1. Psoriasis
Dr. M. Arif Abid

2. Psoriasis Description
Inflammatory, common, chronic, genodermatosis which appears to be due abnormal t lymphocytes function
may be affected Skin, nails and joints forms.
There are several distinct clinical type
The most common presentation is scaly plaques on the elbows, knees, and scalp,

3. 28 days
3- 4 days

4. History Prevalence worldwide estimated at 1-3% of the population.
Etiology is not completely understood.
There are known inherited genetic factors and several established environmental triggers
Men and women are equally affected.
First-degree relatives are at increased risk of developing psoriasis.

5. History onset at any age,peaks during 20s and again in late 50s.
A Early onset of generalized psoriasis implies a less stable, more severe chronic clinical course.
Once expressed, psoriasis is likely to follow a relentless, waxing and waning course Extent and severity of disease varies widely
Environmental factors, including treatment, influence the course and severity.

6. Exacerbating factors human immunodeficiency virus infection
physical trauma (Koebner phenomenon)
infections(Streptococcus and Candida)
drugs:
Ithium
beta-blockers
antimalaria
corticosteroid withdrawal
winter season.
The psychosocial impact can be severe.

7. Clinical Presentations
Variations in the morphology of psoriasis • Chronic plaque psoriasis • Guttate psoriasis (acute eruptive psoriasis) • Pustular psoriasis • Erythrodermic psoriasis • Light-sensitive psoriasis • HIV-induced psoriasis • Keratoderma blennorrhagicum (Reiter syndrome)
Variations in the location of psoriasis • Scalp psoriasis • Psoriasis of the palms and soles • Pustular psoriasis of the palms and soles • Pustular psoriasis of the digits • Psoriasis inversus (psoriasis of flexural areas) • Psoriasis of the penis and Reiter syndrome • Nail psoriasis • Psoriatic arthritis

8. Skin Findings Plaque Psoriasis The most common presentation.
Red, sharply defined, scaling papules that coalesce to form stable, round to oval plaques.
It typically involves extensor extremities(elbows and knees), scalp, and sacrum

9. Skin Findings… Plaque Psoriasis …
Face, palms and soles are not typically involved in this form.
The deep rich red color is a characteristic feature presenting uniformly across the untreated lesion.
The scale is adherent silvery white and reveals bleeding points when removed(the Auspitz sign).
Scale may become extremely dense, especially on the scalp

10. Guttate Psoriasis
This is an unstable form, associated with sudden appearance of innumerable monomorphic 2-5 mm psoriasiform papules on the trunk with silvery scale.
It is often associated with group A streptococcal pharyngitis, viral infections and-less often with systemic steroid withdrawal.

11. Localized Pustular Psoriasis(Palmoplantar Pustulosis)
This chronic recurrent form has been associated with tobacco use.
Small sterile pustules evolve from a red base on palms and soles.
Pustules do not rupture but turn rusty brown and scaly as they reach the surface;
they are often quite painful.
Nail involvement is common

12. . Inverse(Inter triginous) Psoriasis
An uncommon form occurring in flexural or intertriginous areas such as the groin, axillac and under the breasts,
There are smooth, red and sharply defined plaques with a macerated surface, often with odor.

13. Generalized Pustular
Psoriasis An uncommon severe form requiring immediate medical attention.
It may be associated with fever and tenderness.
Affected patients complain of chills and malaise.
It may be drug related.
Sterile pustules are regional or generalized, and often occur in waves with advancing pustules followed by thin desquamation and a new wave of pustules.

14. Erythrodermic Psoriasis
This uncommon severe form requires immediate medical attention.
There is total body redness with chills and skin pain
It may be drug related.

15. Nail Disease
Clinical findings vary and are related to the specific areas of nail matrix involvement.
Matrix:
Pitting results from involvement of the;

16. Nail Disease
Nail matrix involvement and/or involvement of underlying nail bed
onycholysis(separation of nail from nail bed),
subungual debris
oil drop sign

17. Joint Disease Several distinct clinical patterns,
all of which are rheumatoid factor negative.
The asymmetric oligoarthritis is the most common hose with psoriatic arthritis

19. Joint Disease
The distal interphalangeal affects 10% of patients with psoriatic arthritis often with local nail changes

20. Joint Disease
Symmetric polyarthritis is similar to rheumatoid arthritis in presentation.

21. Joint Disease
The mutilating type affects 5% of patients with psoriatic arthritis, it has onset.

22. Joint Disease
The spinal type affects 20% of patients with psoriatic arthritis and is debilitating

23. Differential Diagnosis
Seborrheic dermatitis involves the face more often than psoriasis, but is not mutually exclusive on the scalp
Dyshidrotic eczema(hand/foot) is more vesicular than localized pustular psoriasis
Tinea capitis(scalp) and onychomycosis(nails) should be excluded with a potassium hydroxide exam

24. Treatment The three categories of treatment: topical therapy
phototherapy
systemic therapy-may be combined or alternated

25. Topical Therapy Topical Tar
Preparations(OTC) These are available in lotions, ointments foams and shampoos. They are relatively inexpensive, and may be compounded with topical They may cause irritation, odor, and staining of clothing
Calcipotriene and Calcipotriol
They are vitamin D3 preparations which can be applied every day or twice daily as tolerated in amounts up to 100g per

26. Treament…. Topical Steroids
Topical steroids(group I-V) as monotherapy give fast but temporary relief
Use group I-V topical steroids(applied at a different time of day
These are the best agents for reducing inflammation and itching

27. Scalp Treatment
oil(apply to entire scalp at bedtime, cover with a shower cap and wash out the following morning).
Repeat for 5-10 days.
This treatment removes scale and controls inflammation.
Hot olive oil turbans and manual scale debridement might work for very thick scale
Steroid gels or steroid foams penetrate through hair and into scale.
Calcipotriene in combination with solution bethametasone dipropionate

28. Topical Nail Treatment
Nails are difficult to treat so the physician's goal is to provide symptomatic/cosmetic relief.
Topical calcipotriene solution, clobetasol solution and tazarotene gel may be helpful if applied to the posterior nail fold area;
this requires months of Intra lesional triamcinolone injected into the nail bed is painful to administer but often provides temporary improvement.

29. Phototherapy UVB therapy
Ultraviolet B This is a very effective treatment;
ultraviolet light may be used in combination with topical treatment.
A minority of patients do not respond, and even fewer will get worse.
Ultraviolet B is typically given 3-5 per week.
PUVA therapy
Psoralin + UVA
2 hours After taking 0.6mg/kg 8 methoxy psoralin patient exposed to UVA source

30. Systemic therapy
Systemic therapy is complicated and best managed by a dermatologist.
Rotational Therapy
A rotational approach to therapy minimizes long-term toxic effects from any one therapy and allows effective long-term management.
Methotrexate Methotrexate is effective in unstable erythrodermic, generalized pustular psoriasis and extensive chronic plaque disease.
Work up to a dose of mg weekly.
Give folic acid 1 mg daily, but not on methotrexate day.

31. Systemic therapy … Acitretin
Highly effective for generalized pustular and Erythrodermic psoriasis,
moderately effective for palmoplantar psoriasis.
Useful in combination with psoralen plus ultraviolet A and ultraviolet B. (RePUVA )
Start at mg/day as a single dose.
Side effects are similar to those of isotretinoin, which limits treatment for many patients they include: Teratogenicity, dry skin, sticky skin, myalgias, arthralgias, pseudotumor cerebri, depression, hair loss, hepatitis, pancreatitis or increased cholesterol/triglycerides

32. Seborrheic dermatitis

33. Description
Seborrheic dermatitis is a common, chronic, inflammatory papulosquamous disease.
It has been proposed that Pityrosporum oval yeast is the cause.

34. History All ages can be affected. Infants and adults
There are tow distinct clinical presentations:
Infantile seborrheic dermatitis
Adult seborrheic dermatitis
It has greater severity and is more difficult to control in patients with neurologic disease(e.g. head trauma, Parkinson's disease, stroke) and in patients with human immunodeficiency virus infection.

35. Skin Findings
The papules are moist, transparent to yellow, greasy and scaling, among coalescing red patches and plaques
Usually favors areas where the concentration of sebaceous glands is maximal:
the scalp margins
central face
presternal areas.
Pityrosporum yeast grows favorably in these areas of oil production.
Characteristic locations are the:
eyebrows,
base of eyelashes
nasolabial folds
paranasal skin
and external ear canals.
May affect flexural skin including the postauricular, inguinal, and

36. Pediatric Considerations(cradle cap)
Infants (Cradle Cap)
Infants commonly develop a greasy adherent scale on the vertex of the scalp.
Minor amounts of scale are easily removed by frequent shampooing with products containing sulfur, salicylic acid, or both.
Scale may accumulate and become thick and adherent over much of the scalp and may be accompanied by inflammation and Secondary infection can occur.
It began from 2 month and continue untel 6 to 9 months

37. Treatment
Adults tend to have a chronic course with seasonal remissions and exacerbations
Flares are precipitated by stress, fatigue, and climate changes.
Mild to moderate facial seborrheic dermatitis may respond well to topical antifungals such as ketoconazole cream.
Daily facial washing with antidandruff shampoo or soaps containing zinc pyrithione(ZNP) or selenium sulfide is effective.
Group VI or VII topical steroid creams or lotions hydrocortisone applied twice daily for several days may be required periodically for control.
Mild to moderate scalp involvement is best managed with frequent and extended shampooing with antidandruff shampoos,
Effective formulations may contain ketoconazole, ciclopirox, coal tar, salicylic acid, selenium sulfide,

38. Antifungal therapy includes :
ketoconazole 200mg every day
fluconazole 150 mg every day, or itraconazole 200 mg every day for 1 or 2 weeks.
Indicated for sever un responsive to shampoo and topical steriodes seborrheic dermatitis

39. Pityriasis Rosea

40. Description
Common, self limited, usually asymptomatic, clinically distinctive papulosquamous eruption.
Seasonal clustering of cases in the community are often noted

41. History More than 75% of patients are between 10 and 35 years of age.
Many patients report a mild prodrome or upper respiratory illness within a month of onset
The first lesion herald patch, appears suddenly and asymptomatically, often on the chest or back.
The lesion is an oval plaque of 1-2 cm in diameter, which develops a thin collarette of residual scale inside the border
1-2 weeks later numerous similar but smaller lesions begin to appear
Reach a maximum number within 2 weeks while the herald patch is still present.

43. History
Lesions usually clear spontaneously in 4-12 weeks without scarring,
although postinflammatory pigmentary changes may take months to resolve in darker- skinned people.
Seasonal cases in the spring and fall within the community suggest a viral etiology, though this has not been confirmed Limited outbreaks have occurred in close quarters such as fraternity houses and military barracks.

44. Skin Findings Early lesions are broad-based papules
subsequently develop a thin collarette of scale
the center of the papule desquamates.
Lesions are salmon colored on Caucasian skin and dark brown on African-American skin.
lesions are typically confined to the trunk and proximal extremities
often concentrated on the lower abdomen.

45. Skin Findings …
The long axis of the oval lesions is reminiscent oriented along skin branches, pine tree when fully developed.
most cases of pytirsis rosea are clinically distinct may seem obvious,
Atypical cases do occur and may be confused with other disorders.

46. Lichen Planus

47. Description
An uncommon, inflammatory papulosquamous disorder of unknown etiology
Skin, nails, hair and mucous membranes may be affected.

48. History Rare in children aged under 5 years more common in women
10% of patients have a positive family history
Course is variable and unpredictable
in all types Itching is variable, most often intermittent, and instable
Can occur abruptly as generalized diseasc may be secondary to a drug
Severe oral lichen planus may degenerate to squamous cell carcinoma(in 3% of cases)

49. Skin Findings
The primary lesion is a 2-10mm flat topped papule with an irregular, angulated border (purple polygonal papules).
New lesions are pink but over time they become purple and sharply defined
Surface shows a lacy reticulated pattern of whitish lines(Wickham's striae)
New lesions may develop in areas of injury(the Koebner phenomenon)
There are several clinical forms

50. Papular Lichen Planus The most common clinical presentation.
Papules are located on the flexor surfaces of the wrists and forearms, the ankles and the lumbar region.

51. Hypertrophic Lichen Planus
Lesions that persist become thicker and darker red in color Most often they are on the shins.
Papules aggregate into different patterns.
Vesicles or bullae may appear
Persistent brown staining develops after the lesions resolve.

52. Follicular Lichen Planus
Follicular based on the scalp
Permanent hair loss with associate marked scarring (scarring alopecia).

53. Mucosal Lichen Planus
Most common form is the non-erosiv with a white lacy pattern.
The erosive form is painful with beefy desquamation.
Oral lesions primarily involve the buccal mucosa and lateral edge of the tongue.
This may extend to involve the mucosal lip but rarely extends beyond the vermillion border.
The penis and vulva may be involved, with intense itching and burning, marked mucosal fragility, and erythema.
Secondary candidiasis occurs frequently, likely as a side effect of topical treatment.

54. Nail Involvement
Nail changes may be present in the absence of skin findings.
There are proximal to distal linear depressions in the nail plate ( longitudinal ridging)
Inflammation of the matrix results adhesion of the proximal nail fold to scarred matrix to form a pterygium (scar)

55. Treatment
Sedating antihistamines(hydroxyzine mg every 4 hours) for pruritus.
Group I or II topical steroids twice daily as initial topical treatment for localized disease.
Intralesional triamcinolone acetonide ( 5-10 mg/mL) for hypertrophic lesions.
Prednisone for generalized skin or erosive mucosal involvement; a 4-week course starting at 1 mg/kg/day and gradual decrease of the dosage.
Retinoids(Acitretin) 1mg/kg/day,
cyclosporine(5-6 mg kg/day may be considered for severe recalcitrant forms of lichen planus.
Tacrolimus 0.1% ointment twice daily has been used with some success for erosive oral lesions.

56. Treatment …
Corticosteroids(fluocinonide, fluocinolone actinide, triamcinolone acetonide in an adhesive base(Orabase) for initial treatment for oral lesions, applied directly to the lesions.
Prednisolone tablets, the active form of prednisone; 5 mg tablet dissolved in the mouth.
Swish and swallow

57. Any question?

58. Thanks