DR . S.

AHAMED UWYSE
CONSULTANT DERMATOLOGIST
CNTH
RAGAMA
 It’s a papular squamous disorder (presenting with scaly papules or plaques)
 Multi factorial , chronic, non-infectious inflammatory skin disorder with
exacerbations and remissions.
 Dynamic interactions between multiple cell types involved in innate and adaptive
immune systems and cytokines in response to trigger culminating in the disruption
of skin immune hemostasis .
 2 - 4 % of the general population are affected by psoriasis
 It can start at any age group, but there are two peaks of onset 15 -25 yrs and 50 –
60 yrs
in younger age group , more in females than in males
 20 – 30 % of the cases shows F/H of psoriasis (inherited)
Precise cause of psoriasis is unknown , but, environmental , genetical and immunological
factors involving in the aeitiology – multifactorial disease
Genetic factors
 Polygenic inheritance ( 2 or more genes involving)
 PSORI-1 to PSORI-9 genes involves
 HLA – CW6, HLA - B 13, HLA - B 17, HLA - DR 7, HLA - B 27
 most of the genes involving in - Immune related functions , encodes for protein synthesis
involving in immune reaction and signaling pathways
Trigger factors of psoriasis
 Infections
bacterial - Streptococcal infections (pharyngitis)
HIV infection
 Endocrine factors
Hypocalcaemia
 Psychogenic stress
 Drugs - lithium, IFNs, β-blockers, antimalarials and so on
 Alcohol consumption, smoking and obesity
 Sunlight (10%)
 Trauma - lesions can appear in skin damaged by scratches or surgical wounds
(the Köbner phenomenon)
Chronic plaque psoriasis
 Symmetrically distributed, sharply defined,
erythematous, scaly plaques.
 Sites of predilection -
scalp, elbows, knees ,lumbosacral area ,trunk
and so on
Guttate Psoriasis
 More commonly seen in children and adolescents.
 Frequently preceded by an upper respiratory tract
infection.
( antistreptolysin O, anti - DNase B or
streptozyme titer elevated in half of the patients.)
Scalp psoriasis
 One of the most common sites for psoriasis.
 Individual lesions are discrete (contrast from seborrheic
dermatitis).
 Often advances below the hairline, and to the retroauricular
areas and the posterior upper neck.
 The scales sometimes have an asbestos-like appearance
and can adhere to hair shafts in clumps (pityriasis
amiantacea).
 overlapping of psoriasis and seborrheic dermatitis can also
occur in the scalp - Sebopsoriasis
Flexural psoriasis (Inverse Psoriasis)
 Characterized by shiny, pink to red, sharply demarcated thin
plaques.
 There is much less scale than in untreated
chronic plaque psoriasis.
 Often a central fissure is seen.
 The most common sites of involvement are the retro-auricular
fold, inter-gluteal cleft, inguinal crease, axilla, and infra-
mammary region.
 Localized dermatophyte, candidal or bacterial infections can be
a trigger for flexural psoriasis.
Nail psoriasis
 50% of the cases present with nail changes at the
time of presentation. Later it involves 90% of the cases.
(finger nails > toe nails).
 Associated with an increased incidence of psoriatic
arthritis(50 – 80 % )
 5% 0f the cases, nail changes may occur in isolation

Nail matrix involvement

 Parakeratotic foci in the proximal portion of the nail
matrix – Nail pitting
 mid portion of the matrix - Leukonychia and loss of
transparency.
 Entire nail matrix is - A whitish, crumbly, poorly adherent
nail.
Nail bed involvement
 Exocytosis of leukocytes beneath the nail plate - “oil
drop” or “salmon patch” phenomenon
 Increased capillary fragility - Splinter hemorrhages
 Parakeratosis of the distal nail bed - subungual
hyperkeratosis and distal onycholysis .
Psoriasis of oral mucosa
 Migratory annular erythematous lesions with hydrated
white scale may occur in patients with
acrodermatitis continua of Hallopeau (pustular
psoriasis involving the finger tips and nails) and
generalized pustular psoriasis.
 The most common location is the tongue, and the
clinical (and histologic) appearance is similar to
geographic tongue.
 Occasionally, lesions are observed
on the buccal mucosa.
Erythrodermic Psoriasis
 Unstable form of psoriasis
 Stable psoriatic plaque lesions , becoming reddish and number of
the scales reduced then the erythema spreading and become
generalised
 Erythrodermic psoriasis characterized by generalized erythema with
scaling, may be itchy or with burning sensation, and its onset can be
gradual or acute
 Causes of erythrodermic psoriasis
following application of irritants ,application of potent steroids with
sudden withdrawal, sun burn, alcohol consumption , stress, infection ,
using oral steroid therapy and so on
 Diagnostic clues of psoriatic erythroderma
Previous plaques in classic locations, characteristic nail changes
central facial sparing.
Pustular Psoriasis
Generalized pustular psoriasis
 Pustules may develop at the periphery of the plaque lesions
initially , then becomes generalised
 Trigger factors of pustular psoriasis
Pregnancy
Rapid tapering of oral or topical corticosteroids or other systemic
therapies.
Hypocalcemia
Infections
Topical irritants (localized pattern)
 Types:
von Zumbusch pattern.
generalised erythema with sterile pustular eruption with
constitutional symptoms. marked leucocytosis present
annular pattern
pustules occurring in annular pattern all over the body
 generalized pustular psoriasis may occur during pregnancy
which is referred to as impetigo herpetiformis.
Localised types
 Pustular psoriasis of the palms and soles
sterile pustules of the palmoplantar surfaces admixed with yellow–
brown macules.
Focal infections , stress, smoking have been reported as trigger
factors
 Acrodermatitis continua of Hallopeau
pustules are seen on the distal portions of the fingers and involving
the nailbed, resulting in shedding of nail plates.
Pustulation is often followed by scaling and crust formation.
painful condition
it may involve toes as well
rarely it may go into generalized form
 Psoriatic arthritis occurs in 5–30% of patients with cutaneous psoriasis
 Risk factors for a more severe course of the arthritis:
- Initial presentation at an early age
- Female gender
- Poly-articular involvement
- Genetic predisposition
- Radiographic signs of the disease early on.

 Patients with psoriatic arthritis can also have involvement of the tendons around the
involved joints (tendinitis) and the sites of insertion to bone (enthesitis).
 swelling of the fingers (dactylitis) may also occur.
Types of psoriatic arthritis
 Mono or asymmetric oligoarthritis (most common type).
Inflammation of the DIP and PIP joints of the hands and feet.
Involvement of the PIP and the DIP joints of a single digit can result in the classic
“sausage” digit.
 Arthritis of the distal inter-phalangeal joints
exclusive involvement of the DIP joints.
classic but uncommon presentation.
 Rheumatoid arthritis-like presentation
 Arthritis mutilans (least common type)
Severe, rapidly progressive joint inflammation that results in destruction of the joints and
permanent deformity
Digits become shorter, wider and softer to palpation because of osteolysis and a telescoping
phenomenon.

 Spondylitis and sacroiliitis

 Cardiovascular diseases
Myocardial infarctions, peripheral arterial disease, cerebrovascular accidents,are more
common in patients with severe psoriasis.
This is largely due to an increased risk for having metabolic syndrome.
 Non-alcoholic steatohepatitis (NASH)
Characterized by fatty infiltration, peri-portal inflammation and focal necrosis, is more
commonly observed in patients with psoriasis.
 Crohn’s disease, ulcerative colitis, and psoriasis share an association with
sacro-ilitis and HLA-B27 positivity
 Mainly clinical diagnosis
 Skin biopsy and histology in difficult cases
 Parakeratosis (nuclei retained in the horny
layer).
 Irregular thickening of the epidermis
withelongated rete ridges, but thinning over
dermal papillae which is responsible for the
Auspit’s sign
 Abscense of granular layer
 Polymorphonuclear leucocyte colletion in
the epidermis ( Munro abcess).
 Dilated and tortuous capillary loops in the
dermal papillae.
 T- lymphocyte infiltrate in upper dermis
Pharmacological management
 Topical :
topical Steroids
Vitamin D anaalogues
Retinoids
Calcineurin inhibitors
Salycilic acid
Coal tar and salicylic acid combination
anthralin

 Systemic :
Methotrexate
Cyclosporin
Retinoids
Biologics
 Phototherapy :
PUVA
UVB
Lifestyle modifications
 Avoidance of alcohol
 Cessation of smoking
 Avoidance of fatty meals
 Weight reduction
 Exercise
 Avoiding precipitating factors
Type of psoriasis Treatment of choice Alternative treatments

Stable plaque Vitamin D analogue Coal tar

Local retinoid
Local steroid
Dithranol

Extensive stable plaque UVB Methotrexate

(> 30% surface area) PUVA Cyclosporin A
recalcitrant to local therapy PUVA + Acitretin Acitretin
Sulfasalazine
Mycophenolate mofetil

Widespread small plaque UVB Vitamin D analogue

Coal tar

Guttate Systemic antibiotic Weak tar preparation

Emollients while erupting; then UVB Mild local steroid
Facial Tacrolimus
Mild to moderately potent local steroid
Flexural Tacrolimus
Vitamin D analogue (caution: may irritate)
Mild to moderately potent local steroid +
anticandidal/fungal
Pustular psoriasis of hands and feet Moderately potent or potent local steroid Acitretin
Local retinoid Topical PUVA

Acute erythrodermic, unstable Inpatient treatment with ichthammol paste Acitretin

or generalized pustular Local steroid may be used initially Methotrexate
with or without wet compresses Cyclosporin A
 Stable plaque psoriasis with limited plaque lesions
 Application of topical steroid (moderate to potent)
 Vit D analogue – cacipotriol oint alone or in combination with steroid
 Coaltar and salicylic acid combination
 Stable plaque psoriasis with extensive lesions (more than 30% of the body surface)
 coaltar and salicylic acid combination
 topical Steroid in diluted form (1in 4 or 1 in 6 dilution)
 PUVA therapy alone or in combination with acitretin orally
 methotexate , cyclosporine, acitretin given orally with topical treatment
 Guttae psoriasis
 Oral antibiotics
 Emollients or diluted steroids
 Flexural psoriasis
 Mild to moderate topical steroid therapy
 Vit D analogue
 Topical Calcineurin inhibitors (tacrolimus)
 Anti fungal creams can also be applied
 Palmoplantar psoriasis
 Potent topical steroid
 Coaltar, salicylic acid combination (not suitable for pustular psoriasis)
 Local PUVA therapy
 Methoterxate or cyclosporine in resistant cases
 Generalised erythrodermic or pustular psoriasis
 Emollients
 Diluted topical steroid
 Methotrexate or cyclosporine orally
 Mild to moderate psoriasis:
first-line treatment as monotherapy or in
combination with vit D analogue or salicylic acid
 Severe extensive psoriasis
can be used in combination with salicylic acid or alone in diluted form (1:4) with
oral methotrexate or cyclosporine or acitretin
can be combined with phototherapy

 Mono-therapy for flexural and facial psoriasis (usually mild strength)

Contraindications
 bacterial, viral, and mycotic infections

 atrophy of the skin

 allergic contact dermatitis due to corticosteroids or constituents of the

formulation
Tazarotene (vit A derivative) is used as topical retinoid in psoriasis

Indications
 Mild to moderate psoriasis: second-line treatment as mono-therapy or in
combination.
Contraindications
 Unstable plaque psoriasis in a phase of progression Erythrodermic psoriasis

 Allergic contact dermatitis to tazarotene or constituents of the

formulation
 Pregnancy or lactation
Methotrexate

 Severe extensive psoriasis

 chronic plaque psoriasis with interference of employment or social functioning
 Pustular psoriasis (generalized or localized)

 Erythrodermic psoriasis

 Psoriatic arthritis (moderate to severe)

 Severe nail psoriasis

 Psoriasis not responding to topical treatments, photo(chemo)therapy
and/or systemic retinoids.
cyclosporine
 Severe psoriasis that cannot be managed by topical treatments or
phototherapy alone , cyclosporine added

 While conventional therapies (topical treatments, phototherapy, methotrexate) are

ineffective or inappropriate
 As monotherapy for erythrodermic or pustular psoriasis
 Biologic drug
This is a product which is produced from living organism or contain components of living organism.
Biologics include, proteins, tissues, genes, blood components such as antibodies.
Eg - human insulin, monoclonal abs ( adalimumab ,eternacept,infliximab, trastuzumab and so on)
 Biosimilar
it is a synthetic version of the original biologic drugs
 Biologics are used in various condition including psoriasis
Patients with severe psoriasis, eligible for a systemic treatment.
Patients with psoriatic arthritis, particularly those who have failed other disease-modifying
antirheumatic drugs (DMARDs) .
Patients with moderate to severe psoriasis who are not candidates for topical treatments,
phototherapy, or classic systemic treatments because of insufficient efficacy or contraindications.
Few examples of biologics or biosimilar
Etanercept - anti TNF- α Human fusion protein
Inflximab - anti TNF- α Chimeric antibody
Adalimumab - anti TNF- α Human antibody
Ustekinumab - anti IL-12/23 Human antibody
Secukinumab - anti IL-17A Human antibody
Ixekizumab - anti IL-17A Humanized antibody
Brodalumab - anti IL-17 receptor Human antibody
Guselkumab - anti IL-23 Human antibody
Thank you