Psoriasis

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I-DEFINITION/GENERALITIES:

• It is a chronic and recurrent erythemato-squamous dermatosis of evolution.
• Affecting 1 to 2% of the general population.
• It can occur at any age (20 and 30 years) but remains rare before ten years (10 to 15%)
• Psoriasis affects both men and women at equal frequencies.
• Essentially clinical diagnosis
• Benign dermatosis, The usual form poses only an aesthetic damage, but significantly impairs the quality of life however there are serious forms of part:

• The extent of the lesions.
• The modification of the elemental lesion.
• The association with arthropathies. (erythrodermia, pustular psoriasis, psoriatic arthritis)

• TRT is symptomatic: often based on local therapies, general treatments are reserved for severe forms

Pathogenesis remains poorly understudged:

– Psoriasis is characterized by an acceleration of epidermal renewal

Turn over normal epidermal is 30 days

In psoriasis only 7 days

– this is related to immune disorders

– activation of LT – secretion of different cytokines (TNF Alpha, IL12, IL23 …)

– causing a psoriatic inflammatory reaction

responsible for the increased proliferation of keratinocytes

It is a “multifactorial” condition – genetic factors

30% of psoriatics are family-friendly

Childhood psoriasis is frequently linked to histocompatibility antigens (HLA-Cw6) – environmental factors

Alcohol and tobacco: TRT resistance factors

Infections: especially in childhood psoriasis flare-ups

Psychological factors and medications (lithium salt, beta blockers, IEC, CTC …) can induce or aggravate psoriasis

II- CLINICAL: CLASSIC FORM OF VULGAR PSORIASIS

Elemental injury: rounded and well-restricted erythemato–scaly plaque. – superficial scaly layer

A- The dander on the surface:

Color: white and dull, sometimes musky – Surface: smooth or rough

These dander are dry, of varying size and thickness

– may completely or partially mask the rash

• Brocq’s methodical curettage;

– Bleaching sign

– Sign of candle stain

– Sign of the sticky film.

Pulling off a deep–shot adhesive film

– Sign of bloody dew or sign of AUSPITZ:

Appearance of fine hemorrhagic goutlets (naked dermal taste buds)

B- Erythema is underlying:

– located under the scaly layer

– Characteristic pink colour, cogenty red (infs)

– Disappears at the pressure press. – smooth and dry surface

– no pain, no infiltration, no pruritus.

C– Grouping and topography:

Number:

– Variable,

– rarely isolated plaque psoriasis,

– usually multiple or diffuse

Dimension:

– punctiform “punctata” or in “guttata” drops a few mm in diameter

– Nummular (nummulus-coin) a few cm in diameter

– Plate: more or less geometric or circumcised contours occupying large areas

– Universalis: widespread that affects almost the entirety of the

Topography:

– very evocative of the diagnosis

At the beginning and throughout the duration of the disease; friction zones:

elbows, knees, forearm headboards, tibial regions, sacred region, palms and plants, scalp (refuge area or bastion).

• Areas of friction of clothing or regular handling of a material (Koebner phenomenon).

Functional signs (pruriit): Psoriasis is little or not pruriginous

III- CLINICAL FORMS:

A- Depending on the seat:

1- Clasic forms: bastion:

2- Psoriasis of folds: Psoriasis inverted.

– glossy red plate and smooth little or no flaking

– seat: interfessier folds – inguinaux – genital regions – under breasts – axillary hollow

– Macerated, wet areas; michael rash.

– Two differential diagnoses: eczema and fungus.

3- Scalp psoriasis:

– erythemato-scaly patch of very limited variable sizes covered with large dry dander crossed by the hair (non-afreeciant) – real shell covering the entire scalp

• The thickness of the scalp and the presence of hair mask the rash.
• Often; scaly helmet.
• Two differential diagnoses: scalp moths and infectious moths.

4- Nail psoriasis: 30-50% of cases

– sometimes isolated,

– Appearance of depression punctuated cupiliforms (nail in dice to sew)

– onycholysis with distal detachment

– hyperkeratosis under ungueal

– leuconychia

• No rash-scaly spots.
• Whitish transverse streaks.
• Pachyonychia: thickening of the nail.
• Differential diagnosis: onychomycosis.

5- Psoriasis of palms and plants:

– often bilateral – a keratodermy in ilots or diffuse

Two differential diagnoses:

• Plantar hardwoods and warts.
• Horns at the foot.

6- Facial psoriasis:

Rare, it can take on the appearance of seborrheic dermatitis (sebopsoriasis)

7- psoriasis of the mucous membranes:

– On the language:

Geographical language especially in pustular psoriasis

Scrotal language

– On the acorn: very limited spots, purely erythematous

B- Depending on age:

– may be early: psoriasis of the langes (napkin psoriasis)

– in children: often acute in drops and can follow a rhino-pharyngeal infection The face is more often affected than in adults

C- Psoriasis caused:

– Drugs: they may induce or aggravate psoriasis or be responsible for TRT resistance (lithium salts, beta-blockers, INF alpha) – koebner phenomenon: characterized by the appearance of psoriasis lesions on a skin trauma: streaks of scratching, surgical scars …

D- Serious forms:

1- Pustular Psoriasis:

• Elemental lesion: a yellowish-white pustule on a base of diffuse erythema that dries out quickly and flaks.
• Fever 40oC and altered general condition.
• This psoriasis simulates an infectious disease and its spontaneous prognosis is severe and can lead to the death of the patient.
• Pustular psoriasis can be limited to the hands and feet and simulate eczema: it is acromegaly.
• Pustular psoriasis is often the complication of vulgar psoriasis treated with general corticosteroid therapy.

2- Erythrodermic Psoriasis:

• Diffuse edema with infiltrated and cardboard skin and accentuated wrinkles.
• Touch the elderly subject.
• Hydro-electrolytic loss due to edema; life-threatening prognosis at stake.
• Overinfection and thermoregulation disorders
• Complication of general corticosteroid therapy

3- Arthropathe psoriasis:

• 25% of psoriasis develop arthropathy.
• Mono or trace arthritis, SERONegative arthritis, SPA.

IV- EVOLUTION:

• Chronic disease evolving by flare-ups.
• Functional and vital prognosis are only involved.
• Socio-psychological impact.
• The existence of drugs that induce flare-ups or severe forms of psoriasis: INSAIDs, APS, beta blockers, lithium salts, general corticosteroids.
• Environment:

• holidays, summer and the sun; Improvement.
• Winter; Aggravation.

V- DIAGNOSIS:

A- Positive diagnosis:

1- Clinic:

2- Histology in case of diagnostic doubt:

a)- Epidermis:

• Parakeatic hyperkeratosis.
• Hyperacanthosis.
• Acrobian micro-abscess.

b)- Derme:

• Thickening and dilation of the dermal taste buds.
• Turgescent ships.
• Infiltration of mononucleous cells.

c)– Hypoderma and annexes: No changes

B- Differential diagnosis:

1. Microbial eczema.
2. Epidermo-mycses.
3. Lichen plan: very pruriginous papulo-squamous dermatosis also reaching the mucous membranes.
4. Hematoma (associated lymphoma).

VI-TREATMENT:

A- Limited Psoriasis:

1- Keratolytics:

• Dirty Vaseline 0.5 to 10%.
• Intoxication; dyspnea, stop skin washing.

2- Gearboxes:

• Coal tar.
• Cade oil.
• Dermocorticoids.
• Vitamin D derivatives: Calcipotriol, Daïvonex.

B- Extended Psoriasis:

• PUVAtherapy; Adults.
• PUVB with tar; Children.

C- Severe Psoriasis: Extended or Rebellious:

• Derivatives of acidic vitamin A; Retinoid, Soriatane.
• Retinoid Association with PUVAtherapy.
• Otherwise antimitotic: Injectable methotrexate.

D- Arthropathic Psoriasis:

• InSINS and corticosteroids contrainded.
• Physical means if not Retinoid or Methotrexate.
• Cyclosporin.