Seborrheic Dermatitis, Seborrheic Dermatitis, Psoriasis, Recalcitrant Psoriasis, Recalcitrant Palmoplantar Eruptions, Palmoplantar Eruptions, Pustular Dermatitis, and Pustular Dermatitis, and ErythrodermaErythroderma

P214-239P214-239

ANDREWS’ANDREWS’

DISEASES OF THE SKINDISEASES OF THE SKIN

Seborrheic dermatitisSeborrheic dermatitis

2- 5 % of the population2- 5 % of the population Chronic, superficial, inflammatory disease Chronic, superficial, inflammatory disease

of the skinof the skin Predilection for the scalp, eyebrows, Predilection for the scalp, eyebrows,

eyelids, nasolabial creases, lips, ears, eyelids, nasolabial creases, lips, ears, sternal area, axillae, submammary folds, sternal area, axillae, submammary folds, umbilicus, groin, and gluteal creaseumbilicus, groin, and gluteal crease

Characterized by scanty, loose, dry, Characterized by scanty, loose, dry, moist, or greasy scales, and by crusted moist, or greasy scales, and by crusted pink or yellowish patches of various pink or yellowish patches of various shapes and sizesshapes and sizes

Clinical featuresClinical features

Remissions and exacerbationsRemissions and exacerbations No to mild itchingNo to mild itching On the scalp is the most commonOn the scalp is the most common Pityriasis steatoides – oily type, Pityriasis steatoides – oily type,

accompanied by erythema and accompanied by erythema and accumulation of thick crustaccumulation of thick crust

Frequently spreads beyond the Frequently spreads beyond the scalpscalp

Extreme cases involve the entire scalp Extreme cases involve the entire scalp and may have an offensive odorand may have an offensive odor

Cradle capCradle cap Marginal blepharitis – edges of the lids Marginal blepharitis – edges of the lids

becoming erythematous and granular. becoming erythematous and granular. Conjunctiva may be injectedConjunctiva may be injected

On and in the ears may be mistaken for On and in the ears may be mistaken for otitis externa caused by a fungal otitis externa caused by a fungal infectioninfection

KOH – KOH –

The presternal area is a favored site on the The presternal area is a favored site on the trunktrunk

Common in the groin and the gluteal Common in the groin and the gluteal crease crease

In acute stages the inflammation may be In acute stages the inflammation may be intense, with moist exudation from the intense, with moist exudation from the scalp and ears and papulovesicles on the scalp and ears and papulovesicles on the palms and soles. Secondary infections, palms and soles. Secondary infections, impetiginization, or furunculosis may impetiginization, or furunculosis may ensueensue

May progress to a generalized May progress to a generalized exfoliative stateexfoliative state

In the newborn this type of severe and In the newborn this type of severe and generalized seborrheic dermatitis is generalized seborrheic dermatitis is known as erythroderma known as erythroderma desquamativumdesquamativum

May be associated with or accentuated May be associated with or accentuated by several internal diseasesby several internal diseases

Parkinson’s, HIV, DM, Parkinson’s, HIV, DM,

Etiology and pathogenesisEtiology and pathogenesis

Remains unresolvedRemains unresolved Presence of lipophilic yeast Presence of lipophilic yeast

Pityrosporum ovale in large numbers in Pityrosporum ovale in large numbers in scalp lesionscalp lesion

Also demonstrated in those without Also demonstrated in those without seborrheic dermatitisseborrheic dermatitis

Healthy individuals have been found to Healthy individuals have been found to have higher IgG antibodies to the have higher IgG antibodies to the organismorganism

The significance of P ovale in The significance of P ovale in infantile seborrheic dermatitis has infantile seborrheic dermatitis has not been fully evaluatednot been fully evaluated

Familial tendency toward infantile Familial tendency toward infantile and adult seborrheic dermatitisand adult seborrheic dermatitis

histologyhistology

Epidermis is acanthoticEpidermis is acanthotic There is overlying focal scale crust There is overlying focal scale crust

often adjacent to follicular ostiaoften adjacent to follicular ostia Slight spongiosisSlight spongiosis Dermis contains a perivascular Dermis contains a perivascular

mixed cell inflammatory infiltratemixed cell inflammatory infiltrate

Differential diagnosisDifferential diagnosis

Psoriasis, heavier scale and Psoriasis, heavier scale and erythema, Auspitz’s sign, erythema, Auspitz’s sign, resistance to treatment, nail resistance to treatment, nail involvementinvolvement

Crusted scabies of the scalp in Crusted scabies of the scalp in immunodeficiency syndromesimmunodeficiency syndromes

Otitis externa, blepharitis, tinea Otitis externa, blepharitis, tinea corporis, pityriasis rosea, keratosis corporis, pityriasis rosea, keratosis lichenoides chronicalichenoides chronica

TreatmentTreatment

Selenium sulfide, tar, zinc, Selenium sulfide, tar, zinc, pyrithionate, resorcin shampoospyrithionate, resorcin shampoos

NizoralNizoral Corticosteroid solutionCorticosteroid solution Antimicrobial preparations may be Antimicrobial preparations may be

necessarynecessary Bifonazole shampoo has been Bifonazole shampoo has been

shown effective in treating infants shown effective in treating infants and small childrenand small children

Cortisporin otic usually brings Cortisporin otic usually brings about prompt clearingabout prompt clearing

Desonide Otic Lotion, 0.05% Desonide Otic Lotion, 0.05% Desonide and 2% acidic acid is Desonide and 2% acidic acid is also effectivealso effective

Topical steroids should not be used Topical steroids should not be used for blepharitis, since steroid for blepharitis, since steroid preparations used in area may preparations used in area may induce glaucoma and cataractsinduce glaucoma and cataracts

psoriasispsoriasis

A common, chronic, recurrent, A common, chronic, recurrent, inflammatory disease of the skin inflammatory disease of the skin characterized by round, characterized by round, circumscribed, erythematous, dry, circumscribed, erythematous, dry, scaling plaques of various sizes, scaling plaques of various sizes, covered by grayish white or silvery covered by grayish white or silvery white, imbricated and lamellar white, imbricated and lamellar scalesscales

Predilection for the scalp, nails, Predilection for the scalp, nails, extensor surfaces, elbows, knees, extensor surfaces, elbows, knees, umbilical, and sacral regionumbilical, and sacral region

Typically symmetricalTypically symmetrical May be a solitary macule to more than May be a solitary macule to more than

100100 Usually develops slowly but may be Usually develops slowly but may be

exanthematous, with a sudden onset of exanthematous, with a sudden onset of numerous guttate lesionsnumerous guttate lesions

Subjective symptoms such as itching or Subjective symptoms such as itching or burning may be present and cause burning may be present and cause extreme discomfortextreme discomfort

Scales are micaceousScales are micaceous Auspitz’s sign may be observedAuspitz’s sign may be observed Annular, lobulated, and gyrate Annular, lobulated, and gyrate

figures may be producedfigures may be produced Old patches may be thickened and Old patches may be thickened and

tough, and covered with lamellar tough, and covered with lamellar scales like the outside of an oyster scales like the outside of an oyster shell – psoriasis ostraceashell – psoriasis ostracea

Various other descriptive termsVarious other descriptive terms Psoriasis guttataPsoriasis guttata Psoriasis follicularisPsoriasis follicularis Psoriasis figurata, psoriasis Psoriasis figurata, psoriasis

annulata, psoriasis gyrataannulata, psoriasis gyrata Psoriasis discoideaPsoriasis discoidea Psoriasis rupioidesPsoriasis rupioides Plaque psoriasisPlaque psoriasis

Seborrheic-like psoriasisSeborrheic-like psoriasis

In some cases of psoriasis prominent In some cases of psoriasis prominent features of seborrheic dermatitis may features of seborrheic dermatitis may occur not only if the typical sites of occur not only if the typical sites of psoriasis vulgaris but also in the psoriasis vulgaris but also in the flexural areas such as the antecubital flexural areas such as the antecubital areas, axillae, under the breasts, areas, axillae, under the breasts, groins, umbilicus, and intergluteal groins, umbilicus, and intergluteal areasareas

Sebopsoriasis or seborrheic psoriasisSebopsoriasis or seborrheic psoriasis

Inverse psoriasisInverse psoriasis

Flexural psoriasis or volar psoriasisFlexural psoriasis or volar psoriasis Selectively and almost exclusively Selectively and almost exclusively

involves folds, recesses, and involves folds, recesses, and flexural surfacesflexural surfaces

Scalp quite often participates as Scalp quite often participates as wellwell

Onycholysis, “Oil spots”, and nail Onycholysis, “Oil spots”, and nail pitting may be seenpitting may be seen

““Napkin” psoriasisNapkin” psoriasis

Diaper dermatitis caused by the Diaper dermatitis caused by the irritative effects of urine in the wet irritative effects of urine in the wet diaper area, may imitate a psoriasiform diaper area, may imitate a psoriasiform eruptioneruption

In addition there is commonly an In addition there is commonly an infection with Candida albicansinfection with Candida albicans

Lesions typically clearLesions typically clear Infants may be at risk for psoriasis in Infants may be at risk for psoriasis in

adulthoodadulthood

Psoriatic arthritisPsoriatic arthritis

The incidence of psoriasis is 10 The incidence of psoriasis is 10 times greater in persons with times greater in persons with seronegative arthritis than in seronegative arthritis than in persons without arthritispersons without arthritis

Five clinical patternsFive clinical patterns Asymmetrical distal interphalangeal joint Asymmetrical distal interphalangeal joint

involvement with nail damage, 16%involvement with nail damage, 16% Arthritis mutilans with osteolysis of Arthritis mutilans with osteolysis of

phalanges and metacarpals, 5%phalanges and metacarpals, 5% Symmetrical polyarthritis-like rheumatoid Symmetrical polyarthritis-like rheumatoid

arthritis, with claw hands, 15%arthritis, with claw hands, 15% Oligoarthritis with swelling and Oligoarthritis with swelling and

tenosynovitis of one or a few hand joints, tenosynovitis of one or a few hand joints, 70%70%

Ankylosing spondylitis alone or with Ankylosing spondylitis alone or with peripheral arthritis, 5%peripheral arthritis, 5%

Radiographic findings suggestive of psoriatic Radiographic findings suggestive of psoriatic arthritis include: erosion of terminal arthritis include: erosion of terminal phalangeal tufts, tapering of phalanges or phalangeal tufts, tapering of phalanges or metacarpals, “cupping’ of proximal ends of metacarpals, “cupping’ of proximal ends of phalanges, , bony ankylosis, osteolysis of phalanges, , bony ankylosis, osteolysis of metatarsals, predilection for distal and metatarsals, predilection for distal and proximal interphalangeal joints, proximal interphalangeal joints, paravertebral ossification, asymmetrical paravertebral ossification, asymmetrical sacroiliitis, and rarity of “bamboo spine”when sacroiliitis, and rarity of “bamboo spine”when the spine is involvedthe spine is involved

Nearly half the patients with psoriatic Nearly half the patients with psoriatic arthritis have HLA-B27arthritis have HLA-B27

Rest, splinting, passive motion, and Rest, splinting, passive motion, and aspirin or NSAIDs are appropriateaspirin or NSAIDs are appropriate

Methotrexate, cyclosporine, oral Methotrexate, cyclosporine, oral retinoids, sulfasalazine, tacrolimus, and retinoids, sulfasalazine, tacrolimus, and PUVA are all likely to help both the PUVA are all likely to help both the psoriasis and arthritispsoriasis and arthritis

Systemic steroids however, the long term Systemic steroids however, the long term complications and potential for rebound complications and potential for rebound in cutaneous disease restricts their usein cutaneous disease restricts their use

Guttate psoriasisGuttate psoriasis This distinctive form of psoriasis typical This distinctive form of psoriasis typical

lesions are the size of water dropslesions are the size of water drops Usually occurs as an abrupt eruption Usually occurs as an abrupt eruption

following some acute infection, such as following some acute infection, such as streptococcal pharyngitis streptococcal pharyngitis

Occurs mostly in patients under age 30Occurs mostly in patients under age 30 Recurrent episodes are likely, because of Recurrent episodes are likely, because of

pharyngeal carriage of the responsible pharyngeal carriage of the responsible streptococcusstreptococcus

This type of psoriasis is usually rapidly This type of psoriasis is usually rapidly responsive to topical steroids or UVBresponsive to topical steroids or UVB

Generalized pustular Generalized pustular psoriasispsoriasis(von Zumbusch)(von Zumbusch)

Typical patients have had plaque psoriasis Typical patients have had plaque psoriasis and often psoriatic arthritisand often psoriatic arthritis

The onset is sudden, with formation of The onset is sudden, with formation of lakes of pus periungally, on the palms, lakes of pus periungally, on the palms, and at the edge of psoriatic plaquesand at the edge of psoriatic plaques

Pruritis and intense burning cause Pruritis and intense burning cause extreme discomfortextreme discomfort

There is a fever, and a fetid odor developsThere is a fever, and a fetid odor develops The pustules dry up to form yellow-brown The pustules dry up to form yellow-brown

crusts over a reddish-brown shiny surfacecrusts over a reddish-brown shiny surface

Generalized pustular Generalized pustular psoriasispsoriasis(von Zumbusch)(von Zumbusch)

Mucous membrane lesions are common on Mucous membrane lesions are common on the tongue and in the mouththe tongue and in the mouth

The lips are red and scaly, and superficial The lips are red and scaly, and superficial ulcerations of the tongue and mouth occurulcerations of the tongue and mouth occur

May go through several stagesMay go through several stages A number of cases of acute respiratory A number of cases of acute respiratory

distress syndrome associated with pustular distress syndrome associated with pustular and erythrodermic psoriasis have been and erythrodermic psoriasis have been reportedreported

Systemic complications include pneumonia, Systemic complications include pneumonia, CHF and hepatitisCHF and hepatitis

Generalized pustular Generalized pustular psoriasispsoriasis(von Zumbusch)(von Zumbusch)

Etiology unclearEtiology unclear Iodides, coal tar, steroid withdrawal, Iodides, coal tar, steroid withdrawal,

terbinafine, minocycline, terbinafine, minocycline, hydroxychloroquine, acetazolamide, hydroxychloroquine, acetazolamide, and salicylates may trigger the and salicylates may trigger the attacksattacks

May occur in infantsMay occur in infants Acitretin is drug of choice, with a Acitretin is drug of choice, with a

rapid and predictable responserapid and predictable response Isotretinoin, cyclosporine, Isotretinoin, cyclosporine,

methotrexate, dapsonemethotrexate, dapsone

coursecourse

The course of psoriasis is unpredictableThe course of psoriasis is unpredictable Usually begins on the scalp or elbowsUsually begins on the scalp or elbows May first be seen over the sacrumMay first be seen over the sacrum Onset may be sudden and widespreadOnset may be sudden and widespread First lesions may be limited to the First lesions may be limited to the

fingernailsfingernails Two of the chief features of psoriasis Two of the chief features of psoriasis

are its tendency to recur and persistare its tendency to recur and persist

However, patients may remain completely However, patients may remain completely free of lesions for yearsfree of lesions for years

Koebner’s phenomenonKoebner’s phenomenon – the appearance – the appearance of typical lesions of psoriasis at sites of of typical lesions of psoriasis at sites of eve trivial injuryeve trivial injury

Auspitz’s sign – pinpoint bleeding when Auspitz’s sign – pinpoint bleeding when the psoriatic scale is forcibly removed, this the psoriatic scale is forcibly removed, this occurs because of severe thinning of the occurs because of severe thinning of the epidermis over the tips of the dermal epidermis over the tips of the dermal papillapapilla

Woronoff ring – is concentric blanching of Woronoff ring – is concentric blanching of the erythematous skin at or near the the erythematous skin at or near the periphery of the healing psoriatic plaqueperiphery of the healing psoriatic plaque

On the scalp absence of itching or hair loss, On the scalp absence of itching or hair loss, marked predilection for frontal scalp marked predilection for frontal scalp margin, deep erythema, and resistance to margin, deep erythema, and resistance to effective therapy for seborrheic dermatitis effective therapy for seborrheic dermatitis all suggest psoriasisall suggest psoriasis

The palms and soles are often, sometimes The palms and soles are often, sometimes exclusively, affectedexclusively, affected

““flexural” or inverse psoriasis shows flexural” or inverse psoriasis shows salmon-red, demarcated plaques that salmon-red, demarcated plaques that frequently become eczematized, moist and frequently become eczematized, moist and fissured fissured

Numerous cases of psoriasis of the Numerous cases of psoriasis of the mucous membranes have been reportedmucous membranes have been reported

Fingernails and toenails may be involved. Fingernails and toenails may be involved. Characteristic changes include pits, Characteristic changes include pits, onycholysis and cracking of the free edgesonycholysis and cracking of the free edges

Many studies report an association of Many studies report an association of hepatitis C and psoriasis hepatitis C and psoriasis

Hepatitis C has also been implicated in Hepatitis C has also been implicated in psoriatic arthritis psoriatic arthritis

etiologyetiology

The cause of psoriasis is still unknownThe cause of psoriasis is still unknown Heredity is of significance in some Heredity is of significance in some

casescases Evidence that susceptibility to Evidence that susceptibility to

psoriasis is linked to class I and II psoriasis is linked to class I and II major histocompatibility complex on major histocompatibility complex on human chromosome 6 (17q)human chromosome 6 (17q)

HLA associations include -Cw6, -B57, HLA associations include -Cw6, -B57, and -DR7 for early onset and -Cw2 for and -DR7 for early onset and -Cw2 for late onset psoriasislate onset psoriasis

It is believed also that any individual It is believed also that any individual that has –B13 or –B17 has a fivefold that has –B13 or –B17 has a fivefold risk of developing psoriasis risk of developing psoriasis

In pustular psoriasis HLA-B27 may be In pustular psoriasis HLA-B27 may be seenseen

-B13 and -B17 are increased in -B13 and -B17 are increased in guttate and erythrodermic psoriasis guttate and erythrodermic psoriasis

epidemiologyepidemiology Equal frequency in both sexesEqual frequency in both sexes Mean age of onset is 27 years, Mean age of onset is 27 years,

range is widerange is wide Sunlight improvesSunlight improves Emotional stress aggravatesEmotional stress aggravates 39% of patients experience 39% of patients experience

complete periodic disappearance complete periodic disappearance of psoriasis during its courseof psoriasis during its course

Seen in 1-2% of US population. Not Seen in 1-2% of US population. Not seen in Native Americansseen in Native Americans

Distinct tendency to improvement Distinct tendency to improvement with pregnancywith pregnancy

Exacerbation is common after Exacerbation is common after childbirthchildbirth

pathogenesispathogenesis

Characterized by three main pathogenic Characterized by three main pathogenic features: abnormal differentiation, features: abnormal differentiation, keratinocyte hyperproliferation and keratinocyte hyperproliferation and inflammationinflammation

Accelerated epidermopoiesis has been Accelerated epidermopoiesis has been considered to be the fundamental considered to be the fundamental pathologic event in psoriasis pathologic event in psoriasis

The transit rate of psoriatic The transit rate of psoriatic keratinocytes is increased, and the keratinocytes is increased, and the deoxyribonucleic acid synthesis time is deoxyribonucleic acid synthesis time is decreaseddecreased

Early lesion are infiltrated Early lesion are infiltrated predominantly by lymphocytes in predominantly by lymphocytes in the papillary dermisthe papillary dermis

The cause of T-lymphocyte The cause of T-lymphocyte activation and the role of these cell activation and the role of these cell populations remains unclearpopulations remains unclear

stressstress

Studies have shown a positive Studies have shown a positive correlation between stress and the correlation between stress and the severity of diseaseseverity of disease

Drug-induced psoriasisDrug-induced psoriasis

May be induced by many drugs: May be induced by many drugs: beta blockers, lithium, and beta blockers, lithium, and antimalarials, terbinafine, calcium antimalarials, terbinafine, calcium channel blockers, captopril, channel blockers, captopril, glyburide, and lipid lowering glyburide, and lipid lowering agents such as gemfibrozilagents such as gemfibrozil

PathologyPathology

Regular epidermal hyperplasia with Regular epidermal hyperplasia with long, test-tube-shaped rete ridgeslong, test-tube-shaped rete ridges

Thinning of dermal papillaeThinning of dermal papillae Granular layer is thin or absentGranular layer is thin or absent Overlying parakeratosisOverlying parakeratosis Small collections of neutrophils (Munro Small collections of neutrophils (Munro

microabcesses) may be present in the microabcesses) may be present in the stratum corneumstratum corneum

There is a perivascular mononuclear cell There is a perivascular mononuclear cell infiltrateinfiltrate

Differential diagnosisDifferential diagnosis

Seborrheic dermatitis, pityriasis Seborrheic dermatitis, pityriasis rosea, lichen planus, eczema, rosea, lichen planus, eczema, psoriasiform syphilid, and lupus psoriasiform syphilid, and lupus erythematosis erythematosis

Distribution, quality of the scale Distribution, quality of the scale and presence of Auspitz’s sign, and presence of Auspitz’s sign, symptoms, serologic testing symptoms, serologic testing

treatmenttreatment

Topical Topical Systemic Systemic CombinationCombination Rotating therapeutic approaches, Rotating therapeutic approaches,

especially with systemic agents especially with systemic agents that have varying toxicitiesthat have varying toxicities

Topical treatmentTopical treatment

In many patients topical In many patients topical applications alone will suffice to applications alone will suffice to keep psoriasis under control. keep psoriasis under control. Numerous local medications are Numerous local medications are available available

CorticosteroidsCorticosteroids Most frequent therapyMost frequent therapy Ointments are more effectiveOintments are more effective Creams are preferred in the Creams are preferred in the

intertriginous areas and in exposed intertriginous areas and in exposed areasareas

Effectiveness may be augmented by an Effectiveness may be augmented by an occlusive dressing, prompt response is occlusive dressing, prompt response is usually notedusually noted

Side effects include miliaria, pyoderma, Side effects include miliaria, pyoderma, epidermal atrophyepidermal atrophy

Intralesional corticosteroid Intralesional corticosteroid injectionsinjections

Good results when treating Good results when treating psoriatic nailspsoriatic nails

tarstars

The staining property and the odor The staining property and the odor of the tars may hinder their useof the tars may hinder their use

Coal tar or liquor carbonis Coal tar or liquor carbonis detergents is applied to the lesions detergents is applied to the lesions before ultraviolet treatment in the before ultraviolet treatment in the Goeckerman methodGoeckerman method

dihydroxyanthralindihydroxyanthralin

Anthralin exerts its direct effect on Anthralin exerts its direct effect on keratinocytes and leukocytes by keratinocytes and leukocytes by suppressing neutrophil superoxide suppressing neutrophil superoxide generation and inhibition of generation and inhibition of monocyte derived IL-6, IL-8, and monocyte derived IL-6, IL-8, and TNF-alphaTNF-alpha

Highly irritating and stains skin, Highly irritating and stains skin, clothing and beddingclothing and bedding

tazarotenetazarotene

Appears to treat psoriasis by Appears to treat psoriasis by modulating keratinocyte modulating keratinocyte differentiation and hyperproliferation, differentiation and hyperproliferation, as well as suppressing inflammationas well as suppressing inflammation

Produces local irritationProduces local irritation Combination with topical Combination with topical

corticosteroids aids in patient corticosteroids aids in patient acceptanceacceptance

Vitamin DVitamin D

Vitamin D3 affects keratinocyte Vitamin D3 affects keratinocyte differentiation partly through its differentiation partly through its regulation of epidermal responsiveness regulation of epidermal responsiveness to calciumto calcium

Has been shown to be very effective in Has been shown to be very effective in the treatment of plaque-type and scalp the treatment of plaque-type and scalp psoriasispsoriasis

Combination therapy with high-potency Combination therapy with high-potency steroids may provide greater responsesteroids may provide greater response

Salicylic acidSalicylic acid

Aids in removing of the scale and Aids in removing of the scale and promoting the efficacy of other promoting the efficacy of other topical agentstopical agents

Usually in a 3% to a 5% Usually in a 3% to a 5% concentrationconcentration

Widespread application may lead to Widespread application may lead to salicylate toxicitysalicylate toxicity

Tinnitus, acute confusion, refractory Tinnitus, acute confusion, refractory hypoglycemiahypoglycemia

Ultraviolet lightUltraviolet light In most instances sunlight improves In most instances sunlight improves

psoriasis remarkablypsoriasis remarkably However, burning of the skin may cause However, burning of the skin may cause

Koebner’s phenomenon and an Koebner’s phenomenon and an exacerbationexacerbation

UVBUVB Tar applications or baths before UVB Tar applications or baths before UVB

exposure have been credited with exposure have been credited with enhancing its effectsenhancing its effects

Maintenance UVB phototherapy after Maintenance UVB phototherapy after clearing contributes to the duration of clearing contributes to the duration of remissionremission

Narrow band UVB has been shown Narrow band UVB has been shown to be more effective in treating to be more effective in treating psoriasis than broadbandpsoriasis than broadband

Goeckerman techniqueGoeckerman technique

2 to 5% tar preparation is applied 2 to 5% tar preparation is applied to the skin, and a tar bath is taken to the skin, and a tar bath is taken at least once daily. The excess tar at least once daily. The excess tar is removed with mineral or is removed with mineral or vegetable oil and ultraviolet light is vegetable oil and ultraviolet light is givengiven

Ingram techniqueIngram technique

Consists of a daily coal tar bath in a Consists of a daily coal tar bath in a solution such as 120 ml liquor carbonis solution such as 120 ml liquor carbonis detergens to 80 L of warm waterdetergens to 80 L of warm water

This is followed by exposure to an This is followed by exposure to an ultraviolet light for daily increasing periodsultraviolet light for daily increasing periods

Anthralin paste is then applied to each Anthralin paste is then applied to each psoriatic plaque psoriatic plaque

Talcum powder is sprinkled over the Talcum powder is sprinkled over the lesions, and a stockinette dressing is lesions, and a stockinette dressing is appliedapplied

PUVA therapyPUVA therapy

UVA given 2 hours after ingestion of 8-UVA given 2 hours after ingestion of 8-methoxypsoralen (Oxsoralen), and given methoxypsoralen (Oxsoralen), and given two to three times a weektwo to three times a week

Maintenance treatment is neededMaintenance treatment is needed Risk of enhanced carcinogenesis is provenRisk of enhanced carcinogenesis is proven Reversal of the usual ratio of squamous Reversal of the usual ratio of squamous

cell carcinomas to basal cell carcinomascell carcinomas to basal cell carcinomas Accelerated actinic elastosis, melanocyte Accelerated actinic elastosis, melanocyte

dysplasia, and possible increased dysplasia, and possible increased incidence of melanoma should be incidence of melanoma should be consideredconsidered

Surgical treatmentSurgical treatment

Denervation by surgery has long been Denervation by surgery has long been known to abolish psoriatic plaquesknown to abolish psoriatic plaques

Excision to the depth of the reticular Excision to the depth of the reticular dermisdermis

In a group of 14 patients with In a group of 14 patients with pharyngeal colonization by pharyngeal colonization by streptococci unresponsive to streptococci unresponsive to antibiotic therapy 9 cleared after antibiotic therapy 9 cleared after tonsillectomytonsillectomy

Lasers in psoriasisLasers in psoriasis

Psoriatic plaques can be cleared by Psoriatic plaques can be cleared by destruction of the upper dermisdestruction of the upper dermis

Blood vessels in the psoriatic Blood vessels in the psoriatic dermal papillae can be selectively dermal papillae can be selectively destroyed with yellow lasers destroyed with yellow lasers effectiveness with flashlamp effectiveness with flashlamp pulsed dye laserpulsed dye laser

Some success with CO2 Some success with CO2 resurfacing laserresurfacing laser

hyperthermiahyperthermia

22 chronic psoriatic plaques in 9 22 chronic psoriatic plaques in 9 patients were heated to 42 – 45 C with patients were heated to 42 – 45 C with ultrasound for 30 minutes 3 times a ultrasound for 30 minutes 3 times a week for 4 to 10 treatments. 15 week for 4 to 10 treatments. 15 completely clearedcompletely cleared

Microwave hyperthermia may produce Microwave hyperthermia may produce significant complications such as pain significant complications such as pain over bony prominences and over bony prominences and hypotensionhypotension

Occlusive treatmentOcclusive treatment

Report of clearing of psoriatic Report of clearing of psoriatic lesion by occluding them with tapelesion by occluding them with tape

Has been shown that hydrocolloid Has been shown that hydrocolloid occlusion (with Actiderm) had a occlusion (with Actiderm) had a similar effect on small lesionssimilar effect on small lesions

Systemic treatmentSystemic treatment

CorticosteroidsCorticosteroids MethotrexateMethotrexate CyclosporineCyclosporine DietDiet Oral antimicrobial therapyOral antimicrobial therapy RetinoidsRetinoids dapsonedapsone

CorticosteroidsCorticosteroids

The side effects of orally The side effects of orally administered prednisone are so administered prednisone are so dangerous that its use should be dangerous that its use should be limited to patients with unusual limited to patients with unusual individual circumstancesindividual circumstances

There is a great risk of “rebound” There is a great risk of “rebound” or induction of pustular psoriasis or induction of pustular psoriasis when it is stoppedwhen it is stopped

MethotrexateMethotrexate

Was the first effective systemic drug for Was the first effective systemic drug for psoriasis and is the standard for psoriasis and is the standard for systemic therapysystemic therapy

Methotrexate has greater affinity for Methotrexate has greater affinity for dihydrofolic acid reductase than has dihydrofolic acid reductase than has folic acidfolic acid

The synthesis of deoxyribonucleic acid The synthesis of deoxyribonucleic acid is blocked when dihydrofolic acid is blocked when dihydrofolic acid reductase is bound and thereby cell reductase is bound and thereby cell division is decreaseddivision is decreased

May also affect the inflammatory elements May also affect the inflammatory elements of psoriasis of psoriasis

Indications for its use include psoriatic Indications for its use include psoriatic erythroderma, moderate to severe erythroderma, moderate to severe psoriatic arthritis, acute pustular psoriasis, psoriatic arthritis, acute pustular psoriasis, more than 20% total body surface more than 20% total body surface involvement, localized pustular psoriasis, involvement, localized pustular psoriasis, psoriasis that affects certain areas of the psoriasis that affects certain areas of the body so that normal function and body so that normal function and employment are prevented, lack of employment are prevented, lack of response to phototherapy, PUVA, or response to phototherapy, PUVA, or retinoids retinoids

Prior to start of treatment ensure Prior to start of treatment ensure that there is no history of liver or that there is no history of liver or kidney diseasekidney disease

Alcohol abuse, cirrhosis, severe Alcohol abuse, cirrhosis, severe illness, debility, pregnancy, anemia illness, debility, pregnancy, anemia should be consideredshould be considered

AST, ALT, bilirubin, serum albumin, AST, ALT, bilirubin, serum albumin, creatinin. Alkaline phosphatase, creatinin. Alkaline phosphatase, CBC, platelets, Hep B and C CBC, platelets, Hep B and C serology, and UA should all be serology, and UA should all be evaluated prior to txevaluated prior to tx

Most patients with no risk factors for Most patients with no risk factors for liver disease the first liver biopsy liver disease the first liver biopsy should be obtained at approximately should be obtained at approximately 1.0 to 1.5 g of cumulative 1.0 to 1.5 g of cumulative methotrexate and repeated every methotrexate and repeated every subsequent 1.5 g until a total of 4 g is subsequent 1.5 g until a total of 4 g is reachedreached

3 divided oral doses 12 hrs apart 3 divided oral doses 12 hrs apart weekly, once weekly doses orally and weekly, once weekly doses orally and single weekly subcutaneous injections single weekly subcutaneous injections are effective treatment schedulesare effective treatment schedules

CyclosporineCyclosporine

The therapeutic benefit of the The therapeutic benefit of the immunosupressive features of immunosupressive features of cyclosporine in psoriatic disease may cyclosporine in psoriatic disease may be related to down modulation of be related to down modulation of proinflammatory epidermal cytokinesproinflammatory epidermal cytokines

Biopsies of the kidney in 30 patients Biopsies of the kidney in 30 patients after 2 years of cyclosporine treatment after 2 years of cyclosporine treatment found features consistent with found features consistent with cyclosporine-induced nephrotoxicitycyclosporine-induced nephrotoxicity

Another study concluded that Another study concluded that cyclosporine may be used long-term (5-cyclosporine may be used long-term (5-10 years) in severe, recalcitrant psoriasis 10 years) in severe, recalcitrant psoriasis if renal function is closely monitoredif renal function is closely monitored

Induction of therapy with 2.5 to 3.0 mg/kg Induction of therapy with 2.5 to 3.0 mg/kg given as a divided dose twice daily and given as a divided dose twice daily and may be increased to 5.0 mg/kg/day until a may be increased to 5.0 mg/kg/day until a clinical response is notedclinical response is noted

DietDiet

Controlled studies evaluating various Controlled studies evaluating various dietary restrictions, especially those of dietary restrictions, especially those of low protein intake, showed no low protein intake, showed no appreciable difference in the course of appreciable difference in the course of psoriasis psoriasis

Another study found psoriasis to be Another study found psoriasis to be more severe in patients trying herbal more severe in patients trying herbal remedies, vitamin therapy, and dietary remedies, vitamin therapy, and dietary manipulationmanipulation

Most recent trials have Most recent trials have demonstrated the demonstrated the antiinflammatory effects of fish oils antiinflammatory effects of fish oils rich in n-3 polyunsaturated fatty rich in n-3 polyunsaturated fatty acids in rheumatoid arthritis, acids in rheumatoid arthritis, inflammatory bowel disease, inflammatory bowel disease, psoriasis and asthmapsoriasis and asthma

Oral antimicrobial therapyOral antimicrobial therapy

Recent evidence suggest that Recent evidence suggest that Staphylococcus aureusStaphylococcus aureus and and streptococci secrete a large family streptococci secrete a large family of exotoxins that are superantigens, of exotoxins that are superantigens, producing massive T-cell activationproducing massive T-cell activation

Oral antibiotic for psoriasis patients Oral antibiotic for psoriasis patients infected with these organisms is infected with these organisms is imperativeimperative

RetinoidsRetinoids

Treatment with 13-cis-retinoic acid can Treatment with 13-cis-retinoic acid can produce good results, especially in produce good results, especially in pustular psoriasispustular psoriasis

It is a potent teratogenIt is a potent teratogen Combinations of retinoic acids with Combinations of retinoic acids with

photochemotherapy for chronic plaque photochemotherapy for chronic plaque psoriasis may also be very affectivepsoriasis may also be very affective

EtretinateEtretinate Acitretin, avoid pregnancy for up to 3 Acitretin, avoid pregnancy for up to 3

years following cessation of therapyyears following cessation of therapy

dapsonedapsone

Use is limited largely to Use is limited largely to palmoplantar eruptionspalmoplantar eruptions

Combination therapyCombination therapy

Patient on methotrexate may have Patient on methotrexate may have their dose minimized with their dose minimized with concomitant topical steroid useconcomitant topical steroid use

PUVA with AcitretinPUVA with Acitretin PUVA with cyclosporinePUVA with cyclosporine PUVA with methotrexatePUVA with methotrexate Topical Dovonex with Acitretin, Topical Dovonex with Acitretin,

cyclosporine, methotrexate, and cyclosporine, methotrexate, and phototherapyphototherapy

The principle behind combination therapy is The principle behind combination therapy is the use of agents win which the side effects the use of agents win which the side effects profile is different or partly opposingprofile is different or partly opposing

Hydroxyurea and sulfalsalazine have been Hydroxyurea and sulfalsalazine have been used in severe cases and in combination used in severe cases and in combination with other modalities, such as PUVAwith other modalities, such as PUVA

Particularly useful in topical therapy, where Particularly useful in topical therapy, where the risk profiles are considerably lessthe risk profiles are considerably less

Reiter’s syndromeReiter’s syndrome

Characteristic clinical triad consisting of Characteristic clinical triad consisting of urethritis, conjunctivitis, and arthritisurethritis, conjunctivitis, and arthritis

May also be other features that involve May also be other features that involve the skin , mucous membranes, gi tract, the skin , mucous membranes, gi tract, and cardiovascular systemand cardiovascular system

American Rheumatism Association American Rheumatism Association criterion of peripheral arthritis of more criterion of peripheral arthritis of more than 1 month duration, in association than 1 month duration, in association with urethritis and/or cervicitiswith urethritis and/or cervicitis

Occurs chiefly in young men of HLA-B27 Occurs chiefly in young men of HLA-B27 genotypegenotype

Clinical featuresClinical features

Any one of the triad of urethritis, Any one of the triad of urethritis, conjunctivitis, or arthritis may occur first, conjunctivitis, or arthritis may occur first, accompanied by fever, weakness, and accompanied by fever, weakness, and weight loss.weight loss.

A nonbacterial urethritis may develop with A nonbacterial urethritis may develop with painful and bloody urination and pyuria painful and bloody urination and pyuria

About 1/3 of patients develop conjunctivitisAbout 1/3 of patients develop conjunctivitis Keratitis is usually superficial and very Keratitis is usually superficial and very

painful. Iritis is commonpainful. Iritis is common

An asymmetric arthritis afflicts An asymmetric arthritis afflicts synovial joints, especially those synovial joints, especially those that are weight bearingthat are weight bearing

Onset is sudden with heat and Onset is sudden with heat and tenderness and swellingtenderness and swelling

Pain in one or both heels is a Pain in one or both heels is a frequent symptomfrequent symptom

The skin lesions start as multiple, The skin lesions start as multiple, small, yellowish vesicles that break, small, yellowish vesicles that break, become confluent and form become confluent and form superficial erosionssuperficial erosions

Develop frequently on the genitals Develop frequently on the genitals and palmsand palms

Eruption on the glans penis occurs in Eruption on the glans penis occurs in 25% of patients25% of patients

Lesions on the soles start as pustules, Lesions on the soles start as pustules, become crusted or hyperkeratoticbecome crusted or hyperkeratotic

The eruption is known as The eruption is known as keratoderma blennorrhagicumkeratoderma blennorrhagicum

Penile lesions are frequentPenile lesions are frequent Characterized by perimeatal Characterized by perimeatal

balanitis, these become crusted balanitis, these become crusted and form circinate lesionsand form circinate lesions

Similar lesion are seen on the Similar lesion are seen on the vaginal mucosa of womenvaginal mucosa of women

Nails become thick and brittle, with Nails become thick and brittle, with development of subungal keratosis development of subungal keratosis

Endocarditis, pericarditis, and Endocarditis, pericarditis, and myocarditis, as well as aortic myocarditis, as well as aortic insufficiency occur in someinsufficiency occur in some

In children conjunctivitis is the In children conjunctivitis is the most frequent complaintmost frequent complaint

etiologyetiology

Syndrome has been attributed to many Syndrome has been attributed to many different agents such as different agents such as Shigella Shigella flexneri, Salmonella spp., yersinia spp., flexneri, Salmonella spp., yersinia spp., Ureaplasma urealyticum, Borrelia Ureaplasma urealyticum, Borrelia burgdorferi, Cryptosporidia,burgdorferi, Cryptosporidia, and and Campylobacter fetusCampylobacter fetus

May be responsible for the infectious May be responsible for the infectious enteritis that precedes onset in a small enteritis that precedes onset in a small percentage of patientspercentage of patients

In cases that follow an infection of the In cases that follow an infection of the genitourinary tract, genitourinary tract, Chlamydia Chlamydia trachomatis trachomatis may be associatedmay be associated

HLA-B27 positivity is present in HLA-B27 positivity is present in 80% of cases of Reiter’s syndrome80% of cases of Reiter’s syndrome

This rises to 90 to 100% in patients This rises to 90 to 100% in patients with accompanying sacroiliitis, with accompanying sacroiliitis, uveitis, or aortitisuveitis, or aortitis

May be caused by abnormalities in May be caused by abnormalities in the production and elicitation of the production and elicitation of immune mediators or T cellsimmune mediators or T cells

Laboratory findingsLaboratory findings

No specific changes are No specific changes are characteristic of this syndromecharacteristic of this syndrome

A leukocytosis of 10, 000 to 20, A leukocytosis of 10, 000 to 20, 000/mm3 and an elevated sed rate 000/mm3 and an elevated sed rate are the most consistent findingsare the most consistent findings

histopathologyhistopathology

Identical to psoriasisIdentical to psoriasis

Differential diagnosisDifferential diagnosis

May be confused with rheumatoid May be confused with rheumatoid arthritis, ankylosing spondylitis, arthritis, ankylosing spondylitis, gout, psoriatic arthritis, gonococcal gout, psoriatic arthritis, gonococcal arthritis, acute rheumatic fever, arthritis, acute rheumatic fever, chronic mucocutaneous chronic mucocutaneous candidiasis, and serum sicknesscandidiasis, and serum sickness

treatmenttreatment

Usually mucocutaneous lesions are Usually mucocutaneous lesions are self limited and clear within a few self limited and clear within a few monthsmonths

Topical steroids are helpfulTopical steroids are helpful NSAIDs for the joint diseaseNSAIDs for the joint disease Methotrexate for severe diseaseMethotrexate for severe disease Cyclosporine Cyclosporine AcitretinAcitretin

The course is characterized by The course is characterized by exacerbations and remission in exacerbations and remission in about on third of patientsabout on third of patients

A chronic deforming arthritis A chronic deforming arthritis occurs in a bout 20% of patients, occurs in a bout 20% of patients, with significant disability resulting, with significant disability resulting, chiefly from foot deformitieschiefly from foot deformities

Subcorneal pustular dermatosisSubcorneal pustular dermatosis

(Sneddon-Wilkinson Disease(Sneddon-Wilkinson Disease))

Chronic pustular disease which occurs Chronic pustular disease which occurs chiefly in middle-aged women.chiefly in middle-aged women.

Pustules are superficial and arranged in Pustules are superficial and arranged in annular and serpiginous patterns, annular and serpiginous patterns, especially on the abdomen, axillae and especially on the abdomen, axillae and groinsgroins

Sometimes vesicles are presentSometimes vesicles are present Cultures from pustules are sterileCultures from pustules are sterile Oral lesions are rareOral lesions are rare Some cases occur in association with and Some cases occur in association with and

IgA monoclonal gammopathyIgA monoclonal gammopathy

Subcorneal pustular dermatosisSubcorneal pustular dermatosis(Sneddon-Wilkinson Disease)(Sneddon-Wilkinson Disease)

Dapsone appears to be effective in Dapsone appears to be effective in most casesmost cases

SulfapyridineSulfapyridine AcitretinAcitretin Narrow band UVBNarrow band UVB Corticosteroids, colchicine, and Corticosteroids, colchicine, and

TCN with niacinamideTCN with niacinamide Without treatment this is a chronic Without treatment this is a chronic

condition with remissions of condition with remissions of variable durationvariable duration

Eosinophilic pustular Eosinophilic pustular folliculitisfolliculitis

Also referred to as Also referred to as sterile sterile eosinophilic pustulosis eosinophilic pustulosis

Five times more common in malesFive times more common in males Peak age of onset in the third Peak age of onset in the third

decade, although a number of decade, although a number of pediatric cases have been reportedpediatric cases have been reported

Characterized by pruritic, follicular Characterized by pruritic, follicular papulopustules arranged in groupspapulopustules arranged in groups

Plaques may formPlaques may form

Eosinophilic pustular Eosinophilic pustular folliculitisfolliculitis

Distribution is usually asymmetrical, Distribution is usually asymmetrical, with the face, trunk, and upper with the face, trunk, and upper extremities most often afflictedextremities most often afflicted

Cause is unknown, however, Cause is unknown, however, numerous studies have implicated numerous studies have implicated chemotactic substances, ICAM-1, chemotactic substances, ICAM-1, and cyclooxygenase-generated and cyclooxygenase-generated metabolitesmetabolites

Typical course is one of spontaneous Typical course is one of spontaneous remissions and exacerbations lasting remissions and exacerbations lasting from a few months to several yearsfrom a few months to several years

Eosinophilic pustular Eosinophilic pustular folliculitisfolliculitis

Dapsone or systemic steroids are Dapsone or systemic steroids are the treatment of choicethe treatment of choice

Success with intralesional steroids, Success with intralesional steroids, clofazimine, minocycline, clofazimine, minocycline, isotretinoin, UVB therapy, isotretinoin, UVB therapy, indomethacin, colchicine, indomethacin, colchicine, cyclosporine, and cetirizinecyclosporine, and cetirizine

Must be distinguished from HIV-Must be distinguished from HIV-associated EFassociated EF

Eosinophilic pustular Eosinophilic pustular folliculitisfolliculitis

Another variant has been described that Another variant has been described that occurs early in childhoodoccurs early in childhood

Patients develop sterile pustules and Patients develop sterile pustules and papules preferentially over the scalp and; papules preferentially over the scalp and; however, scattered clusters of pustules however, scattered clusters of pustules may occur over the trunk and extremitiesmay occur over the trunk and extremities

High-potency topical steroids are the High-potency topical steroids are the treatment of choice treatment of choice

Recurrent exacerbations and remissions Recurrent exacerbations and remissions usually occur with spontaneous remissionusually occur with spontaneous remission