Psoriasis is a chronic inflammatory and proliferative disorder of the skin clinically manifested as wellcircumscribed, erythematous papules and plaques

covered with silvery scales typically located over the extensor surfaces and scalp. It is an autoimmune disease.

 First manifestation at any age with two peaks : first peak in the second decade ,second in the sixth decade. Higher prevalence among Scandinavian populations. Male and females are equally affected. It is non contagious. It seems to be passed down through families. There are 70% chance of a twin developing psoriasis if the other twin has psoriasis

 Precise etiology-unknown. Autoimmunity with genetic predisposition is believed to be at the core of the disease process. HLA system provides a potential genetic marker (CW6, CW7, HLA B13, B16, B17, B27, B37, B38, B57, DR4 and DR7). PSOR S1, PSOR S2 & PSOR S3 on chromosomes 6p, 17q & 4 respectively are the chromosomal regions associated with the disease. It alters the set of complex interactions that control skin homeostasis. Psoriatic plaques have epidermal hyperplasia, acute and chronic inflammatory cells, vascular changes of inflammation, activated T cells, activated antigen-presenting cells, neutrophils (their lysosomes cause tissue damage), and hyperproliferating keratinocytes. This result in induction of antigen presentation, cytokine release, and enhanced T-cell activation and lymphokine release. Lymphokines produce inflammation and hyperproliferation of epidermal cells. Accelerated epidermal cell proliferation results from recruitment of a large proportion of resting cells into the proliferative cycle

Genetic Background Provocating Factors Exogenous/Endogenous antigens Antigen presentation by APCs T lymphocyte- mediated Immune response

Secretion of cytokines (TNF)

Inflammation & cellular hyperproliferation Clinical Lesions of psoriasis

Trauma-Physical, chemical, surgical, infective, and vaccinations (Koebner phenomenon)

Infection-streptococcus group A, upper respiratory tract infections.

Drugs-Lithium, withdrawal of systemic corticosteroids, betablockers, antimalarials, ACE inhibitors, tetracycline, penicillin & NSAIDs Sunlight- Too little or too much. Dry air or dry skin Stress Smoking & Alcohol

 Hyperkeratosis with parakeratosis Reduced or absent granular layer (Nails have hypergranulosis). Acanthosis with elongation of rete ridges and a corresponding upward elongation of dermal papillae. Infiltrate: Mononuclear in dermis and polymorphs in the upper epidermis forming microabscess of Munro. Upper dermal vasculature shows dilatation and tortuosity. Thinning of the superjacent malpighian stratum,

normal skin on the right to psoriatic plaque on the left: thickening of the epidermis and keratinization

Munro- Sabouraud microabsces

Sudden or gradual appearance Family history Itchy, elevated red areas with scaling. Joint pain, stiffness & deformity. Severe dandruff on scalp. Koebner reaction-New lesions appear at sites of injury to the skin (Sometimes reverse may occur) Auspitz sign- Vigorous scraping of scales causes pinpoint bleeding Associated diseases- Psoriatic arthritis, inflammatory bowel disease, abdominal obesity, hypertension, insulin resistance, dyslipidemia, cardiovascular disease.

Chronic plaque psoriasis or Psoriasis vulgaris Typical itchy & scaly plaques on extensors, lower back & scalp

Flexural or inverse psoriasis Smooth non scaly lesions(may be moist & lack scaling) on flexors, axilla, groin, umbilical region, under the breasts, skin folds around the genitals and the buttocks Erythrodermic psoriasis Acute form. Generalized inflammatory erythema with profuse scaling, itching & pain

Pustular psoriasisBlisters with noninfectious pus. May be Localized (on hands and feet) or Generalized. Types: Generalized pustular psoriasis, pustulosis palmaris et plantaris, annular pustular psoriasis, acrodermatitis continua, impetigo herpetiformis

Guttate psoriasis Acute form. Common in childhood. Drop-shaped lesions on the whole body

Arthropathic psoriasis Affect joints mainly of fingers and toes resulting in dactylitis(also of hips, knees and spine to cause spondilytis Types:asymmetrical oligoarthritis, symmetrical seronegative rheumatoid-like disease, distal interphalangeal involvement, axial skeletal involvement, arthritis mutilans

Plaque psoriasis is the most common type of psoriasis. It usually causes dry, red skin lesions (plaques) covered with silvery scales.

Plaque psoriasis, so-called vulgaris

Psoriasis, guttate on the arms and chest

Psoriasis, guttate on the cheek

Guttate psoriasis, more common in children and adults younger than 30, appears as small, water-dropshaped sores on the trunk, arms, legs and scalp. The sores are typically covered by a fine

Psoriasis, guttate on the arm

Inverse psoriasis Inverse psoriasis causes smooth patches of red, inflamed skin. It's more common in overweight people and is worsened by friction and sweating.

Inverse psoriasis

Psoriasis causes red patches of skin covered with silvery scales and a thick crust on the scalp that may bleed when removed.

Scalp Psoriasis

Scalp Psoriasis

Psoriasis on ear

Psoriasis can affect fingernails and toenails, causing pitting, abnormal nail growth and discoloration.

Psoritic Arthritis

The least common type of psoriasis, erythrodermic psoriasis can cover your entire body with a red, peeling rash that can itch or burn intensely.

Pustular Psoriasis

Well marginated Raised above the surface Diameter-1-2 cm Red colored surrounded by a pale halo ( the halo of Woronoff) Covered with silvery white, loosely adherent scales which, on vigorous scraping may reveal punctate bleeding points (Auspitz sign) Dry, cracked skin that may bleed Thickened, pitted or ridged nails Typical sites-elbows, knees, shin, knuckles, sacral areas & scalp Symmetrically disposed on extensor surfaces of the body Fissuring within plaques can occur when lesions are present over joint lines or on the palms and soles.

Plaque of psoriasis

Scalp
Diffuse Fine or thick scaling. Can extend beyond the hairline onto the forehead, the back of the neck and around the ears.

Penis
Mostly inverse psoriasis Wellcircumscribed reddish plaque No scales

Nails
Pitting Discoloration Subungual hyperkeratosis or oil-drop sign Onycholysis Thickened friable nail plate

Hands and fee

Diffuse hyperkeratosis Thick scales fissures

Face
Most often affects the eyebrows, the skin between the nose and upper lip, the upper forehead and the hairline.

 Skin examination. Skin Biopsy- For differential diagnosis. Will show clubbed rete pegs if positive. Auspitz Sign Throat culture X-ray Examination- In case of joint pain. Psoriasis area severity index (PASI) calculator may be used to express disease severity, based on severity of lesions and extent of skin involvement into a single score in the range 0 (no disease) to 72 (maximal disease). Psoriasis may be classified as mild, (affects <5% of the body's surface area), moderate (affects 5-10%) & severe (>10% involvement) Six-point Likert scale for self-assessment of pruritus can also be used.

Seborrhoeic dermatitis Lichen simplex Pityriasis rubra pilaris Secondary syphilis Leprosy Lichen planus Candidiasis Tinea corporis and cruris Discoid lupus erythematosus Bowens disease Cutaneous T-cell lymphoma Hyperkeratotic eczema of hands and feet Pityriasis rosea Parapsoriasis Superficial basal cell carcinoma

 Is long term Must be individualized Types: Used either alone or in combinations Topical Phototherapy Systemic

 Topical steroids- Beclometasone,(Intralesional injection of triamcinolone acetonide may also be used) Anthralin(Tree Bark Extract)- Antiproliferative and immunosuppressive Vitamin D3 analogues- Calcitriol & Calcipotriol (Dovonex, Dovobet). Regulate keratinocyte proliferation and maturation. Vitamin A Analogues (Retinoids)- Tazarotene. Regulate keratinocyte proliferation and maturation. Coal tar- Antiproliferative. DHS Tar, Doak Tar, Theraplex T Salicylic acid or Lactic acid(ointment)- Remove scales. Emollients- Reduce scale and itch Dandruff Shampoo Moisturizers, mineral oil, and petroleum jelly- For soothing

Ultraviolet B (UVB) irradiation UV radiation with wavelengths 290-320 nm Effective for treating moderate-tosevere plaque psoriasis Used alone or combined with topical treatments Goeckerman regimen- Coal tar followed by UVB exposure Ingram method- Anthralin application following a tar bath and UVB treatment UVB may be combined with topical corticosteroids, calcipotriene, tazarotene, or bland emollients.

PUVA photochemotherapy Light with wavelengths 320-400 nm Effective for more extensive disease Given 2-3 times per week with maintenance treatments every 24 weeks Photosensitizing drugs Psoralens (methoxsalen, trioxsalen) is given orally, followed by ultraviolet A (UVA) irradiation Can be combined with oral retinoid derivatives

 Antimetabolites- Methotrexate(for psoriatic arthritis), hydroxyurea Vitamin A derivative- Acitretin(for psoriatic arthritis). May be used in combination with phototherapy, methotrexate or cyclosporine. Cyclosporine- Immunosuppressive Mycophenolate mofetil (new, under evaluation drug)- Inhibits synthesis of guanosine. Sulphasalazine- May be used either alone or combined with methotrexate. Fumaric acid esters Hydroxycarbamide, mycophenolate, sulfasalazine, azathioprine and leflunomide Biologic drugs- Psoriasis specific immunosupressants. Adalimumab(for chronic plaque psoriasis), alefacept, etanercept (for psoriatic arthritis), infliximab, ustekinumab Oatmeal Baths Relaxation and antistress techniques

 Psoriasis symptoms can be relieved by changes in diet. Fasting periods, low energy diets and vegetarian diets have improved psoriasis symptoms. Fish oil - It has EPA, DHA & Vitamins A, D, E Cannabis - Anti-inflammatory Homeopathy Dead Sea Salts Oregon Grape Root Extract and Herbal Detox TeaCleanse body of toxins and help optimize the liver function. Aloe vera- Reduce redness, scaling, itching and inflammation.

 Laser therapy (Excimer laser)-A laser can target the psoriasis without affecting the surrounding skin. Because the light treats only the psoriasis plaques, a strong dose of light can be used, which may be useful to treat a stubborn plaque of psoriasis, such as on the scalp, feet, or hands. A laser is a practical treatment for psoriasis that covers a large area. Pulsed dye laser-Similar to the excimer laser, the pulsed dye laser uses a different form of light to destroy the tiny blood vessels that contribute to psoriasis plaques.

Complications are rare & occur due to inappropriate and aggressive therapy: Pain & itching Physical disability Psoriatic arthritis. Pustular psoriasis. Erythroderma and its metabolic complications. Infection, particularly Staph. infections of the patches. Eczematization due to topical agents. Amyloidosis , rare sequel to arthropathic of pustular psoriasis. Psychological consequences : depression, anxiety, lack of self-esteem. Potential complications of systemic therapy.

 No known way to prevent psoriasis. Keeping the skin clean and moist and avoiding specific psoriasis triggers may help

Psoriasis is a life-long condition with no cure but can be controlled with treatment. It may go away for a long time and then return. With appropriate treatment, it usually does not affect general physical health. But most treatments used have various side effects. Guttate psoriasis may clear completely following treatment. Sometimes, however, it may become a chronic (lifelong) condition, or worsen to the more common plaque-type psoriasis. Psoriatic erythroderma is often the result of an exacerbation of unstable plaque psoriasis, particularly following the abrupt withdrawal of systemic treatment. This form of psoriasis can be fatal