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Psoriasis (Clinical
presentation (Generalised/erythrodermic/pustular
…
Psoriasis
Clinical
presentation
Generalised/erythrodermic/pustular
Widespread skin inflammation
Also fever, dehydration
MEDICAL EMERGENCY
Guttate
Small circular/oval plaques (~1cm) on trunk, limbs
Often post-strep infection in children
Can go on to develop chronic plaque form
Flexural
Symmetrical, red, less scaly
Moist flexural areas (axillae, groin, nasal cleft, umbilicus)
Palmoplantar
Palms and soles of feet
Chronic plaque (psoriasis vulgaris)
Symmetrical, well defined erythematous plaques with silver scales
Extensor aspect of limbs, scalp, sacrum, sites of trauma (Kobner)
Palmoplantar pustular
Usually female smokers, thyroid disease
Redness and scaling of hands/feet with yellow/brown pustules
Nail
Pitting, onchylosis, thickening
Discolouration, subungual hyperkertosis
Arthropathy
Seronegative, asymmetrical
arthropathy of DIPs
Monoarthritis, oligoarthritis, spondylitis,
arthritis mutilans, rheumatoid-like
-
Pathophysiology
Triggers
Stress*
Infections (strep, HIV)
Skin trauma (Kobner phenomenon)
Drugs (Li, NSAIDs, B-blockers, antimalarials)
Lifestyle - alcohol, smoking, obesity
Climate changes
-
Plaques
Hyperproliferative epidermis, dilation of blood vessels in dermis (erythema), infiltration of inflammatory cells
CD8 T-cell mediated, with cytokine release; also neutrophils
-
Diagnosis
History
-
FH
Psoriasis, eczema
Skin cancers
PMH
Skin disease
Other autoimmune disease (IBD, thyroid, Addisons, etc)
PC/HPC
Symmetrical, red, silver scale patches
Area of distribution
Previous infections (fungal)
Red flags - weight loss, night sweats, fever
SH
Occupation, smoking, alcohol,
diet, stress, support
Examination
Derm
Well defined, erythematous patches with silver scale
Auspitz sign (bleeds on removal of scale)
Nail signs (pitting, onchylosis)
Joints
Asymmetrical, mono/oligoarthropathy
Arthritis mutilans
-
Severity
classification
-
Severe
10% BSA
Chronic, persistant
Frequent flares
Psychosocial disability
Needs lifelong treatment
Complications
CVD
Increased risk T2DM, HTN, hyperlipidemia,
obesity, CVA (stroke, MI), metabolic syndrome
Comorbidities
Ocular (iritis, uveitis, episcleritis)
IBD, arthritis, nail psoriasis
Psychosocial
Stigma, adverse QoL
Depression, anxiety
Poor body image, mood, impact on school/work
Management
Conservative
Information (control not cure, not contageous)
Advice, support groups
Medical
Systemic
Steroids
Indication: mod-severe psoriasis
E.g. PO prednisolone
MOA: reduces skin inflammation
SEs: skin atrophy, Cushing's, pustular psoriasis
Phototherapy
Indication: plaque/guttate psoriasis, widespread psoriasis
MOA: narrowband UVB or photochemotherapy (psoralen
photosensitising agent + UVA)
SEs: increased skin cancer risk (SCC), premature ageing
Immunosuppressants
Indication: mod-severe/widespread psoriasis, arthropathy
E.g. methotrexate, ciclosporin
SEs: hepatotoxicity, pancytopenia, N+V, teratogenic (methotrexate); nephrotoxicity, HTN (ciclosporin)
Retinoic acid derivatives
Indication: mod-severe psoriasis (inpatient tx)
E.g. acitretin, etretinate
MOA: inhibits vit A, reducing skin proliferation
SEs: dry skin/mucosae, teratogenic, hepatotoxicity, hyperlipidemia, hyperglycaemia
Biologics
Indication: severe refractory psoriasis (specialist use)
E.g. infliximab, adalimumab, etanercept
MOA: inhibit TNF/IL's, dampening inflammation in skin
Topical
Vitamin D analogues
Indication: mild psoriasis, add on therapy
E.g. calcipotroil, calcitrol cream/ointment
MOA: inhibit cell division, normalises proliferation and
differentiation of skin cells (keratinocytes)
SEs: skin irritation, hypercalcaemia (rare)
Steroids
Indication: mild plaque or scalp psoriasis
E.g. topical hydrocortisone, eumovate, betnovate
MOA: reduces skin inflammation
SEs: skin atrophy, Cushing's, pustular psoriasis
Emollients
Indication: all types and severities
E.g. dermol 500 cream, ointment, lotion
MOA: hydration of skin, reducing scaling and irritation
SEs: local skin irritation
Tars
Indication: widespread (inpatient tx); scalp psoriasis (shampoo)
E.g. exorex 1% coal tar lotion
MOA: anti-inflammatory and anti-scaling
DNA synthesis inhibitor
Indication: resistant/refractory psoriasis
E.g. dithranol
MOA: short contact regimens, inhibits keratinocyte proliferation
SEs: skin irritation, clothes/skin staining
Definition
Chronic, inflammatory skin condition
characterised by scaly red plaques,
with relapsing/remitting course