1. Block 18 Week 7: Psoriasis
1
CalumLyons
Psoriasis
Chronic T-cell-mediated autoimmune disease
Histology
 Inflammatory T-cell infiltratedirected againstoneor more antigens
 Abnormal proliferation and differentiation
 Vascular proliferation
Epidemiology
 Psoriasisiscommon
o prevalence 1-3% (Faroes 5%)
 Polygenic with different genes important in different individuals (monozygotic twin
concordance~74%)
 Association with IBD
 May demonstrate Koebner (isomorphic) phenomenon (>40% of cases)
Age of onset has 2 peaks
 5-10 years females;15-19years males
o Genetic influence
 6th-7th decade (male=female)
o No genetic influence
Association between IBD and Psoriasis
 Clinical Studies (Yates, VM et al 1982,Keohane, S et al 1998)
o most refer to Crohn’s
o psoriasisin Crohn’s ranges from4-12% (1.1-3% in controls)
 Genetic studies
o HLA - Cw6, DR7
o genome scans - 16q
 Antigen persistence

2. Block 18 Week 7: Psoriasis
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CalumLyons
o In all cases,except one patient with Crohn’s disease,onset of psoriasis preceded onset of
abdominal diseaseby at least1 year
 Genetic
o FH of psoriasisin 1stdegree relatives
o 5/84 IBD patients; 2/110 non-IBD patients
 Emotional stress of severe IBD
Triggers
 Trauma (Koebner) - In 38-76% of patients
 Infection
o Throat infection (guttate) (tonsillectomy usually makes no difference)
o HIV
o Eg HHV?
 Hormone
o Puberty
o pregnancy
 UV light
o Sunburn
o iatrogenic
 Emotional stress
 Alcohol
 Drugs
o Li+
o Beta blockers
o Antimalarials
o Can usevibramycin and minocin less effective
o Tetracyclines
o Terbinafine
o NSAIDS
o 187 more including CORTICOSTEROIDS
Types of Psoriasis
 Flexural
 Guttate
 Localised pustular (PPP)
 Unstable- Generalised pustular,Erthyrodermic
 Nail
 Hand
 Joint
 acral
Psoriasis Vulgaris
Well demarcated salmon-pink plaques with silvery whitescale - Auspitz sign
 Elbows
 Knees & shins
 Scalp
 Buttocks
 Umbilicus
 Nails (50%)
 genitals

3. Block 18 Week 7: Psoriasis
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CalumLyons
Psoriasis (flexural)
 Commoner in adults
 Partof psoriasisvulgarisor isolated (inverse) psoriasis
 ?Koebner to infection or seborrhoeic dermatitis
 Therefore need to excludeinfection
 Colour is typical
 Scalingmay be absent
Flexural and Extensor Psoriasis
 Flexural psoriasis often occurs in association with extensor
psoriasis
 May fissure
 Secondary infection is COMMON and hard to spot
Treatment
 Consider,exclude or treat infection, especially C.albicans
 Topical steroids (includingcombinations) aremainstay
 Eosin & Brilliantgreen
 Systemics may be needed
Guttate Psoriasis
 Children and young adults
 Infection related
o Especially streptococcal sorethroat
o ?tonsillectomy of littlevalue
 50% clear and 50% are recurrent or progress to chronic Psoriasis
vulgaris
Localised Pustular Psoriasis
 Palmoplantar pustulosis
 Pink & scaly areas studded with pustules
 In all stages
o Yellow
o Brown & flat
o detaching
 Itchy and/or sore
 Chronic and resistantto treatment
o Best evidence for RE-PUVA
 Adults female>male
 Especially smokers

4. Block 18 Week 7: Psoriasis
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CalumLyons
Unstable Psoriasis
Previously stablepsoriasisthathas become erythrodermic or generalised pustular (GPP) as a resultof:
- Irritanttreatments
- Corticosteroids or other drugs
- Infection
- Pregnancy
- UV
- Unknown factors in many cases especially of GPP
GPP can occur in patients with no previous history of psoriasis
 Adults
 Erythema
 Pustules
 Systemic symptoms
 Relapses occur
Management
 Admission
 Supportive therapy and remove trigger
factors
 Emollients
 Retinoid
 Methotrexate iv
Complications
 Hypothermia
 Malabsorption
 Protein and iron loss
 Oedema
 Heart failure
Nail Psoriasis
 Partof all types in up to 50% or more
 May be isolated finding
 Often associated with PsA and dactylitis
 Always check mycology before givingoral terbinafineas itexacerbates
psoriasisaswell as causingTEN
Hyperkeratotic hand & foot Psoriasis
 Thick, fissuringhyperkeratotic plaques on palms and sole
o Thenar and hypothenar
o Possibly no psoriasiselsewhere
 Can be hard to treat
o Fissures
 Lassar’s pasteor superglue
o Emollient
o May be responseto topical tar,retinoid or dithranol aloneor in
combination (steroids)
o Topical PUVA +/- retinoid
Psoriatic arthropathy
Deforming inflammatory arthropathy develops in up to 23% of psoriasis patients
 May predate psoriasis
 Not related to skin severity
 NSAIDS and corticosteroidscan exacerbatethe skin disease

5. Block 18 Week 7: Psoriasis
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CalumLyons
Management
Patient Advice
 Incurable
 Chronic/recurrent
 Not an infection
 Not contagious
 Not a genetic defect
 Drugs and other trigger factors
What do patients want to achieve from
treatment
 Do they wish systemic
 Will they put creams on
Topical
 Emollients
 Occlusion
 Tar
 Dithranol
 Retinoids
 Steroids
 Vitamin D
Topical: choice drug(s) and vehicle
 Child or adult
 Body site
 Tolerability to the patient
 Likelihood of compliance
Corticosteroids
 Block the effect of T-cell mediators of inflammation atthe receptor level
o Therefore there may be a rebound inflammation when they are
withdrawn
o Most other therapies down regulate T-cells and induceapoptosis so
that remission is longer lasting
 Useful atflexures, scalp and ?nails?
 Useful in combination
 Some dermatologists never use any corticosteroids
Tar
 “complex mixtures”
o Crude------highly refined
o Cruder the better
 Availablein creams and ointments as well as solution for bathing
 Combinations with corticosteroid and or salicylic acid available
o Alphosyl
o CTS10% in Eumovate
o Betnovate 25% in CTP
 Anti-inflammatory,antipruritic and antiseptic
 Complications
o Contact dermatitis
o Folliculitis
o No clear evidence of carcinogenicity buttheoretically possible
Dithranol
 Synthetic anthralin
 Ideal vehicleis Lassar’s paste
o Short contact creams and micronised preparationsarefar easier to use at home but less
effective
 Complications
o Irritancy.Unsuitablefor multiplesmall plaques.
o Stains everything in sightincludingbath enamel

6. Block 18 Week 7: Psoriasis
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CalumLyons
Tazarotene
 Retinoid
 Very irritantin somepeople
 Useful in hand psoriasis
Vitamin D analogues
 Effects on cell division and differentiation.Therefore antiproliferativein psoriasis.
 Mild-moderate psoriasis
 Safe and well tolerated. Little stainingetc
 Calcipotriol
 Tacalcitol
 Calcitriol
 Used alone or in combination with emollientor corticosteroid
o Eg Calcipotriol o.n.Eumovate o.m.
o Dovobet
 Better compliancethan separate preparations
 Especially importantas patients can overusesteroids in psoriasis
 Alternating Vit D analogues as for emollients,appears to maintain efficacy.
Light therapy
UVB TL01
 8-12 week courses 3 times per week
 Complications includeburning
 The long term skin cancer risk is notknown
o Effective as is PUVA which is associated with BCC,SCC, MM
 Dead sea
PUVA
 Topical;hands and feet especially
 Systemic
o 8-MOP, 5-MOP (can causenausea)
o Tablets are unlicensed
 Cancer risk increases remarkably after upper level
Complications
Pigmentation, burning, itch,lentigines,malignancies
Contraindications
 Photoaggravated diseases or drugs
 Skin cancers and previous radiotherapy
 Immunosuppression eg posttransplant
 Severe renal,cardiac or liver disease
 Pregnancy
 children
Systemic drugs
Indications
 Psoriasisnotrespondingto other treatment
 Other treatments not tolerated
 Special sites

7. Block 18 Week 7: Psoriasis
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CalumLyons
Methotrexate
 Antimetabolite. Inhibits dihydrofolatereductase
 Anti-inflammatory
 Once WEEKLY treatment
 Test dose 2.5mg
 Maximal benefit begins at 4-8 weeks
Monitor
 initially weekly then
2-3 monthly
 U+E
 LFT
 FBC
 PIIIP
 Maintenance dose 5-
25mg
Contraindications
 BM suppression
 Infection
 UC
 Alcoholism
 Pregnancy, lactation
 Diabetes mellitus and
cirrhosis risk
Side effects
 Nausea
 Cheilitis
 Pulmonary/hepatic
fibrosis
 Skin necrosis
 Drug interactions
(especially thosewith
renal effects)
Ciclosporin
• 3.5-5mg/Kg/day
• Not for long term use becauseof renal damage and hypertension.
Contraindications
 Renal dysfunction
 Uncontrolled
hypertension
 Malignancy
 Infection
 Pregnancy and
lactation
Interactions
 NSAIDS
 Erythromycin
 Grapefruitjuice
 anticonvulsants
Side effects
 Tremor
 Headache
 Hypertrichosis
 Gum hypertrophy
 Hypertension
 Nephrotoxicity
 malignancy
Hydroxyurea
 500-1500mgdaily
 Start dose 500mg
 Slow clinical response
Side effects
 Bone marrow suppression
 Photosensitiveexacerbation.Dermatomyositis-like
Acitretin
• Useful in Ps vulgarisand pustular/ generalised
• Combination with UV
• Similar sideeffects to roaccutanebut desquammation more sever. Also persists in fatfor 2 years
therefore contraception for 2 years
Side effects
 Bone marrow suppression
 Photosensitiveexacerbation.Dermatomyositis-like
Infliximab
Anti-TNF monclonal antibodies

8. Block 18 Week 7: Psoriasis
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CalumLyons
Nails
 Very difficultto treat
 Can be socially and practically disablingtherefore ?systemics?
 Topical treatments littleuse.
 Intralesional steroid?
 Keep nails SHORT
 Nail varnish ( even for men)
Scalp
There is no pointin putting an activetreatment onto thick scale.Therefore:
 SA 10% in EO for 1 month
 Ung cocois co
 Dovonex
 Combinations
 Coal tar pomade
 Dithranol0.25%pomade
Guttate
 May be self-limitingand need no treatment in children
 Outpatient tar treatments eg Alphosyl may be all thatis needed
 UV is highly effective
Children
 Complianceis better and other factors eg alcohol arenot a problem
 Avoid UV
 Early inpatienttreatment
o Providerapid treatment without hazardous therapies
o Improve patient understanding for treatment of a lifelongdisease
Seborrhoeic dermatitis
 Scaly,red, non-itchy, greasy-lookingrash
o Hairline
o Glabella,eyebrows
o Chin
o Occasionally flexures
 Secondary infection is common in flexures
 Seems to be caused by yeasts (Malassezia
furfur) in susceptibleindividuals
 ?part of a psoriasisspectrumor not?
Seborrhoeic Psoriasis or “Sebopsoriasis”
Coincidence of 2 chronic diseases?
 Both worsen with stress and illness
 Both worsen in early HIV
 Scalp psoriasiscan improvewith Nizoral
 Both associated with IBD
 Seb derm worse in PD
General treatment
 Suppression not cure
 Medicated shampoo includingNizoral
 Ketoconazole cream
o Sulphur and salicylic acid
 Topical steroid and combined
 UV phototherapy
 Check for and treat infection