L-13 Papulosquamous Diseases: Psoriasis and Variants

• Papulosquamous diseases involve scaly papules and plaques, appearing as primary or secondary lesions.

Papulosquamous Diseases Examples

• Psoriasis
• Seborrheic dermatitis
• Pityriasis rosea
• Lichen planus

Other Examples

• Lichen sclerosus
• Pityriasis rubra pilaris
• Pityriasis lichenoides et varioliformis acuta (PLEVA)
• Parapsoriasis

Secondary Lesion Examples

• Secondary syphilis
• Cutaneous T-cell lymphoma (CTCL)
• Connective tissue diseases

Psoriasis Overview

• Chronic inflammatory disorder mediated by T lymphocytes causing hyperproliferation of keratinocytes.
• Affects 1-2% of the population and is associated with Cw*0602.

Psoriasis Morphological Variants

• Chronic plaque psoriasis (85%)
• Guttate
• Pustular
• Erythrodermic

Psoriasis Locational Variants

• Scalp
• Palmoplantar
• Inverse
• Nail
• Psoriatic arthritis

Psoriasis Presentation

• Typically onsets in the 20s and 30s.
• Symptoms include scaling, itching, redness, tightness, bleeding, and burning.
• Social and emotional impacts include fear of worsening lesions, embarrassment, unattractive feelings, and depression.

Psoriasis Triggers

• Infection
• Skin trauma (Koebner's phenomenon)
• Stress
• Drugs (ß-blockers, lithium)
• Sunburn

Psoriasis Examinations

• Well-defined and sharply demarcated round or oval lesions.
• Symmetric erythematous plaques covered by white silvery scales on elbows, knees, hands, scalp, lumbosacral, and gluteal crease, involving large areas.

Psoriasis Nail Indications

• Oil drop
• Onycholysis
• Subungal hyperkeratosis
• Splinter hemorrhages
• Pitting
• Crumbling
• Leukonychia
• Red spot in matrix

Auspitz Sign

• Removal of scale causes pinpoint bleeding.

Psoriasis Pathology

• Acanthosis
• Thickened epidermis
• Elongated rete ridges
• Thin or absent granular layer
• Parakeratosis, retention of nuclei in stratum corneum
• Neutrophil microabscesses (Monro's microabscesses)

Psoriasis Treatment Considerations

• Depends on the severity and body surface area affected.
• Emollients are important.
• Discussions on stress, smoking, alcohol, trauma, drugs, infections, blood pressure, cholesterol, blood glucose, weight, and diet.

Psoriasis Medication

• Topical steroids
• Topical phosphodiesterase inhibitor
• Topical calcipotriene (Vitamin D analog)
• Topical keratolytics
• Light therapy (NB-UVB)

Psoriasis Systemic Treatment

• Methotrexate
• Cyclosporine
• Acitretin
• Phosphodiesterase inhibitor
• Biologics (TNF-a inhibitors, IL-17 pathway inhibitors, IL-23 inhibitors)

Biologics Information

• TNF-α inhibitors include Etanercept, Infliximab, Adalimumab, and Certolizumab pegol.
• IL-17 inhibitors include Secukinumab, Ixekizumab, and Brodalumab.
• IL-23 inhibitors include Ustekinumab, Guselkumab, Tildrakizumab, and Risankizumab.
• TNF-a inhibitors increase the risk of TB and fungal infections, with Etanercept posing a lower risk
• Benefits include reduced inflammation and suspended disease progression, which may be used in combination.
• Etanercept, Adalimumab, Infliximab are approved for children
• Certolizumab is a TNF inhibitor safe for use during pregnancy
• Long-term use of biologics can increase the risk of certain cancers.
• Anti-inflammatory effects of anti-TNF drugs diminish, due to antibodies formed against the drug.

Side Effects of Biologics

• Injection site reaction
• Infusion reaction
• Infection
• Headache
• Nausea
• Bowel perforation
• New symptoms and infections

Seborrheic Dermatitis (Seb Derm)

• 10-15% of population affected
• Chronic skin disease that worsens with stress, with cold and dry temperatures, and with decreased hair washing.
• Presents as cradle cap in infants, and dandruff in post-puberty/adults.
• Increased incidence in patients with HIV and Parkinson's.
• Scaly, greasy papules or plaques appear on the scalp, eyebrows, corners of the nose, ears, and chest, is caused by Malassezia furfur.

Diagnosis

• Clinical

Infants Treatment

• Soft baby brush and washcloth with baby shampoo
• Low potency steroid if inflamed.

Adults Treatment

• Daily hair washing with anti-fungal shampoo.
• Topical clobetasol solution for the scalp.
• Lower potency steroid for the face.

Newly Approved Medication

• Roflumilast, a phosphodiesterase 4 inhibitor.

Pityriasis Rosea Presentation

• Patients complain of red bumps on the body.
• Typically, it starts on the back as a large spot and spreads to the abdomen and extremities.
• Patients often report a recent upper respiratory infection (URI).

Pityriasis Rosea Examination

• Erythematous papules and plaques.
• Herald patch (first lesion).
• Christmas tree pattern.

Pityriasis Rosea Self Care

• Self-limiting, reassurance.
• Can take up to 8 weeks to resolve.
• Associated with reactivation of HHV-6 or HHV-7.

Lichen Planus Symptoms

• New itchy bumps on wrists, with a history of tattoos.
• Development of new lesions in response to external trauma (Koebner's phenomenon).
• Pruritic, purple, polygonal, planar papules and plaques.
• Plentiful, polished, presents as 1-5 mm, flat-topped, violaceous, shiny papules.
• With Wickham's striae: a lacy white network, typical and great diagnostic value on flexor aspect of wrist and forearm, lateral neck, buttock, sacrum, anogenital region, penis, and ankle.
• Idiopathic, often in healthy individuals, associated with Hepatitis C.
• Potent topical or intralesional steroids
• Antihistamines for pruritus, oral steroids for oral disease.

Lichen Sclerosus

• Benign, progressive, chronic disease in women, children, and men; post-menopausal women are at highest risk.
• Presents as pruritus and pain in the anogenital region, or on any skin surface, dyspareunia.
• Thin, white, wrinkled skin of labia minora and/or labia majora and carries an increased risk of squamous cell carcinoma.

Lichen Sclerosus Treatment

• High potency topical steroids
• Intralesional steroids for thickened plaques.