Lecture - 3

Psoriasis

Year 3 MBBS
Dermatology
Dr Sharmila V S
 Psoriasis
• Psoriasis – chronic, autoimmune, inflammatory ,
hyperproliferative disorder of skin.
• BUT it is not infectious.
• It is associated with a Strong family history
• It is often aggravated by triggering environmental
factors .
• Age of onset : any age from infancy to 8th decade of
life
 Pathogenesis of Psoriasis

• Autoimmune etiology: Abnormal T cell function

(Th1) results in inflammatory mediators like
cytokines which causes increased proliferation of
keratinocytes

• Increased proliferation of keratinocytes results in

shortening of cell cycle from 28 days to 3-4 days.
• Resulting in decreased epidermal turn over time.
 Environmental factor that exacerbates Psoriasis

 Trauma : new lesions appear at site of injury (even scratching)

called koebner phenomenon
 Infection – streptococcal sore throat, UTI, LRTI, HIV
 Medications - oral lithium, beta-blockers, ACE Inhibitors,
calcium antagonists, antimalarials, interferons, sudden
withdrawal of corticosteroids
 Endocrine : pregnancy, hypocalcemia
 Stress, smoking , sunlight in some
 Alcohol

PNEUMONIC - TIMES
 Types of Psoriasis

• 4 major types: • According to the sites

involved:
1. Plaque type Psoriasis – 1. Scalp psoriasis
most common type 2. Inverse Psoriasis ( involves
2. Guttate Psoriasis flexures – axilla, groin )
3. Erythrodermic Psoriasis 3. Psoriasis of the nail
4. Pustular Psoriasis 4. Psoriatic arthritis
5. Palmoplantar Psoriasis
 History
• Skin lesion may / may not be itchy
• Rash start as small red raised lesion (red plaque) &
gradually increase in size (few mm to several cm)
• White flakes (scales) + on top of red plaques & shed
• Site – usually start on extensors of elbows & knees or
scalp but can occur at any site.
• On scalp, patient often complain it as dandruff.
• Extent of involvement – few areas (<10% BSA as in
plaque type) to large areas (>90% BSA in
erythrodermic type)
 History
• H/o nail changes + (discoloration of nail, lifting of nail
from nail bed)
• H/o joint involvement – pain, swelling, tenderness,
deformity over few or multiple joints.
• No other systemic symptoms like fever, myalgia in
plaque type psoriasis.
• Systemic symptoms occur in severe type (flare up) of
psoriasis ( e.g erythrodermic or pustular psoriasis).
 Physical Examination – Plaque Psoriasis
• Red (erythematous) papules or plaques with well
defined borders and silvery white scales on surface
of the plaques +
• Size vary from few mm (papule) - several cm (plaque)
• Number vary from single to multiple lesions
• Site & distribution
– Localized to few areas like extensors of elbows / knees /
scalp / trunk.
– Generalized plaques seen at many sites (trunk, extremities,
face and scalp).
Localized Plaque Psoriasis
Generalized Plaque Psoriasis
Generalized Plaque Psoriasis
 Physical Examination

• Scales are silvery white

and loosely adherent

• Clinical sign elicited in

Psoriasis
 Auspitzs sign – small
bleeding points are seen
when scales are
removed by scratching.
AUSPITZ SIGN
 Scalp Psoriasis
• Commonly mistaken as
dandruff (seborrheic
dermatitis)

• So, how to differentiate

between scalp psoriasis
& dandruff?
SCALP PSORIASIS

DANDRUFF
Difference between Scalp Psoriasis & Dandruff

Scalp Psoriasis Dandruff ( seborrheic dermatitis)

Thick red plaques + NO thick plaques, mild redness of
scalp +
Scales are thick & adherent to plaques Fine & loose scales are present
Red plaques with scales extend from Redness & scaling do not extend
the scalp below the hair line on to the continuously below the hair line; stop
frontal skin or occipital skin short of the hair margin.
 Other Types- Erythrodermic Psoriasis

• Life threatening type.

• Sudden onset of fever,
malaise, shivers.
• Generalized uniform
redness and scaling
involving >90% of BSA.
• Severe pruritus , pedal
edema and generalized
lymphadenopathy+
 Other types - Pustular Psoriasis

• Life threatening type

• Sudden onset fever,
chills, malaise.
• Marked burning ,
tenderness of skin +
• Generalized erythema
spreads in hours with
pinpoint sterile pustules
– later coalesce to form
lakes of pus
 Other Types - Guttate Psoriasis

• Sudden appearance of
discrete numerous 2-
5mm papules with
silvery scales on the
trunk.
• NO PLAQUES SEEN
• Common in children,
often preceded by
streptococcal infection
(pharyngitis)
 Nail Changes in Psoriasis

• Pitting of nails
• Onycholysis – separation of distal nail plate from the
nail bed
• Subungual hyperkeratosis : subungual deposition of
keratin
• Salmon patches ( oil drop sign) of the nail bed :
yellow-orange discoloration seen via the nail plate
• Nail dystrophy - Crumbling of nail plate
• Transverse lines ( Beaus lines )
 Pitting of Nails
(Common Nail change but not pathognomic)
 Salmon patch (oil drop sign) – yellow orange
discoloration of nails – Pathognomic Nail Change
 Onycholysis & subungual hyperkeratosis

Onycholysis & subungual hyperkeratosis – also occur in fungal infection of nail

So DD is Onychomycosis
Transverse line (Beaus lines)
Nail dystrophy in Psoriasis
(nail becomes crumbled)
 Joint involvement – Psoriatic arthritis

• Pain, Swelling, redness and tenderness of involved

joints.
• Significant early morning stiffness >1/2 hour.
• Later, deformity of joints occur.
• 5 patterns of Psoriatic arthritis occur (next slide)
• Other findings in Psoriatic arthritis include:
– Sausage finger (dactylitis)
– Enthesitis ( tendon involvement)
 5 patterns of Psoriatic Arthritis

1. DIPJ (Distal interphalangeal joint) arthritis – only DIP

joint is involved; PATHOGNOMIC TYPE
2. Asymmetric oligoarthritis
• Common type of joint involvement but NOT
PATHOGNOMIC
• Involves asymmetrically 2-5 joints like PIP, MCP, DIP,
elbow joint, wrist joint, knee joint
• Seronegative arthritis without subcutaneous nodules
 Psoriatic Arthritis – Different patterns

3. Symmetrical polyarthritis : involves multiple joints

PIP, MCP, wrists, ankles & elbows – seronegative
arthritis
4. Spondyloarthritis ( Spondylitis & Sacroilitis) – involve
sacroiliac, hip and cervical area with ankylosing
spondylitis
5. Arthritis Mutilans: destruction of I.P joints leading to
telescopic fingers and mutilated hand.
DIP joint arthritis
Asymmetrical oligoarthritis with
Dactylitis
Arthritis mutilans
 CO-MORBIDITIES

 Association with Internal Diseases

• Cardiovascular diseases : Psoriasis patients have higher risk of
atherosclerosis, Ischemic heart disease, myocardial infarction,
pulmonary emboli.
• Cerebrovascular accidents .
• Peripheral vascular disease
• Metabolic syndrome : Patients with psoriasis have increased
risk of diabetes, hypertension, hyperlipidemia, obesity
• High risk of depression.
• High risk of ulcerative colitis.
 Differential Diagnosis

• Plaque type psoriasis – tinea corporis, discoid eczema,

mycosis fungoides, SCLE.
• Scalp psoriasis – seborrheic dermatitis, tinea capitis

• Inverse psoriasis – intertrigo, candidiasis, tinea cruris

• Pustular psoriasis – Pustular drug eruption

• Acute guttate psoriasis – any maculopapular drug eruption,

secondary syphilis, pityriasis rosea
• Nails- onychomycosis (KOH is mandatory)
 Psoriasis - investigations

1. Skin biopsy (punch biopsy) – the diagnostic test

2. ASO titre – increased in guttate psoriasis
3. Throat culture –to rule out group A beta hemolytic
streptococcus

4. Rule out HIV in case of sudden onset

5. Serum uric acid – increased in 50% of patients, there is an
increased risk of gouty arthritis
6. In inverse psoriasis, do KOH examination to look for any
superimposed candida infection.
 Severity of Psoriasis

• Assessment tools for measuring Psoriasis Severity includes

1. BSA – Measures percentage of body surface affected by
psoriasis based on rule of “ 9 “

2. PASI ( Psoriasis Area and Severity Index ) : Measures

erythema, scaling & induration and extent of involvement
based on 4 regions (head & neck, UL, trunk, LL )

3. DLQI ( Dermatology Life Quality Index) : based on the

questionnaire which assess how much the “psoriasis” has
affected the quality of life OVER THE LAST WEEK.
 Severity of Psoriasis
• To plan treatment, Assess
1. Severity
2. Arthritis
3. Co-morbidities

• Severity assessed as
1. Mild : If BSA ( body surface area ) is involved <10%
2. Moderate : If BSA ( body surface area ) is involved >10% to
30%
3. Severe : If BSA ( body surface area ) is involved >30% or
erythrodermic / pustular psoriasis
 Treatment of Psoriasis
• If < 10 % of body surface area ( BSA ) is involved

TOPICAL THERAPY

• If > 30 % of body surface area ( BSA ) is involved

If phototherapy is
contraindicated or
TOPICAL THERAPY not compliant TOPICAL THERAPY
+ +
PHOTOTHERAPY SYSTEMIC THERAPY
 Treatment of Psoriasis

 Topical agents:  Phototherapy

• Coal tar • NBUVB (Narrow band UVB )
• Corticosteroids • PUVA
• Vitamin D analogues
• Salicylic acid  Systemic therapy
• Pimecrolimus / Tacrolimus • Methrotrexate
• Topical retinoids • Acitretin
• Dithranol • Cyclosporin

 Biologicals (e.g Infliximab)

 Topical therapy - Corticosteroids
 Commonly used Topical steroids :
• Usually potent steroids are applied in trunk and extremities
and less potent steroids are applied on face.

• BVC or BVO ( Betamethasone valerate cream or ointment ) –

comes in different potency ( Full strength, 1:2, 1:4, 1:8 )

• Eumovate ( Clobetasone butyrate ) – applied on face

• Dermovate ( Clobetasol propionate ) – on palms / soles.
• Hydrocortisone – mild potent.
 Potency of steroids - classification
• Mild potent
• Moderately potent
• Potent steroid
• Superpotent steroid

 Potency depends on
• Vehicles – ointments are more potent than creams
• Concentration : BVO 0.1% is more than BVO 0.05%
• Ingredient – betamethasone dipropionate is more
potent than betamethasone valerate
 Topical therapy - corticosteroids
• BVO FS ( 0.1% ) is highly potent – then potency
decreases with 1:2, 1:4, 1:8 ( this is prepared in HKL
by mixing with aqueous cream )

• Superpotent – Dermovate , betamethasone

dipropionate
• Potent - Betamethasone valerate FS ( 0.1% )
• Moderate potent : BVO or BVC 1:4, Eumovate
• Mild potent : Hydrocortisone
 Topical therapy - Corticosteroids
 Adverse effects of Topical steroids:
• Atrophy
• Permanent striae
• Telangiectasia
• Bruising
• Steroid acne
• If applied over eyelids, cataract & glaucoma may occur
• Contact dermatitis to the preservative used in steroid creams.
• Rarely, systemic absorption causing Cushing’s syndrome.
 Topical therapy – Vitamin D analogues

• Calcipotriol ( Daivonex ) ointment or cream – a good non-

steroidal anti-inflammatory topical agent
• Advantage : NO CUTANEOUS ATROPHY.
• Affects keratinocyte differentiation.

• Can be combined with steroids (combination is more effective

than either agent alone)
• Don’t apply more than 100 g / week otherwise,
hypercalcemia occurs.
• Other side effects – irritation, pruritus.
 Topical therapy - Coal tar preparations

 Coal tar ointment, Coal tar solution (LPC - liquor picis

carbonis)
 Polytar shampoo, Sebitar Shampoo– scalp psoriasis
 Cocois co ( coal tar + salicylic acid + precipitated sulphur in
coconut oil ) – used in scalp psoriasis

 Action : suppresses DNA synthesis and thereby inhibits

keratinocyte proliferation.

• Side effects - Irritant ,staining , folliculitis.

• Should not be used on face, body folds and genitalia.
 Topical therapy

 Salicylic acid – keratolytic agents

• Softens the keratin, loosens and removes the scales.
• When used in combination , it allows better penetration of
the other drug by removing the superficial layer of the skin

 Available as ointments, creams, shampoos, paints

• E.g BVO + 2% SAO.
• Cocois co ointment / Salicylic acid shampoo – scalp psoriasis

 Side effects : irritation / stinging

 Other topical therapies

 Tacrolimus /Pimecrolimus ( Calcineurin inhibitors )

• Used in thin lesions in areas prone to atrophy or steroid acne
• So indicated in face / flexural psoriasis
• Pimecrolimus 1% cream is efficacious

 Topical Tazoretene 0.05% and 0.1% (Retinoids)

• Combined with steroids as it causes irritation
• Acts by modulating keratinocyte differentiation and
hyperproliferation
 Phototherapy
• Indicated for patients with moderate to severe chronic plaque
Psoriasis.
• Narrow band UVB ( NBUVB 311 nm ) – effective only in
psoriasis with thin plaques.

• Combined treatment with topical steroids / vitamin D

analogues / tazoretene / tacrolimus / pimecrolimus is
effective.
• UVB + coal tar therapy ( Goeckermans regimen ) is also
effective
 Photochemotherapy

 Oral PUVA : ( Psoralen + UVA )

• Psoralen tablet is taken orally, 2 hours later exposed
to UVA.
• PUVA given 2-3 times / week

 Adverse effect :
• Short term side effects : burning, erythema
• Long term side effects : skin cancer, photoaging
• Oral psoralens – cause cataract
 Systemic therapy

 Methotrexate ( MTX ):
• Given once a week dosing, started with 5mg / week
& increased to 7.5mg / week
• Folic acid 1 mg is given on all other days except the
day of MTX.
• Do baseline LFT, RFT, CBC & then repeat every 3
months.
• Do baseline CXR and repeat once in 1-2 years
 Systemic therapy

 Adverse effects of MTX.

• Hepatotoxicity
• Bone marrow suppression
• Pulmonary toxicity – cough / dyspnoea
• Renal damage – crystalluria
• Oral ulcers
 Systemic therapy

Indications of MTX
• Generalised plaque type
• Erythrodermic
• Pustular psoriasis
• Psoriatic arthritis
 Systemic therapy

Retinoids ( Acitretin )
• Especially first choice in pustular psoriasis

• Do baseline lipid profile, LFT, Pregnancy test (

if applicable ) before starting acitretin.

• RE-PUVA : Retinoids + PUVA effective in

generalised plaque type
 Systemic therapy
Adverse effects of oral retinoids
• Dry lips, dry eyes, dry skin
• Teratogenecity
• Hyperlipidemia
• Increased liver enzymes
• Bone pain ( vertebral hyperostosis )
• Depression
• Pseudotumour cerebri syndrome
 Systemic therapy

 Ciclosporin
• Monitor blood pressure every week
• Monitor serum creatinine once in 2 weeks or once in
a month
• Since ciclosporin causes hypertension &
nephrotoxicity.

 Biologicals : alefacept / etanercept / infliximab

 In summary of Treatment
• Commonly used Topical agents to treat skin lesions
– Topical coal tar onitment
– Topical corticosteroid
– Topical Vit D analogue
– Topical Salicylic acid

• Commonly used Topical agent to treat scalp psoriasis

– Coal tar Shampoo (Polytar, Sebitar)
– Salicylic acid shampoo