Papulosquamous Skin Diseases PDF

PAPULOSQUAMOUS SKIN DISEASES Dr Hanaa Haider  Papulosquamous skin diseases A papulosquamous diorder is a condition which present papules and scaly plaques.  PSORIASIS Psoriasis is a common, chronic, scaly, im...

PAPULOSQUAMOUS SKIN DISEASES Dr Hanaa Haider  Papulosquamous skin diseases A papulosquamous diorder is a condition which present papules and scaly plaques.  PSORIASIS Psoriasis is a common, chronic, scaly, immune-mediated disease that affects the skin of people of all ages (about 2% of the population). Its typically a lifelong condition. There is currently no cure, but various treatments can help to control the symptoms. Etiology :- 1- genetic predisposition ; up to 50% of patients have a positive family history. Environmental factors seem to play a role in the appearance of the disease in genetically predisposed individuals. 2- The exact etiopathogenesis is un known. Its believed to be an immune reaction in which activated T lymphocytes trigger increased epidermal cell proliferation with vascular proliferation. Psoriatic plaques have an increased epidermal cell proliferation rate, i.e the transit time of epidermal cell maturation from the basal cell to the surface in normal skin is about 28 days whereas in psoriatic skin it is only 3-4 days.  Epidemiol ogy Psoriasis is a common disease affecting 1% - 2% of the population. Psoriasis usually first appears in the late teens and in the 50s; both sexes are equally affected although in children (HLA-Cw6 ) girls are more commonly affected than boys.  Provocative factors include : 1- Trauma :- psoriatic lesions may appear at sites of trauma, e.g. scratching (coebner phenomenon) 2- Calcium metabolism:- abnormalities of calcium metabolism, i.e. hypocalcaemia may play a part in the etiology of psoriasis. 3- Immunologic abnormalities. 4- Infection: Typically, streptococcal infection, usually in the form of sore throat is a precipitating factor in patients of guttate psoriasis. 5- Drugs, e.g. antimalarials, B-blockers, and lithium may trigger the appearance of psoriasis in genetically predisposed individual. 6- Climate: psoriasis gets improved with exposure to sunlight and humidity. 7- Psychological factors, e.g. emotional stress, can be an important trigger. 8- Endocrinal factors, e.g. pregnancy may trigger the appearance of psoriasis.  Clinical features The primary psoriatic lesion is a well demarcated, erythematous plaque, topped by laminated silvery scales. Sites most commonly affected include : - extensor surfaces of the limbs, especially on elbows and knees. - sacral area - and scalp (most obvious at the hair line and behind the ears). Psoriasis lesions often are asymptomatic ; mild itching may occur in flexural psoriasis.  Clinical types of psoriasis 1- chronic plaque psoriasis (psoriasis vulgaris) The most common clinical type. Often associated with nail involvement in addition to skin & scalp On scraping of the lesion with glass slide produces pinpoint bleeding (Auspitz`s sign). 2- Guttate psoriasis. Affects children and young adult mainly on the trunk. Typically there are small rounded raindrop-like lesions. Its often preceded by an acute streptococcal infection.  3- scalp psoriasis Erythematous well-define, scaly areas with intact hairs. Can present as solitary plaques, or diffuse scalp involvement. Most obvious at the hair line and behind the ears. Should differentiated from seborrheic dermatitis ( scales of psoriasis are white not yellowish, dry , and shiny, while seborrheic scales are yellowish, greasy, lusterless, and often adherent). 4- Flexural psoriasis Affection of flexural areas, e.g. groins & axillae. Psoriatic scales are decreased or absent due to continuous friction and moisture. Considerable itching often is present. 5- Nail psoriasis Nails are involved in 30%-50% of patients. Include : pits on the nail plate, onycholysis , and subungual hyperkeratosis. Nail involvement often is bilateral and affects hands and feet. Nail psoriasis Psoriasis affects the nail matrix, the nail bed and the hyponychium. Small parakeratotic foci in the proximal portion of the nail matrix lead to pits in the nails. Leukonychia and loss of transparency (less common findings) are due to involvement of the mid portion of the matrix. If the whole nail matrix is involved, a whitish, crumbly, poorly adherent ‘nail’ is seen. Con- Nail psoriasis Psoriatic changes of the nail bed result in the ‘oil spot’ or ‘oil drop’ phenomenon, which reflects an exocytosis of leukocytes beneath the nail plate. Splinter hemorrhages are the result of increased capillary fragility subungual hyperkeratosis and distal onycholysis are due to parakeratosis of the distal nail bed. Vigorous removal of distal subungual debris may be an exacerbating factor 6- palmoplantar psoriasis Palms and soles affected by psoriasis tend to be partially or completely red dry and thickened , often with deep painful fissures. Often there are erythematous, well-defined, scaly lesions.  Classification of psoriatic arthritis Mono- and asymmetric oligoarthritis. Inflammation of the interphalangeal joints–both the distal (DIPs) and proximal (PIPs)–of the hands and feet is the most common presentation of psoriatic arthritis. Involvement of the PIP or both the DIP and PIP joints of a single digit can result in the classic ‘sausage’ digit. In contrast to rheumatoid arthritis, the metacarpophalangeal (MCP) joint is an unusual site for psoriatic arthritis. Asmmetrical distal interphalangeal arthritis Rheumatoid arthritis-like presentation(symmetrical poly arthritis) The clinical manifestations consist of a symmetric polyarthritis that involves small- and medium-sized joints, in particular the PIP, MCP, wrists, ankles and elbows  Arthritis mutilans. severe, rapidly progressive joint inflammation that results in destruction of the joints and permanent deformity. Spondylitis and sacroiliitis. The spondylitis resembles that seen in ankylosing spondylitis, with axial arthritis as well as involvement of the knees and sacroiliac joints; many patients also have peripheral joint involvement. Individuals are often HLA-B27- positive and may have associated inflammatory bowel disease and/or uveitis.  Severe clinical types of psoriasis 1- Pustular psoriasis Characterized by sterile pustules (contain no organism). It may be generalized or localized on the palms and soles. 2- Arthropathic psoriasis It can be oligoarticular or poly articular. Sacroiliac and distal interphalangeal joints are the most commonly involved joints. 3- Erythrodermic psoriasis There is extensive generalized erythema and scale entire body surface. Increased blood flow through skin may lead to high output cardiac failure. It can be precipitated infections, hypocalcaemia, or drugs. INVESTIGATIONS Skin biopsy to confirm diagnosis finding hyperkeratosis, parakeratosis, thin granular layer, , uniform elongated and fused rete ridges, edematous superficial papillary dermis, with dilated capillaries, perivascular lymphocytic infiltrate, Munro’s microabscesses, and spongiform pustules of Kogoj. INVESTIGATIONS Blood count Electrolytes LFTs swabs for bacteriology (secondary infection)  Lichen planus (LP) LP is cutaneous inflammatory disease characterized by itchy, flat- topped, violaceous papules. It usually affects also the mucous membranes(lacy white patches), nail, and rarely hair. Etiology : The cause of LP is unknown. LP is not contagious and does not involve any known pathogen. Genetic factors are important and play a role. LP can be precipitated by trauma or exposure to UV radiation (koebner phenomenon). LP may be ass with hepatitis C-virus infection. It has been suggested that true LP may respond to stress where lesions may present on the mucosa or skin during times of stress in those with the disease. Certain drugs may be involved, e.g. antimalarias, NSAIDs , and gold.  Epidemiology LP affects women more than men (at a ratio of 3:2), and occurs most often in middle aged adults. LP is rare in children. The involvement of mucous membranes is seen frequently and usually is asymptomatic, but occasionally, LP can be complicated by extensive painful erosions. - Clinical features of LP:- Itching is the main symptoms. It can be severe. Sites commonly affected include the flexural surfaces of wrists, the forearms, legs, genitals, and the mucous membrane of the cheeks and lips. Primary lesion is a violaceous or purple, shiny, flat-topped, polygonal, papule. Closed inspection of the surface shows a lacy, reticular pattern of Clinical types of LP 1- Ordinary type 2- Hypertrophic LP 3- Linear LP 4- Lichen planus actinicus 5- Follicular LP ___ cicatricial alopecia 6- LP of the nails _dorsal ptyregium, twenty nail dystrophy 7- LP of mucous membrane ___ whitish streaks, painful ulcer__ SCC 8- Atrophic LP 9- Bullous LP 10- Generalized LP prognosis cutenous ichen planus may resolve spontaneously within one to two years, although recurrences are common. However, lichen planus on mucous membranes may be more persistent(5years) and resistant to treatment. differential diagnosis of lichen planus Lichen nitidus lichen striatus lichenoid drug eruption pityriasis rosea psoriasis secondary syphilis scabies Topical 1. Topical corticosteroid 3. Topical calcineurin inhibitors. 4. Intralesional corticosteroids in hyper trophic lp Systemic therapy Antimalarials (hydroxy chlorquine 200mg twice daily) Griseofulvin long duration (3-6 month )in oral erosive lesions) Systemic corticosteroids. systemic retinoids Cyclosporine ,methotrexate,mycophnolate moftetial Oral metronidazole (500 mg twice daily for 20-60 days) Sulfasalazine phototherapy biologic Basiliximab(anti IL2 receptor) alefacept, efalizumab Thank you