1. Papulosquamous Disorders: Seb Derm, Psoriasis, Palmoplantar, Pust Derm, Erythroderma
Chris Weyer D.O.
Dermatology Resident, PGY-1
Northeast Regional Medical Center

2. Seborrheic Dermatitis
2-5 % of the population
Chronic, superficial, inflammatory disease caused by the yeast, Malassezia globosa
Most commonly affects the scalp
Also, affects the eyebrows, ears, eyelids, nasolabial creases, lips, sternal area, axillae, submammary folds, umbilicus, groin, and gluteal crease
Characterized by itchy, pink, yellow or erythematous patches that may be dry, moist, or greasy

3. Infantile Seborrheic Dermatitis
Presents around 1 week after birth
AKA “Cradle cap”
Superimposed Candida may occur

5. Adult Seborrheic Dermatitis
Erythematous, greasy yellow scale
Symmetrical
If extensive, think about immunosuppression: HIV, diabetes, and Parkinson’s disease

8. Histology of Seb Derm Epidermis is acanthotic
Focal scale crust adjacent to follicular ostia
Slight spongiosis
Adult seb derm has superficial perivascular & perifollicular lymphocytic infiltrate composed mainly of lymphocytes
Older lesions show irregular acanthosis & focal parakeratosis
Histo features are combination of psoriasis & spongiotic derm

9. Treatment-Adolescent & Adult
Regular use of medicated shampoos -- over-the-counter: sulfide, tar, zinc, pyrithionate
Nizoral shampoo & cream
Loprox shampoo & solution
Elidel cream
Corticosteroids for quick control or flares
Key: leave shampoo on scalp for 3 minutes daily; apply before going into shower, as patient will not leave on shampoo for 3 minutes while in shower

10. Infantile seborrheic dermatitis
Responds well to topical therapy
Hydrocortisone 1% on the face & skin folds
This may be combined with an antifungal agent for skin folds
Remove scale after softening with an oil preparation or a weak keratolytic agent
Reassurance

11. 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
Predilection for the scalp, nails, extensor surfaces, elbows, knees, umbilical, and sacral region

13. Psoriasis nail changes
onycholysis, nail pitting, and oil spot phenomenon
Psoriasis nail changes including onycholysis, nail pitting, and oil spot phenomenon

14. Psoriasis clinical features
Koebner’s phenomenon – the appearance of typical lesions of psoriasis at sites of 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
Woronoff ring – is concentric blanching of the erythematous skin at or near the periphery of the healing psoriatic plaque

15. Pathogenesis
Hyperproliferative disorder driven by inflammatory mediators
TH1 cytokines- IL-2,6,8,12; IFN-g, TNF-a
IL-8: accumulation of neutrophils
IL-12: Primary TH1 signal, promotes IFN-g production

16. Inheritence
Heredity has a high influence, incidence increases with generations
Evidence that susceptibility to psoriasis is linked to class I and II MHC chromo 6
Genetic loci: PSORS1 (6); PSORS2 (17q)
HLA asso: early onset -Cw6, -B57, and -DR7 late onset –Cw2

17. Inheritance cont It is also believed that any individual that has
-B13 or –B17 has a fivefold risk of developing psoriasis
pustular psoriasis: HLA-B27
guttate and erythrodermic psoriasis: -B13,-B17
Palmarplantar pust: -B8, -Bw35, -Cw7, -DR3

18. Epidemiology of psoriasis
Seen in 1-2% of US population
Equal frequency in both sexes
Mean age of onset is 27 years
Sunlight may improve psoriasis by decreasing T-cells
Emotional stress, smoking, and alcohol aggravates psoriasis
Increased incidence of celiacs, lymphoma

19. 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

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

22. Types of Psoriasis Seborrheic-Like, “sebopsoriasis” Inverse Napkin
Arthritis
Guttate
Generialized Pustular (von Zumbusch)
Acro dermatitis Continua of Hallopeau
Impetigo Herpetiformis
Keratoderma Blennorrhagica
Erythrodermic

23. Inverse Psoriasis Flexural or intertrigenous location
Shiny erythematous plaques in the axilla that lack scale.

25. “Napkin” Psoriasis Infants 2-8 mo
Erythematous sharply demarcated in diaper area
Lesions typically clear w/ topical tx
Infants may be at risk for psoriasis in adulthood

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

28. Radiographic findings of psoriatic arthritis
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 “bamboo spine”
Nearly half the patients with psoriatic arthritis have HLA-B27
Tx- biologics, MTX, cyclosporin- dz modifying prevent deformity

30. Guttate Psoriasis
Usually, occurs as an abrupt eruption following an acute infection, such as streptococcal pharyngitis
Occurs mostly in patients under age 30
Recurrent episodes are likely
This type of psoriasis is usually rapidly responsive to topical steroids or UVB
Tx strep infx

31. Guttate Psoriasis
A: Small papules and plaques of guttate psoriasis; note Koebner phenomenon
B: Numerous papules due to Koebner phenomenon after sunburn

32. Generalized pustular psoriasis (von Zumbusch)
Typical patients have 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
Pruritus, pain, fever, and malaise
Fetid odor develops

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

35. Acrodermatitis Continua of Hallopeau
Acral erythematious plaques with nail involvment
Fingernails float away on lakes of pus: anonychia
Fingers taper to long keratotic points

36. Impetigo Herpetiformis
Generalized pustular psoriasis of pregnancy
Retinoids not indicated
Prednisone: controversial, may induce pustular flare, also matures fetal lung
Early delivery strongly encouraged

37. Treatment- Topicals
Corticosteroids- class I- 2wks, pulse, occlusion; rapid return when stopped
Calcipotriene- keratinocyte differentiation; plaque and scalp type
Tars- oils and shmp; stinks (literally)
Macrolactams (tacrolimus, pimicrolimus)- prevent steroid atrophy/acne
Salicylic acid- keratolytic
Tazorac- modulate differentiation/proliferation
Anthralin- SCAT, supresses neut superoxide, inhib mono IL-6,8/TNF-a

38. Treatment- Light NB-UVB (311-313nm), MED, 70% response
Goeckerman Tech-
2-5% tar bath QD + UV; clear 18 d w/ long term response
Ingram-
tar bath QD/carbonisdetergens/ UV/ anthalin/talcum/stocking dressing
PUVA- 2x/wk, clear tx; risk cataracts, SCC, MM

39. Methotrexate
First effective systemic drug for psoriasis and is the standard for systemic therapy
Blocks synthesis of deoxyribonucleic acid, which decreases cell division
Indications- erythroderma, arthritis, pustular, lg BSA

41. MTX
For patients with no risk factors for liver disease, the first liver biopsy should be obtained at approximately 1.5g of cumulative methotrexate
Weekly dosing for oral or IM – divided in three doses, 12 hours apart
IM injections have a much lower risk of hepatotoxicity

42. Cyclosporine May down-modulate proinflammatory epidermal cytokines
Rapid clearing and return
Low risk of renal tox w/ <6mo tx
Follow BP, Cr

44. Diet
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
Gluten-free diet
Koo J., Lee E., Lee C.S., Lebwohl M.. Psoriasis. J Am Acad Dermatol 2004;50:

45. 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
Oral antibiotic for psoriasis patients infected with these organisms is imperative

46. Retinoids
Treatment with 13-cis-retinoic acid can produce good results, especially in pustular psoriasis
It is a potent teratogen
Combinations of retinoic acids with photochemotherapy for chronic plaque psoriasis may also be very affective
Etretinate- long ½ life, EtOH changes acitretin
Acitretin – avoid pregnancy for up to 3 years following cessation of therapy

47. Dapsone Use is limited largely to palmoplantar eruptions
2nd-3rd line therapy

48. Combination therapy
Patient on methotrexate may have their dose minimized with concomitant topical steroid use
PUVA with acitretin, cyclosprine, or methotrexate
Topical Dovonex with Acitretin, cyclosporine, methotrexate, and phototherapy

49. Biologic Agents Alefacept (Amevive) Efalizumab (Raptiva)
Etanercept (Enbrel)
Infliximab (Remicaide)
Adalimumab (Humira)
These are indicated for moderate-to-severe plaque psoriasis

50. Journal of the American Academy of Dermatology Volume 53 • Number 2 • August 2005 Copyright © 2005 American Academy of Dermatology, Inc. Biologics in psoriasis: A quick reference guide Valencia D. Thomas, MD ∗ F. Clarissa Yang, MD Joseph C. Kvedar, MD

52. Journal of the American Academy of Dermatology Volume 53 • Number 2 • August 2005 Copyright © 2005 American Academy of Dermatology, Inc. Biologics in psoriasis: A quick reference guide Valencia D. Thomas, MD F. Clarissa Yang, MD Joseph C. Kvedar, MD

53. Reiter’s syndrome Triad: urethritis, conjunctivitis, and arthritis
Can’t see, can’t pee, can’t climb a tree!
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
Young men of HLA-B27 genotype

54. Clinical features May also have fever, weakness, and weight loss
A nonbacterial urethritis may develop with painful and bloody urination and pyuria
About 1/3 of patients develop conjunctivitis
Keratitis is usually superficial and very painful. Iritis is common.

55. Reiter’s syndrome
An asymmetric arthritis afflicts synovial joints, especially those that are weight bearing
Onset is sudden with heat and tenderness and swelling
Pain in one or both heels is a frequent symptom
Sclerosing of the SI joints

56. Cutaneous lesions of Reiter’s
The skin lesions start as multiple, small, yellowish vesicles that break, become confluent, and form superficial erosions
Develop frequently on the genitals and palms
Eruption on the glans penis occurs in 25% of patients

57. Cutaneous features
The eruption is known as keratoderma blennorrhagicum
Penile lesions are frequent
Balanitis circinata
Characterized by perimeatal balanitis
Similar lesion are seen on the vaginal mucosa of women

58. 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
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
HLA-B27 positivity is present in 80%

59. Laboratory findings Non-specific
A leukocytosis of 10, 000 to 20, 000/mm3 and an elevated sed rate

60. Histopathology
Identical to psoriasis

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

62. Treatment
Usually mucocutaneous lesions are self- limited and clear within a few months
Topical steroids
NSAIDs
Methotrexate
Cyclosporine
Acitretin

63. Subcorneal pustular dermatosis (Sneddon-Wilkinson Disease)
Chronic pustular disease, which occurs chiefly in middle-aged women
Pustules are superficial and arranged in annular and serpiginous patterns on the abdomen, axillae and groin
Vesicles may be present
Cultures from pustules are sterile
Oral lesions are rare
Some cases occur in association with an IgA monoclonal gammopathy
Desmocollin 1 autoantigen for Iga pemphigus

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

65. Pathology of Sneddon-Wilkinson

66. Eosinophilic pustular folliculitis
Also referred to as sterile eosinophilic pustulosis
AKA Ofuji’s disease
Males, Asia
HIV
Characterized by pruritic, follicular papulopustules arranged in groups
Histo: eos in or around follicles

67. Eosinophilic pustular folliculitis
Distribution is usually asymmetrical – affects face, trunk, and upper extremities
Cause is unknown – numerous studies have implicated chemotactic substances, ICAM-1, and cyclooxygenase-generated metabolites
Typical course – spontaneous remissions and exacerbations for a few months to several years

68. Eosinophilic pustular folliculitis
Dapsone or systemic steroids are the treatment of choice
Success with intralesional steroids, clofazimine, minocycline, isotretinoin, UVB therapy, indomethacin, colchicine, cyclosporine, and cetirizine

72. Recalcitrant Palmoplantar Eruptions
Recalcitrant pustular eruptions of the hands and feet are often examples of psoriasis
Need to then search for lesions elsewhere on the body(e.g., scalp, ears, glans penis)
Search also for a family history to confirm your suspicion

73. Dermatitis Repens
Aka- acrodermatitis continua and acrodermatits perstans
It’s a chronic inflammatory disease of hands and feet
Rarely, can become generalized
Usually, as a pustule or paronychia

74. Dermatitis Repens Occasionally, mucous membranes are involved
Nails are often dystrophic or destroyed
Lesions cause skin atrophy
Crusted, eczematoid, and psoriasiform lesions may occur, and there may be moderate itching
It is essentially unilateral in its beginning and asymmetrical throughout its entire course

75. Dermatitis Repens Histology Treatment
similar to those seen in psoriasis
the primary lesion is epidermal
An intraepithelial spongiform pustule is formed by infiltration of pmn’s
Treatment
topical mechlorethamine, topical steroids, PUVA, fluorouracil, and sulfapyridine
Acitretin, low dose cyclosporine, Acitretin plus calcipotriol

76. Palmoplantar Pustulosis
AKA pustular psoriasis
In contrast to dermatitis repens it is essentially bilateral and symmetrical
Locations include: thenar/hypothenar eminences or central portion of the palms and soles

77. Palmoplantar Pustulosis
In the course of a week, they tend to dry up, leaving punctate brown scabs that eventually exfoliate
Stages of quiescence and exacerbation characterize the condition
Meds, such as lithium, have been reported to induce
Patches begin as erythematous areas in which pustules form
Start as pinhead-sized, enlarge and coalesce to form small lakes of pus

78. Palmoplantar Pustulosis
Nails may become malformed, ridged, stippled, pitted and discolored
May be associated with psoriasis vulgaris
Some regard palmoplantar pustulosis as a form of psoriasis, while others consider it a separate entity
Female predominance; lack of seasonal variation; different histopathologic features and
Associated with thyroid disorders and cigarette smoking

79. Palmoplantar Pustulosis
May be predisposed to joint disease and possibly SAPHO syndrome-Synovitis, Acne, Pustulosis, Hyperostosis and Osteoarthritis
It’s resistant to most treatments
Acitretin is reportedly effective(1mg/kg/day)
Low-dose cyclosporine (1.25mg/kg/day-3.75mg/kg/day)
Intramuscular Kenalog (40-60mg)may be effective for short-term relief

80. Palmoplantar Pustulosis
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81. 10-33.jpg

82. Pustular Bacterid
Characterized by a symmetric, grouped, vesicular or pustular eruption on palms and soles
Marked by exacerbations and remissions over long periods
No involvement of webs of fingers or toes or flexion creases of toes
WBC may be elevated
Scaling is usually present
Etiology is thought to be a remote focus of infection; infection needs to be treated before resolution will occur

83. Juvenile Plantar Dermatosis
Usually begins as a patchy, symmetrical, smooth, red, glazed macule on great toes, sometimes with fissuring and desquamation in children aged 3-13
Toe webs are rarely involved; fingers may be
Histologically, there is psoriasiform acanthosis and a sparse, lymphocytic infiltrate in the upper dermis
Spongiosis is commonly present
Tx: bed rest, cotton socks and topical steroids
Spontaneous resolution within 4 yrs is the rule

84. 10-36.jpg

85. Infantile Acropustulosis
Intensely itchy vesicopustular eruption of hands and feet
Begins at any age up to 10 months, clearing in a few weeks and recurring repeatedly until final resolution at 6 – 36 months of age
Dapsone at 2mg/kg/day may help
Potent topical steroids aid in symptomatic relief

86. Infantile Acropustulosis
Should prompt an extensive workup to eliminate serious infectious causes (i.e., Tzanck prep, gram stain, KOH prep of pustule)
Some suspect that this condition may be a persistent reaction to prior scabies

87. Acropustulosis of infancy

88. THE END