PSORIASIS

Diagnosis and management

Rufaida Mudrika
Universitas YARSI

Advisor :
dr. Rita Maria Sp.KK

Departement of Dermatovenereolgy
Gatot Soebroto Army Hospital
Central Jakarta, 2018
2 Introduction
▹ Inflammatory and hyperplastic
disease of skin
▹ Characterised by erythema and
elevated scaly plaques
▹ Chronic, relapsing condition
▹ Course of disease often
unpredictable
3 Epidemiology

Prevalence Estimated
Common equal in incidence: ~ 60
skin disorder males and per 100,000 per
females year
4 Onset of Age
Current theory:
2 distinct peaks with possible genetic associations
Early onset (16–22 years)
▸ More severe and extensive
▸ More likely to have affected first-degree family member
Late onset (57–60 years)
▸ Milder form
▸ Affected first-degree family members nearly absent
 COMMON SITES AFFECTED
5 BY PSORIASIS
 Can affect any part of
the body – typically
scalp, elbow, knees and
sacrum

 Extent of disease varies

(Trauma)
 COMMON
TRIGGER Infections (e.g. streptococcal, viral)
FACTORS FOR
6 PSORIASIS
Skin trauma (Koebner phenomenon)

Psychological stress

Drugs (e.g. lithium, beta blockers)

Sunburn

Metabolic factors (e.g. calcium deficiency)

Hormonal factors (e.g. pregnancy)

 PSORIASIS IS A T-CELL MEDIATED,
7
AUTOIMMUNE DISEASE

• Antigen-specific memory T-cells are

primary mediators
• Leads to impaired differentiation and
hyperproliferation of keratinocytes
8 Symptoms of psoriasis

Skin Tightness
Scaling Itching
Redness of skin

Burning
Bleeding Fatigue
sensation
 CLASSIC PSORIASIS
9

 Well-defined and sharply

demarcated
 Round/oval shape lesions
 Usually symmetrical
 Erythematous and raised
plaques
 Covered by white, silvery
scale
 1. Chronic plaque 5. Pustular
– Localised and generalised
2. Gutatte
3. Flexural 6. Local forms
– Palmoplantar
4. Erythrodermic – Scalp
– Nail (psoriatic onychodystrophy)

10
”
TYPES OF PSORIASIS
 CHRONIC PLAQUE
11 PSORIASIS
▹ Most common type – affects
approximately 85%
▹ Features pink, well-defined
plaques with silvery scale
▹ Lesions may be single or
numerous
▹ Plaques may involve large areas
of skin
▹ Classifically affects elbows, knees,
buttocks, and scalp
 CHRONIC PLAQUE PSORIASIS
12
 CHRONIC PLAQUE PSORIASIS
13
 CHRONIC PLAQUE PSORIASIS
14
 GUTTATE
15 PSORIASIS
▹ Numerous and small
lesions ~1 cm diameter
▹ Pink with less scale than
plaque psoriasis
▹ Commonly found on trunk
and proximal limbs
▹ Typically seen in
individuals < 30 years
▹ Often preceded by an
upper respiratory tract
streptococcal infection
 FLEXURAL
16 PSORIASIS
▹ Lesions in skin folds
articularly groin,
gluteal cleft, axillae
and submammary
regions
▹ Often minimal or
absent scaling
▹ May cause
diagnpstic difficulty
when genital or
perianal region is
affected in isolation.
 ERYTHRODERMIC
17 PSORIASIS
▹ Generalised erythema
covering entire skin surface
▹ May evolve slowly from
chronic plaque psoriasis or
appear as eruptive
phenomenon
▹ Patients may become febrile,
hypo/hyperthermic and
dehydrated
▹ Complications include cardiac
failure, infections,
malabsorption and anaemia
▹ Relatively uncommon
 PUSTULAR
18 PSORIASIS
Two forms :
▹ Localised form
• More common
• Presents as deep-seated
lesions with multiple small
pustules on palms and soles
▹ Generalised form
• Uncommon associated with
fever and widespread
pustules across the body
• Inflamed body surface
 PALMOPLANTAR
19 PSORIASIS
▹ Can be hyperkeratotic or
pustular
▹ May mimic dermatitis-
look for psoriatic
manifestations elsewhere
to aid diagnosis
▹ Possibly aggravated by
trauma
20
SCALP PSORIASIS
▹ Varies from minor scaling with
erythme or thick hyperkeratotic
plaques
▹ May extend beyond hairline
▹ Patient scratching may produce
asymmetric plaques
 NAIL PSORIASIS
21
▹ May be present in patients with
any type of psoriasis
▹ Can take several forms :
 Pitting : discrete, well-
circumscribed depressions on
nail surface
 Subungual hyperkeratosis:
silvery white crusting under free
edge of nail with some
thickening of nail plate
 Onycholysis: nail sperates from
nail bed at free edge
 NAIL PSORIASIS
22
23 NAIL PSORIASIS
 NAIL PSORIASIS
24
 PSORIATIC
25 ARTHRITIS
Approximately 5-20% have
associated arthritis
Five major patterns of psoriatic
arthritis:
• Distal interphalangeal
involvement
• Symmetrical polyarthritis
• Psoriatic spondylarthropathy
• Arthritis mutilans
• Oligoarticular, asymmetrical
arthritis
Clinical expressions often overlap
26 Diagnosis psoriasis
▹ Other dermatological disorders can resemble
psoriasis

▹ Diagnosed clinically according to appearance,

distribution, history of lesions and family history

▹ Important to consider non-cutaneous complications

27
DIFFERENTIAL DIAGNOSIS
Localised patches/plaques Guttate
• Tinea • Pityriasis rosea
• Eczema • Drug eruption
• Superficial basal cell carcinoma • Secondary syphilis
and Bowen’s disease • Pityriasis rubra pilaris
• Seborrhoeic dermatitis
• Cutaneous T-cell lymphoma Erythrodermic
Flexural • Eczema
• Tinea • Cutaneous T-cell lymphoma
• Eczema • (mycosis fungoides)
• Candidiasis • Lichen planus
• Seborrhoeic dermatitis
Palmoplantar
• Tinea
28 MANAGING PSORIASIS
▹ Before starting treatment
▹ Establish relationship of
trust with patient Provide
patient with information
 Emphasise benign nature
of disease
 Explain that psoriasis
tends to be chronic and
recurrent
29 MANAGING PSORIASIS
Determine clinical setting before selecting treatment,
considering :
• Disease pattern, severity and extent
• Sites of disease
• Coexistent medical conditions
• Patient’s perception of disease severity
• Time commitments and treatment expense
• Previous treatments for psoriasis
 MANAGING PSORIASIS
30
Goals of management
 Tailor management to individual and address both
 medical and psychological aspects
 Improve quality of life
 Achieve long-term remission and disease control
 Minimise drug toxicity
 Evaluate and monitor efficacy and suitability of individual
treatments
 Remain flexible and respond to changing needs
31 TREATMENT OPTIONS FOR PSORIASIS
▹ Stepwise approach is advised
▹ Treatments include:
 General measures and topical therapy
 Phototherapy
 Systemic and biological therapies
▹ Combination therapies : may reduce toxicity and
improve outcomes
TOPICAL
THERAPIES
33
TOPICAL THERAPIES
• Approximately 70% of patients with mild-to-
moderate psoriasis can be managed with topical
therapies alone
• Tailor to needs of patient
• Potency, delivery vehicle and patient motivation may
affect compliance
• Application may be time-consuming for patients
 TOPICAL THERAPIES:
34 EMOLLIENTS
▹ Include aqueous cream, sorbolene cream, white soft
paraffin and wool fats
▹ Regular use can:
 alleviate pruritus
 reduce scale
 enhance penetration of concomitant topical therapy
 hydrate dry and cracked skin
▹ Soap should be avoided
 TOPICAL THERAPIES:
35 KERATOLYTICS
▹ Over-the-counter products include:
 Salicylic acid
 Urea
▹ Help dissolve keratin to soften and lift psoriasis
scales
▹ May enhance penetration of other actives
 TOPICAL THERAPIES:
36 COAL TAR
▹ Help reduce inflammation and pruritus
▹ May induce longer remissions
▹ Use limited by distinctive smell and ability to stain
clothing and skin
▹ May cause local skin irritation
 TOPICAL THERAPIES:
37 DITHRANOL

▹ Anti-proliferative properties
▹ Particularly effective in thick plaque psoriasis
▹ Initiate therapy at very low concentrations – can
burn skin
▹ Not suitable for face, flexures or genitals
▹ Stains clothes permanently and skin temporarily
 TOPICAL THERAPIES:
38 TAZAROTENE
▹ Topical synthetic retinoid
▹ For treatment of chronic plaque psoriasis
▹ Applied once daily in evening
▹ Commonly causes local irritation
 TOPICAL THERAPIES:
39 CORTICOSTEROIDS
▹ Possess anti-inflammatory, antiproliferative and
immunomodulatory properties
▹ Reduce superficial inflammation within plaques
▹ Potency choice depends on disease severity, location
and patient preference
 TOPICAL THERAPIES:
40 CORTICOSTEROIDS
▹ Adverse effects associated with long-term use include:
• Skin atrophy and telangiectasia
• Hypopigmentation
• Striae
• Rapid relapse or rebound on stopping therapy
• Precipitation of pustular psoriasis
▹ Pituitary-adrenal axis suppression through significant
systemic absorption (rare)
 TOPICAL THERAPIES:
41 CALCIPOTRIOL
▹ Synthetic vitamin D analogue
▹ For chronic plaque-type psoriasis
▹ Reverses abnormal keratinocyte changes by:
 Inducing differentiation
 Suppressing proliferation of keratinocytes
 TOPICAL THERAPIES:
42 CALCIPOTRIOL
▹ Response may require 4–6 weeks
▹ Adverse effects include erythema and irritation
 TOPICAL THERAPIES:
CALCIPOTRIOL/BETAMETHASONE DIPROPIONATE
43 OINTMENT

▹ For plaque-type psoriasis

▹ Combination of calcipotriol and a potent topical
corticosteroid (betamethasone dipropionate)
o Stable formulation for both actives
▹ Provides rapid, effective psoriasis control
44
45

Source : Fitzpatrick's Dermatology in General Medicine

46 OTHER THERAPIES
▹ Phototherapy
▹ Systemic therapies
▹ Biological agents
47 PHOTOTHERAPY
▹ For psoriasis resistant to topical therapy and covering > 10% of
body surface area
▹ Immunomodulatory and anti-inflammatory effects
▹ Three main types of phototherapy:
 Broadband UVB
 Narrowband UVB
 PUVA (administration of psoralen before UVA exposure)
▹ Treatment usually administered 2–3 times/week
48
49

Source : Fitzpatrick's Dermatology in General Medicine

SYSTEMIC
THERAPIES
 51
• Reserved for patients with widespread or
SYSTEMIC severe psoriasis
THERAPIES

• Potentially serious adverse effects and

drug interactions

• Many require PBS authority prescription

from dermatologist
 SYSTEMIC THERAPIES:
52 METHOTREXATE

 Most  Slows  Closely

commonly epidermal cell monitor
used proliferation kidney, liver
systemic and acts as and bone-
treatment immunosuppre marrow
for psoriasis ssant function

Perform PASI score before starting treatment

53 SYSTEMIC
THERAPIES:
CYCLOSPORIN
▹ Immunosuppressive agent
▹ For patients with severe psoriasis that is
refractory to other treatments
▹ Requires ongoing monitoring of
blood elements, and renal and liver
function
54
SYSTEMIC THERAPIES:
ACITRETIN
 Oral retinoid
 For treatment of all forms of severe
psoriasis
 Once-daily oral therapy
 Teratogenic – pregnancy must be
avoided
55
56

Source : Fitzpatrick's Dermatology in General Medicine

57
58
59

BIOLOGICAL
AGENTS
60 BIOLOGICAL AGENTS
• Proteins derived from living organisms that
exert pharmacological actions
• For adults with moderate-to-severe chronic
plaque-type psoriasis who are candidates for
phototherapy or systemic therapy
• Most administered sub-cutaneously
61 BIOLOGICAL AGENTS
Target key parts of immune system that drive psoriasis
Biological agents include:
1. Tumour necrosis factor-alpha inhibitors
• Etanercept
• Adalimumab
• Infliximab
2. Interleukin (IL-12 and IL-32) inhibitor

• Ustekinumab
62
63
64

Source :
Fitzpatrick's
Dermatology
in General
Medicine
65 Complications
▹ Patients with psoriasis have an increased morbidity and mortality
from cardiovascular events, particularly those with severe and
long duration of psoriasis skin disease.
▹ Risk of myocardial infarction is particularly elevated in younger
patients with severe psoriasis.
▹ Psoriasis patients have also been shown to have increased
relative risk of both Hodgkin lymphoma and cutaneous T-cell
lymphoma, especially in patients with more severe disease
66 Prognosis
▹ Guttate psoriasis is often a self-limited disease, lasting
from 12 to 16 weeks without treatment.
▹ In contrast, chronic plaque psoriasis is in most cases a
lifelong disease, manifesting at unpredictable intervals
▹ Erythrodermic and generalized pustular psoriasis have
a poorer prognosis, with the disease tending to be
severe and persistent.
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