1. Ramesh Mehay Programme Director (Bradford VTS)
Psoriasis for Dummies
Ramesh Mehay
Programme Director (Bradford VTS)

2. This presentation will not concentrate on the aetiology/pathogenesis/epidemiology of psoriasis
You can find all that in electronic text books
Instead, we will concentrate on the practical side of things
Things which most doctors have difficulty with

3. Types of Psoriasis Can you spot which types of psoriasis these are?
Each PowerPoint slide has notes which tells you more about the condition if you want to know more
But I suggest you don’t spend too long here.
Being able to recognise them and noting their specific key points is more important

4. Remember, with all these slides if you are having difficulty recognising what it is, go back to basics and describe to yourself what you SEE
Are you ready?

5. First one... Psoriasis Vulgaris
Psoriasis vulgaris (or chronic plaque psoriasis) is the most common pattern of psoriasis seen in about 90% of the cases.
The plaques:
are well circumscribed, round-oval or nummular (coin-sized)
initially may present as erythematous macules (flat and <1 cm) or papules
may have a white blanching ring (Woronoff's ring) in the surrounding skin (2)
may be single or multiple covering the whole body
vary in size - from a few mm's to several cm's (3)
are red with scaly surface; reflects light when gently scratched, creating a "silvery" effect; more vigorous rubbing induces pin point haemorrhage (Auspitz sign)
occur all over body but with predilection for extensor surfaces - especially knees, elbows; lumbosacral regions; scalp; trunk, buttocks and nails
occassionally, involve penis, vulva and flexures, but scaling is absent
scalp involvement is non-scarring - but there may be some hair loss
lesions often symmetrical ; chronic and stable

6. Psoriasis Vulgaris Is a common psoriatic pattern you see
Think: scalp, lumbosacral, elbows and knees
Can you describe what the lesions look like?

7. Characteristically, they are
well-defined, raised, erythematous and scaly lesions , which are "salmon pink" or "full rich red" in colour
surface silvery scale which may be easily removed often leading to pin - point capillary bleeding (Auspitz sign)
they may or may not itch but this is not usually a prominent feature

8. Let’s go a bit quicker

9. Number Two Guttate Psoriasis
Guttate psoriasis often follows acute group B haemolytic streptococcal pharyngitis in persons genetically predisposed to psoriasis. It accounts for 2% of the total cases of psoriasis (1). In a majority of patients it is a self limiting condition (2).
The clinical features include:
presents with salmon pink, dew drop like papules (3)
numerous, small, round psoriatic lesions - less than 1 cm diameter (1)
number of lesions can vary (from 5 or 10 to over 100) (1)
lesions develop acutely and usually has a centripetal distribution pattern (over trunk) but may involve the head and limbs (1)
often erupts suddenly following infection - may rapidly disappear or form stable plaques
may itch, initially
clinically distinguished from pityriasis rosea because pityriasis rosea is a lighter pink colour with scaling confined to the edges of individual lesions
acute episodes in children are usually self limiting, but in adults it may complicate chronic plaque disease (1)
oriasis

10. How do you treat it?
often erupts suddenly after an acute group B haemolytic streptococcal pharyngitis
So, may need to give antibiotics
Then wait and see
May rapidly disappear or form stable plaques
If stable plaques form: calcipotriol, high potency steroids, light therapy
Tonsillectomy if recurrent sore throats with guttate flare ups?

11. Flexural Psoriasis

12. And the third Erythrodermic Psoriasis
erythrodermic psoriasis may develop as the result of slow or rapid progression of existing disease, or less commonly, de novo
plaques cover over 90% of the body surface
protective function of the skin is lost and problems with thermoregulation, septicaemia, dehydration, high output cardiac failure and metabolic changes due to increased cutaneous blood flow may occur (1)
erythrodermic psoriasis may be life threatening

13. What’s important about this type of psoriasis?
It can be life threatening
Esp: high output cardiac failure (so bell the lungs!)
Thermoregulation problems, dehydration and septicaemia can result.
(Admit them straightaway for methotrexate + cyclosporin Rx)
One of the few dermatological emergencies.

14. Number Four
Acute Pustular Psoriasis (a generalised pustular psoriasis)
Acute pustular psoriasis is a potentially life threatening disease characterised by the development of numerous small sterile yellow pustules and widespread areas of erythema. The pustules may coalesce to form large patches of pus.
The condition may arise in patients who have had classical psoriasis for many years. Attacks may be precipitated by infection, drugs, pregnancy, or the withdrawal of topical or systemic corticosteroid therapy.
The patient may present with a high, swinging fever of non -infective origin, but secondary infections may occur (and is potentially lethal).

15. Why is this one important?
Acute pustular psoriasis is a potentially life threatening disease
Attacks may be precipitated by infection, drugs, pregnancy, or the withdrawal of topical or systemic corticosteroid therapy.
The patient may present with a high, swinging fever of non -infective origin, but secondary infections may occur (and is potentially lethal).
(Admit them straightaway for methotrexate + cyclosporin Rx)
Another one of the few dermatological emergencies.

16. The Final Fifth
Pustular Palmoplantar Psoriasis (a localised pustular psoriasis)
Palmoplantar pustular psoriasis is characterised by numerous small, sterile yellow pustules and widespread erythema localised to the palms and soles (1).
The disease may effect a single foot or hand, or the entire surface of both feet and hands.
Pustular palmoplantar psoriasis is associated with classical psoriasis vulgaris in around 25% of the patients (1).
It differs from chronic plaque psoriasis from the following factors:
it is commonly seen in women (9:1)
presents between the ages of years
a strong association with current or past smoking (1)
It is a chronic condition (2). The pustules gradually change into circular, brown, scaly spots and in time, peel off (1). They are uncomfortable or painful rather than itchy.
Psoriatic nail involvement can be commonly seen in palmoplantar pustular psoriasis (1).

17. What do you do about it? Palmoplantar psoriasis is difficult to treat.
Both hyperkeratosis and inflammation should be treated separately
a keratolytic agent for hyperkeratosis
calcipotriol or a moderately potent topical corticosteroid (e.g. betnovate-RD (R) ointment) may help.
isotretinoin has also been used to treat pustular psoriasis
acitretin or methotrexate may be needed in disabling palmoplantar psoriasis

18. Things that cause difficulty
Unstable Psoriasis
Psoriatic arthritis
Scalp Psoriasis

19. General Treatment

20. Specific Treatment