PSORIASIS

Definition

Psoriasis is one of the prototypic papulosquamous skin

diseases characterised by erythematous papules or plaques
with silvery scales. It is a chronic inflammatory skin
disease with increased epidermal proliferation related to
dysregulation of the immune system.
Epidemiology

Psoriasis is said to affect 2% of the world population. The

prevalence is up to 5% in selected Western population.
Psoriasis has a bimodal age of disease onset. The first
peak is around 20 and the second peak is around 60.
People with disease onset around 20 year old have
stronger genetic predisposition. They have a higher
prevalence of having HLA-Cw6. The linkage to genetic
factor is lower for the group with late onset disease.
Etiology

The etiology of psoriasis remains unclear, although there

is evidence for genetic predisposition
There is a that psoriasis could be an autoimmune disease,
no autoantigen that could be responsible has been defined
yet.
Psoriasis can also be provoked by external and internal
triggers, including mild trauma, sunburn, infections,
systemic drugs and stress
Clinical Features

Prototypic lesion: The typical lesion of psoriasis is a

well-demarcated erythematous plaque with silvery scales
on top of the plaque .
The affected patient may experience itchiness. The
plaques may affect anywhere of the skin surface but the
mucosa is normally spared.
The scales may only be loosely attached and easily fall off
from the skin.
The disease may wax and wane, and not uncommonly is
aggravated by trauma and irritation, infections, various
drugs, seasonal changes and psychogenic stress.
Chronic Stable Plaque Psoriasis

Chronic Stable Plaque Psoriasis Sites of predilection of

the characteristic plaques include the extensor surfaces of
the elbows, knees, lower back and scalp. The genitalia and
nails may also be affected. The plaques vary in size .New
lesions may be induced at traumatised skin such as
surgical scar, or even scratch marks (known as Kobner
phenomenon).
Guttate Psoriasis

It is a variant characterised by small coins or even

punctate lesions with less amount of scale affecting
mostly young people. The disease may be precipitated by
upper respiratory tract infection. Over half of these
patients have some evidence of preceding streptococcal
infection. A few may have prolonged disease remission
after the acute episode.
Unstable Psoriasis

Lesions are angry looking with more intense

inflammation. These may be redder in colour with less
scaling. Lesions may be less well-demarcated and
occasionally exudation and crust are found.
Patients may experience more itchiness, irritation and
even pain. Further progression to erythrodermic or
pustular psoriasis can happen.
Inappropriate use of corticosteroids, excessive irritation,
sunburn are some of the factors not uncommonly
associated with unstable psoriasis.
Erythrodermic Psoriasis

When more than 90% of the body is involved by psoriasis,

it is defined as erythrodermic psoriasis.
An affected patient is characterised by having generalised
redness of skin and scaling.
The colour may sometimes be described as dusky red.
The face may occasionally be relatively spared. Individual
plaques may not be obvious.
 Pustules may sometimes be found.
Triggering factors are not uncommonly unidentified.
Affected patients may have systemic symptoms.
 Pustular Psoriasis Tiny superficial pustules with a
background of erythema may occur. The roof of the
pustules is easily broken. These pustules can be
distributed throughout the whole skin surface or more
localised especially in and around the unstable lesions.
Some patients may have lesions with matted scales with a
yellowish hue and if biopsy of these lesions is performed,
the histology shows sheets of subcorneal polymorphs.
Though very discrete pustules may not be seen clinically,
these lesions may be described as pustular psoriasis by
some clinicians.
 Steroid withdrawal is the commonest precipitating
factor encountered by the author as the cause of
pustular psoriasis.
Localised pustular psoriasis on the palms and soles is
reported to be associated with smoking.
 Psoriasis in Specific Body Locations Scalp and face: The
scalp is one of the most common sites affected by
psoriasis. The typical plaques may extend slightly beyond
the hairline . Some may involve the glabella region,
eyebrows, and nasolabial fold, and in this situation it
merges with seborrhoeic dermatitis
 Flexural regions: Lesions located at the axillae,
inframammary folds, groins, intergluteal cleft and prepuce
of the uncircumcised may present as shiny pink to red thin
plaques or even patches. Fissure may sometimes be
present.
 Nail: Nail involvement has been reported in 10 - 80%
of patients with psoriasis . Features include
onycholysis with or without the oil drop
phenomenon, distal subungual hyperkeratosis,
crumbly poorly adherent nail, loss of lustre among
other changes. The finger and toe nails can be
affected. Patients with nail involvement may have a
higher incidence of arthropathy. Psoriatic nails may
also predispose to fungal infection.
Management

The Principle of Management

Appropriate skin care, avoidance of aggravating factors,
the importance of keeping a good treatment history,
cessation of smoking, avoidance of excessive alcohol
drinking, reinforcement of the non-contagious nature and
chronicity of the condition and conveying the message
that psoriasis is amenable to very good control are the
important contents in communication, especially in the
first few encounters.
 Treatment
Topical drugs: topical steroids, vitamin D analogues, tar,
dithranol, keratolytics, calcineurin inhibitors, tazarotene.
UV light therapy: UVB including PUVA, targeted phototherapy
such as UVB delivered with the laser system
Traditional systemic therapy: methotrexate, systemic retinoid,
cyclosporine A
Biologic therapy: etanercept, infliximab, adalimumab which
target TNF ; ustekinumab which targets IL-12 & 23 1
Treatment

Combination therapy with a vitamin D analog

(calcipotriol and calcipotriene) or a retinoid such as
tazarotene and a topical corticosteroid is more effective
than therapy with either agent alone. Oatmeal baths may
be helpful for itching.
Solar or therapeutic ultraviolet (UV) radiation may be
helpful. Various UV light treatments are usednow most
commonly, UVB, although psoralen + UVB (PUVA) is
still used. Among phototherapy options
AAD guideline gives the highest recommendation to oral
PUVA or a combination of PUVA and topical agents.
 Psoralen is a photosensitizer that is ingested prior to light
exposure. PUVA treatment results in conjunctival
hyperemia and dry eye, particularly if sun protection is not
used. With proper eye protection, there does not appear to
be a risk of cataract. Psoralens for either topical (bath) or
systemic use may occasionally be difficult to obtain
because of intermittent availability issues.
According to the AAD guidelines, PUVA can result in
long remissions, but long-term use of PUVA in Caucasians
may increase the risk of squamous cell carcinoma (SCC)
and possibly malignant melanoma. According to the study,
exposure to more than 350 PUVA treatments greatly
increases the risk of SC.
General management

Any anxiety or worry should be identified and the patient

encouraged to relax or seek appropriate help.
Reassurance that it is not infectious or disfiguring must
be given to both patient and family.
Also an open door system should operate so that the
patient can get to a dermatologist or physiotherapist
immediately there is an eruption.
Dieting may be tried if there appears to be any allergy
factor.
Topical Applications

Many patients do well on topical treatment. Treatment

may be:
Simple bland aqueous cream.
Coal tar applications with salicylic acid and zinc oxide in
soft paraffin may be used alone or with UVR.
The patient is usually admitted to hospital.
The ointment is applied every day to the whole body
except face and scalp.
Every 24 hours it is washed off in a bath containing coal
tar solution.
 If UVR is given, it must be after a bath because
suberythema general treatment is given daily using the
Theraktin.
This is the Goeckerman regimen.
Diathranol in Lassars paste is used for resistant psoriasis
 It is highly effective but can burn the normal skin.
The patient may be admitted to hospital or treated as an
outpatient.
If the patient is applying, the physiotherapist should look
out for blisters or reddish purple stains on the skin and
warn the patient of the danger.
UVR with the Theraktin may be given in conjunction with
diathranol as a daily suberythema dose.
The paste is removed in coal tar bath before the UVR and
is then reapplied afterwards.
Corticosteroids cream produces good results at first but
when treatment stops the diseases can return worse than
before. It is useful in an acute eruption and on the face and
hands because there is greater absorption in moist areas.
The dangers of side effects make long-term use
inadvisable.
 Systemic Applications Retinoids- a variant of vitamin A-
taken in tablets form produces marked improvement.
It produces unpleasant side effects such as dryness and
cracking of the mouth, alopecia and pruritus. It is
teratogenic (produces malfunction in a fetus), therefore
must be avoided in pregnancy.
Cytotoxic drugs such as methotrexate are sometimes used
in severe cases.
These have dangers such as damage to bone marrow,
intestinal and liver tissues. Cyclosporine also may be
useful in severe cases.
Physiotherapy Management

Psoriasis can be treated very successfully with UVR.

Two sources are used: the Theraktin and PUVA.
The Theraktin: This is usually in the form of a tunnel
with four fluorescent tubes. The patient lies flat for the
treatment, therefore in order to treat the whole body the
patient is generally naked and lies supine for half the
treatment session and prone for other half.
The spectrum of UVR emitted is 390-280nm and peak
emission is around 313nm,therefore this constitutes UVB
treatment. It may be used alone or in conjunction with
coal tar or diathranol.
 Treatment A suberythema dose is given daily or three times
a week. The prominent parts of the body have a mild
erythema, which fades before the next treatment is due. The
time is maintained to maintain the reaction (e.g. 12.5%
every 1-2 treatments.).
When the lesions start to flatten and heal the same time is
repeated and frequency of treatment reduced to twice
weekly, once weekly and then once a fortnight.
The course of treatment may be spread over 8-12 weeks.
These patients tend to deteriorate during the autumn and
need treatment in the winter or spring. About 75% of
patients with guttate psoriasis respond to UVB.
PUVA

This is psoralen plus UVA and is used for resistant

psoriasis.
UVA is produced from fluorescent tubes, mounted upright
in a hexagonal shaped cabinet inside which the patient
stands throughout the treatment.
The spectrum of UVR emitted is 330-390 nm and peaks at
360 nm.
Infrared rays are also emitted and it is essential to have a
cooling fan so that the patient can tolerate up to hour in
the cabinet.
PUVA Treatment Unit
 A record is kept of the total Joules count. This is essential
because there is an undeniable risk of malignant
melanoma in patients who have been exposed to between
1500 J and 2000 J.
The patient attends three times a week until healing starts,
and then frequency of treatment is reduced to twice
weekly, once weekly, once per fortnight or monthly
holding sessions.
Precautions

Precautions/ dangers/ advice to patients on PUVA.

Do not take psoralen on an empty stomach.
There is a real danger of cataract; therefore protective
goggles are essential during exposure.
Polaroid sunglasses must be worn from the time of taking
the psoralen to at least 12 hours after.
The psoralen is excreted in 8 hours but the effect of
photosensitizing continues.
The physiotherapist should test the glasses with a Black
ray meter; the glasses must screen 90% of UVA.
 Patients are advised to wear protective glasses out of
doors for at least 24 hours after taking the psoralen and
also whilst watching television, a VDU screen or in
fluorescent lighting.
The skin must be covered in bright sunlight and a hat
worn for 24 hours after treatment.
Stop using all ointments during PUVA.
If the skin is dry simple oil or lubricating lotions may be
used.
Do not become pregnant or father a child- contraceptive
measures are essential during PUVA treatment.
A check up is essential every month after completing of
Duration of treatment

This may be 5 minutes at first for skin types I and II and

progressed by 1 minute up to 15 minutes.
It may start at 6 minutes and progress by 2 minutes up to
20 minutes for skin type III and IV.
It may start at 7 minutes and progress by 3 minutes up to
25 minutes for skin type V and VI.