Psoriasis.Valmiki Seecheran.

Y5 MBBS.

Family Medicine Rotation | Dr. Adams.

Objectives.

• To have a brief overview of the background of psoriasis.

• To understand the signs and symptoms.

• To understand the various causes.

• To understand the mechanism.

• To understand the various types of work up.

• To understand the management.

Background.

• ‘’Psoriasis vulgaris’’

• Psoriasis is a chronic, noncontagious, multisystem, inflammatory disorder.

• Skin lesions vary from localized patches to entire body coverage.

• Affects 2-4% of general population.

• Occur at any age. Commonly in 15-25 years. M-F – 1:1.

• 5 types – plaque*, guttate, inverse, pustular and erythrodermic.

Signs & Symptoms.

Plaque psoriasis.

• 85-90% of people with psoriasis.

• Raised areas of inflamed skin covered with silvery-white scaly skin.

• Elbows, knees, scalp & back.

• Uncontrolled plaque psoriasis -> psoriatic eythroderma.

• Severe itching, swelling and pain.

• Often occurs from abrupt withdrawal of glucorticosteroids.

• Fatal – affects the function of skin – temperature and barrier functions.

Pustular psoriasis.

• Raised bumps filled with noninfectious pus.

• Skin around the pustules is red and tender.

• Usually localized to hands and feet - palmoplantar pustulosis.

• Generalized pustular psoriasis (von Zumbusch) – rare psoriasis during pregnancy.

• Annular pustular psoriasis – rare form. Seen during childhood.

Inverse psoriasis.

• Flexural psoriasis.

• Smooth, inflamed patches of skin.

• Affects skin folds – around genitals, armpits, overweight patients ( panniculus), intergluteal cleft and under breasts.

Guttate psoriasis.

• Numerous small, scaly, red/pink, ‘teardrop’ shaped lesions.

• Primarily appears on the trunk but also limbs and scalp.

• Usually preceded by a streptococcal infection – streptococcal pharyngitis.

Other.

• Seborrheic-like psoriasis – red plaques with greasy scales usually on scalp, forehead, skin folds close to the nose, around mouth and trunk.

• Psoriatic arthritis –• painful inflammation of joints and connective tissue – fingers and toes –

sausage shaped – dactylitis.

• Can also affect hip, knees, spine and sacroiliac joint.

• 30% psoriasis affect individuals will develop psoriatic arthritis.

Medical signs

• Other than clinical presentation.

• Auspitz’s sign – pinpoint bleeding when scale is removed.

• Koebner phenomenon – psoriatic skin lesions induced by trauma.

• Itching and pain localized to papules/ plaques.

Auspitz vs Koebner.

Causes.

• Genetics• 1/3 psoriasis patients report a family history.

• PSORS1 to PSORS9.

• Lifestyle• Chronic infections, stress, climate (temperate countries).

• HIV• Advanced HIV. More severe in patients with HIV along with psoriatic arthritis.

• Medication• Beta blockers, calcium channel blockers, statins, NSAIDS, Lithium, terbinafine,

steroid withdrawal.

Mechanism.

• Hyperproliferation of the keratinocytes in the epidermis, with an increase in the epidermal cell turnover rate.

• Skin cells are replaced every 3-5 days in psoriasis rather than the usual 28-30 days.

• Inflammatory cascade involving dendritic cells, macrophages & T-cells -> Premature maturation of kertainocytes.

Diagnosis.

• Clinical presentation!

• Scaly, erythematous plaques, papules, patches – painful + itchy.

• DDx – discoid eczema, seborrheic eczema.

• Skin biopsy – histological – stratum granulosum layer often missing or severely decreased – prematuration.

Treatment.

• Topical agents.• Corticosteroids – continuously 8 weeks.

• Moisturizers – Calcipotriol & coal tar.

• Phototherapy.• 311-313 nanometers. UV-B lamps. UV-A tanning beds. PUVA.

• Systemic agents – methotrexate, ciclosporin, retinoids. – immune suppressants & regulate epithelial cell growth.

• Alternatives- Sea baths – balneotherapy & fish oils.

Prognosis.

• Most people experience mild lesions that can be treated with topical therapies.

• -ve impact on quality of life – physical, aesthetic discomfort.

• Linked with low self esteem & depression.

• Increased risk of diabetes & HTN, Crohn’s disease & Ulcerative colitis.