PSORIASIS-2

WHAT IS THE CLINICAL PRESENTATION OF PSORIASIS??

📌 CLINICAL FEATURES:-

Pruritus is often the dominant symptom.

Skin tightness and burning are frequent in unstable,
erythrodermic or pustular psoriasis.

Pain may be experienced in areas of fissure formation, particularly in
palmoplantar or flexural disease.

The first manifestation of psoriasis may develop at any age and ingeneral, those with earlier onset disease are more likely to have a family history of psoriasis. The course of the disease including the frequency of relapses and remissions varies greatly between individuals

Plaque psoriasis is the most common type of psoriasis, accounting for about 80–90% of all cases. It presents as a papulosquamous lesion, and the diagnosis is based on the typical appearance of individual lesions and their characteristic distribution on the skin. Typical lesions are erythematous, scaly plaques, which are remarkably well demarcated from unaffected skin, with sharply delineated edges.
When multiple, lesions are usually monomorphic and distributed relatively symmetrically over the scalp, trunk and extensor surfaces of the limbs.They vary in diameter from one to several centimetres and are oval or irregular in shape. Large plaques may form by coalescence of smaller plaques and are
commonly seen on the legs and sacral region. Most Psoriatic lesions are surmounted by silvery white micacious scales.The successive removal of scales usually reveals an underlying smooth glossy red membrane with small bleeding points where the supra papillary epidermis has been torn off (Auspitz’s sign). 

A study by Ejaz et al observed that stable plaque psoriasis is the commonest clinical type(88.9%) followed by guttate psoriasis(8.7%), Erythrodermic psoriasis(1.9%) and least common was pustular psoriasis(0.4%).

📌CLASSIFICATION

1)Clinical forms of psoriasis (based on morphology or natural history):-

• Plaque psoriasis (psoriasis vulgaris)
• Acute guttate psoriasis
• Unstable psoriasis
• Erythrodermic psoriasis
• Pustular psoriasis
• Atypical forms of psoriasis

2)Other specified forms of psoriasis (based on age or precipitants):-

• Linear and segmental psoriasis
• Psoriasis in childhood and old age
• Photoaggravated psoriasis
• Drug‐induced or exacerbated psoriasis
• HIV‐induced or exacerbated psoriasis

3)Psoriasis affecting specific sites:-

• Scalp psoriasis
• Follicular psoriasis
• Seborrhoeic psoriasis (sebopsoriasis)
• Flexural psoriasis (inverse psoriasis)
• Genital psoriasis
• Non‐pustular palmoplantar psoriasis
• Nail psoriasis
• Mucosal lesions
• Ocular lesions

📌 CHRONIC PLAQUE PSORIASIS:-

Psoriasis vulgaris is the most common form of psoriasis, seen in approximately 90% of patients.Erythematous, scaly, symmetrically distributed plaques are characteristically localized to the extensor aspects of the extremities, particularly the elbows and knees, along with scalp, lower lumbosacral, buttocks, and genital involvement.

 📍Psoriasis geographica - Single small lesions may become confluent forming plaques in which the borders resemble a land map.

 📍Psoriasis gyrata - Lesions may extend laterally and become circinate because of the confluence of several plaques.

 📍Annular psoriasis - Occasionally, there is partial central clearing, resulting in ring-like lesions. This is usually associated with lesional clearing

📍 Rupioid psoriasis - refers to lesions in the shape of a cone or limpet.

📍 Ostraceous psoriasis - an infrequently used term, refers to a ring like, hyperkeratotic concave lesion, resembling an oyster shell.

 📍Elephantine psoriasis - an uncommon form characterized by thickly scaling, large plaques, usually on the lower extremities.

Nearly 100 years ago, Dr D. L. Woronoff, a dermatologist at the clinic for skin diseases of Moscow,University in Russia, described the clinical appearance of “pseudoatrophic” annular zone surrounding acanthotic psoriatic plaques.  He concluded that this zone inhibited further development of the psoriatic plaque and was more likely to result in regression of psoriasis lesions.This hypopigmented ring (Woronoff ring) surrounding individual psoriatic lesions may be due to the inhibition of prostaglandin synthesis.

📌GUTTATE PSORIASIS:-

In this distinctive form of psoriasis, typical lesions are of the size of water drops, 2– 5 mm in diameter. Lesions typically occur as an abrupt eruption following some
acute infection, such as a streptococcal pharyngitis. Patients with a history of chronic plaque psoriasis may develop guttate lesions, with or without worsening of their chronic plaques.

📌 UNSTABLE PSORIASIS:-

In contrast to the lesions in plaque psoriasis which are static
for prolonged periods, in some individuals and in some phases of the disease, there is more marked activity .This can be in the form of enlargement of plaques which become more intensely erythematous, and the development of many new smaller plaques.

 📌ERYTHRODERMIC PSORIASIS:- 

In this type of psoriasis, most or whole of the body
surface is affected by psoriasis.  Occur in 1–2% of patients. Psoriasis has been found to be the underlying cause in about 25% of cases of erythroderma. 

📌 PUSTULAR PSORIASIS :-

The term, “Pustular psoriasis” is reserved for those forms of the disease in which macroscopic pustules appear. Can be either localised or generalised variant. 

📌PSORIATIC ARTHRITIS

Psoriatic arthritis is a seronegative inflammatory arthritis. 

Five clinical patterns of arthritis occur  :
1. Asymmetrical distal interphalangeal joint involvement with nail damage (16%)
2. Arthritis mutilans with osteolysis of phalanges and metacarpals (5%)
3. Symmetrical polyarthritis-like rheumatoid arthritis, with claw hands (15%)
4. Oligoarthritis with swelling and tenosynovitis of one or a few hand joints (70%)
5. Ankylosing spondylitis alone or with peripheral arthritis (5%).

 📌ASSOCIATIONS OF PSORIASIS:-

Several important diseases occur more often in patients with psoriasis than expected based on their respective prevalence in the general population. Comorbid diseases of psoriasis include Crohn’s disease, cancer, depression, non-alcoholic fatty liver disease, metabolic syndrome (or components of it), and cardiovascular disorders ,all of which contribute substantially to morbidity and mortality in patients with psoriasis. Comorbid disease needs to be treated, therefore the number of drugs taken by patients with psoriasis is substantially higher than in the general population.Life expectancy of patients with psoriasis is substantially reduced, with cardiovascular diseases contributing the most. Association of comorbid disease with psoriasis might be due to similarities in the genetic basis of these diseases.

📍EVIDENCE OF THE ASSOCIATION BETWEEN PSORIASIS AND
METABOLIC SYNDROME

Moderate-to-severe psoriasis is often associated with the clinical features of the metabolic disorders .Study conducted by Armstrong et al is the largest systematic review and the first meta-analysis examining the relationship between psoriasis and metabolic syndrome with 41,853 psoriasis patients from more than1.4 million total participants. They found that patients with psoriasis have a high overall prevalence of metabolic syndrome. These findings emphasize that patients with psoriasis should be screened for metabolic syndrome.

The basis of association between psoriasis and metabolic syndrome is the sharing of a chronic pro-inflammatory state by both the diseases.

*NAFLD-METABOLIC SYNDROME-PSORIASIS TRIAD

These three diseases contribute each other and accentuats the risk of getting each

disease.Sharing of a common pro-inflammatory state is the basis of this triad. This triad is significant as it causes considerable morbidity compared to the patients with any of these individual diseases.