psoriasis

Zhang Jiang-an
Dept. of Dermatology
The first affiliated hospital of
zhengzhou university
Definition
 Psoriasis is a common, genetically
determined, inflammatory and
proliferative disease of the skin, the most
characteristic lesions consisting of
chronic, sharply demarcated, dull-red,
scaly plaques, particularly on the
extensor prominences and in the scalp.
 This disease is enormously variable in
duration and extent and morphological
variants are common.
Epidemiology(1)

 Psoriasis affects 2% population in

Europe and North America.
 The low prevalence of psoriasis in
oriental people is now well-recognized.
In Singapore, it is commoner in Indians
than in Chinese or Malays.
 The sex incidence is equal.
Epidemiology(2)

 The condition may start at any age, even

in the elderly, but the peak onset is in the
2nd and 3rd decades. It is unusual in
children less than 8 years old.
 Females tend to develop psoriasis
earlier than males.
 Patients with a family history of psoriasis
tend to have an earlier age of onset.
Etiology and
pathogenesis(1)
 Genetic predisposition
 The evidence that psoriasis may be
inherited is beyond doubt.
 About 35% of patients show a family
history;
 Identical twin studies show a
concordance of 80%;
 There are strong correlations with the
HLA antigens CW6, B13, B17.
Etiology and
pathogenesis(2)
 Provocation and exacerbation
 Several factors are now accepted as of
importance in provoking a new episode
of psoriasis or in exacerbating pre-
existing disease.
 ①trauma A wide range of injurious local
stimuli, including physical, chemical,
electrical, surgical, infective and
inflammatory insults has been
recognized to elicit psoriatic lesions.
Etiology and
pathogenesis(3)
 ②infection The role of streptococcal
infection, especially in the throat, in
provoking acute guttate psoriasis has
long been recognized.
 ③endocrine factors Many researchers
have found that there are peaks of
psoriasis incidence at puberty and at the
menopause.
Etiology and
pathogenesis(4)
 ④sunlight Although sunlight is generally
beneficial, a small minority of psoriatics
are provoked by strong sunlight and
suffer summer exacerbations in exposed
skin.
 ⑤metabolic factros Hypocalcaemia
(e.g. following accidental
parathyroidectomy) and dialysis have
precipitated psoriasis.
 Etiology and
pathogenesis(5)
 ⑥drugs Some drugs can induce or
exacerbate psoriasis. The most frequent
associations include the administration of
lithium, β-adrenergic blocking agents and
antimalarials, and the withdrawal of
systemically administered corticosteroids.
 ⑦psychogenic factors There is evidence
that the severity of psoriasis may depend
on prior stress, although one controlled
questionnaire study did not support this
view.
Etiology and
pathogenesis(6)
 ⑧alcohol and smoking A Finnish study
confirmed that alcohol is a risk factor for
psoriasis in young and middle-aged
men. The association between smoking
and psoriasis has been reviewed;
reports suggest an increased risk for
both palmoplantar pustulosis and chronic
plaque psoriasis.
Clinnical presentation(1)

 Psoriasis varies in severity from the

trivial to the life-threatening.
 Generally, according to the clinical
features, psoriasis is divided into four
types: psoriasis vulgaris, pustular
psoriasis, psoriatic arthropathy and
erythrodermic psoriasis.
Clinnical presentation(2)

 psoriasis vulgaris--plaque psoriasis(1)

 Plaque psoriasis is the typical
presentation of psoriasis vulgris.
 The lesions often involve the elbows,
knees, scalp hair margin, sacrum.
 The plaques vary in diameter from one
to several centimetres and are oval or
irregular in shape.
Clinnical presentation(3)
 psoriasis vulgaris--plaque psoriasis(2)
 There may be any number of lesions or only a
single one, and, when multiple, may be
symmetrically distributed.
 The red plaques are often surmounted by the
very characteristic silvery white scaling. The
removal of psoriatic scales usually reveals an
underlying smooth, glossy, red membrane with
small bleeding points where the thin
suprapapillary epithelium is torn off (Auspitz
sign).
Clinnical presentation(4)
plaque psoriasis(3) After the removal of scales,
smooth, glossy, red membrane
②

Red plaques covered by

silvery white scaling

The small bleeding point

Clinnical presentation(5)

 psoriasis vulgaris--guttate
psoriasis(1)
 Guttate psoriasis is an acute
symmetrical eruption of “drop-like ”
lesions usually on the trunk and
limbs.
 The form mostly occurs in
adolescents or adults and may follow
a streptococcal throat infection.
Clinnical presentation(6)

Small red drop-like lesions

on the trunk and limbs
Clinnical presentation(7)
Köbner phenomenon(1)
 Köbner phenomenon is that various types of
trauma may elicit the disease in previously
uninvolved skin.
 The reported incidence has varied between
38 and 76% of patients with psoriasis. The
Köbner reaction is often thought to be more
frequent in actively spreading severe
psoriasis.
 The Köbner phenomenon usually occurs 7-14
days after injury.
Clinnical presentation(8)
Köbner phenomenon(2)

After tattoo, the Köbner phenomenon

is presented.
Clinnical presentation(9)

 Modification by
site--scalp
 Often, very thick
plaques develop,
especially at the
occiput, with the
fascicle-like hair.
 Clinnical presentation(10)

 Modification by site—nail involvement

 This is seen in association with all types of
psoriasis of the skin, and is frequently
present with psoriatic arthropathy.
 Although pitting is the most frequent
change seen, discoloration, subungual
hyperkeratosis and onycholysis are
common, and splinter haemorrhages occur.
 Clinnical presentation(11)
Fingernail pitting in psoriasis Subungual hyperkeratosis in psoriasis
Clinnical presentation(12)
Erythrodermic
psoriasis(1)
Two forms exist.
 The first form can be regarded as
extensive plaque psoriasis involving all,
or almost all, the cutaneous surface.
There are usually some areas of
uninvolved skin. The psoriatic
characteristics are retained, mild
treatment is well tolerated, and the
prognosis is good.
Clinnical presentation(13)
Erythrodermic
psoriasis(2)  Extensive chronic
plaque psoriasis
with coalescence
of lesions and the
potential to evolve
into an
erythrodermic
form.
Clinnical presentation(14)
Erythrodermic
psoriasis(3)
The second form is part of the spectrum
of 'unstable' psoriasis. It can be
precipitated by infections,
hypocalcaemia, antimalarials, tar and
withdrawal of corticosteroids. It is more
frequent in arthropathic psoriasis.
Generalized pustular psoriasis may
revert to an erythrodermic state.
Clinnical presentation(15)
Erythrodermic
psoriasis(4)
The characteristics of the disease are
often lost, the whole skin is involved, the
patient may be febrile and ill, the course
is often tumultuous or prolonged,
relapses are frequent, and there is an
appreciable mortality. In contrast to the
stable form, itching is often severe.
Clinnical presentation(16)
Erythrodermic
psoriasis(5)  Acute, unstable,
erythrodermic
psoriasis.
Clinnical presentation(17)
Psoriatic arthropathy (1)
 Psoriatic arthritis is a chronic inflammatory
arthritis that is commonly associated with
psoriasis.
 Approximately 5% of patients with psoriasis
develop psoriatic arthritis.
 the exact etiology is unknown and is probably
multifactorial, including immune-mediated,
genetic, and environmental causes.
Environmental factors may include trauma,
infection, and stress.
Clinnical presentation(18)
Psoriatic arthropathy (2)
 Psoriatic arthritis usually develops in the
fourth to sixth decades of life, but it can
occur at almost any age.
 Psoriasis appears to precede the onset
of psoriatic arthritis in 60-80% of
patients. Occasionally, arthritis and
psoriasis appear simultaneously. In
addition, cutaneous eruptions may be
preceded by the arthropathy.
Clinnical presentation(19)
Psoriatic arthropathy (3)
 Nail pitting, Beau lines, leukonychia,
onycholysis, oil spots, subungual
hyperkeratosis, splinter hemorrhages,
spotted lunulae, and cracking of the free
edge of the nail all support the diagnosis
of psoriatic arthritis, especially of the
distal interphalangeal (DIP) joint type.
Clinnical presentation(20)
Psoriatic arthropathy (4)
 Scaly, erythematous plaques; guttate
lesions; lakes of pus; and erythroderma
are all types of psoriatic skin lesions that
may be seen in the context of psoriatic
arthritis.
 Joint findings may include dactylitis
(sausage digits), enthesopathy
(reflecting inflammation of the insertion
points of tendon into bone), tendonitis,
and spondylitis.
Clinnical presentation(21)
Psoriatic arthropathy (5)
 Psoriatic arthritis is a chronic
inflammatory condition for which no
specific laboratory tests are available.
 The main differential diagnosis is RA,
which is negative in psoriatic arthritis, but
positive (85% of patients) in rheumatoid
arthritis.
Clinnical presentation(22)
Psoriatic arthropathy (5)
 Psoriatic arthritis,
showing peripheral
oligoarthropathy with
sausage-like digital
swelling.
Clinnical presentation(23)
Pustular psoriasis (1)
 Pustular psoriasis is an uncommon form
of psoriasis consisting of pustules on an
erythematous background.
 Cutaneous lesions characteristic of
psoriasis vulgaris may be present
before, during, or after an acute pustular
episode.
Clinnical presentation(24)
Pustular psoriasis (2)
 The following have reportedly triggered an
eruption:
 ①Withdrawal of systemic steroids
 ② Drugs, including salicylates, iodine, et al
 ③ Strong, irritating topicals, including tar,
anthralin, et al
 ④ Infections
 ⑤ Sunlight or phototherapy
 ⑥ Cholestatic jaundice
 ⑦ Hypocalcemia
 ⑧Idiopathic in many patients
Clinnical presentation(25)
Pustular psoriasis (3)
 Generally, pustular psoriasis may be
classified into two types depending on
the clinical course, localized pustular
psoriasis (including palmoplantar
pustulosis and acrodermatitis continua)
and generalized pustular psoriasis.
Clinnical presentation(26)
Pustular psoriasis (4)
 Palmoplantar pustulosis(1)
 Palmoplantar pustulosis is a common
condition in which erythematous and
scaly plaques studded with sterile
pustules persist on the palms or soles.
The disease is chronic and very resistant
to treatment.
Clinnical presentation(27)
Pustular psoriasis (5)
 Palmoplantar
pustulosis(2)
 Within the red
plaque, numerous
pustules are present,
usually 2-5mm in
diameter.
Clinnical presentation(28)
Pustular psoriasis (6)
 Acrodermatitis continua (1)
 A chronic, sterile, pustular eruption
affecting initially the tips of fingers or
toes which tends slowly to extend locally
but which, in adults, may evolve into
generalized pustular psoriasis. Onset is
often related by the patient to minor
trauma, or infection at the tip of the digit.
Clinnical presentation(29)
Pustular psoriasis (7)
 Acrodermatitis
continua (2)
 Acrodermatitis
continua with
destruction of nail
plate and numerous
pustules on the
erythematous
backgroud.
Clinnical presentation(30)
Pustular psoriasis (8)
 Generalized pustular psoriasis(1)
 Generalized pustular psoriasis is a rare
but serious and even life-threatening
form of psoriasis.
 Sheets of small, sterile yellowish
pustules develop on an erythematous
backgroud and may rapidly spread.
 The onset is often acute.
 The patient is unwell, with fever and
malaise.
Clinnical presentation(31)
Pustular psoriasis (9)
 Generalized
pustular
psoriasis(2)
 Sheets of small,
sterile yellowish
pustules develop
on an
erythematous
backgroud.
Diagnosis and differential
diagnosis(1)
 The characteristics already defined are
usually sufficient to enable the diagnosis
to be made, but doubt may arise in
atypical cases, and in particular sites,
and when psoriasis is complicated by or
alternates with other diseases.
Therefore, psoriasis should be
differentiated from some diseases.
Diagnosis and differential
diagnosis(2)
 Psoriasis vulgaris should be
differentiated from the following:
 Seborrheic dermatitis, eczema, lichen
planus, pityriasis lichenoides chronica,
candidiasis, tinea cruris, pityriasis rubra
pilaris, secondary syphilis, et al.
Diagnosis and differential
diagnosis(3)
 Erythrodermic psoriasis should be
differentiated from the erythroderma
from other reasons, such as eczema,
lymphoma, drug eruption, bullous
ichthyosiform erythroderma, et al.
Diagnosis and differential
diagnosis(4)
 Psoriatic arthritis should be
differentiated from the following:
 rheumatoid arthritis, ankylosing
spondylitis, reiter's disease.
Diagnosis and differential
diagnosis(5)
 Localized pustular psoriasis should be
differentiated from the following:
 Tinea, eczema, chronic allergic contact
dermatitis, et al.
 Generalized pustular psoriasis should
be differentiated from the following:
 Subcorneal pustular dermatosis, herpes
gestation, acute generalized eruptive
pustulosis, et al.
Treatment(1)
 General advice (therapy)

 Topical therapy

 UV phototherapy

 Systemic therapy
Treatment(2)
General advice (therapy)
 Rest, mild sedation, removal from a
troublesome environment, a holiday or a
short stay in hospital may all help to turn
the therapeutic tide.
 Harmless placebos may give comfort
and should not be despised.
 Diet is unimportant. Diets rich in zinc and
low in tryptophan, protein do not
influence the disease.
Treatment(3)
Topical therapy
 Topical medicaments include
 Tar
 Dithranol (anthralin)
 Topical corticosteroids
 Intralesional corticosteroid therapy
 Vitamin D analogues
 Topical or intralesional cytostatic therapy
 Occlusive dressings alone
Treatment(4)
UV phototherapy
 UV phototherapy include:

 UVB

 PUVA
Treatment(5)
Systemic therapy
 Methotrexate
 Hydroxyurea
 Retinoids (Etretinate, Isotretinoin,
Acitretin)
 Cyclosporin A
 Systemic corticosteroids
 6-Thioguanine
Treatment(6)
 Most stable discoid psoriasis should first
be approached with outpatient topical
therapy, which disrupts the patient's
routine as little as possible.
 Tar preparations and vitamin D
analogues are appropriate, but
corticosteroids can be used for localized
psoriasis. If necessary, dithranol can be
introduced later but is more difficult to
handle.
Treatment(7)
 If sunlight or UVB phototherapy are
available, light can be added at this
stage or earlier.
 If the psoriasis is severe and extensive
and the above initial measures have
failed, more intensive tar or dithranol
therapy should be considered, in a day-
care unit or a hospital if such facilities
exist, with or without UV phototherapy.
Treatment(8)
 The indications for intralesional
corticosteroid injections, PUVA therapy,
retinoids, cytotoxic drugs and
cyclosporin should be restricted to those
patients whose psoriasis is physically,
socially, economically or emotionally
disabling, and in whom conventional and
conscientious topical therapy has failed.
key points

 Definition of psoriasis
 Four types of psoriasis
 Clinical presentation of psoriasis vulgaris
 Köbner phenomenon