Psoriasis

Psoriasis is a chronic relapsing disease of the skin characterized by variable clinical features. The lesions are erythro-squamous

The vasculature erythema

Increased scale formation Clinical presentation varies from few localized patches to generalized skin involvement.
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Definition
Psoriasis is a common, chronic, relapsing, inflammatory skin disorder with a strong genetic basis, characterized by circular-to-oval red plaques that usually exhibit silvery white scaling.

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Psoriasis
Common locations are elbows, knees & scalp. 5% have arthritis. Onset, at any age, most commonly

teens-twenties.
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Psoriasis
Impacts QOL, difficult to truly get
psoriasis under control.

May be some gender differences,

women may suffer more when afflicted,

aggressive therapies are withheld.

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Psoriasis
Complete remission of disease was experienced

by 35% of patients
Prevalence of depression were 23.3% in

psoriatics which significantly affects Quality of

Life (QOL) Sleep disturbance was seen in 56.6% of psoriatics which significantly affects QOL
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J Dermatol. 2001 Aug; 28(8):419-23

Psoriasis
Severity tends to wax & wane, worse in winter. Negatively affected by cigarette

smoking, alcohol consumption, stress &

skin trauma (Koebnerization: Areas frequently rubbed or damaged can sometimes lead to plaques of psoriasis).
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Incidence - India
Account for 2.3% of the total dermatology out-

patients
Mean age of onset was lower in females More than half of the patients were in 3rd to 4th decade of life 17.34% have involvement of palms and/or soles Most of men with palm/plantar involvement were in regular manual labor
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J Dermatol. 1997 Apr; 24(4):230-4

Pathophysiology
Psoriatic skin exhibits pathological changes in most of

cutaneous cell types.

Histopathological hallmark features that include:-

Hyperproliferation of epidermal keratinocytes Hyperkeratosis Infiltration of immunocytes along with angiogenesis, with
resultant typical thickening and scaling of the
erythematous skin.
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Pathophysiology
Mitotic activity of basal keratinocytes is increased by as
much as a factor of 50 in psoriatic skin, So keratinocytes need only 3 to 5 days in order to move from the basal layer to the cornified layer (instead of the normal 28 to 30 days).

There is accompanied by altered differentiation

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Etiological Factors
Trigger Factors

Genetic Factors HLA (Human leukocyte

antigen) association
Human leukocyte antigens, are the proteins present on the surface of the white blood cell, and most other cells of the human body, which allow the body to recognize self versus nonself.

Biomedical defects
Immuno-pathology
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Trigger Factors
ENVIRONMENTAL

Physical Trauma
Infections Stress Drugs : Beta blockers, ACE inhibitors, Anti-malarials, Oral contraceptives
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 Lithium is believed to act by enhancing the release of inflammatory mediators from neutrophils Beta-blockers by decreasing cyclic adenosine monophosphate and cyclic (AMP)-dependent protein kinase. NSAIDS work by causing a build up of the inflammatory mediator, arachinoidonic acid. Anti-malarials are also associated but for unknown reasons. Associations and exacerbations can be unpredictable, and may occur months after the medication is first taken. Sales Training

Trigger Factors
Alcohol

Hyperglycemia
Climate

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Biomedical Defects in Psoriatic scales

Alterations in levels of cyclic neucleotides
Higher amounts of polyamines and arachidonic acid Increased protease activity Expression of antigens associated with hyperproliferation
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Immunopathology
Presence of numerous T cells in lesions

Cytokine profile of TH1 mediated disease

Immune dependent expression of adhesion
molecules on keratinocytes

Absence of association with TH2 mediated

disorders AD & Urticaria

Antipsoriatic effects of immunobiologicals which

reduce T cell activation & infiltration.
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Immunological abnormalities
Abnormal leucocyte function

Altered lymphokine secretion

Free radical generation

Pathogenesis remains unclear.

All the above could be secondary rather than the cause, as none are the primary defect in psoriasis.
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Classification of psoriasis
Quality of life based definitions of mild, moderate and severe psoriasis

Mild

Moderate

Severe

Disease does not alter the patients QOL

Disease alters the patients QOL

Disease alters the patients QOL

Disease does not have a satisfactory response to treatments that have minimal risks

Minimal impact of The patient expects disease and may not therapy will improve require treatment QOL

Treatments have no known serious risks (eg class 5 topical corticosteroids)

Therapies used have minimal risks (ie may be inconvenient, expensive, timeconsuming Sales Training and less than totally effective)

Patients are willing to accept lifealtering side-effects to achieve less disease or no disease

Classification of psoriasis
Mild Moderate Severe

Generally <2% of body surface area is involved

Generally 2% to 10% of body surface area is involved

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Generally >10% of body surface area is involved Other factors: Patients attitude about disease Location of disease (eg, face, hands, fingernails feet, genitals) Symptoms (eg pain, tightness, bleeding or severe itching) Arthralgias/arthritis

Clinical Classification
Non Pustular Psoriasis vulgaris Psoriatic erythroderma Pustular Generalized pustular psoriasis Pustulosis palmaris & plantaris Guttate psoriasis Annular pustular psoriasis Impetigo herpetiformis
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Clinical features
Well defined, erythematous, scaly papules and plaques of varying sizes
Koebner phenomenon suggest acute, eruptive or florid (Having bright deep red colour) progression Auspitz sign (If one removes the white scale of psoriasis, one may see punctate bleeding points) Negative Koebner phenomenon (absence of lesions at the pressure sites) Psoriatic leucoderma ( hypopigmentation after Sales Training healing)

Psoriasis: Types
Plaque type (Psoriasis vulgaris): Most common, round to oval raised patches of scaly red skin.

Guttate psoriasis: Abrupt onset small patches spread widely. Typically occurs after being infected with a strep throat.
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Psoriasis: Types
Hand / foot psoriasis: Effects mainly hands & feet. Fingernails & toenails can be involved in any type resulting in pits, thickening & yellowish & brown discoloration.

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Psoriasis: Types

Plaque psoriasis

Guttate psoriasis

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Resistant psoriatic plaques over the buttock & posterior thighs

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Resistant plaque-type psoriasis on the elbows

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Psoriasis: Types
Scalp psoriasis: Approximately 50% of psoriasis sufferers are affected by this condition. Appears on scalp as reddened bumps with silvery scales.

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Psoriasis: Types
Inverse psoriasis: Smooth inflamed scores (lesions) without apparent scaling characterize this form. Most often appears in armpit, groin area, under breasts & in other skin folds. Lesions are easily irritated by rubbing & sweating.

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Psoriasis: Types

Scalp psoriasis

Inverse (Flexural) psoriasis

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Psoriasis: Types
Nail psoriasis: Pits of various size & shape appear

in nail. Both fingernails & toenails may be affected.

Nail may become thickened & yellowed.

Nails crumble easily & may become loosened &

detach from nail bed. This condition is very difficult to treat. Hand/foot psoriasis: Effects mainly hands & feet.
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Psoriasis: Types

Erythrodermic psoriasis: Entire body covered with thin red scales.

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Psoriasis: Types

Erythrodermic psoriasis

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Erythrodermic psoriasis
Generalized form of disease Affecting all body sites, including face, trunk and extremities Erythema is most prominent but scaling is less There may be generalized exfoliation
Ann Derm Venereol Suppl. 1989;146:69-71
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Exfoliative psoriasis
Accounts for 16 - 24% of erythroderma

90% or more body area involved

Either gradual progression or sudden explosive course (due to various factors) Nose sign (absence of lesions on the nose) Metabolic effects dictate the course and outcome
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 Pustular psoriasis: Involves small pustules scattered on red plaques.

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Psoriasis: Types

Pustular psoriasis

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Generalized pustular psoriasis

Acute variant of psoriasis

Sudden, generalized eruption of sterile

pustules

May be accompanied with erythroderma

Disseminated over trunk and extremities Accompanied by systemic symptoms like fever
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Generalized pustular psoriasis

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Localized pustular
Also called as Pustulosis of palmaris & plantaris
Affecting palms and soles predominantly May affect trunk

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Localized pustular

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Erythrodermic & pustular psoriasis are serious can be accompanied by systemic symptoms fever & illness.
Sometimes require hospitalization, skin cant retain enough body heat or fluids.

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The course of psoriasis is unpredictable. It has a tendency to recur and persist

Aggravation Relieving

Secondary infection Drugs Beta Blockers Lithium Antimalarials Terbinafine Steroids Lipid lowering drug gemfibrozil Homeopathy Sales Training Irritant oils

Antibiotics Oil massages Change of medications.

General Management
Counseling.

Accept the disease and live with it.

Treatment methods vary accordingly to site, severity, duration, previous Rx and age of patient. Tendency for each remedy to loose its effectiveness gradually. Topical, systemic or combination.
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Goals of Therapy
Provide durable remission period, which is realistic with available therapies & occurs in

40 % of patients.
Provide Substantial improvement

complete clearing is possible.

Provide maintenance therapy after initial improvement. Provide better safety minimize significant side effects.
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Methods to achieve goals of Therapy

Monotherapy Use of a single agent. Combination therapy may improve effectiveness & allow some of the therapies

associated with toxicity to be utilised at lower

doses, considering Benefits Efficacy /

Safety / Patient compliance / Economy when

selecting among various therapies to combine with one another. Sales Training

Methods to achieve goals of Therapy

Concept of Rotational therapy has evolved that is, switching different treatment types every few years (1-2 yrs) after which an alternative therapy is used. This strategy may minimize long term toxicity with any given therapy & decrease resistance to that therapy. Sequential therapy Use of stronger, but

potentially more toxic agents to clear psoriasis initally, followed by use of weaker, less toxic agent
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Psoriasis Therapy
General Emollients, Avoidance of Triggers

Medical
Surgical Laser

Topical, Systemic
Shave Technique 308 nm Excimer Laser
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Psoriasis: Therapy
Depends on location & BSA covered.
Four categories: Steroids, vitamin D derivatives, retinoids (vitamin A derivatives) & tar preparation (cream, lotion, ointments or gels).

Common topical treatment are steroids

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Psoriasis: Therapy
Psoriasis Severity
Surface involvement Treatment

Mild
<2% Topical

Moderate
2 to 10% Topical or UV or oral

Severe
> 10%

UV & or Oral

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the ladder of psoriasis therapy

Step 3

Step 2

Step 1

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Step 1 Topical Therapy

Topical Corticosteroids Coal tar Anthralin Salicylic acid Calcitriol, Calcipotriol, Tacalcitol Tazarotene Topical Methotrexate Tacrolimus, Sales Training Pimecrolimus

Step 2 - Phototherapy
PUVA (Psoralen + UVA)

UVB Broad Band

UVB Narrow Band

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Step 3 Systemic therapy

Retinoids Methotrexate Cyclosporin Dapsone, Sulfasalazine Hydroxyurea

Azathioprine
Mycofenolate mofetil
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Limitations of current therapies

Topical agents: None are predictably effective. All require lengthy treatment to give relief that is often temporary. Poor compliance.

Widespread disease cannot be managed.

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Limitations of current therapies

Treatment
Topical steroids

Drawbacks
Temporary relief (tolerance occurs), less effective with continued use, atrophy and telangiectasia occur with continued use, brief remissions.

Intralesional Only for limited areas, atrophy and steroids telangiectasia occur at injection site.
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Limitations of current therapies

Treatment Anthralin Drawbacks Purple-brown staining, irritating, careful application (only to plaque) required.

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Psoriasis: Therapy
Vehicle makes a difference in potency, ointments being strongest, gels & lotions appropriate for hair bearing areas. Topical steroids are best used in conjunction with one of the newer topical medicines for

treatment.
Calcipotriene & Tazarotene.
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Psoriasis: Therapy
Vitamin D derivative, calcipotriol : Daivonex ointment (Crosslands) Advantages are few long term side effects & does not lose its potency over time. Disadvantages are, works slowly as monotherapy, burning , skin irritation, expensive, hypercalcemia & messier.
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Psoriasis: Therapy
Tazarotene: Does a good job with thick plaques of psoriasis. Works best when paired with topical steroids. Tar: Ionax-T solution (Ranbaxy), moderately effective, odour, contact dermatitis, folliculitis, photosensitisation & dark staining.
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Psoriasis: Therapy
Ultraviolet
Patients on UVB & PUVA have to take a

UV sensitizing oral medicine (a type of

psoralen) or apply a topical psoralen

before being exposed to UVA.

Receive treatments in dermatologists office by trained personnel.
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Psoriasis: Therapy
Ultraviolet
Needs to be given 2-3 times/week over a period of 2-3 mths. Increased risk of skin cancer.

Particularly PUVA can damage eyes.

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Psoriasis: Therapy
Ultraviolet
Last few years narrow band UV has come with advantage of being similar in effectiveness to PUVA, but without requiring ingestion of a sun-sensitizing medication. Also hope is that it may be less cancer causing than PUVA. Requires more precision & some testing Sales Training before beginning treatment.

Psoriasis: Therapy
Acitretin (retinoid), modulate tissue metabolism, decreasing rapidity with which psoriatic skin is made.

Systemic

Taken once or twice a day, depending on the dosage, usually 25-50mg / day. Cannot be taken by women of childbearing years, stored in human tissues for at least 3 years, possiblySales longer. Training

Psoriasis: Therapy
Systemic
Isotretinoin, main drawback isnt quite as effective as acitretin could be combined with UVB or PUVA. Side effects of systemic retinoids are dry lips, hand stickiness, hair loss, photosensitivity & elevations in blood TG as well as liver enzymes.
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Psoriasis: Therapy
Systemic
Methotrexate, Oncotrex Tab & Inj (Sun), Trixilem Tab & Inj (Elder), Zexate Tab & Inj (Dabur) anticancer drug, decreases metabolism in overactive cells.
Given in lower dosages than used for cancer, taken orally 1-2 days of week.
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Psoriasis: Therapy
Systemic
Main drawback, severe liver damage that cant reliably be ascertained by blood tests.
Intermittent liver biopsies are necessary. Anemia, susceptibility to infection, mouth or stomach ulcers & hair loss.
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Psoriasis: Therapy
Systemic
Other side effects are bone marrow depression, leukopenia, thrombocytopenia, megaloblasic anemia, lung toxicity & nephrotoxicity.

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Psoriasis: Therapy
Systemic
Cyclosporine, Imusporin Cap (Cipla), Sandimmun Neoral Cap & Inj (Novartis), Zymmune Inj (Zydus), immunosuppressive agent. Discovery that it could treat psoriasis led to the breakthrough knowledge that psoriasis was an autoimmune disease. Taken orally, dosages 2.5-5 mg/kg (150-400 mg/day for average size adults), expensive than methotrexate.
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Psoriasis: Therapy
Systemic
Cyclosporine, highly effective & probably works faster than any other anti-psoriasis medication available, suitable for people with

very severe forms of psoriasis (e.g. pustular or

erythrodermic psoriasis). Used to get severe psoriasis under control then switch to another, less toxic therapy.
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Psoriasis: Therapy
Systemic
Cyclosporine, long-term, low-dose therapy has also been advocated. Main problem, hypertension & kidney damage. Long-term therapy necessitates 24 hour urine specimens & possibly kidney biopsies. Other side effects are thrombocytopenia, leukopenia, hemolytic anemia, Bilirubinemia
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Psoriasis: Therapy
Even though psoriasis is chronic &

eventually reoccurs, multiple treatment

regimens & disease free intervals are a Welcome relief to those who suffer. Concept of Rotational therapy &

Sequential therapy has evolved over the

years.
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