shri ganasaya namaha. an update on psoriasis by dr. mahesh mathur, md,dvd,dcp (uk) md,dvd,dcp (uk)
TRANSCRIPT
SHRI GANASAYA NAMAHASHRI GANASAYA NAMAHA
AN UPDATE ONAN UPDATE ONPSORIASISPSORIASIS
BYBY
DR. MAHESH MATHUR, DR. MAHESH MATHUR, MD,DVD,DCP (UK)MD,DVD,DCP (UK)
DEFINITIONDEFINITION
COMMON, CHRONICCOMMON, CHRONIC GENETICALLY DETERMINEDGENETICALLY DETERMINED INFLAMATORY & PROLIFERATIVEINFLAMATORY & PROLIFERATIVE CHARACTERISED BY CHARACTERISED BY
- - Well defined,Well defined,
- Dull red- Dull red - Silvery white scaling- Silvery white scaling - involving extensor aspect of body- involving extensor aspect of body - great variability in extent of - great variability in extent of
disease, morphology of lesions & disease, morphology of lesions & duration of disease. duration of disease.
EPIDEMIOLOGYEPIDEMIOLOGY
INCIDANCE & PREVELANCEINCIDANCE & PREVELANCE
1.5 TO 4.8%1.5 TO 4.8% AGE OF ONSET - can occur at any age- AGE OF ONSET - can occur at any age-
5 TO 9 YEARS IN FEMALE- TYPE -I5 TO 9 YEARS IN FEMALE- TYPE -I
15 TO 19 YEARS IN MALE- TYPE-115 TO 19 YEARS IN MALE- TYPE-1
30 TO 40 YEARS- TYPE II30 TO 40 YEARS- TYPE II
RACEAL DIFFERENCERACEAL DIFFERENCE
AETIOLOGY & PATHOGENISISAETIOLOGY & PATHOGENISIS
INHERITED – INHERITED – NO SINGLE PATTERN, NO SINGLE PATTERN, MULTIFACTORIAL MULTIFACTORIAL
MHC CLASS 1 –CW6- 80% ASSOCATION MHC CLASS 1 –CW6- 80% ASSOCATION WITH TYPE I PSORIAIS WITH TYPE I PSORIAIS
FAMILIAL - FAMILIAL - TWIN SUDY – MONOZYGOT PAIR 73%TWIN SUDY – MONOZYGOT PAIR 73%
DIZYGOTC PAIR 20 %DIZYGOTC PAIR 20 %
50% SIBLINGS 50% SIBLINGS IN IN PROBAND PROBAND
WHEN BOTH WHEN BOTH
PARANTS ARE AFFECTED PARANTS ARE AFFECTED
PROVOCATION & EXACERBATIONPROVOCATION & EXACERBATION
TRAUMATRAUMA INFECTIONINFECTION ENDOCRIN FACTO- Pregnancy, MenopauseENDOCRIN FACTO- Pregnancy, Menopause SUN LIGHTSUN LIGHT METABOLICMETABOLIC DRUGS - DRUGS - lithium, beta blocker, antimalarials,systamic lithium, beta blocker, antimalarials,systamic
steroidssteroids PSYCOGENICPSYCOGENIC ALCOHOLALCOHOL AIDSAIDS
PATHOGENESISPATHOGENESIS
T CELL MEDIATEDT CELL MEDIATED KERATINCYTE PROLIFERATIONKERATINCYTE PROLIFERATION HLA CW 6HLA CW 6
IS IT AN IS IT AN IMMUNOLOGICAL IMMUNOLOGICAL
DISEASE ?DISEASE ?
YESYES…..….. CD4+ T CELLS IN DERMISCD4+ T CELLS IN DERMIS CD8+ CELLS INFILTRATING IN EPIDERMIS – CD8+ CELLS INFILTRATING IN EPIDERMIS –
MHC I RESTRICTEDMHC I RESTRICTED MACROPHAGES & NEUTROPHILS MACROPHAGES & NEUTROPHILS
INFILTRATIONINFILTRATION IL1,IL6,IL8,TGF alfa,LTC4, C5aIL1,IL6,IL8,TGF alfa,LTC4, C5a IMMUNO THERAPY BY IMMUNO THERAPY BY METHOTRAXTEMETHOTRAXTE
T CELL MEDIATED T CELL MEDIATED
PATHOLOGY & PATHOGENESISPATHOLOGY & PATHOGENESIS KERATINOCYTE PROLIFERATIVE KERATINOCYTE PROLIFERATIVE
ACTIVITY-ACTIVITY- VASODILATATION OF DERMAL VASODILATATION OF DERMAL
VASSELSVASSELS * * EIGHT FOLD SHORTENING OF EPIDERMAL CELL EIGHT FOLD SHORTENING OF EPIDERMAL CELL
CYCLE CYCLE
* * 36 ~311 h IN NORMAL36 ~311 h IN NORMAL
*TWOFOLD INCRESE IN PROLIFERATIVE CELL *TWOFOLD INCRESE IN PROLIFERATIVE CELL POPULATIONPOPULATION
*100% OF GERMINATIVE CELLS ENTER IN GROWTH *100% OF GERMINATIVE CELLS ENTER IN GROWTH FRACTION- 35,000 CELLS/ SQ.mm~1218 CELLS/SQ.mmFRACTION- 35,000 CELLS/ SQ.mm~1218 CELLS/SQ.mm
PATHOGENESISPATHOGENESIS
CLINICAL PRESENTATIONCLINICAL PRESENTATION
CLINCAL VARIENTCLINCAL VARIENT PLAQUE PSORIASISPLAQUE PSORIASIS GUTATE PSORIASISGUTATE PSORIASIS FLEXURALFLEXURAL NAPKIN PSORIASISNAPKIN PSORIASIS UNSTABLE -UNSTABLE - PUSTULAR- LOCALISED & GENEREALISEDPUSTULAR- LOCALISED & GENEREALISED ERYTHRODERMICERYTHRODERMIC ARTHROPATHIC PSORIASISARTHROPATHIC PSORIASIS
PLAQUE PSORIASISPLAQUE PSORIASIS
PLAQUE PSORIASISPLAQUE PSORIASIS
PLAQUE PSORIASISPLAQUE PSORIASIS
AUSPITZ SIGNAUSPITZ SIGN
PSORIASIS OF PALMPSORIASIS OF PALM
PLAQUE PSORIASISPLAQUE PSORIASIS
PLAQUE PSORIASISPLAQUE PSORIASIS
PLAQUE PSORIASISPLAQUE PSORIASIS
PSORIASIS OF SCALPPSORIASIS OF SCALP
SCALP PSORIASISSCALP PSORIASIS
SCALP PSORIASISSCALP PSORIASIS
CLINICAL PICTURECLINICAL PICTURE
FLEXURAL PSORIASISFLEXURAL PSORIASIS
PUSTURAL PSORIASISPUSTURAL PSORIASIS
LOCALISED -LOCALISED - --THENER EMENECES & INSETP OF FOOT,THENER EMENECES & INSETP OF FOOT,
- MORE IN FEMALES,- MORE IN FEMALES, -NO ASSOCIATION OF HLA ANTIGENS-NO ASSOCIATION OF HLA ANTIGENS GENERALISED -GENERALISED - FEVER,MALASE, SEVER CONSTITUTIONAL FEVER,MALASE, SEVER CONSTITUTIONAL
SYMPTOMS,SYMPTOMS, PUSTULAR ERYTHEMA, FLUXERAL INVOLMENT,PUSTULAR ERYTHEMA, FLUXERAL INVOLMENT, TETANY,HYPOALBUMINAEMIATETANY,HYPOALBUMINAEMIA WITHDRAWAL OF STEROIDS,PREGNANCYWITHDRAWAL OF STEROIDS,PREGNANCY
PUSTULAR PSORIASISPUSTULAR PSORIASIS
GENEREALIZED PUSTULAR GENEREALIZED PUSTULAR PSORIASISPSORIASIS
GUTTATE PSORIASISGUTTATE PSORIASIS
POST STREPTOCOCAL POST STREPTOCOCAL
BETA HAEMOLITICUSBETA HAEMOLITICUS
INFECTIONINFECTION USUALLY CHILDRENUSUALLY CHILDREN NO TYPICAL SCALESNO TYPICAL SCALES RESOLVE SPONTENOUSLYRESOLVE SPONTENOUSLY
GUTTATE PSORIASISGUTTATE PSORIASIS
EXTENSIVE PSORIASISEXTENSIVE PSORIASIS
ERYTHRODERMIC PSORIASISERYTHRODERMIC PSORIASIS
HYPOTHERMIAHYPOTHERMIA
WATER & ELECTROLITE WATER & ELECTROLITE
BALANCEBALANCE
LOSS OF PROTEINLOSS OF PROTEIN
ANEMIAANEMIA
HYPERDYNAMIC HYPERDYNAMIC
CIRCULATIONCIRCULATION
NAIL PSORIASISNAIL PSORIASIS
NAIL PITTINGSNAIL PITTINGS
ONYCHOLYSISONYCHOLYSIS
SUBUNGUAL SUBUNGUAL
HYPERKERATOSISHYPERKERATOSIS
NAIL DYSTROPHIESNAIL DYSTROPHIES
NAIL PSORIASISNAIL PSORIASIS
NAL PITTINGSNAL PITTINGS
NAIL PSORIASISNAIL PSORIASIS
ONYCOLYSISONYCOLYSIS
NAIL PSORIAISNAIL PSORIAIS
NAIL PSORIASISNAIL PSORIASIS
PSORIATIC ARTHRITISPSORIATIC ARTHRITIS
SERONEGATIVE ATHRITISSERONEGATIVE ATHRITIS INCIDENCE- 1.5 TO 3%INCIDENCE- 1.5 TO 3% MALE FEMALE RETIO EQUALMALE FEMALE RETIO EQUAL HLA ASSOCIATION HLA B27,A26,B38,DR4,DR3HLA ASSOCIATION HLA B27,A26,B38,DR4,DR3 SKIN LESION PRECEDS IN 65% CASESSKIN LESION PRECEDS IN 65% CASES AGE OF ONSET- 40TO 60 YEARSAGE OF ONSET- 40TO 60 YEARS
CLINICAL TYPESCLINICAL TYPES
- - PREDOMINANTLY PERIPHERAL MONO OR PREDOMINANTLY PERIPHERAL MONO OR
OLIGO ARTHRITSOLIGO ARTHRITS
- DISTAL INTERPHALINGIAL ARTHRITIS- DISTAL INTERPHALINGIAL ARTHRITIS
-SYMMETRICAL RHEUMATOID LIKE ARTHRITS-SYMMETRICAL RHEUMATOID LIKE ARTHRITS
- ARTHRITIS MUTILANS- ARTHRITIS MUTILANS
-AXIAL ARTHRITIS-AXIAL ARTHRITIS
PSORIATIC ARTHROPATHYPSORIATIC ARTHROPATHY
PSORIASIS ARTHROPATHYPSORIASIS ARTHROPATHY
PSORIATIC ARTHRITISPSORIATIC ARTHRITIS
ARTHRITIS MUTILANSARTHRITIS MUTILANS
Which of the following statements regarding Which of the following statements regarding Psoriasis is correct?Psoriasis is correct? The prevalence in the UK is 10%The prevalence in the UK is 10% Psoriasis is more common at lower geographical Psoriasis is more common at lower geographical
altitudesaltitudes Guttate psoriasis is the most common form of the Guttate psoriasis is the most common form of the
diseasedisease 1% of patients have associated psoriatic 1% of patients have associated psoriatic
arthropathyarthropathy Psoriatic arthropathy precedes cutaneous lesions in Psoriatic arthropathy precedes cutaneous lesions in
29% of cases29% of cases
HISTOPATHOLOGYHISTOPATHOLOGY
HISTOPATHOLOGYHISTOPATHOLOGY
MICRO MUNRO ABSCES FORMATION IN EPIDERMISMICRO MUNRO ABSCES FORMATION IN EPIDERMIS
Which of the following statements regarding Which of the following statements regarding Psoriasis is most truePsoriasis is most true?? Diagnosis requires histological confirmationDiagnosis requires histological confirmation Guttate psoriasis often arises after staphylococcal Guttate psoriasis often arises after staphylococcal
infectioninfection T-cells play a prominent role in the pathogenesis T-cells play a prominent role in the pathogenesis
of psoriasisof psoriasis Ciclosporin is ineffective in the treatment of Ciclosporin is ineffective in the treatment of
psoriasispsoriasis Twin studies have identified no genetic basis for Twin studies have identified no genetic basis for
psoriasispsoriasis
MANAGEMENTMANAGEMENT GENERALGENERAL TOPICALTOPICAL - GAOECKERMAN’S REGIMEN – - GAOECKERMAN’S REGIMEN – 3 TO 6 % COAL TAR 3 TO 6 % COAL TAR
WITH UVAWITH UVA
-INGRAM’S REGIMEN --INGRAM’S REGIMEN -0.05 TO O.1% DIATHRANOL0.05 TO O.1% DIATHRANOL -TOPICAL VIT.D - -TOPICAL VIT.D - I Alfa,25-DIHYDROXY VIT.D 3I Alfa,25-DIHYDROXY VIT.D 3 CALCITRIOL CALCITRIOL CALCIPOTRIOL 50 CALCIPOTRIOL 50 MICROGRAMS/GRAMSMICROGRAMS/GRAMS TACALCITOL – 4 TACALCITOL – 4 MICROGRAMS/GRAMSMICROGRAMS/GRAMS
-TOPICAL CORTICO STEROIDS-TOPICAL CORTICO STEROIDS -TAZAROTENE-TAZAROTENE-TACROLIMUS-TACROLIMUS
PUVA THERAPYPUVA THERAPY
ULTRA VIOLATE (UV) RAYS – B 311nmULTRA VIOLATE (UV) RAYS – B 311nm UVA WITH PSORALINS - PUVAUVA WITH PSORALINS - PUVA
SYSTAMIC – 0.6mg/kg SYSTAMIC – 0.6mg/kg
LOCAL AS BATH 0.1 to 1 % solutionLOCAL AS BATH 0.1 to 1 % solution
PUVA THERAPYPUVA THERAPY
PUVA THERAPYPUVA THERAPYBEFORE AFTERBEFORE AFTER
UVB THERAPY
BEFORE
AFTER
REASONS TO CONSIDER REASONS TO CONSIDER SYSTEMIC THERAPYSYSTEMIC THERAPY
A 74-year-old man with a thirty year history of psoriasis A 74-year-old man with a thirty year history of psoriasis presented with generalised erythroderma of 3 days duration. presented with generalised erythroderma of 3 days duration. Examination reveals him to be shivering but otherwise is well. Examination reveals him to be shivering but otherwise is well. He was treated as an inpatient with emollients and attention to He was treated as an inpatient with emollients and attention to fluid replacement and temperature control but failed to fluid replacement and temperature control but failed to improve after five days. What is the most appropriate next improve after five days. What is the most appropriate next treatment? treatment? Oral hydroxychloroquineOral hydroxychloroquine Oral methotrexateOral methotrexate Oral prednisoloneOral prednisolone Topical coal tarTopical coal tar Topical dithranolTopical dithranol
SYSTAMIC THERAPYSYSTAMIC THERAPY
METHOTREXATE 7.5mg/ weekMETHOTREXATE 7.5mg/ week ORAL RETINOIDSORAL RETINOIDS CYCLOSPORIN 2.5mg/kg/dayCYCLOSPORIN 2.5mg/kg/day STEROIDSSTEROIDS BIOIMUNOLOGICAL AGENTSBIOIMUNOLOGICAL AGENTSINFLIXIMAB,ELALIZUMAB,ALEFAEPTINFLIXIMAB,ELALIZUMAB,ALEFAEPT
HYDROXYUREAHYDROXYUREA
METHOTREXATEMETHOTREXATE
INHIBITS DNA SYNTHESIS BY INHIBITS DNA SYNTHESIS BY
COMPETITIVE INHIBITION OF COMPETITIVE INHIBITION OF
DIHYDROFOLATE REDUCTASE ENZYMEDIHYDROFOLATE REDUCTASE ENZYME
S PHAGE SPECIFIC,S PHAGE SPECIFIC,
EXCERTION BY KIDNY,EXCERTION BY KIDNY,
LIVER CYCLING LIVER CYCLING
LIVERFIBROSISLIVERFIBROSIS
7-5 mg/week DIVIDED DOSES7-5 mg/week DIVIDED DOSES
EXTENSIVE PSORIASIS,EXTENSIVE PSORIASIS,
PUSTULAR PSORIASISPUSTULAR PSORIASIS
PSORIATIC ARTHROPATHYPSORIATIC ARTHROPATHY
ERYTHRODERMAERYTHRODERMA
RETINOIDSRETINOIDS
EETRETINATE 1mg/kgTRETINATE 1mg/kg
ISOTRETINOIN 0.5 to 1 mg/dayISOTRETINOIN 0.5 to 1 mg/day ACITRETIN 25 TO 50 mgACITRETIN 25 TO 50 mg ACT ON GROWTH & DIFFERENTIATION OF EPIDERMAL CELLSACT ON GROWTH & DIFFERENTIATION OF EPIDERMAL CELLS LIPOPHILIC HALF LIFE AS LONG AS 80 DAYSLIPOPHILIC HALF LIFE AS LONG AS 80 DAYS
SIDE EFFECTSSIDE EFFECTS TTERATOGENIC *****ERATOGENIC *****
INCEEAS SERUM LIPIDSINCEEAS SERUM LIPIDS LIVER TOXICITYLIVER TOXICITY DRYNESS OF LIPS EYES, MUCOSADRYNESS OF LIPS EYES, MUCOSACONTRAINDICATED IN PREGNANCYCONTRAINDICATED IN PREGNANCY
MECHANISM OF ACTION OF MECHANISM OF ACTION OF CYCLOSPORINCYCLOSPORIN
CYCLOSPORINCYCLOSPORIN FUNGUS- TALYPOCLADIUM INFLATUSFUNGUS- TALYPOCLADIUM INFLATUS INHIBITORY EFFECT OF T CELLS (IL2)INHIBITORY EFFECT OF T CELLS (IL2) EXTENSIVE, RESISTANT PSORIASISEXTENSIVE, RESISTANT PSORIASIS SIDE FEECTSIDE FEECT RENAL DYSFUNCTION,RENAL DYSFUNCTION, HYPERTENTIONHYPERTENTION GUM HYPERPLASIA,GUM HYPERPLASIA, HYPERTRICOSISHYPERTRICOSIS
PRECAUTIONSPRECAUTIONS PAST MALIGNANCYPAST MALIGNANCY ACUTE INFECTIONS,ACUTE INFECTIONS, NSAD THERAPYNSAD THERAPY
TACROLIMUSTACROLIMUS LEFLUNAMIDELEFLUNAMIDE BIOLOGICAL MODALITIESBIOLOGICAL MODALITIES
ETANERECEPT – 2TNFR+Fc OF IgGETANERECEPT – 2TNFR+Fc OF IgG INFLIXIMAB -- TNF alfaINFLIXIMAB -- TNF alfa ALEFACEPT CHIMERIC LFA -3 IgGALEFACEPT CHIMERIC LFA -3 IgG EFALIZUMAB BINDS TO ICAM -1EFALIZUMAB BINDS TO ICAM -1
TAZAROTENETAZAROTENE
DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS TINEA INECTIONTINEA INECTION DISCOID ECZEMADISCOID ECZEMA LICHEN SIMPLEX CHRONICUSLICHEN SIMPLEX CHRONICUS BOWEN’S DISEASEBOWEN’S DISEASE
COMPLICATIONSCOMPLICATIONS
PROGNOSIS -QUALITY OF LIFEPROGNOSIS -QUALITY OF LIFE