Psoriasis

From Anvita Health Wiki

Contents 1 More Specific Terms 2 Etiology 3 Epidemiology 4 Pathology 5 Microscopic-pathology 6 Genetics 7 Clinical-manifestations 8 Laboratory 9 Complications 10 Differential-diagnosis 11 Management 12 More General Terms 13 Additional Terms 14 Internet Database 15 References

More Specific Terms

• psoriasis vulgaris, Guttate-type
• psoriatic arthritis

Etiology

• unknown
• cold weather exacerbates, incidence higher in colder climates
• hot weather & sunlight improve symptoms
• stress & anxiety exacerbate psoriasis
• trauma to the skin may lead to development of psoriasis in the affected area
• pharmaceutical agents may exacerbate psoriasis:

• steroid withdrawal
• antimalarials
• lithium
• beta-blockers
• ACE inhibitors
• indomethacin, other NSAIDs? [3]

• infections can cause the onset or a flare of psoriasis

• Streptococcal infection (see guttate psoriasis)

• especially children & adolescents
• thought to be related to circulating factors
• pharyngitis & tonsillitis
• cellulitis

• HIV (new onset)

• lesions psoriasis often resolve with increasing severity of immunodeficiency

Epidemiology

• 1%-2% of population is affected
• males & females affected equally
• onset at any age, but 20's most common

Pathology

• ( gross pathology)
• generalized or localized pustular psoriasis, active stage
• spongiform pustules of Kogoj are larger & are characteristic lesion
• KRT17 may act as an autoantigen

Microscopic-pathology

• psoriasis vulgaris, fully developed lesion

• acanthosis with regular elongation of rete ridges which become club shaped
• suprabasal mitotic figures
• thinning of suprapapillary epidermis with occasional presence of small spongiform pustules
• pallor of upper layers of epidermis
• diminished to absent granular layer
• confluent parakeratosis
• Munro microabscesses ( collections of neutrophils in parakeratotic layer, found easily in earlier lesions, less so in long standing lesions)
• spongiform pustules of Kogoj ( collections of neutrophils in spiny and granular layers, small, seen only in early or active stages)
• elongation and edema of dermal papillae
• mild inflammatory infiltrate in papillary and upper dermis, mostly lymphocytes
• dilated tortuous capillaries

• ( spongiform pustules of Kogoj and Munro microabscesses seen for diagnostic certainty)

Genetics

• inhibition of RARRES2 expression
• role for epidermal T-cell integrin alpha-1/beta-1, receptor for basement membrane collagen-4 [7]
• overexpression of cornifelin, kallikrein-8
• coexpression of KRT16 & KRT17
• familial clusterings of psoriasis
• susceptibility associated with HLA class 1 alpha Cw6
• susceptibility associated with increased beta-defensin genomic copy number within beta-defensin gene cluster
• susceptibility associated with deletion of the late cornified envelope LCE3B & LCE3C genes
• mutations or gene deletions of junB [5]
• other implicated genes S100A7A, PLA2G4D, BPIL2, FNDC1, PSORS1C1, PSORS1C2, KPRP, RDHE2, SLC12A8, SLURP2, PSORS1C3, MICA, CASP14, IL20RA, IL20RB, S100A7, FABP5

Clinical-manifestations

• symptoms:

• cosmetic
• scaling
• pruritis
• discomfort or pain
• heat loss
• arthralgia

• signs:

• skin lesions

• erythema
• silvery micaceous scales
• plaques with:

• well- differentiated borders
• symmetric distribution

• Auspitz sign: removal of a plaque will result in a small amount of bleeding
• papulosquamous pustules
• may appear anywhere on the body
• flexural surfaces ( elbows, knees), scalp, ears, intertriginous folds, genitals, nails

• nails

• nail- pitting, thickening
• onycholysis (separation of nail plate from nail bed)
• light brown discoloration of the nails (oil spots)

• joints (also see psoriatic arthritis)

• generally occurs after skin involvement, but may precede it
• most often involves distal interphalangeal joints
• usually asymmetric oligoarthritis
• sacroiliitis
• spondylitis
• joint involvement occurs in 10% of patients with psoriasis
• extent of skin disease does NOT correlate with severity of arthritis

Laboratory

• skin biopsy

Complications

• pustular psoriasis: life threatening variant associated with steroid withdrawal
• erythrodermic psoriasis: life-threatening exfoliative dermatitis
• increased risk of several associated systemic diseases:

• osteoporosis in men [10]
• metabolic syndrome [12]
• coronary artery disease & myocardial infarction [13]
• lymphoma [14]
• diabetes mellitus type 2 [11]
• hypertension [11]

• increase risk of cancer [16]

• lymphoid neoplasms HR=1.8
• pancreatic cancer HR=1.4
  

• disease interaction(s) of erectile dysfunction (ED) with psoriasis

Differential-diagnosis

• eczema
• tinea
• candidiasis
• drug eruptions
• syphilis
• seborrhea
• Paget's disease
• Bowen's disease
• mycosis fungoides
• lichen planus

Management

• topical therapy: usually adequate

• topical glucocorticoids

• first line therapy
• use less potent topical steroids first

• occlusive dressing with or without topical steroids (Topiclude)
• phototherapy

• recommended for Guttate psoriasis & chronic plaque psoriasis
• sunlight often leads to improvement of psoriasis
• UV-B light used in conjunction with tar or anthralin
• PUVA (oral psoralen & UV-A light)

• increased risk of squamous cell carcinoma of the skin with PUVA

• home narrow band UV-B units for use without oral photosensitizer are almost as effective as PUVA [15]
• excimer laser vs pulsed-dye laser [6]

• coal tar
• anthralin
• calcipotriene ( Dovonex) vitamin D analog

• systemic therapy

• methotrexate: especially psoriatic arthritis
• etretinate:

• may be used in conjunction with PUVA
• contraindicated in women who may bear children

• cyclosporin
• hydroxyurea
• glitazones ( rosiglitazone & pioglitazone) off-label use [4]
• etanercept ( Enbrel) safe & effective [18]
• adalimumab ( Humira) safe & effective [18]
• infliximab ( Remicade) for severe refractory psoriasis [9]
• ustekinumab ( Stelara) for severe refractory psoriasis
• brodalumab, an IL17A receptor monoclonal antibody (investigational) appears to be effective [19]
• ixekizumab an IL17 monoclonal antibody (investigational) appears to be effective [19]
• do NOT use systemic glucocorticoids [3]

• rebound worsening upon withdrawal
• possible conversion to pustular form of psoriasis with steroid withdrawal

• tazarotene activates RARRES2 in psoriatic lesions

• referrals

• generalized erythema & scaling involving most of the body ( erythroderma) requires immediate referral to a dermatologist [3]

More General Terms

• psoriasiform dermatitis
• chronic skin disease

Additional Terms

• anthralin (Lasan, Anthra-Derm, Drithocreme)
• calcipotriene; calcipotriol (Dovonex, Dovobet)
• cyclosporin
• etretinate (Tegison)
• hydroxyurea (Hydrea)
• methotrexate (Rheumatrex, MTX)
• oral psoralen & ultraviolet (UV) A light (PUVA)
• psoralen
• psoriatic arthritis
• Topiclude

Internet Database

OMIM: 177900

References

1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 947-48
2. Color Atlas and Synopsis of Clinical Dermatology, Common and Serious Diseases, 3rd ed, Fitzpatrick et al, McGraw Hill, NY, 1997, pg 82-83
3. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, American College of Physicians, Philadelphia 1998, 2006, 2009
4. Prescriber's Letter 11(8):41 2004 Avandia and Actos for Psoriasis Detail-Document#: [1]
5. Zenz R et al. Psoriasis-like skin disease and arthritis caused by inducible epidermal deletion of Jun proteins. Nature 2005 Sep 15; 437:369-75. <PubMed> PMID: [2] (subscription needed) <Internet> [3]
6. Taibjee SM et al, Controlled study of excimer and pulsed dye lasers in treatment of psoriasis Br J Dermatol 2005; 153:960 PMID: [4]
7. Conrad C, Boyman O, Tonel G, Tun-Kyi A, Laggner U, de Fougerolles A, Kotelianski V, Gardner H, Nestle FO. alpha(1)beta(1) integrin is crucial for accumulation of epidermal T cells and the development of psoriasis. Nat Med. 2007 Jul;13(7):836-42. Epub 2007 Jul 1. PMID: [5]
8. Menter A et al, Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 1. Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics. J Am Acad Dermatol 2008 May;58(5):826-50 PMID: [6]
9. Nair RP et al Genome-wide scan reveals association of psoriasis with IL-23 and NF-B pathways. Nat Genet 2009 Feb; 41:199. PMID: [7]
   - Zhang X-J et al Psoriasis genome-wide association study identifies susceptibility variants within LCE gene cluster at 1q21. Nat Genet 2009 Feb; 41:205. PMID: [8]
   - de Cid R et al Deletion of the late cornified envelope LCE3B and LCE3C genes as a susceptibility factor for psoriasis. Nat Genet 2009 Feb; 41:211. PMID: [9]
10. Dreiher J et al. Psoriasis and osteoporosis: A sex-specific association? J Invest Dermatol 2009 Jan 22 <PubMed> PMID: &dopt=Abstract <Internet> [10]
11. Qureshi AA et al Psoriasis and the risk of diabetes and hypertension: A prospective study of US female nurses. Arch Dermatol 2009 Apr; 145:379. PMID: [11]
12. Gisondi P et al. Prevalence of metabolic syndrome in patients with psoriasis: A hospital-based case-control study. Br J Dermatol 2007 Jul; 157:68-73. PMID: [12]
13. Gelfand JM et al Risk of myocardial infarction in patients with psoriasis. JAMA 2006 Oct 11; 296:1735-41. PMID: &dopt=Abstract
14. Gelfand JM et al The risk of lymphoma in patients with psoriasis. J Invest Dermatol 2006 Oct; 126:2194-201. PMID: [13]
15. Koek MBG et al Home versus outpatient ultraviolet B phototherapy for mild to severe psoriasis: Pragmatic multicentre randomised controlled non-inferiority trial (PLUTO study). BMJ 2009 May 7; 338:b1542. [14]
    - Anstey A Home UVB phototherapy for psoriasis. BMJ 2009 May 7; 338:b607. [15]
16. Brauchli YB et al. Psoriasis and risk of incident cancer: An inception cohort study with nested case-control analysis. J Invest Dermatol 2009 Nov; 129:2604. PMID: [16]
17. Menter A et al Guidelines of care for the management of psoriasis and psoriatic arthritis Section 5. Guidelines of care for the treatment of psoriasis with phototherapy and photochemotherapy American Academy of Dermatology [17]
18. van Lumig PPM et al Relevance of laboratory investigations in monitoring patients with psoriasis on etanercept or adalimumab. Br J Dermatol 2011 Mar 24 <PubMed> PMID: [18] <Internet> [19]
19. Papp KA et al. Brodalumab, an anti–interleukin-17–receptor antibody for psoriasis. N Engl J Med 2012 Mar 29; 366:1181. PMID: [20]
    - Leonardi C et al. Anti–interleukin-17 monoclonal antibody ixekizumab in chronic plaque psoriasis. N Engl J Med 2012 Mar 29; 366:1190. PMID: [21]
20. Psoriasis: NIH Institute and Center Resources [22]
21. National Guideline Clearinghouse
    - Psoriasis Finnish Medical Society Duodecin ngc-guideline: [23]
    - Etanercept and efalizumab for the treatment of adults with psoriasis. National Institute for Health and Clinical Excellence ngc-guideline: [24]
    - British Association of Dermatologists guidelines for use of biological interventions in psoriasis 2009. British Association of Dermatologists ngc-guideline: [25]
    - Infliximab for the treatment of adults with psoriasis. National Institute for Health and Clinical Excellence (NICE) ngc-guideline: [26]
    - Guidelines of care for the management of psoriasis and psoriatic arthritis: section 1. overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics. American Academy of Dermatology ngc-guideline: [27]
    - Adalimumab for the treatment of adults with psoriasis. National Institute for Health and Clinical Excellence (NICE) ngc-guideline: [28]
    - Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 3. Guidelines of care for the management and treatment of psoriasis with topical therapies. American Academy of Dermatology ngc-guideline: [29] Ustekinumab for the treatment of adults with moderate to severe psoriasis. National Institute for Health and Clinical Excellence (NICE) ngc-guideline: [30]
    - Diagnosis and management of psoriasis and psoriatic arthritis in adults. A national clinical guideline. Scottish Intercollegiate Guidelines Network (SIGN) ngc-guideline: [31]

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