Psoriasis

Definition Chronic multisystem disease with predominant skin and joint manifestation
2% of population
Skin inflamed hyperproliferates 10X normal rates increased cell turnover

Incidence Peak age: 20-30yo and 50-60yo

M=F
Strong genetic predisposition 30% of patients with FDR of similar disease
T lymphocyte driven disorder to an unknown antigen

Types Based on morphology

-Psoariasis vulgaris (common)
-Pustular psoriasis
-Erythrodermic psoriasis
-Guttate psoriasis
-Flexural psoriasis

Chronic Most common

plaque
psoriasis Skin Lesion Well circumscribed red-pink erythematous plaque with
(Psoriasis coarse silvery gray scales on skin
Vulgaris) Symmetrical, non-itchy
Site Extensor surface : knee/elbow
Scalp : extend beyond hair line
Body : para umbilical
Base of spine (sacral area)
Face
Auspitz sign Appearance of punctate bleeding spots when psoriasis
scales are scraped off
Koebners skin lesions appearing at sites of skin trauma
phenomenon (scratch/surgical scars)
Auspitz sign Koebners phenomenon

Nail Psoriasis
- can affect any part of one or more nails
- often have scaly plaques on the dorsum of the hands and fingers due to
associated plaque psoriasis
Onycholysis separation of nail from the nail bed
affected distal nail plate appears white or yellow
Subungual scaling under the nail due to excessive proliferation
hyperkeratosis of keratinocytes in the nail bed and hyponychium
Pitting sign of partial loss of cells from the surface of nail plate
 Psoriatic arthritis
-Seen in 10% of psoriasis pt
DIP arthritis Most common joint involvement
a/w nail dystrophy

Arthritis mutilans 5% of psoriasis pt

Marked periarticular osteolysis
Bone shortening (telescoping fingers)
Ankylosing spondylitis Unilateral or bilateral sacroilitis and early
cervical spine involvement; only 50% are
HLA B27 positive

Flexural Occur later in life mid elderly obese female

Psoriasis Well demarcated red glazed lesions, non-scaly
Confined to flexor areas : axillae, groin, perianal creases, sub-mammary folds,
napkin areas in infants
Guttate Raindrop like lesion: small circular/oval salmon pink papules with fine scale
psoriasis Presents after 2-3 weeks of strep infection over trunk
Commonly seen in young adults
Less scales, smaller plaque
Resolves within 4 months

Pustular Well demarcated erythema

arthritis Yellow/green pustules sterile collection of inflammatory cells
Localised variant of pustular psoriasis : palmoplantar psoriasis (confined to palm
and soles, a/w heavy smoker)

Erythrodermic Serious, life threatening - widespread intense inflammation of skin

psoriasis Cause : infection, inappropriate use of Dithranol or sudden withdrawal of steroid
May be a/w malaise, fever and circulatory disturbance with loss of heat, water,
electrolytes, iron, protein
Complication : dehydration, heart failure, infection, hypothermia
Treatment Conservative
- Reduce stress
- Avoid holiday in sun
- Avoid skin trauma
Topical
- Emollients reduce scaling, prevent plaque cracking & bleeding
- Coal tar plaque, guttate, scalp, flexures
- Salicylic acid reduce scalings
- Dithranol (anthranol) stable plaque psoriasis; effective but stains, cause
burning
- Steroids only for scalp & flexures
- Vitamin D analogue e.g. calcipotriol suppress plagues, also useful in
flexures
Phototherapy
- UVB 2-3x weekly, increase exposure gradually
- PUVA (psoralene + UVA)
- REPUVA (retinoids + psoralene + UVA) retinoids useful for abnormal
keratinization
Systemic
- Methotrexate generalized pustular psoriasis, erythroderma, psoriatic
arthropathy) 5-30mg once weekly PO. S/E: bone marrow suppression,
hepatic fibrosis
- Azathioprine
- Cyclosporin A
- Hydroxyurea
- Etretinate
- Biological agents (infliximab/etanercept TNFa inhibitor)