1 Psoriasis Diagnosis & Management Dr Rowan Brown February 2009.
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Transcript of 1 Psoriasis Diagnosis & Management Dr Rowan Brown February 2009.
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Pathogenesis
Hyperproliferation of keratinoctyes secondary to cytokine stimulus
Epidermal thickening (acanthosis)
Neutrophil/Lymphocyte infiltration
Development of micro-abscesses in the corneum stratum
Development of dilated capillaries in the dermis (resulting in bleeding points)
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Aetiology
Immune mediated: antigen exposed within the corneum stratum
associated features
HLA CL6 (genetic)
Infection: Streptococcus → guttate psoriasis
Stress → exacerbations
Drugs → Alcohol, β-blockers +nsaids
Koebner Phenomenon (occurring in scar tissue)
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Clinical Features8 clinical subtypes
psoriasis vulgaris (most common)
guttate psoriasis (post infective)
flexoral psoriasis
erythrodermic psoriasis
palmoplantar psoriasis
psoriatic arthritis
nail psoriasis
acute pustular psoriasis
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Acute Pustular Psoriasis
Widespread sterile pustules
These coalesce to form “lakes of pus”
Caused by withdrawl of steroids drugs, pregnancy
Septicaemia
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Psoriasis Vulgaris (Plaque)
Common 0.5-3% of population
Single or multiple plaques
Age 15-40 (mean age 28yrs)
Extensor surfaces, back, sacrum,
hairline, knees, elbows
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Guttate Psoriasis
Multiple small lesions post infection
Often spontaneously resolve in 2-3/12
Respond poorly to topical agents
Differential with pityriasis
(scale confined to edge of lesions)
pityriasis rosacea - scale confined to
edge
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Flexural PsoriasisTypical eczema distribution
Often associated with psoriasis in the hair.
Differential with intertrigo
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Erythrodermic Psoriasis
Results when 90% of body affected
Precipitated by withdrawl of steroids
Consequences:
infection
dehydration
high out-put cardiac failure
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Palmoplantar Psoriasis
Vesicles on soles of hands & feet
Painful rather than itchy
Chronic condition
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Psoriatic Arthritis
5 main clinical subtypes:
symmetrical polyarthritis
asymmetrical oligoarthritis (large joint)
spondylitic (sero-negative)
distal-interphalangeal (nail)
severe mutilans
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Nail Psoriasis
50% of patients with skin involvement
90% of psoriatic arthritis
pitting
onycholysis of distal nail bed
subungal hyperkeratosis
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Treatment
Predominately benign + chronic condition
Topical/Systemic Treatments
Topical: - good for single isolated lesions
Tar - based preparations
Vitamin D-analogues
Steroids (rebound)
Dithranol (inhibits mitochondrial DNA)
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Treatment
Systemic
UVB (nUVB = 311nm wavelength, is more effective)
PUVA = Psoralen + UV light
Useful for multiple lesions, erythrodermic psoriasis, pustular psoriasis
methotrexate (hepatic fibrosis + myelosuppression)
cyclosporin (hypertension, hypertrichosis, skin malignancy +lymphoma)
retinoids (good for pustular psoriasis)