PSORIASIS

Introduction
• Psoriasis is a chronic, noncontagious, multisystem, inflammatory
disorder.
• Patients with psoriasis have a genetic predisposition for the illness.
• commonly manifests itself on the skin of the elbows, knees, scalp,
lumbosacral areas, intergluteal clefts, and glans penis.
• The joints are also affected by psoriasis in up to 30% of patients with
the disease
Etiology
• Psoriasis involves hyperproliferation of the keratinocytes in the
epidermis, with an increase in the epidermal cell turnover rate.
• The cause of the loss of control of keratinocyte turnover is unknown.
• However, environmental, genetic, and immunologic factors appear to
play a role.
Environmental factors
• Many factors besides stress have also been observed to trigger
exacerbations, including cold, trauma, infections (eg, streptococcal,
staphylococcal, human immunodeficiency virus), alcohol, and drugs
(eg, iodides, steroid withdrawal, aspirin, lithium, beta-blockers,
botulinum A, antimalarials).
• One study showed an increased incidence of psoriasis in patients with
chronic gingivitis. Satisfactory treatment of the gingivitis led to
improved control of the psoriasis but did not influence longterm
incidence, highlighting the multifactorial and genetic influences of this
disease
Genetic Factors
• Patients with psoriasis have a genetic predisposition for the disease. The
gene locus is determined. The triggering event may be unknown in most
cases, but it is likely immunologic. The first lesion commonly appears
after an upper respiratory tract infection.
• Psoriasis is associated with certain human leukocyte antigen (HLA)
alleles, the strongest being human leukocyte antigen Cw6 (HLA-Cw6).
In some families, psoriasis is an autosomal dominant trait. Additional
HLA antigens that have shown associations with psoriasis and psoriatic
subtypes include HLA-B27, HLA-B13, HLA-B17, and HLA-DR7
• Obesity is another risk factor for developing psoriasis.
Immunologic Factors
• Evidence suggests that psoriasis is an autoimmune disease. Studies
show high levels of dermal and circulating TNF-α. Treatment with
TNF-α inhibitors is often successful. Psoriatic lesions are associated
with increased activity of T cells in the underlying skin.
• Psoriasis is related to excess T-cell activity.
Epidemiology
• Psoriasis can begin at any age, yet there is a bimodal peak between age
20-30 years and 50-60 years. Approximately 10-15% of new cases
begin in children younger than 10 years. The median age at onset is 28
years.
Pathophysiology
Genetic Predisposition: Psoriasis often runs in families, indicating a
genetic component to the condition. Multiple genes have been
implicated in psoriasis, with variations in certain genes affecting
immune function and skin cell growth.
• Triggering Factors: While genetic predisposition sets the stage,
environmental triggers can initiate or exacerbate psoriasis. Common
triggers include stress, skin injuries (such as cuts, scrapes, or sunburn),
infections (especially streptococcal infections), medications (such as
beta-blockers or lithium), and climate changes.
Immune System Dysfunction: In psoriasis, the immune system becomes
dysregulated, leading to an abnormal immune response. This involves
the activation of various immune cells, particularly T cells, dendritic
cells, and inflammatory cytokines.
• Activation of T Cells: In psoriasis, certain T cells, particularly T helper
17 (Th17) cells, play a central role. These cells produce cytokines such
as interleukin-17 (IL-17) and interleukin-22 (IL-22), which promote
inflammation and stimulate keratinocyte proliferation.
Inflammatory Cascade: Cytokines released by activated T cells, along
with other immune cells like dendritic cells, trigger an inflammatory
cascade in the skin. This leads to dilation of blood vessels, recruitment
of immune cells to the skin, and activation of keratinocytes.
• Keratinocyte Proliferation: Keratinocytes are the predominant cells in
the epidermis (outer layer of the skin). In psoriasis, they undergo rapid
proliferation, driven by the inflammatory signals from immune cells
and the abnormal immune response. This results in an accelerated
turnover of skin cells.
Impaired Differentiation: Normally, as skin cells move from the basal
layer to the surface, they undergo a process of differentiation and
maturation. In psoriasis, this process is disrupted, leading to the
accumulation of immature keratinocytes on the skin surface.
• Formation of Plaques: The rapid proliferation and impaired
differentiation of keratinocytes result in the formation of characteristic
plaques seen in psoriasis. These plaques are composed of thickened,
red patches covered with silvery scales.
• Chronic Inflammation: The ongoing immune activation and
inflammation perpetuate the cycle of abnormal skin cell growth,
leading to the chronic nature of psoriasis. This inflammation can
extend beyond the skin, contributing to systemic complications and
comorbidities.
Types of Psoriasis
Plaque Psoriasis (Psoriasis Vulgaris): Plaque psoriasis is the most
common form, accounting for about 80% of cases. It presents as raised,
red patches covered with silvery-white scales, known as plaques. These
plaques can appear anywhere on the body but often develop on the
scalp, elbows, knees, and lower back.
• Guttate Psoriasis: Guttate psoriasis typically begins during childhood
or young adulthood and is characterized by small, red, teardrop-shaped
lesions. It often follows a streptococcal infection and may resolve on
its own or develop into plaque psoriasis.
Inverse Psoriasis: Inverse psoriasis appears as smooth, red patches of
irritated skin in skin folds, such as the armpits, groin, under the breasts,
and around the genitals. Unlike typical psoriasis plaques, these areas
lack scales due to the moist environment.
• Pustular Psoriasis: Pustular psoriasis is characterized by pus-filled
blisters (pustules) surrounded by red, inflamed skin. It can be localized
to specific areas of the body (localized pustular psoriasis) or affect
larger areas (generalized pustular psoriasis), and it may be
accompanied by fever and other systemic symptoms.
Erythrodermic Psoriasis: Erythrodermic psoriasis is a rare but severe
form of psoriasis that can affect the entire body. It presents as
widespread redness, inflammation, and shedding of scales, often
resembling a severe burn. Erythrodermic psoriasis can be life-
threatening and requires immediate medical attention.
• Nail Psoriasis: Nail psoriasis affects the nails, causing changes such as
pitting, discoloration, thickening, crumbling, or separation from the
nail bed. It can occur in conjunction with other forms of psoriasis or as
an isolated condition.
• Scalp Psoriasis: Scalp psoriasis affects the scalp, leading to redness,
scaling, and itching. It can extend beyond the hairline onto the
forehead, neck, and behind the ears. In severe cases, scalp psoriasis
may require specialized treatment, such as medicated shampoos or
topical treatments.
Clinical Manifestation
Worsening of a long-term erythematous scaly area
Sudden onset of many small areas of scaly redness
Recent streptococcal throat infection, viral infection, immunization, use of antimalarial drug, or
trauma
Family history of similar skin condition
Pain (especially in erythrodermic psoriasis and in some cases of traumatized plaques or in the joints
affected by psoriatic arthritis)
Pruritus (especially in eruptive, guttate psoriasis)
Afebrile (except in pustular or erythrodermic psoriasis in which the patient may have high fever)
Dystrophic nails
Long-term rash with recent presentation of joint pain
• Joint pain without any visible skin findings
Investigations
Laboratory Tests: Laboratory tests may be ordered to assess for
underlying systemic inflammation, screen for comorbidities, or monitor
treatment response. Common tests may include:
Complete blood count (CBC) to assess for anemia or leukocytosis.
C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) to
measure levels of inflammation.
Liver function tests (LFTs) and renal function tests (RFTs) to monitor
for potential medication-related side effects.
• HLA-B27 testing in individuals with suspected psoriatic arthritis.
• Imaging Studies: Imaging studies, such as X-rays or ultrasound, may be
used to evaluate joint involvement in individuals with suspected
psoriatic arthritis and assess for signs of joint damage or inflammation.
• Genetic Testing: Genetic testing may be considered in individuals with a
family history of psoriasis or psoriatic arthritis to assess for specific
genetic markers associated with the condition.
• Dermatological Assessment: Dermatological assessments, such as the
Psoriasis Area and Severity Index (PASI) or the Body Surface Area
(BSA), may be used to quantify the extent and severity of psoriasis
involvement and monitor changes over time.
• Skin Biopsy: A skin biopsy may be performed to confirm the
diagnosis of psoriasis, especially in cases where the clinical
presentation is atypical or other skin conditions are suspected. A small
sample of skin tissue is taken and examined under a microscope by a
pathologist.
• Nail Examination: Examination of the nails, including inspection and
palpation, may be performed to assess for nail changes characteristic
of psoriasis, such as pitting, ridges, discoloration, or separation from
the nail bed.
Treatment
Topical Treatments:
Corticosteroids: Topical corticosteroids are commonly used to reduce inflammation
and itching in mild to moderate psoriasis. They come in various strengths and
formulations, such as creams, ointments, foams, and gels.
Vitamin D Analogues: Topical vitamin D analogues, such as calcipotriene
(calcipotriol) and calcitriol, help to regulate skin cell growth and reduce inflammation.
Topical Retinoids: Topical retinoids, such as tazarotene, are derived from vitamin A
and help to normalize skin cell growth and reduce scaling.
• Coal Tar Preparations: Coal tar preparations have anti-inflammatory and
antiproliferative effects and are available in various formulations, including
creams,Shampoos and ointments.
Phototherapy (Light Therapy):
Narrowband UVB Therapy: Exposure to narrowband ultraviolet B
(UVB) light can help to slow down the abnormal growth of skin cells
and reduce inflammation. It is often used for moderate to severe
psoriasis.
• PUVA Therapy: PUVA (psoralen plus ultraviolet A) therapy involves
the combination of a photosensitizing medication (psoralen) with UVA
light exposure. It is used for more severe cases of psoriasis that have
not responded to other treatments.
Systemic Medications:
Oral Retinoids: Oral retinoids, such as acitretin, are synthetic forms of
vitamin A that can help to reduce skin cell production and inflammation. They
are typically used for severe psoriasis that has not responded to other
treatments.
Methotrexate: Methotrexate is an immunosuppressive medication that can
help to slow down the growth of skin cells and reduce inflammation. It is used
for moderate to severe psoriasis and psoriatic arthritis.
• Cyclosporine: Cyclosporine is an immunosuppressive medication that
works by suppressing the immune system’s response. It is used for severe
psoriasis that has not responded to other treatments
But is typically used short-term due to the risk of side effects.
• Biologic Therapies: Biologic therapies, such as TNF-alpha inhibitors
(e.g., etanercept, adalimumab), IL-17 inhibitors (e.g., secukinumab,
ixekizumab), IL-23 inhibitors (e.g., ustekinumab, guselkumab), and
IL-12/23 inhibitors (e.g., ustekinumab), target specific molecules
involved in the immune response and are highly effective for moderate
to severe psoriasis and psoriatic arthritis.
Other Treatments:
Oral Medications: Oral medications, such as oral corticosteroids or oral
immunosuppressants, may be used for severe cases of psoriasis but are
typically reserved for short-term use due to the risk of side effects.
Moisturizers: Regular use of moisturizers can help to soothe dry skin
and reduce itching and scaling.
• Lifestyle Modifications: Lifestyle modifications, such as stress
management, maintaining a healthy weight, avoiding triggers (e.g.,
certain medications, infections, stress), and minimizing skin trauma,
can help to reduce the frequency and severity of psoriasis flare-ups.