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
TONY SCARIA 2010
KMC
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
KMC
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 ,
TONY SCARIA 2010
KMC
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
TONY SCARIA 2010
KMC
21. • Woronoff‘s ring
Psoriatic plaques occasionally appear to be immediately encircled by a paler halo
Woronoff‘s ring
TONY SCARIA 2010
KMC
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
KMC
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
TONY SCARIA 2010
KMC
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
TONY SCARIA 2010
KMC
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
KMC
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
KMC
37. PENILE PSORIASIS
• ABSENT SCALING
• Scaling is absent in
• Guttate psoriasis
• Glans in uncircumcised patients
• Flexures
• Groins axillae vulva
inframammary folds
TONY SCARIA 2010
KMC
38. Parapsoriasis
• Well defined maculo popular erythematous lesion in middle and old
age mycosis fungoides
TONY SCARIA 2010
KMC
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
KMC
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
TONY SCARIA 2010
KMC
41. Radiological signs in PsA
• Whiskering
• Marginal erosions with adjacent bony proliferation
• Mouse ear
TONY SCARIA 2010
KMC
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
KMC
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
KMC
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 tarUVB 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
TONY SCARIA 2010
KMC
49. Psoralens bind to dna & form addcuts
• Natural
• 8 MOP
• Synthetic
• Trimethoxy
psoralen
TONY SCARIA 2010
KMC
50. • Systemic therapy
• MTX , cyclosporine , retinoids (aciretin), PUVA
• Indications
• Erythrodermic
• PsA
• Pustular
• Interfering with employment
• >20% of BSA
• >10% PASI
TONY SCARIA 2010
KMC
58. Lichen planus
• 5P
• Pruritic
• Plain (flat topped)
• Polygonal
• Purple
• Papules
WIKINHAMS STRIAE APPEAR ON
PRESSING OR EXAMINATION
WITH OIL
TONY SCARIA 2010
KMC
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
TONY SCARIA 2010
KMC
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
KMC
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
KMC
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)
TONY SCARIA 2010
KMC
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
TONY SCARIA 2010
KMC
82. • CIGARETTE PAPER LIKE
SCALE
• PERIPHERAL
COLLARETTE
TONY SCARIA 2010
KMC
86. • Lesions resemble that of secondary syphilis
• But unlike in syphilis,palms and soles are not involved
TONY SCARIA 2010
KMC
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;
TONY SCARIA 2010
KMC
93. PRP keratoderma in palmoplantar regions/
keratodermic sandal
TONY SCARIA 2010
KMC
94. Rx OF PRP
• STEROIDS
• RETINOIDS
• SALICYLIC ACID
• SYSTEMIC AZITRETIN
TONY SCARIA 2010
KMC
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
KMC