Psoriasis Overview (NGU School of Medicine) PDF

S.S-D Psoriasis overview Dr. Lina El Shimy, Msc. Assistant Lecturer of dermatology, NGU.  Intended learning outcomes By the end of this session students should be able to: Ø Explain different types and patterns of psoriasis Ø Recognize the varying...

S.S-D Psoriasis overview Dr. Lina El Shimy, Msc. Assistant Lecturer of dermatology, NGU.  Intended learning outcomes By the end of this session students should be able to: Ø Explain different types and patterns of psoriasis Ø Recognize the varying morphology of psoriasis Ø Outline the treatment of psoriasis Ø Outline the management of life-threatening conditions in psoriasis  Psoriasis Psoriasis is a complex, chronic, multi-factorial, systemic, immune mediated inflammatory disease that involves hyperproliferation of the keratinocytes in the epidermis, with an increase in the epidermal cell turnover rate. Historically the word “Psora” was used by the Greek referring to a desquamative condition.  Epidemiology Ø Incidence Ø 1 – 2 % worldwide population (genetic predisposition) Ø Juvenile psoriasis 0.7% Ø Sex: F = M Ø Bimodal age of onset Ø Type I – youth Ø Type II - adult  Pathogenesis Ø Alteration of cell kinetics of keratinocytes shortening cell cycle results in 28-fold production of keratinocytes (4-5 days instead of 37-40 days). Ø T-cell mediated disease. Ø Associated co-morbidities in moderate to severe disease: depression, cardiovascular disease, metabolic syndrome (obesity, hypertension, hyperlipidaemia), IBD, COPD, uveitis, NASH, cancer.  Triggering factors Ø Infections (post streptococcal infection, HIV) Ø Psychogenic stress Ø Weather (worse in winter) Ø Drugs (ß-blockers, anti-malarial drugs, lithium, rapid withdrawal of steroids) Ø Trauma (koebnerisation) Ø Endocrine (Hypocalcaemia) Ø Alcohol & smoking Ø Sunlight  Types of psoriasis Plaque (vulgaris) Guttate Inverse Erythrodermic Pustular § Generalised § localised  Plaque psoriasis The disease most commonly manifests on the: Extensor surface of the elbows and knees scalp lumbosacral areas intergluteal clefts glans penis up to 30% of patients, the joints are also affected. Chronic plaque psoriasis Ø Accounts for 80-90% of all psoriatic patients Ø Chronic well demarcated red/pink plaque Ø Copious silver- white scaling. Ø Koebner’s phenomenon Ø Single / multiple lesions Ø Symmetrical / extensor surfaces Chronic plaque psoriasis Ø Accounts for 80-90% of all psoriatic patients Ø Chronic well demarcated Ø Scaling may predominate Ø Koebner’s phenomenon (Itching) Ø Single / multiple lesions Ø Symmetrical / extensor surfaces Chronic plaque psoriasis Ø The genitalia is affected in 45% of psoriasis patients. Ø Well demarcated erythematous plaques and scales on the glans, shaft of the penis and scrotum. Chronic plaque psoriasis Chronic plaque psoriasis Inverse psoriasis Ø Occurring in skin folds, this will often lack the scale seen in other locations. Ø Shiny pink to red sharply demarcated thin plaques. Plantar Psoriasis  Nail signs Ø Fingernails & toenails frequently involved Ø pits Ø onycholysis ( non-specific ) Ø subungual hyperkeratosis Ø Salmon drop/ oil drop Ø Nail disease very difficult to treat Nail pitting Onycholysis Nail pitting Sub-angual hyperkeratosis  Psoriatic arthropathy Psoriatic arthropathy in hands 5 types: Asymmetric ( 60 – 70 % ) Symmetric poly-arthropathy ( 15 %) DIP ( 5 % ) Destructive (5 % ) Axial arthritis ( 5 % )  Pathology of psoriasis Surface silver scale parakeratosis Erythematous base Munro microabcess Dilatation of capillaries Regular acanthosis GUTTATE Latin: “gutta = drop” Ø Post streptococcal throat infection. Ø Young adults. Ø Shower of scattered discrete lesions. Ø 3 mm to 1 cm lesions, round or slight oval.  Pustular LOCALISED: Palmoplantar commonly - Palms & soles studded with STERILE pustules on erythematous base Other areas less commonly affected. GENERALISED: Life threatening: abrupt onset + Fever, tender skin lesions Localized Pustular Psoriasis Generalised Pustular Psoriasis Studded Sterile Postules on an erythematous base Generalised Pustular Psoriasis Generalised Pustular Psoriasis  Generalised Pustular Psoriasis Ø Dermatological Emergency!! Ø Life-threatening Ø Patient unwell Ø Fever Ø Lethargy Ø Dehydration Ø Renal failure, cardiac failure, sepsis Ø Death  Generalised Pustular Psoriasis Ø Treatment: Ø Admit/ITU if necessary Ø Greasy emollients Ø IV support Ø Systemic therapy Ø Avoid or treat concurrent infection  Erythrodermic Psoriasis Generalized erythema and scaling affecting >80-90%BSA Systemic affection including peripheral edema, tachycardia, fluid and protien loss, hypothermia Common causes include Psoriasis, atopic dermatitis, mycosis fungoides, drug reactions  Erythroderma-complications Ø Dermatologic Emergency !! Ø Fluid and protein loss Ø Hypothermia Ø Infection Ø SHOCK Psoriasis in skin of colour Psoriasis Treatment Strategy Therapeutic Ladder Treatment Modalities 1st Line Topical agents (in combinations) Ø Vitamin D3 analoges (calcipotriol) Ø Topical retinoids (Tazarotene) Ø Keratolytics (topical salicylic acid) Ø Moisturizers Ø Topical corticosteroids/TCI Ø Novel topicals (PDE4 inhibitors/ aryl hydrocarbon agonists) Ø Tar Ø Dithranol 2nd Line Biological agents 3rd line Systemic agents (Traditional/ Novel) 4th line Phototherapy (narrow band UVB/ psoralen plus UVA= PUVA  Topical Treatment Indications for topical therapy in psoriasis: 1. Mild to moderate localized disease as mono- therapy 2. Adjuvant therapy in severe or extensive disease (combined with systemic therapy or phototherapy  Topical Treatment Novel topical therapy: 1. Roflumilast (ZORYVE) cream: Topical phosphodiesterase 4 inhibitor PDE4 FDA approved in July 2022 for adult plaque psoriasis 2. Tapinarof cream: FDA approved in May 2022 for adult plaque psoriasis Aryl hydrocarbon receptor agonist Topical Treatment Topical Treatment  Systemic Treatment Indications for systemic therapy in psoriasis: 1. Chronic plaque psoriasis of large surface area > 10-15% or resistant to topical therapy 2. Erythrodermic Psoriasis 3. Pustular Psoriasis 4. Psoriatic arthropathy 5. Nail Psoriasis 6. Small area but affecting the quality of life  Systemic Treatment Ø Traditional Ø Methotrexate Ø Ciclosporine Oral corticosteroids Ø Retinoids (Acitretin) contraindicated Ø Biologic therapies Ø Novel oral Ø Apremilast Ø JAK inhibitors  Biological Agents Monoclonal Antibody therapy: Anti-TNF alpha: Etanercept (Enbrel), Infliximab (Remicade), Adalimumab(Humira) Anti p40 subunit of IL-12/23: Ustekinemab (Stelara) IL-17 inhibitors: Secukinumab (Cosentyx), Brodalumab (Siliq) IL-23 inhibitors: Guselkumab (Tremfya), Risankizumab (Skyrizi) IL-36R: Spesolimab (recently approved in GPP as monotherapy)  Systemic Treatment Novel oral therapy: 1. JAK inhibitors Deucravacitinib (SOTYKTU): selective tyrosine kinase 2 inhibitor FDA approved in 2022 for moderate to severe plaque psoriasis in adults Tofacitinib (XELJANZ): FDA approved for psoriatic arthritis 2. Apremilast (Otzela): Oral phosphodiesterase 4 inhibitor PDE4 FDA approved in 2014 for adult psoriasis and psoriatic arthritis What’s in the future ?  Summary Psoriasis is a complex, chronic, multifactorial, inflammatory immune-mediated disease that involves hyperproliferation of the keratinocytes in the epidermis, with an increase in the epidermal cell turnover rate Psoriasis has a bimodal age onset and can appear at any age from infancy to adulthood. The disease most commonly manifests on the skin of the elbows, knees, scalp, lumbosacral areas, intergluteal clefts, and glans penis. In up to 30% of patients, the joints are also affected. Treatment is based on surface areas of involvement, body site(s) affected, the presence or absence of arthritis, and the thickness of the plaques and scale. Topical treatment is used for limited disease while moderate to severe disease require phototherapy, immunosuppressive treatment or biological therapy to control the disease.  References: Dermatology: 2-Volume Set , 4th Edition by Jean L. Bolognia, MD, Julie V. Schaffer, MD and Lorenzo Cerroni Fitzpatricks Dermatology in General Medicine 9th Edition by Sewon Kang (Author) Thank you