Psoriasis and other papulosquamous dermatoses. Andrea Szegedi MD. DSci.

Transcription

1 Psoriasis and other papulosquamous dermatoses Andrea Szegedi MD. DSci.

2 Pityriasis rosea Pityriasis rosea irritata

3 Pityriasis rubra pilaris Follicular erythematous papules Diffuse erythematous patches with pityriasiform scale Islands of normal skin are spared

4 Pityriasis rubra pilaris Palms and soles are red and hyperkeratotic, fissured

5 Psoriasis vulgaris One of the most common human skin diseases It is characterized by excessive growth and aberrant differentiation of keratinocytes. The trigger of the keratinocyte response is thought to be the activation of the cellular immune system, with T cells, dendritic cells and various immune-related cytokines and chemokines. It is a multifactorial disease with polygenetic background. It is not infectious. It cannot be cured, but patients can be symptom free.

6 It is not just a skin disease, it can cause systemic inflammation.

7 Epidemiological data 2% of population suffers from psoriasis in Europe and in USA It is rarer in Africa, Japan, among Eskimos, American Indians and Afro-Americans Male: female 1:1 The disease starts with dermal symptoms in 75 % With arthropathia psoriatica in 25-30% In 10% skin signs and arthritis start together at the beginning It begins at the age of 28 on the average, but it can begin at any age Type I psoriasis: <40 years, family anamnesis: +, 2/3 of the cases, HLACw6: + Type II psoriasis: >40 év, family anamnesis: -, 1/3 of the cases,

8 Psoriasis vulgaris Beginning of the disease HLAassociation: Family anamnesis: Type I Between years Cw6, B13 Bw57, DR7 positive Type II Between years Cw2, B27 negative

9 Examination of twins in psoriasis Monozygote Heterozygote Total Farber 1 73% 27% 82 Brandrup 2 64% 14% 36 Total 71% 22% Arch Dermatol 1974, 109:207 2 Arch Dermatol 1978, 114:874 Psoriasis has a genetic background

10 Localization of the psoriasis succeptibility (PSORS) genes

11 Provoking factors Stress Cold weather of winters (except for: photosensitive psoriasis, which is better during winters) Physical trauma of the skin (Koebner-phenomenon) Phototoxic reaction, severe sunburn The systemic activation of the immune system: infections (bacterial, viral, HIV), allergic reactions to medications Medications: corticosteroids, litium, anti-malarial drugs like chloroquine, beta-blockers, NSAID, ACE inhibitors, progesteron, IF-α, IL-2 Smoking: in case pustular psoriasis of palms and soles

12 Genetic background Endogenous triggers Environmental triggers Immune dysregulation Uncontrolled inflammation Uncontrolled keratinocyte proliferation

13 Immunological background of psoriasis It is an Immune Mediated Inflammatory Disease (IMID)

14 Histology -Epidermal thickening, acanthosis -Disturbancies of keratinocyte differentiation: parakeratosis -Polymorphonuclear cells (PMNG) are present in the epidermis (Munro s abscess) -Activated granulocytes -Loose vessels, inflammatory infiltration in the dermis

15 KERATINOCYTE Normal Psoriatic Cellcycle S-fase 3-5% 20-25% M-fase 0,4% 2,5% Cycle time 457h 38h Transit time 28 days 3-4 days

16 PMNG and Ly extravasation Loose vessels

17 Munro s abscess

18 Physical and mental rankings of psoriasis and other diseases Cngestive heart failure 11 5 Psoriasis 10 9 NIDDM 9 3 Chronic lung disease 8 10 Infarction Arthritis Hypertension Physical rank Mental rank Depression 4 11 Cancer 3 6 Dermatitis 2 8 Healthy Rapp SR et al. J Am Acad Dermatol., 1999, 41,

19 Most common locations of lesions in patients with psoriasis Location % of patients Scalp 80 Elbows 78 Legs 74 Knees 57 Arms 54 Trunk 53 Other 38 Palms and soles 12

20 Scoring the severity of psoriasis Severity Involved skin surface % Mild Bellow 3% Moderate Between 3-10% 25% 8% 2% Mild Moderate Severe Severe Above 10% 65% Potentially fatal forms: 1. Erythrodermia psoriatica 2. Psoriasis pustulosa generalisata Mild, but with systemic therapy

21 Clinical forms Chronic plaque type: 80-90% Erythroderma psoriatica: 5% Psoriasis pustulosa (generalized, palmo-plantaris): 5% Guttate Inverse

22 Psoriasis pustulosa Psoriasis pustulosa palmoplantaris (Barber)

23 Psoriasis pustulosa psoriasis pustulosa generalisata (Zumbusch)

24 Erythrodermic psoriasis

25 Psoriasis inversa

26 Köbner sign

27 Nail matrix and nail plait involvement in psoriasis Onychorrhexis, nail plate crumbling Leukonychia Onychorrhexis

28 Nail matrix and nail plait involvement in psoriasis

29 Nail bed involvement in psoriasis Oil drop, salmon patch Onycholysis Salmon patch Onychodystrophy, nail bed hyperkeratosis

30 Psoriatic arthritis(pa): Clinical forms 1. Psoriatic oligoarthritis (70%) assymmetric mainly knee, ankle, wrist, 2. Asymmetric DIP form classic (10%) often nail involvement too 3. Arthritis mutilans (5%) osteolisis on fingers 4. Symmetric polyarthritis (15%) RA like form, but RF negative unbending joints in the morning, general symptoms are correlated with PA activity 5. Psoriatic spondylarthritis (5%) ~ SPA, 40-60% HLA-B27 +

31 Therapeutical options in psoriasis Local therapy 1. Dithranol 2. Corticosteroid 3. Tar 4. Vitamin D analogues 5. Topical retinoid 6. Salicylic acid 7. Sulphur 8. Tacrolimus, pimecrolimus Phototherapy 1. UVB 2. Narrow band UVB 3. Goeckerman: Tar + UVB 4. PUVA 5. Excimer laser Systemin therapy 1. Retinoid (Neotigason) 2. Methotrexate 3. Cyclosporin A (Sandimmun Neoral) 4. Fumaric acid 5. Biological agents: Alefacept (Amevive), Efalizumab (Raptiva), Etanercept (Enbrel) és Infliximab (Remicade), Adalimumab (Humira)

32 Therapy of psoriasis - Local treatment Dithranol Local corticosteroids Tar Vitamin D analogues Topical retinoid Salicylic acid Sulphur Tacrolimus, pimecrolimus

33 Phototherapy UVB Narrow band UVB Goeckerman: Tar + UVB PUVA Excimer laser

34 Systemic therapy of psoriasis Acitretine (Neotigason) Methotrexat Cyclosporin A (Sandimmun) Fumaric acid

35 Therapy of psoriasis Combined Therapy RE - PUVA PUVA + SUP

36 Neotigason Acitretin - syntetic retinoid Effective in: chronic plaque type, guttate form, pustulosus form and in psoriatic erythrodermia Long-term application is also safe Used in several combinations, but with MTX only in exceptional cases. Dose: in monotherapy: mg/day, in combination: mg/day

37 Headache Possible side-effects of Neotigason Ophthalmological examination is needed Increased Liver Enzimes Periungual pyogen granuloma, paronychia Hyperostosis, osteoporosis Hyperlipidaemy Depression Interactions with medications Cheilitis, hair loss, dry eyes, fragile nails, adhesive skin Pregnancy Often temporal and reversible, advice to suspend alcohol and ASA consumption, Dose reduction, other causes? Dose reduction, silver-nitrate, cryoth., steroid gel Any connection is questionable Proper internal medicinal treatment Any connection is questionable Glibenclamid, ethanol, progestin contraceptives Depends on the dose, reversible effects It is forbidden to apply it on pregnant women, or those who want to be pregnant.

38 Methotrexate (MTX) Mechanism of effect: Effective: In case of moderate and severe psoriasis, psoriatic erythrodermia, pustulosus forms, in case of psoriatic arthritis. Dose, on the average: mg/week in three parts, max. dose: 30 mg/week Hepatotoxic, teratogenic, bone marrow suppressive After 1,5 g-2 g total dose liver biopsy is recommended, or stop the drug A new possibility to realise cirrhosis at an early stage: measurement of III. collagen amino terminal propeptid

39 Side-effects of MTX Nausea Stomatitis aphtosa Increased Liver Enzimes Megaloblastic anaemia Thrombocytopaenia White blood cell reduction Acute pneumonitis Pregnancy Medicine interactions 1-5 mg Folic acid,or giving sc. or im. the mtx Blood cell count check, dose reduction, Folic acid, Leucovorin To suspend alcohol and liver harming medicine consumtion, GGT and AP increase is not the consequence of MTX, dose reduction, Blood cell count (and Urine sample) check, biopsy To look for medicine interactions: NSAID, Sumetrolim, dose reduction, Folic acid Dose reduction, blood and urine check, (sz.e.) to suspend Dose reduction, blood and urine check, (sz.e.) to suspend To suspend MTX, chest x-ray, Checking To suspend MTX for both parents three months before the planned pregnancy. Several: NSAID (Ibuprofen), Sumetrolim, salicilate,

40 MTX treatment contraindicated Pregnant women, breast-feeding mothers, women who plan pregnancy Alcoholists Patients with liver and kidney problems In case of active infections In case of damaged immune response Anaemia, diseases of the bown marrow Gastric ulcer In case of Aspirin, Ibuprofen, Sumetrolim consumption

41 Sandimmun Neoral Cyclosporin A To treat moderate and severe plaque form psoriasis, and erythrodermia psoriatica The most common side-effect is nephrotoxicity, to avoid it, the following application is recommended: 1. Do not apply for more than one or two years. 2. The increase of the ceratinin rate in the serum should be smaller than 30% of the starting rate. 3. 2,5 mg/body-weight kgm starting dose in two parts, increasing it to maximum 5 mg. Should be used in rotational therapy.

42 Other side-effects of Sandimmun Neoral Increase of serum K To avoid meals that are rich in K. internal medicinal treatment, to suspend the use of the medication Reduction of serum Mg Meal supplements Hypertonia Medicine interactions Gingiva hyperplasia Hypertrichosis, paresthesia Pregnancy Hyperlipidaemia Ca channel blockers are effective, do not use ACE inhibitors, thiazid diuretics several Proper mouth-hygiene, combine it with retinoid Not contraindicated internal medicinal treatment

43 Contraindications of Sandimmun therapy In case of active infection Patients with cancer Uncontrolled hypertension Patients with damaged kidney In case of taking several medicines

44 Biological agents in psoriasis 1. TNF-α antagonists Etanercept Enbrel Infliximab Remicade Adalimumab Humira 2. T lymphocyte modulatory agents Alefacept Amevive Efalizumab Raptiva 3. IL-12/IL-23 p40 subunit blocking agents Ustekinumab - Stelara