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Psoriasis

Updated : January 31, 2024





Background

Psoriasis is a chronic inflammatory and proliferative skin condition that causes thickened, itchy, red patches of skin with silvery scales. It can range in severity from mild, with just a few small patches, to severe, with widespread, thick lesions covering large areas of the skin, such as the scalp, elbows, knees, and lower back.

It is believed to be caused by an overactive immune system, which causes skin cells to grow and multiply rapidly. Psoriasis is not contagious, but it is a life-long condition that is often genetic. Psoriasis has no known cure, and flare-ups cause the condition to wax and wane.

 

Epidemiology

The prevalence of psoriasis varies widely between populations and regions. The mean age of onset for the first presentation of psoriasis can range from 15 to 20 years, with a second peak occurring at 55 to 60 years. In the United States, it is estimated that approximately 7.5 million people are affected with psoriasis, with the prevalence being higher among adults aged 18-45.

In Europe, the prevalence of psoriasis is estimated to be 2-3%. In the United Kingdom, it is estimated that 2.2% of the population has psoriasis. It is estimated that the prevalence in India is between 1.4% and 8.4%. The estimated prevalence in China is between 1.2% and 6.4%.

 

Anatomy

 

 

Pathophysiology

The pathophysiology of psoriasis is complex it involves a combination of genetic, environmental, and immune system factors. The most accepted theory is that psoriasis occurs due to the activation of T-cells in the skin, which triggers the release of inflammatory cytokines and other immune mediators. These cytokines cause the increased production of skin cells, leading to the formation of the characteristic red and scaly patches seen in psoriasis.

Normally, skin cells are produced and replaced every 28 to 30 days. This process occurs much more quickly in individuals with psoriasis, with new skin cells produced every 3 to 4 days. This rapid production of new skin cells leads to the accumulation of excess skin cells on the skin’s surface, which form the characteristic red, scaly patches. The skin cells are produced at an accelerated rate, leading to a build-up of thick, scaly plaques on the skin.

The immune system inaccurately attacks healthy skin cells, leading to inflammation and the production of excess skin cells. This leads to the formation of red, scaly patches on the skin, known as plaques. The plaques can be itchy and painful and can crack and bleed if scratched or rubbed. Psoriasis also appears to be linked to an imbalance of certain hormones, such as cortisol, which can affect the immune system and lead to psoriasis flares.

At the microscopic level, the skin of individuals with psoriasis shows several characteristic changes, including hyperproliferation, parakeratosis, acanthosis, hypogranulosis, and inflammation. In addition to these changes in the skin, physiological changes occur in the body as a result of the condition. These changes may include an abnormal response in the immune system, which is thought to be a significant contributor to the development of psoriasis.

 

Etiology

The exact cause of psoriasis is not fully understood, but it is believed to be related to an immune system problem. It is thought to be triggered by genetic, environmental, and immune system factors. Research has shown that psoriasis has a vital genetic component. Individuals with a family history of psoriasis are more likely to develop the condition.

Environmental factors, infections such as strep throat, can trigger the development of psoriasis or cause a flare-up of the condition. Stress can trigger or worsen psoriasis. Smoking and excessive alcohol consumption is a risk factors for the development of psoriasis and can also worsen the condition.

Some medications, such as lithium and beta blockers, can trigger the development of psoriasis or cause a flare-up of the condition, and cold, dry weather can worsen psoriasis.

 

Genetics

Prognostic Factors

The prognosis of psoriasis can vary widely from person to person. Some individuals may experience only mild flare-ups that can be easily managed with treatment. In contrast, few individuals may have more severe and persistent symptoms that can significantly impact their quality of life. In general, the long-term prognosis is good, as most cases of the condition can be effectively managed with proper treatment.

However, individuals with psoriasis have a higher risk of developing other conditions, such as diabetes, heart disease, and depression. Individuals with psoriasis need proper treatment to manage their symptoms and reduce the risk of developing these other health problems. Early and effective treatment is key to an excellent long-term outcome for people with psoriasis. This can help control symptoms, prevent flare-ups, and reduce the risk of other disorders.

 

Clinical History

Psoriasis is a skin condition characterized by red, raised patches of skin covered with silver-colored scales. These patches most often appear on the scalp and the extensor surfaces of the limbs, especially the knees, elbows, and lower back. The symptoms of psoriasis may include worsening of a long-term erythematous scaly area, sudden onset of small areas of redness, recent infections or immunizations, a family history of similar skin conditions, pain, especially in erythrodermic psoriasis or psoriatic arthritis, itching, dystrophic nails, a rash with recent joint pain, or joint pain without any visible skin findings.

In about 10% of patients, psoriasis can also affect the eyes, causing symptoms such as redness and tearing due to conjunctivitis or blepharitis. The nonocular symptoms of psoriasis, including discomfort or pain from the rash and stiffness, pain, swelling, or tenderness in the joints due to psoriatic arthritis, are usually more noticeable. The most commonly affected joints in psoriatic arthritis are the fingers, wrists, toes, knees, and ankles.

It can present in several forms, including plaque, guttate, rupioid, erythrodermic, pustular, inverse, elephantine, and psoriatic arthritis. The appearance of psoriasis can vary depending on the body site affected, such as the scalp, palms, and soles of the feet, genital area, and nails. It can also vary in its appearance and presentation at different body sites.

Physical Examination

A physical examination for psoriasis typically includes a thorough inspection of the skin to identify the characteristic lesions of psoriasis. These may appear as red, raised patches of skin with silvery-white scales, known as plaques. The plaques may be itchy and painful and can occur anywhere on the body but are most commonly found on the scalp, elbows, knees, and lower back. During the physical exam, other signs of psoriasis, such as nail changes such as pitting, thickening, or separation of the nail from the nail bed, and swelling and redness of the joints, are also checked.

Psoriasis can also affect the eyes and surrounding tissues, causing symptoms such as blepharitis, ectropion, conjunctivitis, and dryness of the cornea. These symptoms can lead to other complications, such as scarring of the eyelids, loss of eyelashes, and abnormal eyelid positioning. In some cases, psoriasis may also cause inflammation of the middle layer of the eye.

One characteristic of psoriasis is the Koebner phenomenon, in which new skin lesions may form at the site of an injury or irritation, such as a cut, burn, or exposure to radiation. This can indicate that the disease is active and may be more difficult to control. The Koebner phenomenon is one way to assess the severity and progression of psoriasis.

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

  • Eczema
  • Pityriasis rosea
  • Seborrheic dermatitis
  • Secondary syphilis
  • Mycosis fungoides
  • Tinea

Laboratory Studies

 

 

Imaging Studies

 

 

Procedures

 

 

Histologic Findings

 

 

Staging

 

 

Treatment Paradigm

The Psoriasis Area Severity Index (PASI) is the most extensively used assessment tool for evaluating the severity of the condition and determining treatment efficacy. For mild to severe psoriasis, topical treatment is indicated. Emollients and moisturizers may enhance barrier performance while maintaining the stratum corneum’s moisture. Coal tar, dithranol, corticosteroids, vitamin D analogs, and retinoids are administered initially as topical agents.

Methotrexate may be helpful in individuals who do not respond to these medications. Although it should only be administered occasionally, cyclosporine can stimulate a therapeutic response. Switch to biological therapies and, in certain instances, combine with methotrexate when patients do not respond.

Both PUVA therapy, which combines psoralen with ultraviolet radiation (UVA), and NBUVB (Narrowband UVB light) with a range of 311 to 313 nanometers. Without the negative effects of psoralen, such as gastrointestinal discomfort, cataract development, and carcinogenic complications, NBUVB is equally effective. Children, pregnant or nursing women, and even older adults can take it without risk. The most effective treatment for guttate psoriasis is phototherapy.

Oral corticosteroids, such as prednisone, are sometimes used to treat severe or recalcitrant psoriasis. However, they are generally not used as the first line of treatment due to their potential side effects. Oral steroids can cause various side effects, including weight gain, high blood pressure, and an increased risk of infection.

Topical corticosteroids are often used as the first line of treatment for mild to moderate psoriasis. They are usually well-tolerated and can reduce inflammation and slow skin cell production.

Topical calcipotriol is a vitamin D analog can help slow down the production of skin cells and reduce inflammation. Topical retinoids are medication related to vitamin A and can help slow down skin cell production. Topical coal tar is a thick, dark liquid that is made from coal and is used to slow down the production of skin cells and reduce inflammation. usually applied to the skin as a cream, ointment, or shampoo. Topical salicylic acid is a keratolytic agent can help soften and remove scales from the skin.

Biologicals, which include infliximab, adalimumab, etanercept, and interleukin antagonists, are artificial proteins that disrupt the immunological mechanism in psoriasis. The patient should have a TB and hepatitis workup before initiating any biological treatment. These patients pose a considerable risk of infection. Hence every effort should be made to prevent the patient from being severely immunocompromised.

Retinoids such as isotretinoin and acitretin are used to treat severe cases of psoriasis. They are usually reserved for individuals who do not respond to other forms of treatment, such as topical medications or phototherapy.

For fear of triggering the Kobner reaction, patients with psoriasis should avoid any skin damage. Beta-blockers, chloroquine, and NSAIDs should not be taken by individuals who have psoriasis. In addition, they should abstain from alcohol due to the possibility of fatty liver.

 

by Stage

 

 

by Modality

 

 

Chemotherapy

 

 

Radiation Therapy

 

 

Surgical Interventions

 

 

Hormone Therapy

 

 

Immunotherapy

 

 

Hyperthermia

 

 

Photodynamic Therapy

 

 

Stem Cell Transplant

 

 

Targeted Therapy

 

 

Palliative Care

 

 

Medication

 

 

 

acitretin 

25-50 mg orally every day
Note: off-label
Indicated for palmoplantar pustulosis, Darier's disease, Sjogren-Larsson syndrome, lichen planus



anthralin 

1% cream: Rub enough of the cream into the affected areas of the skin until it is fully absorbed
0.5% cream: Apply the product as directed after washing the hair, and then remove it by washing or showering the hair



brodalumab 

Indicated for moderate to severe plaque psoriasis:


210mg subcutaneous at 0,1 and 2 weeks, then,
210mg subcutaneous every two weeks
Consider terminating therapy if an acceptable response has not been reached after 12-16 weeks



methoxsalen 

Take orally with food or milk 2 hours before exposure to UVA (every other day)
Body weight guidelines
>115 kg: 70 mg
91-115 kg: 60 mg
81-90 kg: 50 mg
66-80 kg: 40 mg
51-65 kg: 30 mg
30-50 kg: 20 mg
<30 kg: 10 mg
May increase dose to 10 mg later 15 therapy sessions (stop increasing more after this)



fluocinonide 

Apply a slight coating topically once daily or every 12 hours as needed



fluocinonide 

Apply a slight coating topically once daily or every 12 hours as needed



grapefruit 


Indicated for Atherosclerosis, hypercholesterolemia, psoriasis, atopic dermatitis, fiber supplement
For the pharmacologic effects, more than four glasses of juice every day
Or
1-9 glasses of juice every day
Or
240 ml of the double strength juice two times a day



echinacea 

Topical
Use on the impacted region



shark cartilage 

Ranging from 500 mg to 4.5 gm, taken orally in 2 to 6 divided doses daily



cyclosporine 

Neoral or Gengraf: Administer 1.25 mg/kg orally twice a day
doses of 0.5 mg/kg/day may be increased after 4 weeks and every 2 weeks if necessary.
Do not exceed 4 mg/kg in a day.
Treatment should be stopped if no improvement is shown after six weeks at the highest recommended dosage of 4 mg/kg daily.



coal tar bath products 

Mixed with the bath water, let it soak for around 5 to 20 minutes, and then gently pat skin dry
Use daily for three days



benzoic acid/salicylic acid/ichthammol/ triamcinolone acetonide 

Clean and dry the affected area of skin and apply thin layer of ointment for 2 to 3 times daily



hydrocortisone butyrate 

Apply one time or two times a day in a thin layer application on the affected area



efalizumab 

Take an initial dose of 0.7 mg/kg through subcutaneously one time
Take a maintenance dose of 1 mg/kg subcutaneously weekly



ulobetasol 

0.5ml intradermally, as suggested by the in vivo studies
Indications: it is indicated in the treatment of skin conditions such as localized psoriasis, pruritis, etc.



clobetasol propionate 

Shampoo: Apply a thin layer to the dry scalp every day, let it sit for 15 minutes, add water, lather, and thoroughly rinse.
Foam: Apply to damaged scalp region every 12 hours for up to 2 weeks; do not use more than 50 g per week



diflucortolone 

Administration in thin layers twice daily to the affected area



 

benzoic acid/salicylic acid/ichthammol/ triamcinolone acetonide 

for >12 years old:
Clean and dry the affected area of skin and apply thin layer of ointment for 2 to 3 times daily



ulobetasol 

The drug is not recommended for use in children under 12 years of age
For children of 13 years and above:
0.5ml intradermally, as suggested by the in vivo studies



clobetasol propionate 

Below 12 years
Safety and efficacy not established
Above 12 years (shampoo)
Apply a small layer to the dry scalp every day and, let it sit for 15 minutes, then thoroughly rinse with water and soap.
Mild to Moderate Plaque-type Psoriasis
Below 12 years
Safety and efficacy not established
>12 years (foam)
Apply to the afflicted region of the scalp every 12 hours for up to two weeks; no more than 50 g/week



diflucortolone 

Administration in thin layers twice daily to the affected area



 

Media Gallary

References

 

 

Psoriasis

Updated : January 31, 2024




Psoriasis is a chronic inflammatory and proliferative skin condition that causes thickened, itchy, red patches of skin with silvery scales. It can range in severity from mild, with just a few small patches, to severe, with widespread, thick lesions covering large areas of the skin, such as the scalp, elbows, knees, and lower back.

It is believed to be caused by an overactive immune system, which causes skin cells to grow and multiply rapidly. Psoriasis is not contagious, but it is a life-long condition that is often genetic. Psoriasis has no known cure, and flare-ups cause the condition to wax and wane.

 

The prevalence of psoriasis varies widely between populations and regions. The mean age of onset for the first presentation of psoriasis can range from 15 to 20 years, with a second peak occurring at 55 to 60 years. In the United States, it is estimated that approximately 7.5 million people are affected with psoriasis, with the prevalence being higher among adults aged 18-45.

In Europe, the prevalence of psoriasis is estimated to be 2-3%. In the United Kingdom, it is estimated that 2.2% of the population has psoriasis. It is estimated that the prevalence in India is between 1.4% and 8.4%. The estimated prevalence in China is between 1.2% and 6.4%.

 

 

 

The pathophysiology of psoriasis is complex it involves a combination of genetic, environmental, and immune system factors. The most accepted theory is that psoriasis occurs due to the activation of T-cells in the skin, which triggers the release of inflammatory cytokines and other immune mediators. These cytokines cause the increased production of skin cells, leading to the formation of the characteristic red and scaly patches seen in psoriasis.

Normally, skin cells are produced and replaced every 28 to 30 days. This process occurs much more quickly in individuals with psoriasis, with new skin cells produced every 3 to 4 days. This rapid production of new skin cells leads to the accumulation of excess skin cells on the skin’s surface, which form the characteristic red, scaly patches. The skin cells are produced at an accelerated rate, leading to a build-up of thick, scaly plaques on the skin.

The immune system inaccurately attacks healthy skin cells, leading to inflammation and the production of excess skin cells. This leads to the formation of red, scaly patches on the skin, known as plaques. The plaques can be itchy and painful and can crack and bleed if scratched or rubbed. Psoriasis also appears to be linked to an imbalance of certain hormones, such as cortisol, which can affect the immune system and lead to psoriasis flares.

At the microscopic level, the skin of individuals with psoriasis shows several characteristic changes, including hyperproliferation, parakeratosis, acanthosis, hypogranulosis, and inflammation. In addition to these changes in the skin, physiological changes occur in the body as a result of the condition. These changes may include an abnormal response in the immune system, which is thought to be a significant contributor to the development of psoriasis.

 

The exact cause of psoriasis is not fully understood, but it is believed to be related to an immune system problem. It is thought to be triggered by genetic, environmental, and immune system factors. Research has shown that psoriasis has a vital genetic component. Individuals with a family history of psoriasis are more likely to develop the condition.

Environmental factors, infections such as strep throat, can trigger the development of psoriasis or cause a flare-up of the condition. Stress can trigger or worsen psoriasis. Smoking and excessive alcohol consumption is a risk factors for the development of psoriasis and can also worsen the condition.

Some medications, such as lithium and beta blockers, can trigger the development of psoriasis or cause a flare-up of the condition, and cold, dry weather can worsen psoriasis.

 

The prognosis of psoriasis can vary widely from person to person. Some individuals may experience only mild flare-ups that can be easily managed with treatment. In contrast, few individuals may have more severe and persistent symptoms that can significantly impact their quality of life. In general, the long-term prognosis is good, as most cases of the condition can be effectively managed with proper treatment.

However, individuals with psoriasis have a higher risk of developing other conditions, such as diabetes, heart disease, and depression. Individuals with psoriasis need proper treatment to manage their symptoms and reduce the risk of developing these other health problems. Early and effective treatment is key to an excellent long-term outcome for people with psoriasis. This can help control symptoms, prevent flare-ups, and reduce the risk of other disorders.

 

Psoriasis is a skin condition characterized by red, raised patches of skin covered with silver-colored scales. These patches most often appear on the scalp and the extensor surfaces of the limbs, especially the knees, elbows, and lower back. The symptoms of psoriasis may include worsening of a long-term erythematous scaly area, sudden onset of small areas of redness, recent infections or immunizations, a family history of similar skin conditions, pain, especially in erythrodermic psoriasis or psoriatic arthritis, itching, dystrophic nails, a rash with recent joint pain, or joint pain without any visible skin findings.

In about 10% of patients, psoriasis can also affect the eyes, causing symptoms such as redness and tearing due to conjunctivitis or blepharitis. The nonocular symptoms of psoriasis, including discomfort or pain from the rash and stiffness, pain, swelling, or tenderness in the joints due to psoriatic arthritis, are usually more noticeable. The most commonly affected joints in psoriatic arthritis are the fingers, wrists, toes, knees, and ankles.

It can present in several forms, including plaque, guttate, rupioid, erythrodermic, pustular, inverse, elephantine, and psoriatic arthritis. The appearance of psoriasis can vary depending on the body site affected, such as the scalp, palms, and soles of the feet, genital area, and nails. It can also vary in its appearance and presentation at different body sites.

A physical examination for psoriasis typically includes a thorough inspection of the skin to identify the characteristic lesions of psoriasis. These may appear as red, raised patches of skin with silvery-white scales, known as plaques. The plaques may be itchy and painful and can occur anywhere on the body but are most commonly found on the scalp, elbows, knees, and lower back. During the physical exam, other signs of psoriasis, such as nail changes such as pitting, thickening, or separation of the nail from the nail bed, and swelling and redness of the joints, are also checked.

Psoriasis can also affect the eyes and surrounding tissues, causing symptoms such as blepharitis, ectropion, conjunctivitis, and dryness of the cornea. These symptoms can lead to other complications, such as scarring of the eyelids, loss of eyelashes, and abnormal eyelid positioning. In some cases, psoriasis may also cause inflammation of the middle layer of the eye.

One characteristic of psoriasis is the Koebner phenomenon, in which new skin lesions may form at the site of an injury or irritation, such as a cut, burn, or exposure to radiation. This can indicate that the disease is active and may be more difficult to control. The Koebner phenomenon is one way to assess the severity and progression of psoriasis.

  • Eczema
  • Pityriasis rosea
  • Seborrheic dermatitis
  • Secondary syphilis
  • Mycosis fungoides
  • Tinea

 

 

 

 

 

 

 

 

 

 

The Psoriasis Area Severity Index (PASI) is the most extensively used assessment tool for evaluating the severity of the condition and determining treatment efficacy. For mild to severe psoriasis, topical treatment is indicated. Emollients and moisturizers may enhance barrier performance while maintaining the stratum corneum’s moisture. Coal tar, dithranol, corticosteroids, vitamin D analogs, and retinoids are administered initially as topical agents.

Methotrexate may be helpful in individuals who do not respond to these medications. Although it should only be administered occasionally, cyclosporine can stimulate a therapeutic response. Switch to biological therapies and, in certain instances, combine with methotrexate when patients do not respond.

Both PUVA therapy, which combines psoralen with ultraviolet radiation (UVA), and NBUVB (Narrowband UVB light) with a range of 311 to 313 nanometers. Without the negative effects of psoralen, such as gastrointestinal discomfort, cataract development, and carcinogenic complications, NBUVB is equally effective. Children, pregnant or nursing women, and even older adults can take it without risk. The most effective treatment for guttate psoriasis is phototherapy.

Oral corticosteroids, such as prednisone, are sometimes used to treat severe or recalcitrant psoriasis. However, they are generally not used as the first line of treatment due to their potential side effects. Oral steroids can cause various side effects, including weight gain, high blood pressure, and an increased risk of infection.

Topical corticosteroids are often used as the first line of treatment for mild to moderate psoriasis. They are usually well-tolerated and can reduce inflammation and slow skin cell production.

Topical calcipotriol is a vitamin D analog can help slow down the production of skin cells and reduce inflammation. Topical retinoids are medication related to vitamin A and can help slow down skin cell production. Topical coal tar is a thick, dark liquid that is made from coal and is used to slow down the production of skin cells and reduce inflammation. usually applied to the skin as a cream, ointment, or shampoo. Topical salicylic acid is a keratolytic agent can help soften and remove scales from the skin.

Biologicals, which include infliximab, adalimumab, etanercept, and interleukin antagonists, are artificial proteins that disrupt the immunological mechanism in psoriasis. The patient should have a TB and hepatitis workup before initiating any biological treatment. These patients pose a considerable risk of infection. Hence every effort should be made to prevent the patient from being severely immunocompromised.

Retinoids such as isotretinoin and acitretin are used to treat severe cases of psoriasis. They are usually reserved for individuals who do not respond to other forms of treatment, such as topical medications or phototherapy.

For fear of triggering the Kobner reaction, patients with psoriasis should avoid any skin damage. Beta-blockers, chloroquine, and NSAIDs should not be taken by individuals who have psoriasis. In addition, they should abstain from alcohol due to the possibility of fatty liver.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

acitretin 

25-50 mg orally every day
Note: off-label
Indicated for palmoplantar pustulosis, Darier's disease, Sjogren-Larsson syndrome, lichen planus



anthralin 

1% cream: Rub enough of the cream into the affected areas of the skin until it is fully absorbed
0.5% cream: Apply the product as directed after washing the hair, and then remove it by washing or showering the hair



brodalumab 

Indicated for moderate to severe plaque psoriasis:


210mg subcutaneous at 0,1 and 2 weeks, then,
210mg subcutaneous every two weeks
Consider terminating therapy if an acceptable response has not been reached after 12-16 weeks



methoxsalen 

Take orally with food or milk 2 hours before exposure to UVA (every other day)
Body weight guidelines
>115 kg: 70 mg
91-115 kg: 60 mg
81-90 kg: 50 mg
66-80 kg: 40 mg
51-65 kg: 30 mg
30-50 kg: 20 mg
<30 kg: 10 mg
May increase dose to 10 mg later 15 therapy sessions (stop increasing more after this)



fluocinonide 

Apply a slight coating topically once daily or every 12 hours as needed



fluocinonide 

Apply a slight coating topically once daily or every 12 hours as needed



grapefruit 


Indicated for Atherosclerosis, hypercholesterolemia, psoriasis, atopic dermatitis, fiber supplement
For the pharmacologic effects, more than four glasses of juice every day
Or
1-9 glasses of juice every day
Or
240 ml of the double strength juice two times a day



echinacea 

Topical
Use on the impacted region