Psoriasis Flashcards
What is psorisis?
Chronic, non-infectious, auto-inflammatory skin disease with exacerbations and remissions
Psoriasis is characterized by?
well-demarcated erythematous plaques topped by silvery scale on certain predilection areas
Note; has a high psycosocial burden
Epidemiology?
- Prevalence 1-4% of the population worldwide
– US 3.7%
– Africans, African Americans and Asians: 0.4-0.7%
– East Africa: data not sufficient - Men= Women
- Psoriasis can occur in children but is less common as atopic dermatitis
Psoriasis triggers?
- Infection
e.g. streptococcus, HIV - Drugs
e.g. β-blockers, lithium, antimalarials, ACE inhibitors, nonsteroidal anti-inflammatory drugs - Stress
- Trauma
Pathophysiology key findings?
- Abnormal epidermal proliferation and differentiation: from 23 d to 3-5 d
- Inflammation
- Increased angiogenesis
Pathophysiology of psoriasis caused by triggers?
- Trigger leads to activation of T cells, dendritic cells and macrophages
- These activated cells release interleukins and chemokins
- This leads to a proliferation of the keratinocytes
Histopathology of psoriais?
- Parakeratosis (persistence of nuclei in stratum corneum)
- Acanthosis
- Inflammation
- Increased angiogenesis
Different variants of psoriasis?
- Classic plaque psoriasis
- Scalp psoriasis
- Flexural or inverse psoriasis
- Nail psoriasis
- Palmoplantar psoriasis
- Pustular palmoplantar psoriasis
- Guttate psoriasis
- Erythrodermic psoriasis
- Psoriatic arthritis
General findings of psoriasis?
- Sharply demarcated erythemato-squamous plaques, with silvery white scales
- Usually asymptomatic, although some patients have mild pruritis
- Limited - generalized
Typical general phenomena of psorisis?
- Candle-wax or silvery scales
- Koebner phenomenon
- Auspitz sign
Predilection sites psoriasis?
- Scalp 80%
- Elbows 78%
- Legs 74%
- Knees 57%
- Arms 54%
- Trunk 53%
- Sacral 38%
- Palms and soles 12%
Describe chronic plaque psoriasis?
- Diagnosed in 80-90% patients
- Symmetrical distributed, sharply defined erythematous squamous plaques
- Coin to palm sized plaques usually present months to years
- Nails in 10 to 55%
Describe scalp psoriasis?
- Most commonly involved
- Especially hairline and temporal regions
- Spread 1-2 cm into adjacent skin
- Usually no hair loss
Describe flexural/inverse psoriasis?
Psoriasis in intertriginous areas
1. Sharply demarcated shiny, red/pink plaque
2. Different appearance
– No scaling
– Plaques are thinner
– Often pruritic
3. Often centrally fissure
4. Fungal/bacterial infections are a common trigger
Describe nail psoriasis?
- 30-80%
- Finger nails more common than toe nails
- Pain + restriction in daily activities
- Most patients with psoriatic arthritis have nail involvement
Describe features of nail psoriasis?
- Pits
- Distal onycholysis
- Oil spots
- Subungual hyperkeratosis
- Splinter hemorrhages
Describe palmoplantar psoriasis?
- symmetric, sharply demarcated, erythematous plaques
- Adherent scaling
Describe pustular palmoplantar psoriasis?
- Individual or coalescing sterile pustules 1mm to 1 cm: Begin yellow then turn brown
- Mainly in women
- Smoking ++
- Rare in children
- 70%: hands and feet, 20% only feet, 10% only hands
How to tell if it is erytrodermic psoriaisis?
- Previously classic plaques
- Facial sparing
- Nail changes
- More adherent scaling
Describe guttate psoriasis?
- “Droplet” lesions mainly trunk
- Usually children and young adults
- Sudden onset
- Spares palms and soles
- Often preceded by infection: streptococcal
- In children good prognosis, in adults tend to be chronic
Describe erytrodermic psoriasis?
Difficult to distinguish from other causes of erythroderma
Pathophysiology of psoriatic arthritis?
- Inflammation and TNF-a cause abnormal fast epidermal turnover
> Plaques on the surface - TNF-a causes inflammation of synovial membranes and lead to
bone erosions, hyperostoses and deformation
Describe psoriatic arthritis?
- 20 % of cutanous psoriasis pts have psoriatic arthritis
- Seronegative (rheumafactor negative) spondyloarthritis
- Mainly hands, feet, knees, wrists and ankles
- Erosive changes (X-ray)
Describe the relationship between psoriasis and HIV?
- Development of eruptive psoriasis or sudden exacerbation of a pre existent psoriasis can be due to HIV infection
- Severity increases with degree of immunodeficiency
- Less responsive to treatment
- Often negative family history
Predeliction of sites of psoriasis in HIV?
- Face, often seborrhoic distribution
- Flexures
- Palmoplantar surfaces – Nails
- More often erythroderma
Ddx for chronic plaque psoriasis?
- Discoid eczema
- Tinea corporis
- Bowen’s disease
- Subacute lupus erythematosis
- Mycosis fungoides
Ddx for Guttate psoriasis?
- Secondary syphilis
- Tinea corporis
- Pityriasis rosea
Ddx for erytroderma?
- Atopic dermatitis
- Pityriasis rubra pilaris
- Drug reactions
- Sezary syndrome
Ddx for pustular palmoplantar psoriasis?
- Eczema
- Fungal Infection
Explain the high social burden of psoriasis?
- Difficulty finding a job
- Job complications e.g time off work, discrimination
- Financial distress
- Embarrassment when show psoriasis in public
- Sexual activity concerns
Management of psoriasis?
- patient education
- lifestyle modification
- medical treatment
Comorbidities associated with Psoriasis?
- Cardiovascular disease
- Metabolic syndrome
- Obesity
- Depression
- Increased risk for infection (most clearly in patients with erythrodermic psoriasis)
- Malignancies
- Psoriatic arthritis
- Other immune-mediated inflammatory diseases (Crohn’s disease)
Explain patient eductaion?
- Chronic skin disorder which waxes and wanes
- Disease course can be very unpredictable
- Treatment is to get control of the disease and not to cure it
- Complete clearance may not be achievable
- Get rid of myths that its contagious or a sign of cancer
- Explain how to apply topical therapies
Lifestyle modification?
- Healthy diet (As less sugar as possible, lots of fresh vegetables)
- No smoking/alcohol
- Sleeping
- Exercise
- Stress management: mindfulness/meditation
Medical treatment?
- topical
- phototherapy
- systemic
Topical treatment?
- Corticosteroids
- Vitamin D3 analogue (Calcitriol)
- Tar
- Dithranol
Phototherapy treatment?
- Sunlight
- UVB
- PUVA
Systemic treatment?
- MTX
- Ciclosporin
- Fumarates
- Retinoids (acitretin)
- Apremilast
- Biologicals
Treatment for mild psoriasis?
Only topical treatment
1. First remove scaling
– Salicylic acid 10%
– Application of emollients
2. Potent corticosteroids (+/- vit. D. derivate)/Tar/Dithranol
- Potent corticosteroid under occlusion (2x/wk, leave on for 2-3 days)
Moderate/severe psoriasis treatment?
- Continue local therapy with emollient/salicylic acid
- Treatment with UVB/PUVA therapy or exposure to sunlight: 2-3 times a week, 3 months
Severe psoriasis treatment?
- systemic therapy
- fumarates
- biological
What is the systemic therapy in treating severe psoriasis?
- Methotrexate
- more suitable for long term treatment, but hepatotoxic - Ciclosporin
- rapid response, but risk of hypertension and nephrotoxicity - Acitretin
- oral retinoid
- mono therapy mainly effective in pustular and erytrodermic psoriasis,
combination with PUVA is effective in chronic plaque psoriasis
Methotrexate dose?
10-25 mg ONCE a week
Investigations to be done when administering methotrexate?
Lab-Tests:
1. Cellular Blood count+ diff. at baseline,
- after 1 & 2 weeks, then 2-monthly,
(Bone marrow !)
2. Renal FT, Liver FT.
Contraindications of methotrexate?
- Family planning (female)
- Pregnancy/Breast feeding
- Severe infections
- Severe reduced Liver and renal function
- Alcohol abuse
- Hematologic disease
- Restricted lung capacity
- Severe heart insufficiency
