PSORIASIS

Eve Therese A. Ramos M.D., FPDS

•  An autoimmune, chronic, benign
hyperproliferative disorder of the skin
•  10-30% will develop psoriatic arthritis
•  Multifactorial : genetic, environmental,
immunologic
•  Characterized by symmetrical, well
defined red plaques with a thick silvery
scale
 ETIOPATHOGENESIS

1.  Genetic factors

•  Mode of inheritance uncertain - polygenic
•  HLA system - potential genetic markers: HLA Cw6,
B13, B16, and B27
–  1 parent has PSO = 8% offspring
–  Both parents have PSO = 41% offspring

2.  Provocating factors
•  Physical Trauma – Koebner’s phenomenon
•  Infection
»  Streptococcal pharyngitis
»  HIV infection - disease worsens
 ETIOPATHOGENESIS
•  Drugs:
» Lithium
» Systemic corticosteroids
» Beta-blockers
» Antimalarials
» NSAIDs
•  Sunlight – beneficial to most patients but sometimes
worsen
•  Stress
•  Smoking
•  Alcohol
•  Endocrine - fluctuate with hormonal changes
» Begins during puberty
» Pregnancy improves but flares during post-
partum period
3. Role of immune response
GENETIC BACKGROUND
↓
PROVOCATING FACTORS
↓
EXOGENOUS/ENDOGENOUS ANTIGENS
↓
ANTIGEN PRESENTATION BY APC’s
↓
T LYMPHOCYTE-MEDIATED IMMUNE RESPONSE
↓
SECRETION OF CYTOKINES
↓
INFLAMMATION & CELLULAR HYPERPROLIFERATION
↓
CLINICAL LESION OF PSORIASIS
•  Principal abnormality in Psoriasis is an
alteration of the cell kinetics of keratinocytes
– Hyperproliferation
•  Cell replacement occurs 7x faster than
normal…basal cell is shed in 4 days ( normal is
28 days)
 HISTOPATHOLOGY
§  Hyperkeratosis with parakeratosis ((+) of nucleated keratinocytes in
the stratum corneum) → lack of maturation of cells

§  Reduced or absent granular layer

§  Acanthosis with elongation of rete ridges and upward elongation of
dermal papillae.

§  Infiltrate: Mononuclear in dermis and polymorphs in the upper
epidermis forming collections called “Munros microabcess”

§  Upper dermal vasculature shows dilatation and tortuosity
LOW POWER VIEW
HIGH POWER MAGNIFICATION
MUNROS MICROABSCESS
 CLINICAL FEATURES
History
§  (+) Family history
§  1st manifestation any age but 2 peak groups:
§  1st peak in the 2nd decade
§  2nd peak in the 6th decade
§  Onset following trauma, infection, sunburn or
psychological stress
§  Complains of prominent itchy, elevated red areas with
increased scaling
§  Joint pain, stiffness, & deformity in 10% with psoriatic
arthritis
§  New lesions appear at sites of injury to the skin =
KOEBNER PHENOMENOM
KOEBNER PHENOMENON
SURGICAL INSCISION
KOEBNER PHENOMENOM
BURNING WITH SUN LAMP
 KOEBNER PHENOMENOM
X-RAY FOR CANCER OF THE ESOPHAGUS
Types of presentations

I.  Chronic plaque psoriasis

§  The most common
§  Persistent & chronic
§  Presents with typical plaques at the
extensors, elbows, knees, umbilicus, lower
back and scalp

CHRONIC PLAQUE PSO
EXTENSORS – ELBOWS & KNEES
CHRONIC PLAQUE PSO
SCALP
GENERALIZED CHRONIC PLAQUE PSO
II.  Guttate psoriasis
§  More common in childhood
§  Acute eruption of drop-shaped lesions
distributed widely over the body
§  Usually follows an upper respiratory
infection (Acute streptococcal infection)
§  Good chance of spontaneous complete
clearing
GUTTATE PSORIASIS
CLOSE-UP VIEW GUTTATE LESIONS
III.  Flexural psoriasis (Inverse Psoriasis)
§  lesions are present over the flexors and
intertriginous areas:
  Axilla
  Groin
  Umbilical region
Inframammary folds
§  Lesions are moist and lack typical scaling
§  Patients have typical psoriasis elsewhere
FLEXURAL PSORIASIS
INVERSE PSORIASIS
 IV.  Pustular psoriasis
A.  Localized pustular psoriasis
–  Persistent pustular eruptions of hands and feet

§  Pustulosis palmaris et plantaris
•  Groups of sterile pustules occur in crops on one or both hands
and/or feet
•  Associated with thickened, scaly, red skin developing into painful
cracks
•  not infectious

§  Acrodermatitis continua of Hallopeau

•  Dermatitis repens
•  Rare, chronic, localized, sterile pustular eruption of fingers and
toes
•  Middle-aged women
•  After localized trauma or infection on a single digit
•  Onychodystrophy and anonychia → osteolysis of distal phalanx

LOCALIZED PUSTULAR PSORIASIS
PUSTULOSIS PALMARIS ET PLANTARIS
LOCALIZED PUSTULAR PSORIASIS
PUSTULOSIS PALMARIS ET PLANTARIS
LOCALIZED PUSTULAR PSORIASIS
ACRODERMATITIS CONTINUA OF HALLOPEAU
 IV.  Pustular psoriasis
B.  Generalized pustular psoriasis
–  Explosive eruption of generalized pustules with systemic
disturbances
–  Preceding history of chronic plaque psoriasis
–  After withdrawal of systemic steroid therapy or application of
irritants
§  Pustular psoriasis of Von Zumbusch
§  Pustular psoriasis, Annular type
§  Impetigo herpetiformis (Gen. pustular PSO in pregnancy)

GENERALIZED PUSTULAR PSORIASIS
PUSTULAR PSORIASIS OF VON ZUMBUSCH
PUSTULAR PSORIASIS
ANNULAR TYPE
 PUSTULAR PSORIASIS
IMPETIGO HERPETIFORMIS (Gen. pustular PSO in pregnancy)

 IV.  Psoriatic arthritis

§  Accompany any variety of psoriasis in 10% of

patients
§  Several forms:
»  Asymmetrical oligoarthritis = MC
»  Symmetrical seronegative rheumatoid-like disease
»  Distal interphalangeal involvement = most
characteristic, rare
»  Axial skeletal involvement
»  Arthritis mutilans = destructive mutilating form
 PSORIATIC ARTHRITIS
X-RAY

Deformity in the phalanges, osteolysis, articular ankylosis

PSORIATIC ARTHRITIS
V.  Erythrodermic psoriasis
§  Erythroderma (Exfoliative dermatitis)
§  Generalized inflammatory erythema with profuse
scaling
§  Precipitated by:
• 
Infections
• 
Low calcium
• 
Withdrawal of oral corticosteroids
• 
Withdrawal of excessive use of strong topical corticosteroids
• 
Strong coal tar preparations
§  Complications include:
•  Dehydration ▪ Protein loss &
•  Heart failure malnutrition
•  Infection ▪ Edema
•  Hypothermia ▪ Death



ERYTHRODERMIC PSORIASIS
ERYTHRODERMIC PSORIASIS
 Physical exam
Features of typical plaque lesions:
§  Well marginated with distinct border
§  Raised above the surface
§  Diameter of 1 to several cm , round or oval shape & may
merge together → geographic patterns
§  Rich red color & surrounded by pale halo (Woronoff’s ring)
§  Covered with silvery white, mica-like, loosely adherent
scales & on removal reveal punctate bleeding points (Auspitz
sign)
§  Symmetrical on extensor surfaces of the body
§  Typical sites - elbows, knees, shin, knuckles, sacral areas and
scalp
§  Uniformity - Same features irrespective of site except on
palms, soles & flexors
 TYPICAL LESIONS OF PSORIASIS

WELL MARGINATED & RAISED ABOVE THE SURFACE




TYPICAL LESIONS OF PSORIASIS

ROUND OR OVAL IN SHAPE

TYPICAL LESIONS OF PSORIASIS









WORONOFF’S RING
AUSPITZ SIGN
 Physical exam
Nail involvement
§  in 25 to 50% of cases & consist of:
§ Nail pitting
§ Discoloration
§ Subungual hyperkeratosis
§ Onycholysis = give rise to oil-drop sign
§ Thickened friable nail plate

PSORIASIS - NAILS










NAIL PITTING

PSORIASIS – NAILS











SUBUNGUAL HYPERKERATOSIS
PSORIASIS – NAILS










ONYCHOLYSIS
 DIFFERENTIAL DIAGNOSIS
Seborrheic dermatitis
§  Indistinguishable in sites & morphology
§  Scales are yellowish or gray-white & “greasy-looking”
 DIFFERENTIAL DIAGNOSIS
Candidiasis
§  Especially in intertriginous psoriasis
§  KOH should be done to rule out yeast infection


 DIFFERENTIAL DIAGNOSIS
Cutaneous T-cell Lymphoma
§  Especially Mycosis fungoides stage
§  Malignancy involving entire lymphoreticular system
§  Skin lesions are the 1st manifestation
 DIFFERENTIAL DIAGNOSIS

Pityriasis Rosea
§  fine scaling papules & plaques with characteristic
colarette of fine scales following lines of cleavage
(christmas tree pattern)
 DIFFERENTIAL DIAGNOSIS

Lichen planus
§  Violaceous color, flat-top, polygonal papules
with whitish streaks (Wickham’s striae) best seen
with hand lens after applying mineral oil
 DIFFERENTIAL DIAGNOSIS

Tinea corporis
§  Rarely a problem except in single lesions
§  KOH mandatory
 TREATMENT
Three main modalities of therapy:
§  Use alone or in combination
I.  TOPICAL THERAPY – 1st-line approach
1.  Topical steroid
§  Applied 2X a day
§  Intralesional injection of triamcinolone acetonide into
isolated plaques

2.  Anthralin (Dithranol)
§  Derived from chrysarobin
§  Antiproliferative and immunosuppressive action.
§  Short-contact therapy
§  Irritant and can stain cloth (reversible brownish pigmentation)

Temporary staining due to dithranol applied to psoriasis lesions
3.  Vitamin D3 analogues: Calcitriol and Calcipotriol
§  Regulates keratinocyte proliferation and maturation
§  S/E (high dose) : irritation, hypercalcemia & kidney stones

5.  Retinoids (Tazarotene)

§  Regulate keratinocyte proliferation and maturation
§  Main side effect is irritation
§  Special precaution: women of child-bearing age

6.  Coal tar

§  Antiproliferative effect
§  Combined with steroid therapy
§  Solution also used for scalp psoriasis

7.  Salicylic acid – 2 to 10% ointment

§  Combined with topical steroids
§  Removes scales and aids in penetration of steroids
Crude coal tar application for psoriasis
Plaques treated with Calcipotriol 6 weeks before and after
 II.  PHOTOTHERAPY - 2 main forms:

A.  UVB - Ultraviolet B (UVB) irradiation

§  Ultraviolet radiation with wavelengths 290-320 nm
§  Alone or combined with 1 or more topical treatments
•  Goeckerman regimen - Coal tar followed by UVB exposure
•  Ingram method - Anthralin application following a tar bath and
UVB treatment
§  Usually combined with topical corticosteroids, calcipotriene,
tazarotene or simply bland emollients
§  Effective for moderate-to-severe plaque psoriasis
§  Narrow-band UVB (UVB of 311 nm) effective and low potential for
photodamage
 II.  PHOTOTHERAPY

B.  PUVA photochemotherapy – (PUVA)

§  Photosensitizing drug methoxsalen (8-MOP) oral→
ultraviolet A (UVA) irradiation
§  Utilizes light with wavelengths 320-400 nm.
§  MOA: Decreases cellular proliferation by interfering with
DNA synthesis & induces immunosuppression by its action
on T cells
§  2-3 times/ week outpatient basis & maintenance every 2-4
weeks until remission
§  Adverse effects → nausea, pruritus and burning & long-term
complications→ increased risks of photo damage and skin
cancer
§  Combined with oral retinoid derivatives to decrease
cumulative dose of UVA radiation to the skin
 Phototheraphy Cabinet (UVB)

whole body unit control panel

 III.  SYSTEMIC THERAPY

Indications:
1.  When both topical treatments & phototherapy have failed
3.  Very active psoriatic arthritis
5.  Erythrodermic psoriasis
7.  Generalized pustular psoriasis

A.  Antimetabolites:
a.  Methotrexate
•  Weekly oral or intramuscular dose of 15 to 25 mg
•  CBC, platelets, LFT, urinalysis, & creatinine - normal before
starting
•  Main side effects - nausea, vomiting, hepatic dysfunction
b.  Hydroxyurea
•  Alternative antimetabolite
•  More toxic than methotrexate and rarely used
 III.  SYSTEMIC THERAPY

B.  Acitretin
§  Synthetic vitamin A derivative
§  10 to 20 mg/day gradually increased to maximum dose of 50mg/
day
§  Main S/E : teratogenicity, hypertriglyceridemia, xerosis of skin,
chelitis & alopecia
§  Can be used in combination with phototherapy, methotrexate or
cyclosporine

D.  Cyclosporine
§  MOA: Selectively inhibits T-helper cell production of IL-2 →
immunosuppressive effect
§  3 to 6mg/kg per day (a new microemulsion formulation may be
used in a lower dosage)
§  Side effects are hypertension and nephrotoxicity
III.  SYSTEMIC THERAPY

D.  Mycophenolate mofetil

§  MOA: inhibits synthesis of the nucleotide
guanosine
§  500mg 4 X a day with a maximum dose of 4
gm
§  Side effects : teratogenicity, neutropenia, GI
symptoms, & opportunistic infections

F.  Sulphasalazine
§  Alone or combined with methotrexate
§  For psoriatic arthropathy
 COMPLICATIONS
§  Many of the complications (pustular psoriasis,
erythroderma) due to inappropriate & aggressive
therapy
§  Psoriatic arthritis
§  Pustular psoriasis
§  Erythroderma and its metabolic complications
§  Infection particularly Staph. Infections
§  Eczematization due to topical agents
§  Psychological consequences: depression, anxiety,
lack of self-esteem
§  Potential complications of systemic therapy should
not be overlooked
 PROGNOSIS
§  Course of plaque psoriasis is unpredictable
§  Duration of active disease, time or frequency
of relapses & duration of a remission is
unpredictable
§  Rarely life threatening but often intractable to
treatment with relapses occurring in majority
§  Both early onset and (+) family history are
considered poor prognostic indicators
§  Suggested - stress associated with an
unfavorable prognosis