Psoriasis Vulgaris

  • Psoriasis is a complex, chronic, multifactorial, inflammatory disease that involves hyperproliferation of the keratinocytes in the epidermis, with an increase in the epidermal cell turnover rate
  • Environmental, genetic, and immunologic factors appear to play a role
  • Characterised by red, scaly, sharply demarcated indurated papules and plaques of various sizes
  • Prominent itchy, red areas with increased skin scaling and peeling
  • New lesions appearing at sites of injury/trauma to the skin (Koebner phenomenon)
  • Actual clearance of lesions following trauma to the skin (Reverse Koebner phenomenon)
  • Exacerbation in winter, improvement in summer
  • Significant joint pain, stiffness, deformity in 10-20%
  • Family history of similar skin condition
  • Trauma : Mechanical, chemical, radiation
  • Infections : Streptococcus, staphylococcus, HIV
  • Stress
  • Alcohol and smoking
  • Metabolic factors : hypocalcemia
  • Sunlight : usually beneficial but in some may cause exacerbatio

How is it diagnosed?

  • Lesions: Erythematous, scaly papules and plaques. Characteristic lesions include well-demarcated, erythematous plaques with adherent silvery white scales.
  • Cardinal features: ERYTHEMA, INDURATION & SCALING.
The commonest type is Psoriasis vulgaris.
  • Sites: Mostly extensors sites are involved. Elbows, knees, scalp, lumbosacral areas, intergluteal clefts.
Palms / soles involved commonly.
  • On scraping a lesion of psoriasis with a blunt glass slide, silvery scales are observed followed by a glistening transparent membrane. On removal of this membrane [Bulkeley’s membrane] multiple small bleeding points are observed.
  • This sign is absent in pustular psoriasis and inverse psoriasis

While eliciting the Auspitz sign,the characteristic coherence of scales seen as if one scratches a wax candle (candle grease sign)

How is it treated?

  • Avoidance of trauma or irritating agents
  • Weight reduction in obese patients
  • Reduce intake of alcoholic beverages
  • Reduce emotional stress
  • Sunlight and sea bathing improve psoriasis except in photosensitive

Emollients

  • Minimize the symptoms of itching and tenderness
  • Help prevent irritation and thus the potential for
  • Subsequent Koebnerization

Tar

Antiproliferative effect

2% or 3% crude coal tar

  • Alternative is 4 to 10% LCD
  • (liquor carbonis detergens, a tar distillate)

Anthralin

May restore normal epidermal

  • proliferation and keratinization
  • Stains clothes, irritant

Salicylic acid

  • Keratolytic agent
  • Adjuvant to other topicals

Topical corticosteroids

  • Mainstay of topical treatment especially for plaque psoriasis
  • Antiinflammatory, antiproliferative, and immunosuppressive actions
  • Can be used as monotherapy 1-2 times daily or combined with other topical agents

Topical vitamin D analogues

  • Inhibition of keratinocyte proliferation and enhancement of keratinocyte differentiation
  • Calcipotriene, Calcitriol, Tacalcitol, Maxacalcitol, Becocalcidiol
  • Topical retinoids
  • Tazarotene (0.05% / 0.1%)
  • Act by normalizing abnormal keratinocyte differentiation, diminishing hyperproliferation, and by decreasing expression of inflammatory markers
  • Calcineurin inhibitors
  • Tacrolimus/ Pimecrolimus
  • Act by blocking the synthesis of numerous inflammatory cytokines
  • Facial & intertriginous psoriasis

Indication

  • Generalized psoriasis unresponsive to topicals.
  • Narrow band UVB is not only more effective than broad band UVB but also leads to rapid clearance of lesions.

Dosage :

  • Initial dosing according to skin type (130-400 mJ/cm2) or MED (50% of MED)[ MED = Minimal erythema dose]
  • Subsequent dosage increase by 15-65 mJ/cm2 or ≤10% of initial MED
  • Treatment 3-5 times/week

Methotrexate

Indication: Severe, recalcitrant, disabling psoriasis that is not adequately responsive to other forms of therapy.

Dosing: Weekly single oral dose Total dose should not ordinarily exceed 30 mg/wk

A test dose of 2.5-5 mg is recommended

Folate supplementation: Cyclosporine, Acitretin

Consult with experienced Doctors

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