PSORIASIS. -Multi factorial. -Papulosquamous disorder. -Genetically determined (few) -Chronic Scaly lesions. -Seasonal variations
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1 PSORIASIS -Multi factorial -Papulosquamous disorder -Genetically determined (few) -Chronic Scaly lesions -Seasonal variations -Recurrences & remissions
2 Etiology & Pathogenesis T-cell mediated autoimmune disease -Early onset Hereditary HLACW6 -Late Onset Non inheritable
3 Genetic Predisposition - Multifactorial - Familial aggregation - HLA B13, HLA B17, HLACW6
4 PREDISPOSITION -Familial - Risk 3 times one parent -60% children both parent -Genetic -Autosomal dominant -Twin heritability - 90% -HLA B 13 B 17 B 27
5 PROVOKING/PRECIPITATING FACTORS -Predisposed individual -TRAUMA (Isomorphic/Koebner s phenomena) -INFECTION ( Streptococcal Guttate Psoriasis) -PREGNANCY( Pustular Psoriasis) -CLIMATE : Summer,Winter -HYPOCALCEMIA
6 Drugs -Anti malarial -B-Blockers -Lithium -High dose steroid (sudden withdrawal) Psychogenic factors Dialysis
7 Mechanism of Proliferation Cell cycle time Basal epidermis cycling & resting cells Recruitment of cycling cells Growth fraction Accelerated epidermopoiesis
8 HISTOPATHOGENESIS Accelerated epidermopoiesis- Main feature Parakeratosis- Nucleated cells in s.corneum Absence of granular layer Presence of PMNL Intradermal abscess of PMNL - Spongiform pustules of Kogoj - Munro microabscesses
9 Mechanism Immunological disease -Cyclic AMP,Cyclic GMP - Arachidonic acid & by products like PG (HETE), Leukotrienes - Polyamines : Putresine & spermidine - Proteinase activity - Interleukins - Activity of PMNL, Langerhans cells, monocytes
10 HPE : Variable Acanthosis Parakeratosis, absence of granular layer Elongation of rete ridges PMNL infiltrate in dermis Munro s micro abscess (epidermis)
11 Clinical Features Both sexes equally affected Females earlier Age of onset years years
12 PSORIASIS VULGARIS -Both sexes, -All ages (20-40 years) Clinically Extensors, palms, soles, scalp Well defined lesions Scaly plaques, papules
13 Characteristic sign Easily removable silvery scales GRATTAGE SIGN AUSPITZ SIGN Halo of Woronoff-clear peripheral zone
14 Koebner phenomena present
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16 Modification by site Scalp -Asbestos like scaling -Pityriasis amiantacea
17 Flexural - No scaling, - Glazed hue
18 Flexural Psoriasis
19 Napkin Psoriasis Penis No scaling Linear/Zonal psoriasis
20 Palmoplantar Psoriasis Palms/ soles
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25 NAIL CHANGES (25-50%) Distal onycholysis Subungual hyperkeratosis Oil drop sign Pitting Destruction/Discoloration
26 NAIL CHANGES
27 Nail Matrix - Pitting - Ridges & grooves Nail Bed - Subungual hyperkeratosis - Onycholysis
28 Nail Changes
29 Clinical Variants Psoriasis vulgaris
30 Elephantine Psoriasis
31 Rupioid Psoriasis Ostraceous Psoriasis Atypical psoriasis Guttate Psoriasis
32 Guttate Psoriasis Streptococcal throat infections Child Adolescent Monomorphic Respond to antibiotics May lead to Psoriasis vulgaris in predisposed
33 Guttate Psoriasis
34 Erythrodermic Psoriasis -Some ppt. factor -Disease characteristics may be lost -Febrile -Severe itching
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36 Metabolic complications - Hypo/Hyperthermia - High output cardiac failure - Hypoalbuminaemia - Malabsorption
37 Pustular Psoriasis Localized -Chronic -Palmoplantar
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44 Pustular Psoriasis Generalized -Von Zumbusch -Acute
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46 Pustular psoriasis Withdrawal of steroid Erythrodermic psoriasis
47 Impetigo Herpetiformis -Pregnancy -Onset in last trimester -Starts in flexures -Severe constitutional disturbance -Risk of placental insufficiency -Recurs
48 Psoriatic arthritis -Seronegative -HLA B27
49 Psoriatic arthropathy -Distal symmetrical I.P. -Oligo- mono arthritis -Seronegative Rh. Arthritis like arthritis -Psoriatic arthritis multilans -Ankylosing spondylitis like
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52 X-ray Findings - Local demineralization - Pencil in cup deformity
53 Course & Prognosis - Chronic - Intractable - Relapse is the rule
54 TREATMENT a)topical -5% Crude coal tar(goekerman s regimen) Dithranol (anthranilin) 1-2% (short contact therapy) Combined coal tar + Dithranol (Ingram regimen) Topical steroids (mild) UV-B Therapy
55 Topical treatment Contd. Liquor Picis carbonis Keratolytics Emollients Topical PUVA Topical Methotrexate Calcipotriol Vit. D analogue
56 b) Systemic Therapy Methotrexate ( mg/kg/week) PUVA Psoralens + UVA Retinoids etretinate/ acitretin 0.5mg/kg/day Cyclosporine Corticosteroids
57 Thank You
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