| How is the epidemiology of psoriasis? | • Psoriasis is a global health problem with a worldwide prevalence 2%
- Variation between countries
- Equally prevalent in both sexes
- Prevalence increasing
• 75% of patients experience onset before 40 years of age: 35 to 50% of patients experience onset prior the age of 20 years
• Up to 7.5 million people in the US are affected
• Affects men and women equally
• Can affect all races
• Often appears first in young adults
• Age of onset in 2 peaks: ages 20-30 and ages 50-60, but can be seen at any age
• Up to 30% of patients with psoriasis will develop psoriatic arthritis |
| What is psoriasis? | • Psoriasis is a chronic, systemic inflammatory condition that manifests primarily as a skin disorder
• There are multiple types of psoriasis, including plaque, inverse (or intertriginous), erythrodermic, pustular, and guttate
• Many patients with psoriasis have more than 1 type |
| What are key clinical points in psoriasis? | • In the typical psoriasis, the general condition is not altered
• Psoriasis is not contagious
• Pruritus is present during flare-ups in 50% of cases
• Psoriasis decreases without leaving a scar
• Lesions can be painful, especially in the palms and plants where cracks may appear
65% mild, 25% moderate and 8% severe |
| What are environmental factors affecting psoriasis? | Infections (starts as rhinopharyngitis episodes [viral/GBS], occurs or worsens w/HIV infection)
Drugs (beta blockers, rebound effects w/coritcosteroids)
Psychological (emotional shocks, trauma, pro-inflammatory neuromediators secretion) |
| How is dx of psoriasis? | • The diagnosis of psoriasis is clinical
• Skin biopsy is only indicated when there is a diagnostic doubt for atypical lesions
• Classical presentation: Plaque-Psoriasis
• More often than not, these lesions are multiple and symmetrical, sometimes diffuse
• The size of the lesions is variable: plaque psoriasis; nummular psoriasis
• Elective locations (bastion areas): Areas exposed to friction and physical trauma: elbows (and cubital edge of the forearm) knees, legs, lower back sagging region, scalp , nails, palms and soles
• Usually respect for the face |
| How is classification of psoriasis based on morphology? | Plaque (scaly, very well demarcated, round, erythematous papule, surface is white greyish thick or may be stripped by the tx revealing the underlying rash, Multiple symmetrical bilateral diffuse sometimes, affect 80-90% of the pts, may have auspitz sign [bleed after removal] or koebner [induced by trauma])
Inverse (erythematous patches located in skin folds, felxural disribution, lack scale)
Guttate (due drop like lesions 1-10 mm salmon pink papules w/fine scales can be triggered by strep pharyngitis managed by Abx, ATB, topical tx, Band UVB)
erythrodermic (generalized erythema covering entire body surface area w/varying degree of scaling)
Pustular (clinically apparent pustules, generalized Von Zumbusch variant, localised palms and soles) |
| How is dermatoscopy of PsO? | • Red dots
• Regular distribution
• White scales |
| What is palmoplatar pustulosis? | • Pustular damage to a type of palmoplantar pustulosis that may be associated with sternal or sternoclavicular joint damage (SAPHO syndrome) |
| What is acrodermatitis continua of hallopeau (ACH)? | • ACH is a rare inflammatory disease characterised by
pustular eruptions beginning in the tips of fingers and
toes
• The pustules may vary in extent over a chronic, recurrent
course
• ACH is often triggered by localized trauma or infection at the distal phalanx (the tip of the digit). 80% begin in only
one digit, most commonly the thumb
• Pustulation of the nail bed and its growth site (matrix)
can result in onychodystrophy and anonychia (loss of nail)
• There may be osteolysis resulting in a wasted and
tapered tip of finger or toe
• Evolution: Generalized pustular pso, conjonctivitis, oral
inflammation, urethritis
• Treatment: Topical potent CSteroids, tacrolimus,
methotrexate |
| What is genital and scalp psoriasis? | Genital: scaly or non-scaly erythematous lesions aggravated during sexual intercourse.
Scalp: Psoriatic lesions affecting the skin or the scalp are similar and characterised by well-defined red, silver white scaly plates
Scalp involvement may affect as many as 90% of psoriatic patients Scalp psoriasis is highly visible and causes significant psychosocial disability
Psoriatic lesions usually advance just beyond the scalp margin, but sometimes extend onto the face and behind the ears
Rarely causes hair loss but can engain the hair follicles causing it
Anterior head the lesions are inflammatory and produce red crown discretely flaking |
| How is face psoriasis? | AKA sebopsoriasis
Rare, it can mimic a seborrheic dermatitis: erythema and thin scales of the eyebrows and the nasolabial fold Locations at the ear conch and external ear canal are possible |
| How is nail psoriasis? | Pitting: punctate depressions of the nail plate surface
• Onycholysis: separation of the nail plate from the nail bed
• Subungual hyperkeratosis: abnormal keratinization of the distal nail bed
• Oil drop sign: irregular area of yellow-orange discoloration visible through the nail plate
• Most of the lesions in nail psoriasis arise from disease in the nail matrix and/or nail bed
• The nail plate is formed primarily from the nail matrix with secondary contribution from the nail bed |
| How is psoriatic arthritis? | • PsA in the presence of PsO
• Member of the seronegative spondyloarthropathies
• About 30% of PsO
• Can occur at any age, but most commonly appears between the ages of 30 and 50 years
• Symptoms can range from mild to severe
• Severity of skin disease and arthritis may not correlate
• Dactylitis and enthesitis
• Flare and remissions |
| How is screening and tx goals for psoriasis? | • Health care providers are encouraged to actively seek signs and symptoms of PsA at each visit
• PsA may appear before the diagnosis of PsO
• Treatment goals include:
Alleviate signs and symptoms PsA, Inhibit structural damage, Maximize quality of life QoL
Screening Tool: PEST questionnaire [swollen joints? arthritis? nails holes? heel pain? swollen finger w/out reason?] and MIND (morning stiffness, inflamed joint, enthesitis, dactylitis) |
| What is erythrodermic psoriasis? | • Generalized psoriasis to more than 90% of the skin surface with abundant flaking. Fever, malaise
• It may be caused by a rebound after stopping certain therapeutic agents )general corticosteroid therapy).
• As any erythroderma, can be complicated by superinfection, vitamin deficiency, thermoregulation disorders, dehydration and hemodynamic disorders
• The patient should be admitted in hospital ungently, ICU, Burns |
| What is generalized pustular psoriasis? | • It may appear immediately or complicate Plaque Psoriasis
• May be triggered by various medications
• Sudden start with altered general condition, high fever and bright red closets that are covered with non follicular surface pustules that can confluence into large tablecloths essentially located on the trunk
• Evolution can be severe, which can put the prognosis at risk
• Histo: Spongiform, non follicular and aseptic pustular lesions, which differentiates them from infectious pustules |
| What are drugs that worsen psoriasis? | • Systemic corticosteroid treatment or withdrawal
• β blockers
• Lithium
• Antimalarials
• Interferons
• NSAID's
• NB. Antibiotics are not common triggers of guttate psoriasis |
| How is psoriasis evaluation? | Consider BSA percentage involved, lesion location and thickness, +/- psoriatic arthritis, symptom burden, psychosocial factors, QoL effects
DLQI done to assess impact on QoL |
| How is psoriasis a systemic disease? | . |
| What are objectives assessed in Pso? | • PASI (Psoriasis Area Severity Index):
• Psoriasis assessment clinical trials and better understand trials: erythema, induration, scale, (1-4), area (1-6)
• BSA (Body Surface Area) :1 hand= 1% of BSA
• Recent consensus: BSA; DLQI
• The percentage of patients whose PASI score is reduced by 75% (PASI75) is often used as an endpoint and as a means of comparing efficacy rates across clinical trials
• Recently: PASI 90, 100 |
| How is PASI score? | . |
| How is tx of psoriasis? | Topical corticosteroids (symptomatic relief and tx, organized according to their potency from high (class I) to low (class VII)
Class I 1000 times more potent than hydrocortisone 1%
strength differs according to the molecule not the concentration |
| What are classes of topical corticosteroids? | . |
| How is absorption of topical corticosteroids? | better absorbed in areas of inflammation and lesions, more absorbed in stratum corneum of infants compared to adults
anatomic regions w/thin epidermis are more permeable, oinments are more potent than creams or lotions |
| What are side effects of topical corticosteroids? | Local (skin atrophy, telangiectasis, striae, acne, allergic dermatitis, hypopigmentation. Higher potency = higher side effects, give in shortest time possible)
Systemic (rare, glaucoma, HPA axis suppression, Cushing's , HTA, hyperglycemia) |
| How is tx duration using topical corticosteroids? | Class I (<4 weeks), High and medium class (<6-8 weeks), Low potency (rare side effects, 1-2 weeks tx for first manifestations to avoid side effects)
Long-term management use least potent steroid
Stop tx when resolves [gradual reduction of potency and dosing to avoid rebound flares]
May use intermittent therapy to maintain long-term disease control [twice weekly]
If no response to tx consider refferal to a dermatologist |
| What are tx tips? | Treating thin sites (face, neck, folds) needs greater caution regarding potency
No absolute limit for steroid use
Address pt fear
Topical therapies in case no improvement (Reconsider dx, potency, instructions, compliance to tx, side effects)
Often poor tx outcomes is due to poor topical therapy adherence, due to cost, side effects, feels of tx...) |
| How is systemic tx of PsO? | • Phototherapy UVB-311nm NB: Targeted UVB therapy can be effective for “diffuse areas of psoriasis”. 2-3 sessions per week
• Methotrexate: a toxic folic acid analog C20H22N8O5 that is used to treat certain cancers, severe psoriasis, and rheumatoid arthritis. The dose in psoriasis is 15-25 mg/week with regular screening CBC, LFT’s
• Cyclosporine: an immunosuppressive drug C62H111N11O12 that is a cyclic polypeptide obtained as a metabolite from a fungus (Tolypocladium inflatum) and is used especially to prevent rejection of transplanted organs and in the treatment of rheumatoid arthritis and psoriasis. Contraindicated in HTN
• Apremilast: anti-PDE4.
Inhibition of PDE4 results in ↑ intracellular levels of cyclic adenosine monophosphate (cAMP). Indicated in PsO and PsA |
| How is pathogenesis of PsO? | • Complex genetic disease with many enviromental factors
• Hyperproliferative state resulting in thick skin and excess scale
• Skin proliferation is caused by cytokines released by immune cells
• Systemic treatments of psoriasis will target these cytokines and immune cells
In patients with psoriasis, the immune response is uncontrolled, resulting in a chronic production of pro-inflammatory cytokines. Multiple cytokine pathways are involved |
| Table of pathogenesis of PsO? | . |
| How are anti-inflammatory therapy options for psoriasis? | . |
