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Seborrheic Dermatitis, Psoriasis, Recalcitrant Palmoplantar Eruptions, Pustular Dermatitis, and Erythroderma P214-239ANDREWS’ DISEASES OF THE SKIN.

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Presentation on theme: "Seborrheic Dermatitis, Psoriasis, Recalcitrant Palmoplantar Eruptions, Pustular Dermatitis, and Erythroderma P214-239ANDREWS’ DISEASES OF THE SKIN."— Presentation transcript:

1 Seborrheic Dermatitis, Psoriasis, Recalcitrant Palmoplantar Eruptions, Pustular Dermatitis, and Erythroderma P ANDREWS’ DISEASES OF THE SKIN

2 Seborrheic dermatitis 2- 5 % of the population 2- 5 % of the population Chronic, superficial, inflammatory disease of the skin Chronic, superficial, inflammatory disease of the skin Predilection for the scalp, eyebrows, eyelids, nasolabial creases, lips, ears, sternal area, axillae, submammary folds, umbilicus, groin, and gluteal crease Predilection for the scalp, eyebrows, eyelids, nasolabial creases, lips, ears, sternal area, axillae, submammary folds, umbilicus, groin, and gluteal crease Characterized by scanty, loose, dry, moist, or greasy scales, and by crusted pink or yellowish patches of various shapes and sizes Characterized by scanty, loose, dry, moist, or greasy scales, and by crusted pink or yellowish patches of various shapes and sizes

3 Clinical features Remissions and exacerbations Remissions and exacerbations No to mild itching No to mild itching On the scalp is the most common On the scalp is the most common Pityriasis steatoides – oily type, accompanied by erythema and accumulation of thick crust Pityriasis steatoides – oily type, accompanied by erythema and accumulation of thick crust Frequently spreads beyond the scalp Frequently spreads beyond the scalp

4 Extreme cases involve the entire scalp and may have an offensive odor Extreme cases involve the entire scalp and may have an offensive odor Cradle cap Cradle cap Marginal blepharitis – edges of the lids becoming erythematous and granular. Conjunctiva may be injected Marginal blepharitis – edges of the lids becoming erythematous and granular. Conjunctiva may be injected On and in the ears may be mistaken for otitis externa caused by a fungal infection On and in the ears may be mistaken for otitis externa caused by a fungal infection KOH – KOH –

5 The presternal area is a favored site on the trunk The presternal area is a favored site on the trunk Common in the groin and the gluteal crease Common in the groin and the gluteal crease In acute stages the inflammation may be intense, with moist exudation from the scalp and ears and papulovesicles on the palms and soles. Secondary infections, impetiginization, or furunculosis may ensue In acute stages the inflammation may be intense, with moist exudation from the scalp and ears and papulovesicles on the palms and soles. Secondary infections, impetiginization, or furunculosis may ensue

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8 May progress to a generalized exfoliative state May progress to a generalized exfoliative state In the newborn this type of severe and generalized seborrheic dermatitis is known as erythroderma desquamativum In the newborn this type of severe and generalized seborrheic dermatitis is known as erythroderma desquamativum May be associated with or accentuated by several internal diseases May be associated with or accentuated by several internal diseases Parkinson’s, HIV, DM, Parkinson’s, HIV, DM,

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10 Etiology and pathogenesis Remains unresolved Remains unresolved Presence of lipophilic yeast Pityrosporum ovale in large numbers in scalp lesion Presence of lipophilic yeast Pityrosporum ovale in large numbers in scalp lesion Also demonstrated in those without seborrheic dermatitis Also demonstrated in those without seborrheic dermatitis Healthy individuals have been found to have higher IgG antibodies to the organism Healthy individuals have been found to have higher IgG antibodies to the organism

11 The significance of P ovale in infantile seborrheic dermatitis has not been fully evaluated The significance of P ovale in infantile seborrheic dermatitis has not been fully evaluated Familial tendency toward infantile and adult seborrheic dermatitis Familial tendency toward infantile and adult seborrheic dermatitis

12 histology Epidermis is acanthotic Epidermis is acanthotic There is overlying focal scale crust often adjacent to follicular ostia There is overlying focal scale crust often adjacent to follicular ostia Slight spongiosis Slight spongiosis Dermis contains a perivascular mixed cell inflammatory infiltrate Dermis contains a perivascular mixed cell inflammatory infiltrate

13 Differential diagnosis Psoriasis, heavier scale and erythema, Auspitz’s sign, resistance to treatment, nail involvement Psoriasis, heavier scale and erythema, Auspitz’s sign, resistance to treatment, nail involvement Crusted scabies of the scalp in immunodeficiency syndromes Crusted scabies of the scalp in immunodeficiency syndromes Otitis externa, blepharitis, tinea corporis, pityriasis rosea, keratosis lichenoides chronica Otitis externa, blepharitis, tinea corporis, pityriasis rosea, keratosis lichenoides chronica

14 Treatment Selenium sulfide, tar, zinc, pyrithionate, resorcin shampoos Selenium sulfide, tar, zinc, pyrithionate, resorcin shampoos Nizoral Nizoral Corticosteroid solution Corticosteroid solution Antimicrobial preparations may be necessary Antimicrobial preparations may be necessary Bifonazole shampoo has been shown effective in treating infants and small children Bifonazole shampoo has been shown effective in treating infants and small children

15 Cortisporin otic usually brings about prompt clearing Cortisporin otic usually brings about prompt clearing Desonide Otic Lotion, 0.05% Desonide and 2% acidic acid is also effective Desonide Otic Lotion, 0.05% Desonide and 2% acidic acid is also effective Topical steroids should not be used for blepharitis, since steroid preparations used in area may induce glaucoma and cataracts Topical steroids should not be used for blepharitis, since steroid preparations used in area may induce glaucoma and cataracts

16 psoriasis A common, chronic, recurrent, inflammatory disease of the skin characterized by round, circumscribed, erythematous, dry, scaling plaques of various sizes, covered by grayish white or silvery white, imbricated and lamellar scales A common, chronic, recurrent, inflammatory disease of the skin characterized by round, circumscribed, erythematous, dry, scaling plaques of various sizes, covered by grayish white or silvery white, imbricated and lamellar scales Predilection for the scalp, nails, extensor surfaces, elbows, knees, umbilical, and sacral region Predilection for the scalp, nails, extensor surfaces, elbows, knees, umbilical, and sacral region

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19 Typically symmetrical Typically symmetrical May be a solitary macule to more than 100 May be a solitary macule to more than 100 Usually develops slowly but may be exanthematous, with a sudden onset of numerous guttate lesions Usually develops slowly but may be exanthematous, with a sudden onset of numerous guttate lesions Subjective symptoms such as itching or burning may be present and cause extreme discomfort Subjective symptoms such as itching or burning may be present and cause extreme discomfort

20 Scales are micaceous Scales are micaceous Auspitz’s sign may be observed Auspitz’s sign may be observed Annular, lobulated, and gyrate figures may be produced Annular, lobulated, and gyrate figures may be produced Old patches may be thickened and tough, and covered with lamellar scales like the outside of an oyster shell – psoriasis ostracea Old patches may be thickened and tough, and covered with lamellar scales like the outside of an oyster shell – psoriasis ostracea

21 Various other descriptive terms Various other descriptive terms Psoriasis guttata Psoriasis guttata Psoriasis follicularis Psoriasis follicularis Psoriasis figurata, psoriasis annulata, psoriasis gyrata Psoriasis figurata, psoriasis annulata, psoriasis gyrata Psoriasis discoidea Psoriasis discoidea Psoriasis rupioides Psoriasis rupioides Plaque psoriasis Plaque psoriasis

22 Seborrheic-like psoriasis In some cases of psoriasis prominent features of seborrheic dermatitis may occur not only if the typical sites of psoriasis vulgaris but also in the flexural areas such as the antecubital areas, axillae, under the breasts, groins, umbilicus, and intergluteal areas In some cases of psoriasis prominent features of seborrheic dermatitis may occur not only if the typical sites of psoriasis vulgaris but also in the flexural areas such as the antecubital areas, axillae, under the breasts, groins, umbilicus, and intergluteal areas Sebopsoriasis or seborrheic psoriasis Sebopsoriasis or seborrheic psoriasis

23 Inverse psoriasis Flexural psoriasis or volar psoriasis Flexural psoriasis or volar psoriasis Selectively and almost exclusively involves folds, recesses, and flexural surfaces Selectively and almost exclusively involves folds, recesses, and flexural surfaces Scalp quite often participates as well Scalp quite often participates as well Onycholysis, “Oil spots”, and nail pitting may be seen Onycholysis, “Oil spots”, and nail pitting may be seen

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25 “Napkin” psoriasis Diaper dermatitis caused by the irritative effects of urine in the wet diaper area, may imitate a psoriasiform eruption Diaper dermatitis caused by the irritative effects of urine in the wet diaper area, may imitate a psoriasiform eruption In addition there is commonly an infection with Candida albicans In addition there is commonly an infection with Candida albicans Lesions typically clear Lesions typically clear Infants may be at risk for psoriasis in adulthood Infants may be at risk for psoriasis in adulthood

26 Psoriatic arthritis The incidence of psoriasis is 10 times greater in persons with seronegative arthritis than in persons without arthritis The incidence of psoriasis is 10 times greater in persons with seronegative arthritis than in persons without arthritis

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28 Five clinical patterns Asymmetrical distal interphalangeal joint involvement with nail damage, 16% Asymmetrical distal interphalangeal joint involvement with nail damage, 16% Arthritis mutilans with osteolysis of phalanges and metacarpals, 5% Arthritis mutilans with osteolysis of phalanges and metacarpals, 5% Symmetrical polyarthritis-like rheumatoid arthritis, with claw hands, 15% Symmetrical polyarthritis-like rheumatoid arthritis, with claw hands, 15% Oligoarthritis with swelling and tenosynovitis of one or a few hand joints, 70% Oligoarthritis with swelling and tenosynovitis of one or a few hand joints, 70% Ankylosing spondylitis alone or with peripheral arthritis, 5% Ankylosing spondylitis alone or with peripheral arthritis, 5%

29 Radiographic findings suggestive of psoriatic arthritis include: erosion of terminal phalangeal tufts, tapering of phalanges or metacarpals, “cupping’ of proximal ends of phalanges,, bony ankylosis, osteolysis of metatarsals, predilection for distal and proximal interphalangeal joints, paravertebral ossification, asymmetrical sacroiliitis, and rarity of “bamboo spine”when the spine is involved Radiographic findings suggestive of psoriatic arthritis include: erosion of terminal phalangeal tufts, tapering of phalanges or metacarpals, “cupping’ of proximal ends of phalanges,, bony ankylosis, osteolysis of metatarsals, predilection for distal and proximal interphalangeal joints, paravertebral ossification, asymmetrical sacroiliitis, and rarity of “bamboo spine”when the spine is involved Nearly half the patients with psoriatic arthritis have HLA-B27 Nearly half the patients with psoriatic arthritis have HLA-B27

30 Rest, splinting, passive motion, and aspirin or NSAIDs are appropriate Rest, splinting, passive motion, and aspirin or NSAIDs are appropriate Methotrexate, cyclosporine, oral retinoids, sulfasalazine, tacrolimus, and PUVA are all likely to help both the psoriasis and arthritis Methotrexate, cyclosporine, oral retinoids, sulfasalazine, tacrolimus, and PUVA are all likely to help both the psoriasis and arthritis Systemic steroids however, the long term complications and potential for rebound in cutaneous disease restricts their use Systemic steroids however, the long term complications and potential for rebound in cutaneous disease restricts their use

31 Guttate psoriasis This distinctive form of psoriasis typical lesions are the size of water drops This distinctive form of psoriasis typical lesions are the size of water drops Usually occurs as an abrupt eruption following some acute infection, such as streptococcal pharyngitis Usually occurs as an abrupt eruption following some acute infection, such as streptococcal pharyngitis Occurs mostly in patients under age 30 Occurs mostly in patients under age 30 Recurrent episodes are likely, because of pharyngeal carriage of the responsible streptococcus Recurrent episodes are likely, because of pharyngeal carriage of the responsible streptococcus This type of psoriasis is usually rapidly responsive to topical steroids or UVB This type of psoriasis is usually rapidly responsive to topical steroids or UVB

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33 Generalized pustular psoriasis (von Zumbusch) Typical patients have had plaque psoriasis and often psoriatic arthritis Typical patients have had plaque psoriasis and often psoriatic arthritis The onset is sudden, with formation of lakes of pus periungally, on the palms, and at the edge of psoriatic plaques The onset is sudden, with formation of lakes of pus periungally, on the palms, and at the edge of psoriatic plaques Pruritis and intense burning cause extreme discomfort Pruritis and intense burning cause extreme discomfort There is a fever, and a fetid odor develops There is a fever, and a fetid odor develops The pustules dry up to form yellow-brown crusts over a reddish-brown shiny surface The pustules dry up to form yellow-brown crusts over a reddish-brown shiny surface

34 Generalized pustular psoriasis (von Zumbusch) Mucous membrane lesions are common on the tongue and in the mouth Mucous membrane lesions are common on the tongue and in the mouth The lips are red and scaly, and superficial ulcerations of the tongue and mouth occur The lips are red and scaly, and superficial ulcerations of the tongue and mouth occur May go through several stages May go through several stages A number of cases of acute respiratory distress syndrome associated with pustular and erythrodermic psoriasis have been reported A number of cases of acute respiratory distress syndrome associated with pustular and erythrodermic psoriasis have been reported Systemic complications include pneumonia, CHF and hepatitis Systemic complications include pneumonia, CHF and hepatitis

35 Generalized pustular psoriasis (von Zumbusch) Etiology unclear Etiology unclear Iodides, coal tar, steroid withdrawal, terbinafine, minocycline, hydroxychloroquine, acetazolamide, and salicylates may trigger the attacks Iodides, coal tar, steroid withdrawal, terbinafine, minocycline, hydroxychloroquine, acetazolamide, and salicylates may trigger the attacks May occur in infants May occur in infants Acitretin is drug of choice, with a rapid and predictable response Acitretin is drug of choice, with a rapid and predictable response Isotretinoin, cyclosporine, methotrexate, dapsone Isotretinoin, cyclosporine, methotrexate, dapsone

36 course The course of psoriasis is unpredictable The course of psoriasis is unpredictable Usually begins on the scalp or elbows Usually begins on the scalp or elbows May first be seen over the sacrum May first be seen over the sacrum Onset may be sudden and widespread Onset may be sudden and widespread First lesions may be limited to the fingernails First lesions may be limited to the fingernails Two of the chief features of psoriasis are its tendency to recur and persist Two of the chief features of psoriasis are its tendency to recur and persist

37 However, patients may remain completely free of lesions for years However, patients may remain completely free of lesions for years Koebner’s phenomenon – the appearance of typical lesions of psoriasis at sites of eve trivial injury Koebner’s phenomenon – the appearance of typical lesions of psoriasis at sites of eve trivial injury Auspitz’s sign – pinpoint bleeding when the psoriatic scale is forcibly removed, this occurs because of severe thinning of the epidermis over the tips of the dermal papilla Auspitz’s sign – pinpoint bleeding when the psoriatic scale is forcibly removed, this occurs because of severe thinning of the epidermis over the tips of the dermal papilla Woronoff ring – is concentric blanching of the erythematous skin at or near the periphery of the healing psoriatic plaque Woronoff ring – is concentric blanching of the erythematous skin at or near the periphery of the healing psoriatic plaque

38 On the scalp absence of itching or hair loss, marked predilection for frontal scalp margin, deep erythema, and resistance to effective therapy for seborrheic dermatitis all suggest psoriasis On the scalp absence of itching or hair loss, marked predilection for frontal scalp margin, deep erythema, and resistance to effective therapy for seborrheic dermatitis all suggest psoriasis The palms and soles are often, sometimes exclusively, affected The palms and soles are often, sometimes exclusively, affected “flexural” or inverse psoriasis shows salmon- red, demarcated plaques that frequently become eczematized, moist and fissured “flexural” or inverse psoriasis shows salmon- red, demarcated plaques that frequently become eczematized, moist and fissured

39 Numerous cases of psoriasis of the mucous membranes have been reported Numerous cases of psoriasis of the mucous membranes have been reported Fingernails and toenails may be involved. Characteristic changes include pits, onycholysis and cracking of the free edges Fingernails and toenails may be involved. Characteristic changes include pits, onycholysis and cracking of the free edges Many studies report an association of hepatitis C and psoriasis Many studies report an association of hepatitis C and psoriasis Hepatitis C has also been implicated in psoriatic arthritis Hepatitis C has also been implicated in psoriatic arthritis

40 etiology The cause of psoriasis is still unknown The cause of psoriasis is still unknown Heredity is of significance in some cases Heredity is of significance in some cases Evidence that susceptibility to psoriasis is linked to class I and II major histocompatibility complex on human chromosome 6 (17q) Evidence that susceptibility to psoriasis is linked to class I and II major histocompatibility complex on human chromosome 6 (17q) HLA associations include -Cw6, -B57, and -DR7 for early onset and -Cw2 for late onset psoriasis HLA associations include -Cw6, -B57, and -DR7 for early onset and -Cw2 for late onset psoriasis

41 It is believed also that any individual that has –B13 or –B17 has a fivefold risk of developing psoriasis It is believed also that any individual that has –B13 or –B17 has a fivefold risk of developing psoriasis In pustular psoriasis HLA-B27 may be seen In pustular psoriasis HLA-B27 may be seen -B13 and -B17 are increased in guttate and erythrodermic psoriasis -B13 and -B17 are increased in guttate and erythrodermic psoriasis

42 epidemiology Equal frequency in both sexes Equal frequency in both sexes Mean age of onset is 27 years, range is wide Mean age of onset is 27 years, range is wide Sunlight improves Sunlight improves Emotional stress aggravates Emotional stress aggravates 39% of patients experience complete periodic disappearance of psoriasis during its course 39% of patients experience complete periodic disappearance of psoriasis during its course Seen in 1-2% of US population. Not seen in Native Americans Seen in 1-2% of US population. Not seen in Native Americans

43 Distinct tendency to improvement with pregnancy Distinct tendency to improvement with pregnancy Exacerbation is common after childbirth Exacerbation is common after childbirth

44 pathogenesis Characterized by three main pathogenic features: abnormal differentiation, keratinocyte hyperproliferation and inflammation Characterized by three main pathogenic features: abnormal differentiation, keratinocyte hyperproliferation and inflammation Accelerated epidermopoiesis has been considered to be the fundamental pathologic event in psoriasis Accelerated epidermopoiesis has been considered to be the fundamental pathologic event in psoriasis The transit rate of psoriatic keratinocytes is increased, and the deoxyribonucleic acid synthesis time is decreased The transit rate of psoriatic keratinocytes is increased, and the deoxyribonucleic acid synthesis time is decreased

45 Early lesion are infiltrated predominantly by lymphocytes in the papillary dermis Early lesion are infiltrated predominantly by lymphocytes in the papillary dermis The cause of T-lymphocyte activation and the role of these cell populations remains unclear The cause of T-lymphocyte activation and the role of these cell populations remains unclear

46 stress Studies have shown a positive correlation between stress and the severity of disease Studies have shown a positive correlation between stress and the severity of disease

47 Drug-induced psoriasis May be induced by many drugs: beta blockers, lithium, and antimalarials, terbinafine, calcium channel blockers, captopril, glyburide, and lipid lowering agents such as gemfibrozil May be induced by many drugs: beta blockers, lithium, and antimalarials, terbinafine, calcium channel blockers, captopril, glyburide, and lipid lowering agents such as gemfibrozil

48 Pathology Regular epidermal hyperplasia with long, test- tube-shaped rete ridges Regular epidermal hyperplasia with long, test- tube-shaped rete ridges Thinning of dermal papillae Thinning of dermal papillae Granular layer is thin or absent Granular layer is thin or absent Overlying parakeratosis Overlying parakeratosis Small collections of neutrophils (Munro microabcesses) may be present in the stratum corneum Small collections of neutrophils (Munro microabcesses) may be present in the stratum corneum There is a perivascular mononuclear cell infiltrate There is a perivascular mononuclear cell infiltrate

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50 Differential diagnosis Seborrheic dermatitis, pityriasis rosea, lichen planus, eczema, psoriasiform syphilid, and lupus erythematosis Seborrheic dermatitis, pityriasis rosea, lichen planus, eczema, psoriasiform syphilid, and lupus erythematosis Distribution, quality of the scale and presence of Auspitz’s sign, symptoms, serologic testing Distribution, quality of the scale and presence of Auspitz’s sign, symptoms, serologic testing

51 treatment Topical Topical Systemic Systemic Combination Combination Rotating therapeutic approaches, especially with systemic agents that have varying toxicities Rotating therapeutic approaches, especially with systemic agents that have varying toxicities

52 Topical treatment In many patients topical applications alone will suffice to keep psoriasis under control. Numerous local medications are available In many patients topical applications alone will suffice to keep psoriasis under control. Numerous local medications are available

53 Corticosteroids Most frequent therapy Most frequent therapy Ointments are more effective Ointments are more effective Creams are preferred in the intertriginous areas and in exposed areas Creams are preferred in the intertriginous areas and in exposed areas Effectiveness may be augmented by an occlusive dressing, prompt response is usually noted Effectiveness may be augmented by an occlusive dressing, prompt response is usually noted Side effects include miliaria, pyoderma, epidermal atrophy Side effects include miliaria, pyoderma, epidermal atrophy

54 Intralesional corticosteroid injections Intralesional corticosteroid injections Good results when treating psoriatic nails Good results when treating psoriatic nails

55 tars The staining property and the odor of the tars may hinder their use The staining property and the odor of the tars may hinder their use Coal tar or liquor carbonis detergents is applied to the lesions before ultraviolet treatment in the Goeckerman method Coal tar or liquor carbonis detergents is applied to the lesions before ultraviolet treatment in the Goeckerman method

56 dihydroxyanthralin Anthralin exerts its direct effect on keratinocytes and leukocytes by suppressing neutrophil superoxide generation and inhibition of monocyte derived IL-6, IL-8, and TNF-alpha Anthralin exerts its direct effect on keratinocytes and leukocytes by suppressing neutrophil superoxide generation and inhibition of monocyte derived IL-6, IL-8, and TNF-alpha Highly irritating and stains skin, clothing and bedding Highly irritating and stains skin, clothing and bedding

57 tazarotene Appears to treat psoriasis by modulating keratinocyte differentiation and hyperproliferation, as well as suppressing inflammation Appears to treat psoriasis by modulating keratinocyte differentiation and hyperproliferation, as well as suppressing inflammation Produces local irritation Produces local irritation Combination with topical corticosteroids aids in patient acceptance Combination with topical corticosteroids aids in patient acceptance

58 Vitamin D Vitamin D3 affects keratinocyte differentiation partly through its regulation of epidermal responsiveness to calcium Vitamin D3 affects keratinocyte differentiation partly through its regulation of epidermal responsiveness to calcium Has been shown to be very effective in the treatment of plaque-type and scalp psoriasis Has been shown to be very effective in the treatment of plaque-type and scalp psoriasis Combination therapy with high-potency steroids may provide greater response Combination therapy with high-potency steroids may provide greater response

59 Salicylic acid Aids in removing of the scale and promoting the efficacy of other topical agents Aids in removing of the scale and promoting the efficacy of other topical agents Usually in a 3% to a 5% concentration Usually in a 3% to a 5% concentration Widespread application may lead to salicylate toxicity Widespread application may lead to salicylate toxicity Tinnitus, acute confusion, refractory hypoglycemia Tinnitus, acute confusion, refractory hypoglycemia

60 Ultraviolet light In most instances sunlight improves psoriasis remarkably In most instances sunlight improves psoriasis remarkably However, burning of the skin may cause Koebner’s phenomenon and an exacerbation However, burning of the skin may cause Koebner’s phenomenon and an exacerbation UVB UVB Tar applications or baths before UVB exposure have been credited with enhancing its effects Tar applications or baths before UVB exposure have been credited with enhancing its effects Maintenance UVB phototherapy after clearing contributes to the duration of remission Maintenance UVB phototherapy after clearing contributes to the duration of remission

61 Narrow band UVB has been shown to be more effective in treating psoriasis than broadband Narrow band UVB has been shown to be more effective in treating psoriasis than broadband

62 Goeckerman technique 2 to 5% tar preparation is applied to the skin, and a tar bath is taken at least once daily. The excess tar is removed with mineral or vegetable oil and ultraviolet light is given 2 to 5% tar preparation is applied to the skin, and a tar bath is taken at least once daily. The excess tar is removed with mineral or vegetable oil and ultraviolet light is given

63 Ingram technique Consists of a daily coal tar bath in a solution such as 120 ml liquor carbonis detergens to 80 L of warm water Consists of a daily coal tar bath in a solution such as 120 ml liquor carbonis detergens to 80 L of warm water This is followed by exposure to an ultraviolet light for daily increasing periods This is followed by exposure to an ultraviolet light for daily increasing periods Anthralin paste is then applied to each psoriatic plaque Anthralin paste is then applied to each psoriatic plaque Talcum powder is sprinkled over the lesions, and a stockinette dressing is applied Talcum powder is sprinkled over the lesions, and a stockinette dressing is applied

64 PUVA therapy UVA given 2 hours after ingestion of 8- methoxypsoralen (Oxsoralen), and given two to three times a week UVA given 2 hours after ingestion of 8- methoxypsoralen (Oxsoralen), and given two to three times a week Maintenance treatment is needed Maintenance treatment is needed Risk of enhanced carcinogenesis is proven Risk of enhanced carcinogenesis is proven Reversal of the usual ratio of squamous cell carcinomas to basal cell carcinomas Reversal of the usual ratio of squamous cell carcinomas to basal cell carcinomas Accelerated actinic elastosis, melanocyte dysplasia, and possible increased incidence of melanoma should be considered Accelerated actinic elastosis, melanocyte dysplasia, and possible increased incidence of melanoma should be considered

65 Surgical treatment Denervation by surgery has long been known to abolish psoriatic plaques Denervation by surgery has long been known to abolish psoriatic plaques Excision to the depth of the reticular dermis Excision to the depth of the reticular dermis In a group of 14 patients with pharyngeal colonization by streptococci unresponsive to antibiotic therapy 9 cleared after tonsillectomy In a group of 14 patients with pharyngeal colonization by streptococci unresponsive to antibiotic therapy 9 cleared after tonsillectomy

66 Lasers in psoriasis Psoriatic plaques can be cleared by destruction of the upper dermis Psoriatic plaques can be cleared by destruction of the upper dermis Blood vessels in the psoriatic dermal papillae can be selectively destroyed with yellow lasers effectiveness with flashlamp pulsed dye laser Blood vessels in the psoriatic dermal papillae can be selectively destroyed with yellow lasers effectiveness with flashlamp pulsed dye laser Some success with CO2 resurfacing laser Some success with CO2 resurfacing laser

67 hyperthermia 22 chronic psoriatic plaques in 9 patients were heated to 42 – 45 C with ultrasound for 30 minutes 3 times a week for 4 to 10 treatments. 15 completely cleared 22 chronic psoriatic plaques in 9 patients were heated to 42 – 45 C with ultrasound for 30 minutes 3 times a week for 4 to 10 treatments. 15 completely cleared Microwave hyperthermia may produce significant complications such as pain over bony prominences and hypotension Microwave hyperthermia may produce significant complications such as pain over bony prominences and hypotension

68 Occlusive treatment Report of clearing of psoriatic lesion by occluding them with tape Report of clearing of psoriatic lesion by occluding them with tape Has been shown that hydrocolloid occlusion (with Actiderm) had a similar effect on small lesions Has been shown that hydrocolloid occlusion (with Actiderm) had a similar effect on small lesions

69 Systemic treatment Corticosteroids Corticosteroids Methotrexate Methotrexate Cyclosporine Cyclosporine Diet Diet Oral antimicrobial therapy Oral antimicrobial therapy Retinoids Retinoids dapsone dapsone

70 Corticosteroids The side effects of orally administered prednisone are so dangerous that its use should be limited to patients with unusual individual circumstances The side effects of orally administered prednisone are so dangerous that its use should be limited to patients with unusual individual circumstances There is a great risk of “rebound” or induction of pustular psoriasis when it is stopped There is a great risk of “rebound” or induction of pustular psoriasis when it is stopped

71 Methotrexate Was the first effective systemic drug for psoriasis and is the standard for systemic therapy Was the first effective systemic drug for psoriasis and is the standard for systemic therapy Methotrexate has greater affinity for dihydrofolic acid reductase than has folic acid Methotrexate has greater affinity for dihydrofolic acid reductase than has folic acid The synthesis of deoxyribonucleic acid is blocked when dihydrofolic acid reductase is bound and thereby cell division is decreased The synthesis of deoxyribonucleic acid is blocked when dihydrofolic acid reductase is bound and thereby cell division is decreased

72 May also affect the inflammatory elements of psoriasis May also affect the inflammatory elements of psoriasis Indications for its use include psoriatic erythroderma, moderate to severe psoriatic arthritis, acute pustular psoriasis, more than 20% total body surface involvement, localized pustular psoriasis, psoriasis that affects certain areas of the body so that normal function and employment are prevented, lack of response to phototherapy, PUVA, or retinoids Indications for its use include psoriatic erythroderma, moderate to severe psoriatic arthritis, acute pustular psoriasis, more than 20% total body surface involvement, localized pustular psoriasis, psoriasis that affects certain areas of the body so that normal function and employment are prevented, lack of response to phototherapy, PUVA, or retinoids

73 Prior to start of treatment ensure that there is no history of liver or kidney disease Prior to start of treatment ensure that there is no history of liver or kidney disease Alcohol abuse, cirrhosis, severe illness, debility, pregnancy, anemia should be considered Alcohol abuse, cirrhosis, severe illness, debility, pregnancy, anemia should be considered AST, ALT, bilirubin, serum albumin, creatinin. Alkaline phosphatase, CBC, platelets, Hep B and C serology, and UA should all be evaluated prior to tx AST, ALT, bilirubin, serum albumin, creatinin. Alkaline phosphatase, CBC, platelets, Hep B and C serology, and UA should all be evaluated prior to tx

74 Most patients with no risk factors for liver disease the first liver biopsy should be obtained at approximately 1.0 to 1.5 g of cumulative methotrexate and repeated every subsequent 1.5 g until a total of 4 g is reached Most patients with no risk factors for liver disease the first liver biopsy should be obtained at approximately 1.0 to 1.5 g of cumulative methotrexate and repeated every subsequent 1.5 g until a total of 4 g is reached 3 divided oral doses 12 hrs apart weekly, once weekly doses orally and single weekly subcutaneous injections are effective treatment schedules 3 divided oral doses 12 hrs apart weekly, once weekly doses orally and single weekly subcutaneous injections are effective treatment schedules

75 Cyclosporine The therapeutic benefit of the immunosupressive features of cyclosporine in psoriatic disease may be related to down modulation of proinflammatory epidermal cytokines The therapeutic benefit of the immunosupressive features of cyclosporine in psoriatic disease may be related to down modulation of proinflammatory epidermal cytokines Biopsies of the kidney in 30 patients after 2 years of cyclosporine treatment found features consistent with cyclosporine-induced nephrotoxicity Biopsies of the kidney in 30 patients after 2 years of cyclosporine treatment found features consistent with cyclosporine-induced nephrotoxicity

76 Another study concluded that cyclosporine may be used long-term (5-10 years) in severe, recalcitrant psoriasis if renal function is closely monitored Another study concluded that cyclosporine may be used long-term (5-10 years) in severe, recalcitrant psoriasis if renal function is closely monitored Induction of therapy with 2.5 to 3.0 mg/kg given as a divided dose twice daily and may be increased to 5.0 mg/kg/day until a clinical response is noted Induction of therapy with 2.5 to 3.0 mg/kg given as a divided dose twice daily and may be increased to 5.0 mg/kg/day until a clinical response is noted

77 Diet Controlled studies evaluating various dietary restrictions, especially those of low protein intake, showed no appreciable difference in the course of psoriasis Controlled studies evaluating various dietary restrictions, especially those of low protein intake, showed no appreciable difference in the course of psoriasis Another study found psoriasis to be more severe in patients trying herbal remedies, vitamin therapy, and dietary manipulation Another study found psoriasis to be more severe in patients trying herbal remedies, vitamin therapy, and dietary manipulation

78 Most recent trials have demonstrated the antiinflammatory effects of fish oils rich in n-3 polyunsaturated fatty acids in rheumatoid arthritis, inflammatory bowel disease, psoriasis and asthma Most recent trials have demonstrated the antiinflammatory effects of fish oils rich in n-3 polyunsaturated fatty acids in rheumatoid arthritis, inflammatory bowel disease, psoriasis and asthma

79 Oral antimicrobial therapy Recent evidence suggest that Staphylococcus aureus and streptococci secrete a large family of exotoxins that are superantigens, producing massive T-cell activation Recent evidence suggest that Staphylococcus aureus and streptococci secrete a large family of exotoxins that are superantigens, producing massive T-cell activation Oral antibiotic for psoriasis patients infected with these organisms is imperative Oral antibiotic for psoriasis patients infected with these organisms is imperative

80 Retinoids Treatment with 13-cis-retinoic acid can produce good results, especially in pustular psoriasis Treatment with 13-cis-retinoic acid can produce good results, especially in pustular psoriasis It is a potent teratogen It is a potent teratogen Combinations of retinoic acids with photochemotherapy for chronic plaque psoriasis may also be very affective Combinations of retinoic acids with photochemotherapy for chronic plaque psoriasis may also be very affective Etretinate Etretinate Acitretin, avoid pregnancy for up to 3 years following cessation of therapy Acitretin, avoid pregnancy for up to 3 years following cessation of therapy

81 dapsone Use is limited largely to palmoplantar eruptions Use is limited largely to palmoplantar eruptions

82 Combination therapy Patient on methotrexate may have their dose minimized with concomitant topical steroid use Patient on methotrexate may have their dose minimized with concomitant topical steroid use PUVA with Acitretin PUVA with Acitretin PUVA with cyclosporine PUVA with cyclosporine PUVA with methotrexate PUVA with methotrexate Topical Dovonex with Acitretin, cyclosporine, methotrexate, and phototherapy Topical Dovonex with Acitretin, cyclosporine, methotrexate, and phototherapy

83 The principle behind combination therapy is the use of agents win which the side effects profile is different or partly opposing The principle behind combination therapy is the use of agents win which the side effects profile is different or partly opposing Hydroxyurea and sulfalsalazine have been used in severe cases and in combination with other modalities, such as PUVA Hydroxyurea and sulfalsalazine have been used in severe cases and in combination with other modalities, such as PUVA Particularly useful in topical therapy, where the risk profiles are considerably less Particularly useful in topical therapy, where the risk profiles are considerably less

84 Reiter’s syndrome Characteristic clinical triad consisting of urethritis, conjunctivitis, and arthritis Characteristic clinical triad consisting of urethritis, conjunctivitis, and arthritis May also be other features that involve the skin, mucous membranes, gi tract, and cardiovascular system May also be other features that involve the skin, mucous membranes, gi tract, and cardiovascular system American Rheumatism Association criterion of peripheral arthritis of more than 1 month duration, in association with urethritis and/or cervicitis American Rheumatism Association criterion of peripheral arthritis of more than 1 month duration, in association with urethritis and/or cervicitis Occurs chiefly in young men of HLA-B27 genotype Occurs chiefly in young men of HLA-B27 genotype

85 Clinical features Any one of the triad of urethritis, conjunctivitis, or arthritis may occur first, accompanied by fever, weakness, and weight loss. Any one of the triad of urethritis, conjunctivitis, or arthritis may occur first, accompanied by fever, weakness, and weight loss. A nonbacterial urethritis may develop with painful and bloody urination and pyuria A nonbacterial urethritis may develop with painful and bloody urination and pyuria About 1/3 of patients develop conjunctivitis About 1/3 of patients develop conjunctivitis Keratitis is usually superficial and very painful. Iritis is common Keratitis is usually superficial and very painful. Iritis is common

86 An asymmetric arthritis afflicts synovial joints, especially those that are weight bearing An asymmetric arthritis afflicts synovial joints, especially those that are weight bearing Onset is sudden with heat and tenderness and swelling Onset is sudden with heat and tenderness and swelling Pain in one or both heels is a frequent symptom Pain in one or both heels is a frequent symptom

87 The skin lesions start as multiple, small, yellowish vesicles that break, become confluent and form superficial erosions The skin lesions start as multiple, small, yellowish vesicles that break, become confluent and form superficial erosions Develop frequently on the genitals and palms Develop frequently on the genitals and palms Eruption on the glans penis occurs in 25% of patients Eruption on the glans penis occurs in 25% of patients Lesions on the soles start as pustules, become crusted or hyperkeratotic Lesions on the soles start as pustules, become crusted or hyperkeratotic

88 The eruption is known as keratoderma blennorrhagicum The eruption is known as keratoderma blennorrhagicum Penile lesions are frequent Penile lesions are frequent Characterized by perimeatal balanitis, these become crusted and form circinate lesions Characterized by perimeatal balanitis, these become crusted and form circinate lesions Similar lesion are seen on the vaginal mucosa of women Similar lesion are seen on the vaginal mucosa of women

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90 Nails become thick and brittle, with development of subungal keratosis Nails become thick and brittle, with development of subungal keratosis Endocarditis, pericarditis, and myocarditis, as well as aortic insufficiency occur in some Endocarditis, pericarditis, and myocarditis, as well as aortic insufficiency occur in some In children conjunctivitis is the most frequent complaint In children conjunctivitis is the most frequent complaint

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92 etiology Syndrome has been attributed to many different agents such as Shigella flexneri, Salmonella spp., yersinia spp., Ureaplasma urealyticum, Borrelia burgdorferi, Cryptosporidia, and Campylobacter fetus Syndrome has been attributed to many different agents such as Shigella flexneri, Salmonella spp., yersinia spp., Ureaplasma urealyticum, Borrelia burgdorferi, Cryptosporidia, and Campylobacter fetus May be responsible for the infectious enteritis that precedes onset in a small percentage of patients May be responsible for the infectious enteritis that precedes onset in a small percentage of patients In cases that follow an infection of the genitourinary tract, Chlamydia trachomatis may be associated In cases that follow an infection of the genitourinary tract, Chlamydia trachomatis may be associated

93 HLA-B27 positivity is present in 80% of cases of Reiter’s syndrome HLA-B27 positivity is present in 80% of cases of Reiter’s syndrome This rises to 90 to 100% in patients with accompanying sacroiliitis, uveitis, or aortitis This rises to 90 to 100% in patients with accompanying sacroiliitis, uveitis, or aortitis May be caused by abnormalities in the production and elicitation of immune mediators or T cells May be caused by abnormalities in the production and elicitation of immune mediators or T cells

94 Laboratory findings No specific changes are characteristic of this syndrome No specific changes are characteristic of this syndrome A leukocytosis of 10, 000 to 20, 000/mm3 and an elevated sed rate are the most consistent findings A leukocytosis of 10, 000 to 20, 000/mm3 and an elevated sed rate are the most consistent findings

95 histopathology Identical to psoriasis Identical to psoriasis

96 Differential diagnosis May be confused with rheumatoid arthritis, ankylosing spondylitis, gout, psoriatic arthritis, gonococcal arthritis, acute rheumatic fever, chronic mucocutaneous candidiasis, and serum sickness May be confused with rheumatoid arthritis, ankylosing spondylitis, gout, psoriatic arthritis, gonococcal arthritis, acute rheumatic fever, chronic mucocutaneous candidiasis, and serum sickness

97 treatment Usually mucocutaneous lesions are self limited and clear within a few months Usually mucocutaneous lesions are self limited and clear within a few months Topical steroids are helpful Topical steroids are helpful NSAIDs for the joint disease NSAIDs for the joint disease Methotrexate for severe disease Methotrexate for severe disease Cyclosporine Cyclosporine Acitretin Acitretin

98 The course is characterized by exacerbations and remission in about on third of patients The course is characterized by exacerbations and remission in about on third of patients A chronic deforming arthritis occurs in a bout 20% of patients, with significant disability resulting, chiefly from foot deformities A chronic deforming arthritis occurs in a bout 20% of patients, with significant disability resulting, chiefly from foot deformities

99 Subcorneal pustular dermatosis (Sneddon-Wilkinson Disease ) Chronic pustular disease which occurs chiefly in middle-aged women. Chronic pustular disease which occurs chiefly in middle-aged women. Pustules are superficial and arranged in annular and serpiginous patterns, especially on the abdomen, axillae and groins Pustules are superficial and arranged in annular and serpiginous patterns, especially on the abdomen, axillae and groins Sometimes vesicles are present Sometimes vesicles are present Cultures from pustules are sterile Cultures from pustules are sterile Oral lesions are rare Oral lesions are rare Some cases occur in association with and IgA monoclonal gammopathy Some cases occur in association with and IgA monoclonal gammopathy

100 Subcorneal pustular dermatosis (Sneddon-Wilkinson Disease) Dapsone appears to be effective in most cases Dapsone appears to be effective in most cases Sulfapyridine Sulfapyridine Acitretin Acitretin Narrow band UVB Narrow band UVB Corticosteroids, colchicine, and TCN with niacinamide Corticosteroids, colchicine, and TCN with niacinamide Without treatment this is a chronic condition with remissions of variable duration Without treatment this is a chronic condition with remissions of variable duration

101 Eosinophilic pustular folliculitis Also referred to as sterile eosinophilic pustulosis Also referred to as sterile eosinophilic pustulosis Five times more common in males Five times more common in males Peak age of onset in the third decade, although a number of pediatric cases have been reported Peak age of onset in the third decade, although a number of pediatric cases have been reported Characterized by pruritic, follicular papulopustules arranged in groups Characterized by pruritic, follicular papulopustules arranged in groups Plaques may form Plaques may form

102 Eosinophilic pustular folliculitis Distribution is usually asymmetrical, with the face, trunk, and upper extremities most often afflicted Distribution is usually asymmetrical, with the face, trunk, and upper extremities most often afflicted Cause is unknown, however, numerous studies have implicated chemotactic substances, ICAM-1, and cyclooxygenase-generated metabolites Cause is unknown, however, numerous studies have implicated chemotactic substances, ICAM-1, and cyclooxygenase-generated metabolites Typical course is one of spontaneous remissions and exacerbations lasting from a few months to several years Typical course is one of spontaneous remissions and exacerbations lasting from a few months to several years

103 Eosinophilic pustular folliculitis Dapsone or systemic steroids are the treatment of choice Dapsone or systemic steroids are the treatment of choice Success with intralesional steroids, clofazimine, minocycline, isotretinoin, UVB therapy, indomethacin, colchicine, cyclosporine, and cetirizine Success with intralesional steroids, clofazimine, minocycline, isotretinoin, UVB therapy, indomethacin, colchicine, cyclosporine, and cetirizine Must be distinguished from HIV- associated EF Must be distinguished from HIV- associated EF

104 Eosinophilic pustular folliculitis Another variant has been described that occurs early in childhood Another variant has been described that occurs early in childhood Patients develop sterile pustules and papules preferentially over the scalp and; however, scattered clusters of pustules may occur over the trunk and extremities Patients develop sterile pustules and papules preferentially over the scalp and; however, scattered clusters of pustules may occur over the trunk and extremities High-potency topical steroids are the treatment of choice High-potency topical steroids are the treatment of choice Recurrent exacerbations and remissions usually occur with spontaneous remission Recurrent exacerbations and remissions usually occur with spontaneous remission

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