PSORIASIS

Classification
1. Based on Morphological Types:
• Chronic stable plaque psoriasis (psoriasis vulgaris)
• Guttate psoriasis
• Pustular psoriasis
• Erythrodermic psoriasis
• Rupioid, elephantine and ostraceous psoriasis.
Classification

2. Based on Site of Involvement:

• Scalp psoriasis
• Flexural (inverse) psoriasis
• Nail psoriasis
• Palmoplantar psoriasis
• Genital psoriasis
• Psoriatic arthritis.
Classification
3. Atypical Forms of Psoriasis:
• Linear and zonal lesions
• Follicular
• Photosensitive
• Seborrheic psoriasis
• Annular psoriasis
• Circinate psoriasis
• Nummular psoriasis
• Serpiginous psoriasis
• Geographic psoriasis
• Mucosal lesions— annular plaques, diffuse areas of erythema,
geographic tongue; very rare
• Ocular lesions— blepharitis, conjunctivitis, keratitis, xerosis,
symblepharon, trichiasis, uveitis; extremely rare
Clinical Features

● Most lesions are asymptomatic.

● Typical age of onset - third decade (though it may develop at any time
from birth onward).
● Erythematous papules and plaques. Lesions – variable size, sharply
circumscribed, dry, and usually covered with layers of silvery white,
micaceous scales.
● Grattage test - scrapping a scaly lesion to look for type of scales.
● Auspitz’s sign is typical of psoriasis – 3 components:
o Silvery white micaceous scales on scrapping.
o Shiny membrane called Bulkley’s membrane on continued scrapping.
o Bleeding points on removal of membrane.
● Extensor surfaces of the extremities, scalp and lumbosacral region are
commonly involved.
● Lesions of active psoriasis appear in areas of epidermal injury-Koebner
phenomenon.
Clinical Features
● An acute variant, guttate or eruptive psoriasis - seen in
younger patients, characterized by an abrupt eruption of small
drop shaped lesions, associated with acute group A beta hemolytic
streptococcal infection of pharynx in the preceding 7 to 10 days.
● Nail involvement is common. The most frequent alteration of
nail plate surface is the presence of pits.
● Nail matrix changes include:
○ pitting
○ longitudinal ridging
○ grooves
○ leukonychia
○ erythema of lunula
○ thickening of nails
○ crumbling of nail plate
○ trachynonychia.
Clinical Features

● Nail bed changes include:

○ subungual hyperkeratosis
○ distal onycholysis
○ salmon (oily) patches
○ splinter haemorrhages (thin red or black longitudinal lines in
distal portion of nail due to psoriatic involvement of nail bed
capillaries, which are longitudinally oriented).
● Paronychia results from involvement of periungual skin of proximal
nail fold with retention of scales between ventral nail fold and nail
plate.
Clinical Features
● Psoriatic arthritis is of various types—
○ Distal interphalangeal joint arthritis,
○ asymmetrical oligoarthritis,
○ polyarthritis (rheumatoid arthritis like),
○ arthritis mutilans and predominantly
○ axial arthritis (psoriatic spondylitis and/ or sacroiliitis).
● It characteristically involves the terminal interphalangeal joints (fig), large joints
are also affected, resembling rheumatoid arthritis. However, the rheumatoid
factor is absent. In severe cases, the disease may affect the entire skin and
presents as psoriatic erythroderma.
● Psoriasis rarely presents as:
○ Generalized pustular psoriasis (von-Zumbusch type acute exanthematic type (fig) or
generalized pustular psoriasis of pregnancy - Impetigo herpetiformis).
○ Localized pustular psoriasis occurs as acrodermatitis continua of Hallopeau (localized
to the distal portions of the hands and feet) (Fig) or pustulosis palmaris et plantaris
(chronic, relapsing disorder occurring on the palms, soles, or both).
Diagnosis

● Psoriasis may be confused with :

○ seborrheic dermatitis
○ secondary syphilis
○ dermatophyte infections
○ cutaneous lupus erythematosus
○ eczema
○ lichen planus
○ pityriasis rosea
○ Bowen’s disease or lichen simplex chronicus.
● Diagnosis is mostly clinical supplemented at times of doubt by
histopathology of skin lesion.
Histopathology
 Hyperkeratosis and parakeratosis.
 Within parakeratotic areas of the horny layer,
accumulations of neutrophils forms, which
are called as Munro micro abscesses.
 Hypo or absent granular layer.
 Regular acanthosis.
 Spongiform pustule of Kogoj -
neutrophils accumulation in Malpighian layer.
 There is regular elongation of the rete ridges
with thickening in their lower portion, looking
like elephant feet.
 There is thinning of the supra papillary
portion of the epidermis.
 The dermal papillae contain enlarged and
tortuous capillaries that are very close to the
skin surface and impart a characteristic
erythematous hue to the lesions.
 Sparse lymphocytic infiltrate in the upper
dermis.
Differential Diagnosis

● Seborrhoeic dermatitis
● Pityriasis rosea
● Pityriasis rubra pilaris
● Dermatophyte infection (tinea corporis)
● Discoid lupus erythematosus
● Subacute lupus erythematous
● Eczema
● Lichen planus
● Secondary syphilis
● Drug eruptions
● Pityriasis lichenoides chronica
Treatment

● Psoriasis is a treatable condition.

● Treatment pyramid for psoriasis:
Topical Therapies

● Emollients— Such as coconut oil, vaseline, or liquid paraffin.

● Coal tar (2, 5, 10% ointment)
● Anthralin (0.1 to 10% cream or ointment)
● Topical steroids/ intralesional steroids
● Vitamin D analogues
○ Naturally occurring – calcitriol (1α, 25-dihydroxyvitamin D3)
○ synthetic analogues - calcipotriol, tacalcitol, maxacalcitol.
● Tazarotene (0.1 to 0.05% gel)
● Topical methotrexate gel
● Tacrolimus (0.03, 0.1%)
Medications Used in Phototherapy

● Concurrent use of topical or oral medications, psoralen (5

methoxy psoralen, 8 methoxy psoralen, trimethyl psoralen)
along with UVA or UVB phototherapy is done.
● Psoralen along with UVA from sunlight (PUVASOL).
● Narrow band UVB.
● Methotrexate and PUVA combination (Me-PUVA).
● Retinoids and PUVA combination (RePUVA).
● Excimer LASER (308 nm).
 Systemic Medications for Psoriasis

● Methotrexate (0.4 to 0.6 mg per kg body weight).

● Cyclosporine (3-5 mg per kg body weight).
● Etretinate and Acitretin (0.5-1 mg per kg body weight).
● Hydroxyurea (maximum up to 500 mg three times a day).
● Sulfasalazine (3-4 gm/day).
● Mycophenolate mofetil ( 1-2 gm/day, can increase maximum up to
4 gm/day).
● Oral tacrolimus ( 0.05- 0.15 mg/kg body weight per day).
● Fumaric acid esters 30 mg per day up to 240 mg three times a
day.
● Many of these medications are used in combination and rotated
periodically.
● HIV associated psoriasis may respond to zidovudine based HAART
 Biologic Agents

● Biologics are agents that selectively block the immunologic steps

in the pathogenesis of psoriasis.
● Alefacept, efalizumab, etanercept, and infliximab are currently
approved for the treatment of adults with moderate to severe
plaque psoriasis, and phase 3 trials for adalimumab are ongoing.
Course and Prognosis

● Course of psoriasis is prolonged but unpredictable.