Objectives:
Definition
Epidemiology
Etiology
Provoking factors g
Pathogenesis
Classification
Clinical features and complications
Diagnosis
Diagnosis
Treatment
Definition:
is a non infectious chronic inflammatory disease of the skin is a non infectious, chronic inflammatory disease of the skin , characterised by well-defined erythematous plaques and
papules with silvery scales and typical extensor distribution.
Epidemiology:
Age of onset: g
Early peak: the mean age is 22 years(8 years in children)
Late peakp
: the
mean age is 55 yearsg yIncidence:
Americas: 1-2% , rare in American blacks & almost absent in Red Indians
Europe: 1-2%
Japanese & west Africans: very low incidence.
Sex:
equal incidence in both male and female.Etiology:
Exact etiology is unknown but multiple factors are involved
Genetic predisposition:
The mode of transmission is still controversy.
10%
St
If one parent has psoriasis If both parents have psoriasis
10%
50%
Stress
.
Immunological factors:
*HLA-Cw6HLA Cw6.
*success of immunosuppressive drugs.
*development of psoriasis after B.M transplantation.p p p
*presence of T-cells in the skin lesions.
Others:(provoking factors).
Provoking factors:
A number of factors may provoke onset or aggravation of A number of factors may provoke onset or aggravation of psoriasis
¾Trauma .
¾Infection.
¾Drugs.
¾Sunlight.
¾Stress.
¾Smoking and alcohol
¾Smoking and alcohol.
¾Endocrinal factors.
Pathogenesis:
1)Alteration of cell kinetics of keratinocytes : 1)Alteration of cell kinetics of keratinocytes :
a. Shorting of the cell cycle from 311 h to 36 h(8 folds).
b. Decreased transit time from 1 month to 1 week.
2)Abnormal keratinocytes differentiation :
a. Normal epidermis :
K5/k14 are expressed in basal keratinocytes K5/k14 are expressed in basal keratinocytes.
K1/k10 are expressed in suprabasal kerationcytes.
Involucrin found in granular and cornified layers.
b P i ti id i b. Psoriatic epidermis:
Basal keratinocytes continue to express k5/k14, however keratins k1/k10.
are replaced by so called hyperprolifration associated keratins k5/k16.
Involucrin expressed prematurely in lower suprabasal layer.
3)immunopathogensis:
genetic background and provocating factors genetic background and provocating factors Exogenous/endogenous unknown antigeng / g g
Antigen presentation by APCs
T lymphocyte-mediated immune response Secretion of cytokines(mainly Th-1 cytokines)
Inflammation & cellular hyperprolifration Cli i l l i f i i
Clinical lesions of psoriasis
Cytokines in psoriasis:
*
T helper 1 cytokines increased(INF gamma IL 2)*
T-helper 1 cytokines increased(INF gamma,IL-2).*TNF alpha increased.
*IL-10 decreased (anti inflammatory cytokines)IL 10 decreased (anti inflammatory cytokines).
*IL-22 increased ,secreted by newly discovered Th-17 cells which are distinct from Th-1 and Th-2 cells.
Classifications : A)
Psoraisis vulgaris:A)
Psoraisis vulgaris:i. Chronic plaque(scalp,nails,inverse,palmoplanter)
ii. Acute guttate.g
B)psoriatic erytheroderma.
C)Pustular psoriasis:
i. Generalized acute pustular psoriasis(von zumbusch)
ii. Palmoplantar pustulosis.
D)P h
D)Psoriatic arthritis.
History:
1 Worsening of a long-term erythematous scaly area
1. Worsening of a long-term erythematous scaly area.
2. Sudden onset of many small areas of scaly redness .
3. Recent streptococcal throat infection, use of antimalarialp , drug, or trauma.
4. Family history of psoriasis.
5. Pain.
6. Pruritus.
Fever malaise headache
7. Fever, malaise ,headache.
8. Vesicles
9 long-term rash with recent presentation of joint pain
9. long term rash with recent presentation of joint pain
Physical examination:
Findings on physical examination depend on the type of Findings on physical examination depend on the type of psoriasis.
Plaque psoriasis is characterized by raised inflamed lesions covered with
il hit l Th l b d t l i fl d
a silvery white scale. The scale may be scraped away to reveal inflamed skin beneath. This is most common on the extensor surfaces of the knees, elbows, scalp, and trunk. Auspitz sign
Nail psoriasis
O h l i
Onycholysis
Nail pitting
Oil drop
Subungual hyperkeratosis
Splinter hemorrhage Leukonychia
Beau’s lines
Scalp psoriasis affects approximately 50% of patients, presenting as erythematous raised plaques with silvery white scales on the scalp.
Inverse psoriasis: in the armpits, groin, under the breasts, and in other skin fold around the genitals and the buttocks. This type of psoriasis first shows
l i th t d d ll l k th l i t d ith up as lesions that are very red and usually lack the scale associated with plaque psoriasis because of the moist nature of these areas
Acute guttate:The lesions of this type of psoriasis look like small, red, localized drops on the skin. In fact, the term guttate comes from that Latin
d tt i “d ” G tt t i i ll t t th t k word gutta meaning “drop.” Guttate psoriasis usually starts on the trunk, arms, or legs and sometimes spreads to the face, ears, or scalp.
The palms and the bottoms of the feet are usually not affected.
Palmoplantar psoriasis: is a chronic, recurring condition that affects the palms of hands and soles of feet. It looks similar to other types of skin
conditions such as hand dermatitis but the appearance of psoriasis lesions conditions, such as hand dermatitis, but the appearance of psoriasis lesions elsewhere on the body is an indicator of psoriasis.
Pustular psoriasis presents as sterile pustules appearing on the hands and feet or, at times, diffusely, and may cycle through erythema, pustules, and
li scaling.
A)Acute generalized pustular psoriasis :
B)palmoplantar pustulosis:
Erythrodermic psoriasis: presents as generalized erythema, pain, itching, and fine scaling.
Psoriatic arthritis: affects approximately 10% of those with skin symptoms. May be present without any visible psoriasis in 10 %.
There are five types of psoriatic arthritis:
Symmetric arthritis Asymmetric arthritis Asymmetric arthritis
Distal interphalangeal predominant (DIP) Spondylitis
A h i i il Arthritis mutilans
Clinical Type of psoriasis Differential Diagnosis Plaque type psoriasis Atopic dermatitis, irritant Plaque type psoriasis Atopic dermatitis, irritant
dermatitis, cutaneous T-cell lymphoma, pityriasis rubra pilaris, seborrheic
d i i
dermatitis
Acute guttate psoriasis Pityriasis rosea, secondary syphilis, drug eruption Localized Pustular
psoriasis
Pustular drug eruption, dyshidrotic eczema, subcorneal pustular dermatosis
dermatosis Generlized Pustular
psoriasis
Pustular drug eruption, subcorneal pustular dermatosis
Erythrodermic psoriasis Drug eruption, eczematous dermatitis, mycosis
fungoides, pityriasis rubra l
pilaris
Clinical Type of psoriasis Differential yp p Diagnosis g Scalp psoriasis Seborrheic dermatitis,tinea
capitis.
Inverse psoriasis Tinea Inverse psoriasis Tinea
,candidiasis,intertrigo,extra mammary paget`s
disease,gluconoma
syndrome,langerhans cell histiocytosis,hailey hailey disease.
Nails psoriasis onychomycosis
Complications of psoriasis:
1)Psoriatic arthritis and joints deformities 1)Psoriatic arthritis and joints deformities.
2)Erythroderma and its metabolic complications.
3)Infection, particularly Staph. Infections. ) , p y p
4)Amyloidosis , rare complication of arthropathic pustular psoriasis.
5)Psychological consequences : depression, anxiety, lack of self- esteem.
6)Gouty arthritis 6)Gouty arthritis
7)Potential complications of systemic therapy
Diagnosis of psoriasis:
A diagnosis of psoriasis is usually based on the appearance of A diagnosis of psoriasis is usually based on the appearance of the skin. There are no special blood tests or diagnostic
procedures for psoriasis. Sometimes a skin biopsy,or scraping, may be needed to rule out other disorders and to confirm the may be needed to rule out other disorders and to confirm the diagnosis
.
Dermatopathology :
¾Overall thickening of the epidermis (acanthosis) with
¾Overall thickening of the epidermis (acanthosis) with
Thinning of the epidermis over elongated dermal papillae.
¾Increased mitosis of keratinocytes,fibroblast,endothelial cells.y , ,
¾Parakeratosis.
¾Inflammtory cells in the dermis(T-lymphocytes &
macrophages) in the epidermis(polymorphonuclear cells) forming microabscesses of Munro in the stratum corneum.
parakeratosis
Microabscesses of munro Microabscesses
Dialted & tortuous capillaries Dialted & tortuous capillaries
I l thi ki f id i
Irregular thicking of epidermis
Upper dermal T lymphocytes
Serology:
9 ASO titer increased in acute guttate psoriasis
9 ASO titer increased in acute guttate psoriasis.
9HIV may associated with acute psoriasis.
9URIC ACID increased in 50 % of patients & usually correlate
9URIC ACID increased in 50 % of patients & usually correlate with the extent of the disease.
Bacterial Culture:
9Throat culture for group A beta hemolytic streptococcus f
infection.
Mycologic studies including potassium hydroxide wet amount Mycologic studies including potassium hydroxide wet amount preparation & culture: to rule out fungal infection
Treatment:
Factors affecting selection of treatment:
1)Age
2)Type of psorisis
3)Site & extent of involvment) 4)Previous treatment
5)Asociated medical disorders
Treatment modalities in the management of psoriasis:
•Topical agents.p g
•Phototherapy.
•Systemic agents.
Localized psoriasis:
1)Trunk & extremities:
1)Trunk & extremities:
•Topical steroids.
•Topical anthralin.
•Vitamin D3 analogues (calcipotrene).
•Topical tacrolimus.
•Topical retinoids
•Topical retinoids .
•Tar therapy.
•salicylic acid.
•Narrow band UVB phototherapy & PUVA photochemotherapy plus topical treatment.
2) Scalp
:
tar or ketokonazole shampoo followed by topical steroid.
tar or ketokonazole shampoo followed by topical steroid.
3) Palms & soles:
•topical steroids, if failed
•PUVA photochemotherapy,
•Systemic retinoids can be combined with topical steroids or PUVA photochemotherapy (much more efficacious)
4) Palmoplantar pustulosis:
PUVA “soaks” of hands & feet. MTX or CS for recalcitrant cases.
5) I i i
5) Inverse psoriasis:
initial therapy with topical steroids, topical vitamin D3 derivatives , topical retinoids,topical tacrolimus or pimecrolimus.
6) Nails:
PUVA photochemotherapy, systemic retinoids,MTX,CS
Generalized psoriasis:
1)Acute guttate:
1)Acute guttate:
• Antibiotics.
• Narrow band UVB irradiation.
2)Plaque type:
• Narrow-band UVB phototherapy.
• Oral PUVA photochemotherapyOral PUVA photochemotherapy.
If recalcitrant plaque type:
O l PUVA UVB t i ti id Oral PUVA or UVB + systemic retinoids
+ topical vitamin D3 analogues +MTX
Other combinations:
Acitretin + topical calcipotriene
Cyclosporine + topical calcipotrieney p p p
Generalized pustular psoriasis:
If patient is ill with generalized rash he should.p g
•Hospitalized & isolated as patients with extensive burns
•Supportive(Fluid replacement,electrolytes).
•Topical(Topical lubricants Antiseptic baths)
•Topical(Topical lubricants, Antiseptic baths) .
•Systemic( Systemic retinoids Systemic steroids I.V antibiotics).
Psoriatic erythroderma:
•Need hospitalization & isolation.p
•Room temperature adjusted to the patient’s need.
•Topical (water baths,oil bath, followed by bland emollients).
•Systemic (steroids retinoids)
•Systemic (steroids,retinoids).
•Supportive(fluid,electrolytes,protein replacement).
Psoriatic arthritis:
•MTX
Infliximab
•Infliximab
•Etanerecept
BIOLOGICS UDNER CLINICAL TRIALS:
¾IL-10
¾Anti IL 12/23 biologics(ustikinumab):
*IL-23(p19,p40) is critical for the survival & proliferation of the Th-17 ll
cells.
*IL-12(p35,p40) is needed by Th-1 cell for their proliferation.
*Ustikinumab is a new monoclonal Ab that specifically target the Th-17 p y g
& Th-1 pathways by targeting the shared p40 subunit of the IL-23 & IL- 12 .
