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Psoriasis
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- 2. Definition • Inflammatory & Proliferativedisease • Well defined , red , scaly plaques • Extensor prominences & scalp • Genetic & Environmental • Variable duration
- 3. Epidemiology Prevalence 1.5 –3 % Incidence 60 / 100000 in an year Seasonal variation 68% winter Morphological variants 10% Age of onset – bimodal Two peaks – 16-22 & 57-60 Sex – equal in males &females
- 4. Aetiology • GENETIC &ENVIRONMENTAL • More in 1st & 2nd degree relatives • 64% monozygotic twins • 15% dizygotic twins • 41% both parent • 14% one parent • 02% no parent
- 5. Genetic………… • Type-1 • Hereditary •HLA CW6 • Early onset • Severe • Type-2 • Sporadic • No HLA • Late onset • Mild
- 6. Environmental • Trauma -koebner & reverse koebner • Infection - strepto , HIV • Drugs - beta blockers , NSAIDS , lithium , chloroquin , withdrawal of steroid • Metabolic - hypocalcemia , pregnancy • Psychogenic , alcohol , smoking and AIDS • Winter and Sunlight
- 7. Pathogenic mechanism • Epidermalhyper proliferation • Dilatation & proliferation of dermal b.v • Accumulation of inflammatory cells esp neutrophils & T lymphocytes
- 8. Chronic plaque psoriasis •Well defined , red , dry , scaly , plaques • Scales - abundant , loose , silvery-white • Woronoffs ring – hypopigmented halo • Auspitz sign - multiple , minute , bleeding points – Grattage • Koebner phenomenon - 7-14 days
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- 14. Guttate psoriasis • Children& young adults • Acute streptococcal infection • Multiple, round to oval, 2 mm 1 cm • Trunk & proximal limbs • Good prognosis
- 16. Erythrodermic psoriasis • Erythema& scaling > 90 % BSA • Sudden withdrawal steroid, local irritant • Cutaneous vasodilatation heat loss • Hyperpyrexia and increased BMR • Loss of protein, iron, vit B12, folate • Anaemia , hypocalcemia , hypoalbuminemia • Dermatogenic enteropathy • Dermopathic lymphadenitis
- 18. Psoriasis unguis • 25- 50 % cases • Pitting • Discoloration • Subungual hyperkeratosis • Onycholysis • Splinter haemorrhage • Oil drop sign
- 19. Pustular psoriasis • Localised& Generalised • Localised pustular psoriasis Palmoplantar pustulosis Acrodermatitis continua
- 20. Palmoplantar pustulosis • Chroniccondition • Red , scaly plaques • Studded with sterile pustules • Palms & soles • Thenar , hypothenar eminence • Instep , medial & lateral border
- 22. Acrodermatitis continua • Chronic, sterile , pustular eruption • Tips of fingers & toes • Common in children • Red scaly plaque studded with pustules • Nail dystrophy • Osteolysis of distal phalanx
- 23. Generalised pustular psoriasis •Acute GPP • GPP of pregnancy • Infantile & juvenile GPP • Annular & linear GPP • Psoriasis with pustule
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- 25. Acute generalised pustular •HLA B27 • Most severe GPP • Sudden onset • High fever , malaise , joint pain • Multiple , erythematous patches • Tiny superficial , sterile pustules
- 26. GPP of Pregnancy •Last trimester of pregnancy • Starts in flexures • Symmetrical & grouped • Severe constitutional symptoms • Still birth, neonatal death • Recurrence common
- 27. Infantile & juvenileGPP • 25 % onset in 1st year • More in males • Usually benign • Spontaneous remission • Juvenile – onset 2 -10 years
- 28. Annular GPP • Subacuteor chronic • Systemic symptoms absent • Red scaly annular plaque • Pustules at the periphery
- 29. Localised form ofGPP ●Psoriasis with pustules ●Unstable psoriasis ●Tiny superficial pustules ●In & around psoriatic plaque
- 30. Psoriatic arthritis • Oligoarticulararthritis • Classical psoriatic arthritis • Rheumatoid type • Arthritis mutilans • Axial arthritis
- 31. Psoriatic arthritis • Seronegativeinflammatory arthritis • Rheumatoid factor negative • HLA B27,CW6 ,B13 ,B17 ,DR3 • 65 % cases skin lesion precede arthritis • 19 % cases arthritis precede • 16 % cases both together
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- 33. Differential diagnosis • Seborrheicdermatitis • Eczema - legs & hands • Lichen simplex chronicus • Candidiasis & tinea • Pityriasis rubra pilaris • Syphilis & drug eruptions
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- 40. Topical • Emollients • Corticosteroid •Coal tar • Dithranol • Calcipotriol • Topical photochemotherapy • Tazarotene
- 41. systemic • Methotrexate • Phototherapy •Retinoids • Cyclosporin • Hydroxyurea • biologicals
- 42. Others • Excimer laser •Photodynamic therapy
- 43. Coal tar • Antimitotic/ antiproliferative • Stable , scalp , palmoplantar • Crude coal tar , liquor picis carbonis • Folliculitis , acne , phototoxicity • ACD , ICD ,carcinogenicity
- 44. Dithranol • Anti inflammatory, antiproliferative • Stable plaque psoriasis • Palmoplantar • Erythema , irritation • Staining of cloth
- 45. calcipotriol • Synthetic analogue1-25 dihydroxy cholecalciferol • Stable plaque psoriasis • Max wkly application 100g • Skin irritation hypercalcemia
- 46. Topical corticosteroid • Scalp,face,neck,flexures,genitalia •Palms & soles • Limited plaque psoriasis
- 47. Side effects • Skinatrophy,striae • Telangiectasia • Hypertrichosis • Hypopigmentation • Glaucoma • Tachyphylaxis • Pituitary adrenal suppression
- 48. Topical PUVA • Palmoplantarpsoriasis • Palmoplantar pustular psoriasis • Localised recalcitrant • Nail psoriasis • Oral PUVA cotraindicated • Side effects - phototoxicity ,ocular ,skin cancers
- 49. tazarotene • Topical retinoid •0.05 – 0.1 % • Pruritus , burning , erythema , desquamation , contact dermatitis
- 50. Methotrexate • Antiproliferative –inhibit DHFR • Immunosuppressant • Anti inflammatory
- 51. Indication • Erythrodermic psoriasis •Psoriatic arthritis • Pustular psoriasis • Psoriasis adversely affect ability maintain employment • Extensive plaque psoriasis >20% BSA • No response to phototherapy / retinoids
- 52. contraindication • Pregnancy &lactation • Renal dysfunction • Abnormal liver function • Reproductive age gp • Excessive alcohol consumption • Hematological disease • Active peptic ulcer
- 53. Adverse effects • BMsuppression • Hepatotoxicity • GIT- ulcerative stomatitis • Pulmonary – pneumonitis ,fibrosis • Teratogen ,abortifacient • Cutaneous – ulceration , alopecia ,painful erosion of psoriatic plaque • MTX osteopathy –pain ,osteoporosis and compression fracture tibia
- 54. Oral retinoids • Acitretin, etretinate • Pustular , erythrodermic ,severe plaque • Side effects – mucocutaneous, ocular, teratogenic ,hyperlipidemia,elevated liver enzymes , depression , pseudo tumor cerebri ,musculoskeletal
- 55. phototherapy • Narrow bandUVB • PUVA –Psoralen + UVA • Re PUVA –retinoid + PUVA
- 56. Biological therapy • Antibodies, fusion proteins • Etanercept – Pso arthritis • Infliximab – blocks TNF - alpha • Alefacept – first therapy • Efalizumab , adalimumab • Opp infection ,lymphoproliferative diseases,SCC ,high cost
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