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Psoriasis and lichen planus
Department of DermatologySRM MCH & RC
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WHAT IS PSORIASIS
• Psoriasis is a common, chronic, disfiguring, inflammatory and proliferative condition of the skin; in which both genetic and environmental influences play a critical role characterised by red, scaly, sharply demarcated indurated plaques of various sizes, particularly over extensor surfaces and scalp.
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Aetiopathogenesis
• Genetic predisposition:
HLA-B13, B17, and Cw6
• Epidermal hyperproliferation
• Antigen driven activation of autoreactive T-cells
• Angiogenesis
• Multifactorial inheritance
• Overexpression of Th1 cytokines such as IL 2, IL 6, IL 8, IL 12, INF - γ, TNF α
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Trigger factors
• Trauma (Koebner phenomenon): Mechanical, chemical, radiation trauma.
• Infections: Streptococcus, HIV
• Stress
• Alcohol and smoking
• Metabolic factors: pregnancy, hypocalcemia
• Sunlight: usually beneficial but in some may cause exacerbation
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Trigger factors
Drugs:
Beta-blockers
NSAIDS
ACE inhibitors
Lithium
Antimalarials
Terbinafine
Calcium channel blockers
Captopril
Withdrawal of corticosteroids
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Morphology
• Classical Lesion: Erythematous, round to oval well defined scaly plaques with sharply demarcated borders
• Scales: Psoriatic plaques typically have a dry, thin, silvery-white or micaceous scale.
• Sites: Elbows, knees, extensors of extremities, scalp & sacral region in a symmetric pattern. Palms/ soles involved commonly
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CLASSICAL LESION
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Morphology
• Auspitz sign:
Removing the scale reveals a smooth, red, glossy membrane with tiny punctate bleeding points
• Grattage test:
On grattage, characteristic coherence of scales seen as if one scratches a wax candle(‘signe de la tache de bougie)
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KOEBNER PHENOMENON
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Morphological Types
• Chronic plaque psoriasis: plaques with less scaling
• Follicular psoriasis: follicular papules.
• Linear psoriasis: linear arrangement of plaques
• Annular/ figurate psoriasis: ring shaped or other patterns.
• Rupoid, elephantine and ostraceous psoriasis
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GUTTATE PSORIASIS
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Distributional Variation
• Scalp psoriasis
• Palmoplantar psoriasis
• Nail psoriasis: pitting, onycholysis, subungual hyperkeratosis, or the oil-drop sign. (25-50%)
• Mucosal psoriasis
• Inverse psoriasis:
– spares the typical extensor surfaces
– affects intertriginous (i.e, axillae, inguinal folds, inframammary creases) areas with minimal scaling.
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NAIL AND SCALP
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INVERSE AND SEBO PSORA
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PALMOPLANTAR PSORIASIS
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Psoriasis in children and in HIV
Psoriasis in children:
• Plaques not as thick as in adults, less scaly
• Diaper area in infants, flexural areas in children
• Face involvement more common than in adults
Psoriasis in HIV:
• Acute onset
• Severe flares
• Poor prognosis
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Complicated psoriasis
• Erythrodermic psoriasis
• Generalised pustular psoriasis
• Psoriatic arthritis
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ERYTHRODERMIC AND PUSTULAR
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PUSTULAR PSORIASIS
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Differential diagnosis
• Nummular eczema
• Tinea corporis
• Lichen planus
• Secondary syphilis
• Pityriasis rosea
• Drug eruption
• Candidiasis
• Tinea unguium
• Seborrheic dermatitis
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Treatment
General measures:
• Counselling regarding the natural course of the disease
• Weigh reduction in obese patients.
• Avoidance of trauma or irritating agents.
• Reduce intake of alcoholic beverages.
• Reduce emotional stress
• Sunlight and sea bathing improve psoriasis except in photosensitive
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Topical therapy• Emollients: white soft paraffin & liquid paraffin
• Corticosteroids: Potent steroids like fluocinolone acetonide, betamethasone dipropionate or clobetasol propionate
• 5-10% Coal tar: for stable but resistant plaques
• 0.1-1% dithranol: for few stable, thick, resistant plaques
Contd…
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Topical therapy• Keratolytics & humectants: as adjuvants eg.
Salicylic acid 3-10%, urea 10-20%
• Calcipotriene
• Tazarotene
• Macrolactams (calcineurin inhibitors): Tacrolimus & Pimecrolimus.
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Phototherapy 1. Extensive and widespread disease
2. Resistance to topical therapy
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Systemic Agents Indications:• Resistant to both topical treatment and
phototherapy• Active psoriatic arthritis.• Physically, psychologically, socially or
economically disabling disease • Steroids: only used in life threatening situations
like erythrodermic & pustular psoriasis. • Cyclosporin: Immune modulator
– Used in erythrodermic & resistant psoriasis– Limitations: expensive & nephrotoxic and
hypertensive
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Systemic Agents • Methotrexate:– Three doses of 2.5-5 mg orally 12 hrly or 7.5-15
mg single dose; administered every week.– Contraindicated in hepatic & renal diseases.
Close monitoring of blood counts & hepatic function essential.
• Acitretin: – For widespread psoriasis; combination with
PUVA reduces total cumulative dose of UV irradiation
– Contraindicated in pregnancy & women of child bearing age
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Prognosis • Course of plaque psoriasis is unpredictable.
• Characterised by remissions and relapses
• Often intractable to treatment
• Relapses in most patients
• Improves in warm weather
• Poor Prognostic factors:
Early onset, Family history, Stress, HIV infection
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LICHEN PLANUS
DEPARTMENT OF DERMATOLOGY
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Definition
• Lichen Planus is a common inflammatory disorder of skin characterized clinically by distinctive, violaceous, flat topped papules; and histologically by a band like lymphocytic infiltrate at the dermo-epidermal junction.
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Aetiology
• Exact cause unknown• Probably immunologically mediated• Genetic predisposition:
HLA-B7, HLA-DR1, HLA-DR10• Associations: ulcerative colitis, alopecia areata,
vitiligo, hepatitis, and primary biliary cirrhosis.• Drugs:
NSAIDs, Chloroquine, ACE inhibitors, hypoglycaemic agents Mercury, gold, nickel sensitivity seen in oral lichen planus
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Clinical features
• Lichen planus can involve skin, mucous membranes, genitalia, nails and scalp.
• Associated with pruritus
• Commonly affects young adults
• Males and females equally affected
• Various clinical types seen
• Characteristic papules/ plaques of Lichen planus :
Violaceous, erythematous, flat topped, shiny, and polygonal; varying in size from 1 mm to greater than 1 cm in diameter. They can be discrete or arranged in groups of lines or circles.
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LP WITH WICKHAMS STRIAE
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Clinical types
• Acute wide spread: involving flexor surface of wrists, forearms, shins, ankles, dorsae of feet, anterior thighs and flanks
• Chronic localized: around ankle & wrist.
• Hypertrophic: extensor surfaces of lower extremities
• Actinic: nummular patches with a hypopigmented zone surrounding a hyperpigmented center
• Lichen Planus Pigmentosus: Diffuse macular, slate grey or brownish pigmentation of face, neck, upper limbs
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Clinical types
• Annular: buccal mucosa and the male genitalia.• Linear: zosteriform lesion on extremities• Vesicular and bullous: lower limbs, oral cavity• Atrophic: resolution of annular or hypertrophic
lesions.• Erosive: mucosal surfaces• Follicular: Lichen planopilaris ; more common in
women than in men, scarring alopecia may result.• Oral: reticular( white lace-like), atrophic, erosive,
plaque• Genital : common in men; typically annular lesion
on glans seen• Nail: thin striated nails with pterygium
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ACTINIC, CLASSICAL,GENERALISED, KOEBNER
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GENITAL, HYPERTROPHIC, ORAL
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FOLLICULAR AND NAIL LP
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LP PIGMENTOSUS
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Differential diagnosis
• Disseminated Eczema
• Scabies
• Drug eruption
• Pityriasis Rosea
• Psoriasis
• Prurigo nodularis
• Secondary syphilis
• Mucosal lesions: candidiasis, leukoplakia, pemphigus
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Treatment
• Lichen Planus is a self-limited disease that usually resolves within 8-12 months.
• Topical: Calamine lotion, Steroids, Cyclosporin, Tacrolimus
• Systemic: Antihistaminics, Steroids, Dapsone, Griseofulvin, Retinoids, PUVA, Cyclosporin
Acute widespread LP:• Prednisolone 0.5-1 mg/kg/ day tapered over few
weeks for symptomatic control and rapid resolution. Monitoring of side-effects & judicious use recommended.
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Treatment
Mild cases & localised lesions : • Antihistamines • Topical steroids eg: Fluocinolone acetonide,
Betamethasone valerateHypertrophic Lichen Planus: • Topical clobetasol propionate• Intralesional injection of triamcinolone acetonide
(40mg/ml)Oral Lichen Planus:• Topical steroids in orabase• Tacrolimus, cyclosporin• Systemic steroids• Dapsone
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Prognosis / Complications
• Lesions resolve with pigmentation that may last for many months
• Recurrent episodes can occur
• Oral lesions may be premalignant
• Scarring alopecia