pustular
• Localised
• Generalised
• Acute generalised (von zumbuch)
• Impetigo herpetiformis (pregnancy)
• Psoriasis with arthropathy
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27. Chronic stable plaque psoriasis (psoriasis
vulgaris)
• Most common type
• elbows , knees , lower back,scalp,nails and napkin area
• Infants  napkin rash
• Elephantile and rupoid psoriasis
• Extensive scaling
• Rupoid psoriasis
• Limpet like cone shaped ,hyperkeratotic
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28. TONY SCARIA 2010
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29. guttate /eruptive/rain drop psoriasis
• in younger patients (children)
• characterized by an abrupt eruption of small drop shaped lesions.
• a/w acute group A beta haemolytic streptococcal infection of pharynx
in the preceding 7 to 10 days
• GOOD PROGNOSIS
• Rx
• Antistreptococcal antibodies
MINIMAL SCALING
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30. RUPIOID PSORIASIS
• ADHERENT SCALE
• LIMPET LIKE
• CONICAL
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31. Erythrodermic psoriasis
• Skin becomes universally red
and scaly
• Shivering + (compensate for
heat loss)
• Local irritant effect of
tar/dithranol/withdrawal of
steroid  erythroderma
• Rx
• MTX
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32. Pustular psoriasis
• Rare but serious type
• Precipitated by steroid use following withdrawal of steroids (hence
oral steroids are not used) , infection, hypocalcemia,pregnancy
,topical irritant
• Sterile pustules on erythematous base
• On palms and soles(acrodermatitis pustulosa)
• More common in smokers
• Rx
• Retinoids TONY SCARIA 2010
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33. Pustular psoriasis (ctd)
• Generalised pustular psoriasis of pregnancy  IMPETIGO
HERPETIFORMIS
• a/w hypothyroidism,hypocalcemia
• Rx  corticosteroids
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34. Von zumbusch phenomenon
• Acute generalised pustular psoriasis
• Rx
• Retionids , MTX
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35. WITHDRAWAL OF SYSTEMIC
CORTICOSTEROIDS
• ERYTHRODERMIC
• PUSTULAR PSORIASIS
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36. Inverse /seborrheic /flexural psoriasis
• Classical lesions of scalp a/w FLEXORS (against typical extensor
involvement  inverse) moist lesions in body folds (groins ,axillae,
submammary region,navel)
• No visible scales
• Resistant to Rx
TONY SCARIA 2010
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37. PENILE PSORIASIS
• ABSENT SCALING
• Scaling is absent in
• Guttate psoriasis
• Glans in uncircumcised patients
• Flexures
• Groins axillae vulva
inframammary folds
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38. Parapsoriasis
• Well defined maculo popular erythematous lesion in middle and old
age  mycosis fungoides
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39. Psoriatic arthritis
• In 30% psoriatic patients
• Skin lesions (early) joint involvement (late)
• Nail changes+
• PsA features include
• DIP joint involvement
• Dactylitis (sausage digitals)
• Arthritis mutilans(severe destructive arthritis)
• Corneal nodules
• Liver damage
• Rx
• MTX ,etanarcept TONY SCARIA 2010
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40. Radiological signs
• Opera glass hand (telescoping)
• Telescoping of bones in to its
neighbours with shortening of digits
• Pencil in cup sign
• Tapering of proximal phalanx and
bony prolifern of distal phalanx
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41. Radiological signs in PsA
• Whiskering
• Marginal erosions with adjacent bony proliferation
• Mouse ear
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42. TONY SCARIA 2010
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43. TYPES OF PSORIATIC ARTHRITIS
• CLASSIC  DIP
• OLIGOARTICULAR ASYMMETRIC MOST COMMON TYPE
• POLYARTICULAR SYMMETRIC
• ARTHRITIS MUTILANS
• SPONDYLITIS/SACROILITIS (AXIAL)
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44. Criteria for PsA caspar
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45. TONY SCARIA 2010
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46. Measures of psoriasis involvement
• Physical index’
• Psoriasis Area and Severity index (PASI)
• Physical global assessment (PGA)
• Salford psoriasis index (SPI)
• Quality of life index
• Dermatology life quality index (DQLI)
• Koo menter psoriasis instrument
• Short form 36
TONY SCARIA 2010
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47. treatment
• Topical therapy
• Emollients: white soft paraffin & liquid paraffin
• Corticosteroids: Potent steroids like fluocinolone acetonide, betamethasone
dipropionate or clobetasol propionate (for face and flexures)
• 5-10% Coal tar: for stable but resistant plaques
• 0.1-1% dithranol: for few stable, thick, resistant plaques
• Keratolytics & humectants: as adjuvants eg. Salicylic acid 3-10%, urea 10-20%
• Vtamin D analogues :Calcipotriene
• Tazarotene (topical retinoid)
• Macrolactams (calcineurin inhibitors): Tacrolimus & Pimecrolimus.TONY SCARIA 2010
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48. • Phototherapy with oral (2hrs b4 phototherapy) or topical psoralens
• Narrow band UVB
• goeckerman regimen
• (2-5 % coal tar applied over skin coal tar bath remove excess tarUVB light)
• Ingram technique
• Coal tar bath  UV exposure anthralin (dithranol)
• PUVA : systemic,topical and bath
• Catract, premature aging , skin malig
• Broad band UVB
• Balneotherapy
• High concentration saltwater bath + UVB
• 308nm excimer laser
Used with caution in patients on cyclosporine
and immunosuppression  increased risk of
SCC
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49. Psoralens bind to dna & form addcuts
• Natural
• 8 MOP
• Synthetic
• Trimethoxy
psoralen
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50. • Systemic therapy
• MTX , cyclosporine , retinoids (aciretin), PUVA
• Indications
• Erythrodermic
• PsA
• Pustular
• Interfering with employment
• >20% of BSA
• >10% PASI
TONY SCARIA 2010
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51. • METHOTREXATE
• HEPATOTOXIC
• TERATOGENIC
• CYCLOSPORINE
• NEPHROTOXIC
• RENAL HTN
• AZITRETIN
• TERATOGENIC
• DIFFUSE INTERSTITIAL SKELETAL HYPEROSTEOSIS 
TONY SCARIA 2010
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52. • Biologics
• TNF inhibitors
• Etanarcept, adalimumab,infliximab,
• IL 12/23 monoclonal ab
• Ustekinumab
• IL 17 ANTAGONIST SECUKINUMAB
• T cell modulators
• Alefacept,
• Efalizumab (withdrawn  progressive
multifoal leukoencephalopathy)
TONY SCARIA 2010
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53. PHOTOTHERAPY
• PUVA
• PHOTOCHEMOTHERAPY
• PSORALEN FOLLOWED BY UVA LIGHT
• PHOTOTHERAPY  BY USING NARROW BAND UVB 311nm
TONY SCARIA 2010
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54. Treatment of choice
• Impetigo herpetiformis
• Prednisolone
• PsA
• MTX,etanarcept
• c/c placque
• Nb UVB,PUVA
• Von zumbusch
• Retionids , MTX
• Pustular
• Retinoids TONY SCARIA 2010
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55. TONY SCARIA 2010
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56. Not found in psoriasis
• Alopecia
• Face involvement
• Scalp psoriasis may extend to forehea
• CNS involvement
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57. Lichen planus
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58. Lichen planus
• 5P
• Pruritic
• Plain (flat topped)
• Polygonal
• Purple
• Papules
WIKINHAMS STRIAE APPEAR ON
PRESSING OR EXAMINATION
WITH OIL
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59. Associations
• a/c or c/c
• Cell mediated immune response of unknown orgin
• Hepatitis C
• Drugs
• Gold,pencllamine,antimalrials,diuretics,phenothiazines
• Allergy to mercury in dental filling
• In patients with c/c GVHD
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60. Histology
• Liquefactive basal cell degeration
• Degenerated basal cells (colloid /
civette bodies/hyaline/cytoid)
•  pigment incontinence
• max joseph space ***
• Lymphocyte infiltrate in to dermis
• Rete dermis (saw tooth appearance )TONY SCARIA 2010
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61. PIGMENT INCONTINENCE 
ENGULFED BY MACROPHAGES
MEALANOPHAGES
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62. TONY SCARIA 2010
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63. Max joseph space
• Degeneration of basal cells sub epidermal clefts
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64. • Bunch of grape appearance
• On immunofluorescence
• d/t IgM on colloid body surface
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65. Sites
• Wrist and ankles
• Flexor aspect of forearm,shins,
• Lower back
• Genitalia (as annular white lesion)
• Painful and pruritic
• Oral mucosa (white net like/lace like eruption)
• Wickhams striae
• d./t wedge shaped hypergranulosis
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66. TONY SCARIA 2010
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67. • Koebner phenomenon + in LP
• Nail changes in LP
• 20 nail dystrophy
• Longitudinal grroving & ridging
• Hyperpigmentation
• Subungal hyperkeratosis
• Onycholysis
• Longitudinal melanonychia
• Nail plate thinning
• Pterygium unguis
• Characteristic of LP
• Forward growth of of proximal nail fold with adherence to
nail plate
20 nail dystrophy
Pterygium unguis
TONY SCARIA 2010
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68. ONYCHORRHEXIA
LONGITUDINAL RIDGING
BRITTLE NAILS
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69. TONY SCARIA 2010
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70. TRACHONYCHIA / 20 NAIL SYNDROME
• DESTRUCTION OF 20 NILS
• ALOPECIAL AREATA
• PSORIASIS
• LICHEN PLANUS
• ECZEMA’
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71. Confirmation of LP by skin biopsy
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72. Lichen planopilaris
• LP in hairy areas
• MC in females
• Scarring alopecia
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73. LICHEN PLANUS IN PALM AND SOLE
• YELLOWISH PUNCTATE DOT LIKE
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74. • Residual hyperpigmentation & scarring can occur
• Malignant transformation of oral,genital and esophageal lesions
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75. LICHEN PLANUS
• A/W LIVER DISORDERS
• HEP B
• HEP C
• PRIMARY BILIARY CIRRHOSIS
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76. Treatment
• Spontaneous resolution
• 6months – 2years
• HEAL WITH HYPERPIGMENTATION
• Topical glucocorticoids
• Antihistamines
• HCQ oral LP
• HYPERTROPHIC TYPE SALICYLIC ACID
• PHOTOTHERAPY IN GENERALISED
MOST TRETAMENT RESISTANT IS
HYPERTROPHIC LICHEN PLANUS
TONY SCARIA 2010
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77. LICHEN NITIDUS
• SKIN COLOURED GLISTENING PAPULE 
SHINY
• TRUNK & FOREARM
• VARIANT OF LICHEN PLANUS
• KOEBNER PHENOMENON +
Pin head sized papules
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78. Pityriasis rosea
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79. Pityriasis (fine scales) rosea (rose coloured)
• Young females +
• Collarette of scales on leading edge that does not extend to the
border of lesion (trailing scale)
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80. • CAUSED BY HHV7 > HHV6
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81. • Initially a HERALD (mother) PATCH appears on the trunk several
small salmon coloured lesion on trunk ,neck and thigh
• Lesions on the back  arranged parallel to ribs  CHRISTMAS TREE
PATTERN along langers lines
HERALD patch CHRISTMAS TREE PATTERN
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82. • CIGARETTE PAPER LIKE
SCALE
• PERIPHERAL
COLLARETTE
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83. Herald patch  positive hanging curtain sign
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84. • aetiology
• HHV-6 and HHV-7
• ACE inhibitors
• Self limiting
• Resolves in 4- 10 weeks
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85. RX
• SELF LIMITING
• NTIHISTAMINES
• MILD STEROIDS
• CALAMINE
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86. • Lesions resemble that of secondary syphilis
• But unlike in syphilis,palms and soles are not involved
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87. Pityriasis rubra pilaris
• resembles closely the psoriasis especially in the erythrodermic phase.
The follicular accentuation, focal areas of sparing (islands of normal
skin), sometimes more salmon coloration of pityriasis rubra pilaris
and the acquired palmoplantar keratoderma with yellow orange tinge
help to differentiate the condition clinically;
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88. PRP
• PRP OCCURS D/T DEFECTIVE RBP
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89. TONY SCARIA 2010
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90. CF
• MULTIPLE FOLLICULAR
PROMINENCESATTENUATION OF HAIR
FOLLICLES
• WITH ISLANDS OF SPARING
• MC SITE IS TRUNK
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91. • Follicular plugging, parakeratotic shoulder and
• perifollicular lymphohistiocytic infiltrate
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92. Islands of sparing in PRP
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93. PRP keratoderma in palmoplantar regions/
keratodermic sandal
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94. Rx OF PRP
• STEROIDS
• RETINOIDS
• SALICYLIC ACID
• SYSTEMIC  AZITRETIN
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95. Lichen nitidus
• Small glistening flesh coloured to
pink or reddish brown papules of
unknown etiology
• Histology
• Tuberculoid like granuloma with claw
clutching the ball appearance of rete
pigs
TONY SCARIA 2010
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