Psoriasis Clinical features Psoriasis is a common, chronic, and recurrent inflammatory disease of the skin characterized by circumscribed, erythematous,

dry, scaling plaques of various sizes. The lesions are covered by silvery white lamellar scales. The lesions have a predilection for the scalp, nails, and extensor surfaces of the limbs, umbilical region, and sacrum. The eruption is usually symmetrical and develops slowly. Itching may be present. When the scales removed a bleeding points appear (Auspitzs sign). When the lesions increase in size they become annular or polycyclic in shape. The isomorphic response (Koebners phenomenon) is the appearance of typical lesions at the site of trivial injury. Involved nail can demonstrate distal Onycholysis, pitting, oil spots, and subungual hyperkeratosis. Types Inverse psoriasis This form involves the folds such as axillae, inframammary folds, groins, and intergluteal creases. Psoriatic arthritis Will develop in up to 30 percent of people who have psoriasis. Psoriatic arthritis is seronegative spondyloarthropathy and therefore occurs more commonly in patients with tissue type HLA-B27. Guttate psoriasis In this form typical lesions are the size of water drops, 2 to 5 mm in diameter. They erupt abruptly following some acute infection, such as streptococcal pharyngitis. It occurs mostly in patients under age 30. This type of psoriasis usually responds rapidly to UVB and semisynthetic penicillin. Generalized pustular psoriasis

In this form, the onset is sudden. Beside plaque psoriasis and often psoriatic arthritis the patient develops 1. 2. 3. 4. 5. Generalized pustular eruption Generalized erythema Intense itch and burning sensation The patient is frequently ill with fever Hypocalcemia, cachexia, and respiratory distress may develop

Episodes are often provoked by withdrawal of systemic steroids. Usually there is a strong family history Acitretin is the drug of choice. Cyclosporine, Methotrexate, biological are also effective. Palmoplanter psoriasis Palms and soles are sometimes exclusively affected, showing discrete erythematous dry scaling patches, circumscribed verrucous thickening, or pustules on erythematous base. The patches usually begin in mid portion of the palm or sole, and gradually expand. This is type is typically chronic and resistant to treatment. Erythrodermic psoriasis Patients with psoriasis may develop generalized erythroderma. The patient will present with extensive erythema, scaling, extensive hair fall, intense itching. Mortality rate reaches 7% due to sepsis, respiratory distress, high cardiac output. Course The course of psoriasis is unpredictable. In some cases remain localized to the original areas for years. Two chief features of psoriasis are its tendency to recur and its persistence. Inheritance and epidemiology Patients with psoriasis often have relatives with the disease. Psoriasis occurs with equal frequency in both sexes. 2% of US population has psoriasis, while it occurs
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less frequently in the tropics. The onset is at mean age 27 years, but the range is wide from the neonatal period to the 70s. Severe emotional stress tends to aggravate psoriasis. In pregnancy there is tendency to for improvement, while after delivery it tends to exacerbate Pathogenesis Psoriasis is hyperproliferative disorder, but the proliferation is driven by a complex cascade of inflammatory mediators. T-lymphocytes and cytokines play pivotal roles in the pathophysiology of psoriasis. Some drugs may precipitate psoriasis like, beta-blockers, lithium, Antimalarials, terbinafine. Treatment Topical treatment Topical application of corticosteroid is beneficial in localized psoriasis, but side effects include o Epidermal atrophy o Steroid acne o Miliaria o Telangiectasia o Striae distensa o Bacterial, viral, and fungal infections Intralesional corticosteroid is beneficial in localized psoriasis refractory to topical steroid, at dose 5 mg/ml every one month. Calcipotriene, is a vitamin D3 affects the keratinocytes differentiation partly through its regulation of epidermal responsiveness to calcium. Calcineurin inhibitors, include tacrolimus and pimecrolimus are used to escape the side effects of topical steroid. Topical Salicylic acid, is a keratolytic agent used in cream and shampoo forms. Over use of this product will induce tinnitus, confusion, and hypoglycemia. Ultraviolet radiation, In most instances sunlight will improves psoriasis.
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Narrow band 311 nm UVB is effective PUVA, ingestion of 8-methoxasoralen followed by exposure to UVA after 2 hours, 2-3/week is highly effective. Most patients clear after 25 treatments but maintenance therapy is required. Sides effects include o Cataract, so protective eye wear must be used in days of treatment o Increases the risk of skin cancers especially squamous cell carcinoma Systemic treatment Corticosteroid, is contraindicated in psoriasis because it will cause rebound or induction of pustular psoriasis when therapy is stopped. Methotrexate, this folic acid antagonist remains the standard against which other systemic treatments are measured. Methotrexate has a great affinity for dihydrofolic acid reductase than folic acid. The synthesis of DNA is blocked when dihydrofolic acid reductase is bound to and thereby cell division is reduced. Indications for the use of systemic treatment are psoriatic erythroderma, psoriatic arthritis, generalized pustular psoriasis, palmoplanter psoriasis, and wide spread plaque psoriasis. Methotrexate is toxic to liver and decreases renal clearance, so it is important to be sure that the patient has no history of kidney or liver diseases, also Methotrexate is not advised in cases of alcohol abuse, severe illness, debility, pregnancy, anemia, active infectious diseases .The most frequently reported adverse reactions include ulcerative stomatitis, leucopenia, nausea, and abdominal distress. Suppressed hematopoiesis causing anemia, aplastic anemia, leucopenia and/or thrombocytopenia. The patient must be tested for liver function test, kidney function test, complete blood count, hepatitis profile, HIV, urine analysis. Liver biopsy may be performed after every 1.5 gram cumulative dose to monitor the development of cirrhosis. Aminoterminal procollagen lll peptide may reduce the need for liver biopsy. Most patients require between 15 to 30 mg a week, the dose can be given as a single dose or divided into three doses 12 hours apart orally. Cyclosporine, it downmodulates the proinflammatory epidermal cytokines. The dose is 2 to 5 mg/kg/day. Monitoring of blood pressure and serum creatinine is essential.
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 Retinoids, acitretin and isotretinoin are highly effective in pustular psoriasis. Biologic agents, three agents block TNF, o Infliximab is a chimeric monoclonal antibody to TNF and require IV infusion on 5 mg/kg every 6 to 8 weeks in the maintenance therapy. o Etanercept is a fusion protein of human TNF type 2 receptor and the FC region of IgGm1, and is given at 50 mg biweekly in the first 12 weeks as induction period followed by 50 mg weekly o Adalimimab is a recombinant fully human IgG1 monoclonal antibody to TNF. The dose is 40 mg S.C every 2 weeks. The biological therapies suppress the normal immune response, so they may be associated with reactivation of tuberculosis, demyelinating diseases, and serious systemic opportunistic infection.