1. Psoriasis
Family Medicine Presentation
Joel E. Rodriguez Ramos
Sunday, February 10, 13
2. Case
• A 54-year-old man present to your office with
white scaly papules and plaques on his elbows,
extensor arms, knees, and shins. In the past 6
months, these lesions have become worse. Upon
further examination scaly and flaky eruptions are
seen on his scalp and feet. The lesions are itchy
and irritating. Family history does not reveal
members with similar symptoms. He is a heavy
smoker who has been unsuccessful in previous
attempts at smoking cessation.
Sunday, February 10, 13
5. Epidemiology
• Incidence: 60 per 100,000 persons a year
• Accounts to 260,000 new cases yearly
• Mean onset: 28 y/o
• Equal distribution amongst genders
Sunday, February 10, 13
6. Etiology
• No specific source has been identified
• Suggested reasons:
• Mono-zygote twin studies have
demonstrated genetic correlations with
the disease.
• The MHC I and II on chromosome 6, as
well as, the PSOR 1 and PSOR 2 genes
have been linked as plausible factors
involved.
Sunday, February 10, 13
7. • Upper respiratory infections,
streptococcal pharyngitis and viral
infections have been linked to Psoriasis
flares
• An immunological influence is seen in
patients who are immunocompromised,
on systemic corticosteroids, beta-
blockers, lithium and antimalarial
drugs.
Sunday, February 10, 13
8. Pathophysiology
• “Skin Cell Hyperplasia”
• Hyper-proliferative disorder
involving the inflammatory
cascade mediators.
• Increased basal and
suprabasal mitotic activity
resulting in the excessive
migration of cells to the
stratum corneum.
• Large quantities of dead cells
present clinically as scales.
Sunday, February 10, 13
9. Pathophysiology
• Pro-inflammatory Cytokines, T-Cells,
Macrophages and EGF are involved.
• In particular, TNF-! is high in serum,
synovium, and psoriatic plaques.
Sunday, February 10, 13
10. Signs and Symptoms
• Acute, Chronic or Intermittent
manifestations
• Erythematous, circumscribed scaly
papules and plaques
• Irritating, Itchy and Burning
• Found at: Elbows, Extensor surfaces,
Knees, Sole of feet, Trunk, Scalp and
less commonly on Nails
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11. Did you know?
There are five
manifestations of
Psoriasis?
Sunday, February 10, 13
13. • Rippled or Pitted nails, earliest sign
• Only present in ~10% of patients
Sunday, February 10, 13
14. Guttate Psoriasis
• Scaly plaques
• Teardrop-shaped
• Pink to salmon color
• Usually on the trunk
• Spares the palms and soles
• Precipitated by Infections
• Ex: Strep Throat
Sunday, February 10, 13
15. Pustular Psoriasis
• Erythematous papules
or plaques
• Studded with pustules
• On palms or soles
• AKA: Palmo-Plantar
Pustular Psoriasis.
• Precipitated by stress,
infection or medications
Sunday, February 10, 13
16. Erythrodermic Psoriasis
• Severe, intense,
generalized erythema
and scaling
• Covers the entire body
• May or may not have
had pre-existing psoriasis
• Precipitated by stress,
infection or medications
Sunday, February 10, 13
17. Psoriatic Arthritis
• Joint involvement that causes
inflammatory damage and
deformity.
• Asymmetric arthritis in around
50% of cases.
• Affects ~10% of people with
psoriasis.
• Most people with nail psoriasis
have psoriatic arthritis.
• Commonly involves fingers,
hands, toes, and feet.
Sunday, February 10, 13
18. Risk Factors
• Stress
• Smoking
• 1.7x increased risk
• Trauma
• Koebner’s Phenomena
• Medications
• Infections
• Family History
• Immunocompromised
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19. Most Accurate Test
• Skin Biopsy
• Munro Neutrophilic Micro-abscess and Intra-epidermal
Spongiform Pustules affecting the Stratum Corneum
Munro Normal Pustule
Sunday, February 10, 13
20. Clinical Test
• Diagnosis can be reached by physical
examination alone thus no serological nor
cytological tests are required.
• ‘Psoriasis Area & Severity Index’ and
‘National Psoriasis Foundation Score’
criteria
Sunday, February 10, 13
21. Next Step in Management?
• Mild - Moderate Psoriasis
• Topical Corticosteroids (1st-line)
• Topical Calcipotriol (Vit-D analog)
• Topical Reinoids
• Topical Coal Tar
• Topical Dithranol (DNA replication)
• Phototherapy (3rd-line)
Sunday, February 10, 13
22. Next Step in Management?
• Moderate - Severe Psoriasis
• Oral Retinoids (1st-line)
• Methotrexate (Anti-Proliferative)
• Cyclosporines (PMN Degranulation)
• Infliximab, Adalimumab or Etanercept
(Monoclonal Antibody against TNF-!)
• Laser Therapy (3rd-line)
Sunday, February 10, 13
23. Prognosis
• Chronic Illness, with long remissions
• Complications
• Psoriatic Arthritis
• Secondary skin Infections
• Phototherapy induced Skin Cancer
• Drug induced Nephrological and Hepatocellular toxicities
• Tuberculosis Reactivation
• Cardiovascular complications
• Patients should have follow-up monitoring every 3 to 6 months
Sunday, February 10, 13
24. Current Research
• Cardiovascular Risk and Psoriasis: the Role of Biologic
Therapy. Puig, L. 2012
• “One of the most clinically important aspects of recent
advances in our understanding of psoriasis has been the
detection of an association between this disease and an
increased prevalence of cardiovascular risk factors.”
• “This increase in prevalence is, in turn, linked to a greater
risk of morbidity and mortality related to acute myocardial
infarction, cerebrovascular accident, and peripheral arterial
disease.”
• “The chronic systemic inflammation present in psoriasis
could explain why moderate to severe psoriasis is an
independent risk factor for cardiovascular disease.”
Sunday, February 10, 13
26. References
• Puig, L. (2012). Cardiovascular risk and Psoriasis: The Role of Biologic Therapy, Actas dermo-
sifiliográficas.
• E-Medicine - http://www.emedicine.com
• Medline Plus - http://www.nlm.nih.gov/medlineplus
• Pub Med Health - http://www.ncbi.nlm.nih.gov
• MedicineNet.com Image Collection - http://www.medicinenet.com/image-collection/
Sunday, February 10, 13
