Psoriasis😊

Psoriasis

• 51 (HLA B51) yr old Nolan (Anti enolase) on a Bus (behcets)

Definition & Associations

• Systemic inflammation

• Genetic linkages
• Associated with PSORS1 and HLA CW6 genes

• Immune factors

Pathogenesis

• Turn over time → ↓ to 4 days

• Skin inflammation targets skin

• Inflammatory cells in epidermis

• Leads to:
• Dilation of blood vessels
• Thickening of epidermis
• Angiogenesis

• Major immune factors:

Helper cells	Products
↑↑ TH1	Interferon γ TNF α
↑↑ TH17	↑↑ IL 17
↑↑ TH22	↑↑ IL 22

• No Th2 response

Histopathology

• Dermal changes > Epidermal changes

Clinical Features

• Asymptomatic

• Environmental factors
• Sunlight improves
• Winter exacerbation
• Alcohol and smoking deteriorate

• Involves B/l symmetrical extensors mainly

• many variants

Lesions:

• Salmon coloured lesions

• Silvery white scale (typical)

• Well-defined plaques with scaling (secondary)

• Erythematous

• Indurated

• Thickened

• Scaly

Woronoff's ring:

• Perilesional pallor or hypopigmentation
• Due to local PGE2 ⛔
• vasoconstriction halo

• Worn off ring → itt itt pazhakiya ring → Hypopigmentation (color poi) → Felt sorry

Signs

1. Auspitz sign:
• Pinpoint bleeding points
• Aka Sign of last hautchen

2. Grattage test/Candle wax sign:
• Increased scaling upon scraping
• Mnemonic: Grutty (Grattage) Candle () scraping ()

3. Berkeley's membrane:
• Shiny dermo-epidermal junction

Koebner's phenomenon (isomorphic):

• Lesions of similar morphology develop along trauma lines

• Seen in psoriasis, lichen planus, vitiligo

• All or none phenomenon

Types:

• True Koebner:
• Psoriasis
• lichen planus
• vitiligo
• True → Story (Psoriasis) → We (Vitilligo) Like (Lichen Planus)

• Pseudokoebner:
• Warts
• molluscum
• Pseudo → Kallatharam → What (Wart) Moluu ()

• Occasional Koebner:
• Darier's disease
• Erythema Multiforme (EM)
• Occasional appearance → Dario (Dariers) → Has many forms (Multiforme)

• Questionable:
• Pemphigus vulgaris
• LE

Variants of Psoriasis (Site/Morphology)

Scalp Psoriasis:

• Erythematous scaly plaques

• Crosses hairline

• Not itchy

• No alopecia

Pityriasis amiantacea:

• asbestos-like scaling

• Mnemonic: Amaan (amiantacea) nte scalpil asbestoss veenu → Felt pitty

Palms and soles

Flexural/Inverse Psoriasis:

• Unusual appearance on flexures
  (no scaling, no induration)

• Difficult to differentiate from intertrigo/fungal
• In fungal → edges are not well demarcated → splashing

• Biopsy for diagnosis

• Not very symptomatic

Nail Psoriasis:

• Mnemonic: PSO → Pitting, Salmon patch, Oildrop

• A/w psoriatic arthrtis

• Most common: Pits (deep, random, irregular, large - DRILL)
• Mnemonic: Felt Sorry when drilled into finger → drilled appearance

• Other features:
• Onycholysis (distal)
• Nail plate crumbling

• Specific: Salmon patch/Oil drop sign
• Translucent orangish-yellowish red discoloration proximal to onycholysis
• Mnemonic: Felt sorry → so applied oil into nails

Differentiation from Onychomycosis:

• Onychomycosis:
• Mnemonic: Oncho → tOe (Otto)
• More common toenails
• no pits/salmon patch
• KOH+

• Nail Psoriasis:
• More common fingernails
• pits/salmon patch
• KOH-

Major findings in Nail psoriasis

• POLISH
• Pits
• Onycholysis
• Leukonychia
• Salmon patch
• Subungual Hyperkeratosis

Psoriatic Arthritis:

• Seronegative arthritis

• HLA b27 associated

• Classification by Moll and Wright

• Most common:
• Asymmetric oligoarthritis

• Most common joint:
• Distal interphalangeal (DIP)

• Other patterns:
• Symmetric polyarthritis
• Arthritis mutilans, spinal

• Criteria
• CASPAR criteria

• Mnemonic: Sorry mole → joint pain vannalle

Guttate Psoriasis:

• Usually in children

• Often after streptococcal throat infection

• Smaller, less scaly, erythematous plaques on trunk

• Raindrop appearance

• Treatment: Antibiotics (amoxicillin, penicillin)

Unstable Psoriasis:

• Not stable;
• increased redness, pain, tenderness

• Constitutional symptoms:
• fever, joint pains

• Forms:
• Erythrodermic psoriasis
• Pustular psoriasis

• Aggravating factors:
• Steroid withdrawal,
• coal tar,
• pregnancy,
• stress,
• infections,
• hypocalcemia

Erythrodermic Psoriasis:

• Redness and scaling >90% BSA

Summary of Terms in Psoriasis

• Associated with PSORS1 and HLA CW6 genes
• Contract work CW6 - sorry

• Parakeratosis

• Monro's microabscesses

• neutrophil collection

• Hyperkeratosis

• Acanthosis

• Kogoj's spongiform pustules

• Camel foot appearance/Rete Ridges

• Suprapapillary thinning → Vasodilation

• Winter exacerbation

• Salmon coloured lesions

• Silvery white scale (typical)

• Woronoff's ring: local PGE2 → hypopigmentation

• Auspitz sign/Sign of last hautchen

• Grattage test/Candle wax sign

• Berkeley's membrane

• Koebner's phenomenon (isomorphic) → All or none phenomenon

• Pityriasis amiantacea → asbestos-like scaling in scalp

• Mnemonic: POLISH → Pitting, Onycholysis, Leukonychia, Crumbling, Salmon patch, Oildrop

• Psoriatic Arthritis → Moll and Wright classification → Asymmetric oligoarthritis → DIP → Mnemonic: Sorry mole → joint pain vannalle

• Guttate Psoriasis → streptococcal throat infection → children → Raindrop appearance → Antibiotics

• Erythrodermic Psoriasis → Redness and scaling >90% BSA

• Pustular Psoriasis → Sterile pus → Lakes of pus
• Acute Generalized Pustular Psoriasis (Von Zumbusch's)
• Impetigo Herpetiformis:
• Impeti Herpti → Pause (Pustular) → SORRY (psoriasis)
• in pregnancy → Third trimester → low birth weight → Steroids (oral, safe in pregnancy) > Cyclosporin

Pustular Psoriasis:

• Sterile pus development (neutrophils)

• Lakes of pus
• Lake of pus → acid (acetreitin) ozhichu → to win zumba
• Acetreitin: (Vitamin A → Category X → washout = 3 years):

Acute Generalized Pustular Psoriasis (Von Zumbusch's):

• Treatment: Acitretin

Impetigo Herpetiformis:

• Mnemonic: Impeti Herpti → Pause (Pustular) → SORRY (psoriasis)

• Pustular psoriasis in pregnancy (misnomer)

• Erythematous plaques with pustules/lakes, scaling/fringing on margins

• Third trimester

• Can recur

• Associated with low birth weight

Treatment:

• Steroids (oral, safe in pregnancy) > Cyclosporin
• Only condition in psoriasis where oral steroids are given
• Because Steroids in psoriasis cause rebound phenomenon

Treatment of Psoriasis

Topical Treatment:

• For
• <10% BSA or
• <10 PASI (Psoriasis Area Severity Index)

Plaque psoriasis Rx

• First line topical → Topical corticosteroids

• First line systemic → Methotrexate

Agents:

• Corticosteroids
• DOC topical

• Calcineurin inhibitors
• for sensitive areas
• Calcineurin Inhibitor
• Tacrolimus
• Pimecrolimus (for face and flexures)

• Emollients, moisturisation, hydration

• Retinoids

• Vitamin D analogues

• Goeckerman's coal tar
• Man → go work (Goecker) in coal tar ()

• Anthralin
• Ingram (anthralin)
• In Anthra gramam

• Salicylic acid

Phototherapy:

• NBUVB (Narrow Band UVB):
• Preferred
• Wavelength: 311-313 nm
• UVB → B → 3
• Narrow → II → 11

• PUVA (Psoralen + UVA):
• Less common
• Because of Risk of skin cancers, cataracts
• D/t psoralen

• Targeted phototherapy:
• Excimer lasers (targeted UVB)
• Wavelength: 308 nm
• (Xenon chloride)
• Target → X → Excimer, Xenon, 8 (308)

Lasers:

Principle	Laser	Uses
Photocoagulation	ㅤ	• POAG, ROP, PDR = Retina Problems
ㅤ	• Nd: YAG (532 nm) ↳ Double frequency	• Proliferative DR → Panretinal photocoagulation • Laser trabeculoplasty
ㅤ	• Argon green (514 nm)	• Rx of POAG • AG → Argon Green
ㅤ	• SLT (532 nm)	• Prophylaxis in other eye in POAG
ㅤ	• Diode red laser	• Retinopathy Of Prematurity (ROP)
Photodisruption	Disrupt Yagam	ㅤ
ㅤ	• Nd-YAG/Nd-glass	• SMILE (Myopia surgery) • Flash (FLACS) adichapo • Cap (PCO) vach Smile (SMILE) • Glass (NdGlass) vachond photodirupt () ayi.
ㅤ	• Nd-glass 1054 nm	• FLACS (Cataract Sx) → 1054 nm ↳ Femtosecond Laser ↳ Used for 2 steps 1. CCC 2. Nuclear fragmentation.
ㅤ	• Nd-YAG 1064 nm	• Posterior Capsular Opacification (PCO) / ↳ After-cataract ↳ Occurs 6-12 months postop Cataract Sx ↳ M/c complication. ↳ Elschnig’s pearls (90%) ↳ Nd-YAG posterior capsulotomy / (Peripheral Iridotomy)
Photoablation	ㅤ	ㅤ
ㅤ	• Excimer	In Psoriasis • Targeted UVB (Phototherapy) • Xenon Chloride (308 nm) In LASIK, PRK for myopia • Argon & Fluoride (193nm) • Most commonly used in refractory surgeries

 

Systemic Treatment:

• Mnemonic:
• One girl had psoriasis
• Travelling in cycle (cyclosporin) → at 12 year old → met (methotrexate) an alpha (TNF alpha) → 23 year (IL12,23 → us) old → told him to have sex and kiss at 17 (IL 17 → seculizumab, ixekizumab) year age
• Lake of pus → acid (acetreitin) ozhichu → to win zumba
• Acetreitin: (Vitamin A → Category X → washout = 3 years):

• Methotrexate:
• Choice for plaque and erythrodermic psoriasis
• Dihydrofolate reductase inhibitor
• Weekly doses

• Acitretin
• Choice for pustular psoriasis or HIV+ patients
• Lake of pus → acid (acetreitin) ozhichu → to win zumba
• Acetreitin: (Vitamin A → Category X → washout = 3 years):

• Cyclosporin:
• Crisis drug for acute severe control (short-term)
• Side effects:
• kidney derangement,
• gum hyperplasia,
• hirsutism,
• hypertrichosis,
• hypertriglyceridemia
• hypertension
• Gingival hyperplasia

• Biologicals:
• Travelling in cycle (cyclosporin) → at 12 year old → met (methotrexate) an alpha (TNF alpha) → 23 year (IL12,23 → us) old → told him to have sex and kiss at 17 (IL 17 → seculizumab, ixekizumab) year age
• Anti-TNF alpha:
• Etanercept, Infliximab, Adalimumab
• IL17A inhibitor:
• Secukinumab, Ixekizumab (S for 17)
• SeventEEEEn → Se, Ixe
• IL12/23 inhibitor:
• Ustekinumab (US means 2 → 12, 23)

Pityriasis Rubra Pilaris (PRP)

• Pityriasis: Scaly

• Rubra: Red

• Pilaris: Hair follicle

• Pityriasis Rubra Pilaris (PRP)
• kandapo pityy () thonni → Red hair (Mudi (pilaris)) ulla oruthan (Red scaly papules) → chess board (Checkboard pattern) nte mukalil → PRP Sandal (PRP sandal: Hyperkeratosis of palms and soles) itt keri → Knuckle vach Nutmug (Nutmeg crater papules: on knuckles, IP joints) pottikkunn → From an Island (Island of sparing)

Clinical Features

• Checkboard pattern

• Islands of sparing (typical)
• Differs from psoriasis
• Scaling less marked than psoriasis

• Red scaly papules, predominantly interfollicular
• Erythema between papules

• Peri follicular

• PRP sandal: Hyperkeratosis of palms and soles

• Nutmeg crater papules:
• Hyperkeratotic erythematous papules on knuckles, IP joints

Types

• Six types

• Type 6 associated with HIV

Treatment

• Retinoids or Acitretin

• Methotrexate

Lichen Planus

• Mnemonic: Lichen Planus →

• I like only one on planet - joseph (max jooseph space)
• He is Hep B & C positive
• Thick skinned (Hyperkeratosis) Granpa (hypergranulosis)
• He has a wikk, stria (Wickham’s Striae → hypergranulosis in hand)
• Saw like tooth (Saw-toothed rete ridges b/w epidermis and dermis)
• He has dental amalgam
• Mudi illa (Cicatrising alopecia)
• Bites my Lace with his mouth (Lacy lesion in mouth)
• Theri parayum (Pterygium)
• Runs on track (trachyonychia → Longitudinal ridging)
• Runs on hill - Post inflammatory hyperpigmentation → Hilled lesions of lichen plannus
• Worship Siva (Civette bodies in stratum basale)
• Rub more than scratch

• Also A/w Hep B & C

• Autoimmune

• Affect Basement membrane zone

Clinical Features

• Papulo-Squamous Disorder: Affects:
• Skin
• Mucosa
• Hair and Nails

• Pruritic with Flexures → Rubs more than scratch

• Characteristic Lesion: "5 P's"
• Purplish
• Plane/flat-topped
• Pruritic
• Polygonal
• Papules and Plaque

• Common Sites: Flexors of wrist or ankle

Post-Inflammatory Hyperpigmentation:

• Lichen Planus with called post-inflammatory hyperpigmentation

• Hyperpigmented Macules are known as Hilled lesions of Lichen Planus.
• Runs on track and hill
• Hyper → Hilled

Koebner’s Phenomenon:

• Papules develop along trauma line

Wickham’s Striae:

• Whitish streaks on lesions (seen with hand lens)

• Due to hypergranulosis

Oral Lesions

• Symptoms:
• Pain
• Burning sensation with hot/spicy food

• Lacy reticular white pattern on mucosa

 

• Examination:

• Dental Amalgam:
• Can cause oral lesions

• Other Affected Mucosa:
• Genital
• Rectal

Variants in Oral Mucosa

• Types:
1. Reticular (most common)
1. Lacy white
2. Erosive
3. Atrophic
4. Ulcerative (premalignant condition)

Trachyonychia

• Longitudinal ridging of nails
  (most common)

• Onycholysis also seen

• Mnemonic: Lichen planus → Lines on a plane

Pterygium

• Finding:
• Wing-shaped extension of proximal nail fold onto nail plate

• Appearance:
• Tenting of nails

• Mnemonic: Like a lace → it extends

Cicatricial/Scarring Alopecia

• Cause:
• Lichen Planus

• Mechanism:
• Hair follicles destroyed

• Result:
• Scarring with no hair regrowth
• Irreversible

Histopathology

 

Treatment

Topical

• Corticosteroids

• Calcineurin Inhibitors
• Tacrolimus
• Pimecrolimus
• Applied to face, flexure regions, mucosa

• Antihistamine

• Local anesthetics
• For oral mucosa involvement

Intralesional

• Corticosteroid injections
• For hypertrophic lesions

Systemic

• For severe forms

• Commonly used systemic agents:
• Oral Corticosteroid
• Dapsone
• HCQS
• Azathioprine
• MMF (Mycophenolate Forfeited)
• NO METHOTREXTAE

Phototherapy

• NB-UVB Phototherapy
• Used especially in children with widespread lesions

Lichen Sclerosis

• Dyspareunia

• Itching

• Whitish plaques