questions 2

Psoriasis

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Topic updated on 09/10/17 6:45pm

Snapshot
  • A 42-year-old man presents to his dermatologist for management of his psoriasis. He reports an itchy and rough rash along his elbows, knees, and scalp. While he was previously treated for this disease in childhood, he has been off treatment for years. Physical exam reveals 2-7 cm pink plaques with overlying silvery scales. When the scale is scratched off, there is pinpoint bleeding. He is started on an intensive topical therapy regimen with corticosteroids and vitamin D analog.
Introduction
  • Clinical definition
    • idiopathic and chronic inflammatory disease characterized by silver scales and thickened skin
      • most common subtype is plaque psoriasis
  • Epidemiology
    • incidence
      • US incidence
        • 2% of population
    • demographics
      • normallly, > 40 years of age but can affect people of all ages
    • risk factors
      • smoking
      • skin trauma
      • alcohol abuse
      • stress
      • cold weather
  • Etiology
    • idiopathic
    • drugs
  • Pathogenesis
    • hyperproliferation of basal stem keratinocytes
    • ↑ inflammation, especially inflammatory markers IL-6, C-reactive protein, TNF-α, E-selectin, ICAM-1
  • Associated conditions
    • psoriatic arthritis
Presentation
  • Symptoms
    • painful or pruritic skin lesions
    • joints may be painful or stiffens
      • especially in feet and hands
  • Physical exam
    • well-circumscribed, pink papules and flat-topped plaques with silvery scales
    • common locations
      • scalp
      • trunk
      • buttocks
      • extensor surface of limbs
    • positive Auspitz sign
      • when scales are scraped off, there is pinpoint bleeding
        • results from exposure of dermal papillae
    • nail pitting
Studies
  • Labs
    • electrolytes
      • there may be electrolyte imbalances if psoriasis is extensive
  • Histology
    • acanthosis with parakeratosis (thickened stratum corneum with retained nuclei)
    • Munro microabscesses
    • ↑ stratum spinosum
    • ↓ stratum granulosum
Differential
  • Atopic dermatitis
  • Seborrheic dermatitis
Treatment
  • Conservative
    • emollients
      • indication
        • for all patients
  • Medical
    • topical corticosteroids
      • indication
        • first-line and often used in combination with topical calcipotriene
    • topical calcipotriene (vitamin D analog)
      • indication
        • first-line and often used in combination with topical corticosteroids
    • systemic non-biologic therapies
      • indication
        • moderate-to-severe psoriasis
        • used in combination with topical therapies
      • drugs
        • acitretin
        • methotrexate
        • cyclosporine
        • apremilast
          • especially for those with psoriatic arthritis as well
    • systemic biologic therapy
      • indication
        • moderate-to-severe psoriasis
      • drugs
        • tumor necrosis factor inhibitors
          • adalimumab
          • etanercept
          • infliximab
        • anti-interleukin agents
          • secukinumab
          • ustekinumab
    • narrowband ultraviolet B
      • indications
        • for patients who are contraindicated to systemic therapy
Complications
  • Psoriatic arthritis
  • Other HLA-B27 associated autoimmune diseases


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