Papulosquamous Disorders PDF

Papulosquamous Disorders Dr. Mateen Ahmed Ali M.B.Ch.B C.A.B.D.V Lecturer in University of Duhok - College of Medicine Papulosquamous Disorders Psoriasis Pityriasis Rosea Lichen Planus Psoriasis Psoriasis is a chronic multisystem disease with predominantly skin and joint manife...

Papulosquamous Disorders Dr. Mateen Ahmed Ali M.B.Ch.B C.A.B.D.V Lecturer in University of Duhok - College of Medicine Papulosquamous Disorders Psoriasis Pityriasis Rosea Lichen Planus Psoriasis Psoriasis is a chronic multisystem disease with predominantly skin and joint manifestations, Skin disease characterized by well-defined erythematous plaques covering with a thick whitish-silvery scale. Age of onset occurs in two peaks: ages 20-30 and ages 50-60, but can be seen at any age About 30% of patients with psoriasis have a first-degree relative with the disease Waxes and wanes during a patient’s lifetime, is often modified by treatment initiation and cessation and has few spontaneous remissions Auspitz’s sign its mean appearing pinpoint bleeding after scraching of psoriatic skin lesion due to thinning epidermis over dermal papillae. Köbner phenomenon its mean appearing of new skin lesion at site of trauma. Epidemiology It affects about 1-3% of the population. Female:male ratio is 1:1. Any age can be affected, but it appears most often between 15- 40 years. Pathogenesis: Genetics:Polygenic inheritance with variable penetrance. The sequence of events is unclear. T cell-mediated inflammatory reaction and subsequent epidermal proliferation, migration of neutrophils into the epidermis and proliferation of vessels in papillary dermis. Triggering or Precipitating factors: A- Physical trauma (Koebner’s phenomenon) B- Infections: acute streptococcal infection c- Stress D- Hormonal and Metabolic factors E- Sunlight F- Drugs: systemic or Class I topical corticosteroids, oral lithium, antimalarial drugs, interferon and beta-adrenergic blockers. Ask about Health-Related Behaviors  Studies have revealed smoking as a risk factor for psoriasis  Alcohol consumption is more prevalent in patients with psoriasis and it may increase the severity of psoriasis  A higher BMI is associated with an increased prevalence and severity of psoriasis 8 Histopathology: 1.Hyper and parakeratosis 2.Acanthosis: Test-tube appearance 3.Munro microabscess 4.Dialated and tortuous capillaries 5.Perivascular inflammatory infiltrate  Presentation Plaque psoriasis (vulgaris) Guttate psoriasis Scalp psoriasis Nail psoriasis Flexural psoriasis Plamoplantar psoriasis Pustular psoriasis Erythrodermic psoriasis Psoriatic arthropathy Plaque pattern This is the most common type. Lesions are well demarcated and range from a few millimetres to several centimetres in diameter. The elbows, knees, lower back and scalp are sites of predilection. Flexures Psoriasis: Psoriasis of the submammary, axillary and anogenital folds is not scaly although the glistening sharply demarcated red plaques.  Guttate psoriasis This is usually seen in children and adolescents Acute onset of raindrop-sized lesions on the trunk and extremities Often preceded by streptococcal pharyngitis and may be the first sign of the disease. Nail psoriasis: Nail pitting Onycholysis Subungual hyperkeratosis Oil spot lesion Nail dystrophy Psoriatic Arthropathy 1.Distal interphalangeal 2.Asymmetric mono or oligoarthritis 3.Rheumatoid arthritis-like 4.Ankylosing spondylitis-like 5.Arithritis Mutilans Plaque psoriasis (vulgaris) Scalp psoriasis Guttate psoriasis Pustular Psoriasis Characterized by psoriatic lesions with pustules. Often triggered by corticosteroid withdrawal. When generalized, pustular psoriasis can be life-threatening. These patients should be hospitalized and a dermatologist consulted. 23  Palmoplantar Psoriasis May occur as either plaque type or pustular type. Often very functionally disabling for the patient. The skin lesions of reactive arthritis typically occur on the palms and soles and are indistinguishable from this form of psoriasis. 24 Psoriatic arthritis Managements Options for patients with psoriasis less than 20%. Topical steroids Calcipotriol (dovonex) Tazarotene Anthralene Tar preparations Intralesional steroid injection Therapeutics options for patients with psoriasis more than 20% UVB and narrow band ultraviolet B light (NB-UVB) PUVA (psorialine and UVA) Methotraxate Acitretine Cyclosporine Biological therapy (adalimumab ,etanercept, infliximab) Pityriasis rosea common, benign, usually asymptomatic, distinctive, self-limiting skin eruption of unknown etiology. There is some evidence Human herpesvirus 6 is the latest suspect. Most patients young adults; male:female ratio 1:1. More common spring and fall. CLINICAL MANIFESTATIONS. Typically, the herald patch, a single 2- to 10-cm round-to-oval lesion, abruptly appears. A fine, wrinkled, tissue-like scale remains attached within the border of the plaque, giving the characteristic ring of scale, called collarette scale It may occur anywhere, but is most frequently located on the trunk or proximal extremities Numerous lesions on the back, oriented along skin lines, give the appearance of “Christmas-tree distribution TYPES: 1.Ordinary type. 2.Papular type. 3.Inverted type. 4.Flexural type. 5.Inflammatory type. 6.Purpuric type. 7.Aborted type. DIFFERENTIAL DIAGNOSIS: 1.Guttate psoriasis. 2.Secondary Syphilis. 3.Multiple tinea corporis. 4.Pityriasis versicolor. 5.Seborrheoic dermatitis 6.Discoid eczema 8.Drug rash. Treatment Self limiteted Topical steroid Antihistamine Sunlight or artificial UVB Erythomycine  Pityriasis rosea treatment Pityriasis rosea is self-limiting The mean duration is about 5 weeks More than 80% resolve by 8 weeks without treatment Most patients only need to be reassured About 25% request treatment for mild to severe pruritus Soothing anti-itch lotions available over-the-counter, topical steroids, and oral antihistamines may help Quality evidence for these treatments is lacking Erythromycin given for 2 weeks helped improve the rash in one study, but subsequent studies failed to validate this 41 LICHEN PLANUS Types Annular Atrophic Linear Bullous Follicular Hypertrophic Ulcerative LP Actinicus Presentation Typical lesions are violaceous or lilac-coloured, intensely itchy, flat-topped papules that usually arise on the extremities, particularly on the volar aspects of wrists and legs. Wickham’s striae. Histopathology 1.Hyperkratosis without parakeratosis. 2.Focal hypergranulosis. 3.Acanthosis Saw-teeth appearance. 4.Liqufactive degeneration. 5.Band-like inflammatory infiltrate. TREATMENT: -Potent Topical steroids. -Systemic steroids. -Retinoids,Cyclosporine or PUVA Forty five years old male patients presented with multiple erythematous plaques covered with white silvery scales involve upper and lower extremities with few lesions on trunk associated with moderate itching with relapse and remission, he consult a doctor and diagnosed was psoriasis , he is hypertensive, Diabetic ,BMI=38. 1-what is sign to confirm diagnosis? 2-what is other site examine in such patient? 3-what is histopathological finding? 4-what is types of antihypertensive aggravated condition? 5 –what is new treatment for this condition? 6-On examination there is swelling of distal interphalangeal joint A-what is the diagnosis? B-what is the treatment of choice? C-what is risk of treatment in this patient?