Download Clinical picture of psoriasis

12/7/2014
Highlights on Clinical
Picture of Psoriasis
PROF DR
DOAA MAHGOUB
CAIRO UNIVERSITY
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Chronic Plaque Psoriasis
 Symmetric distribution of sharply defined,
erythematous, scaly plaques.
The scalp, elbows, knees and presacrum are
sites of predilection, as are the hands and
feet.
Plaques may persist for months to years at
the same locations.
 Although the course of this disease is
chronic, periods of complete remission do
occur .
Chronic Plaque Psoriasis
 Because the percentage of body surface
area involved does not reflect the severity of
the individual lesions with respect to
erythema, induration and scaling, the
Psoriasis Area and Severity Index (PASI)
was formulated.
 A score for nail involvement has also been
proposed, known as the Nail Psoriasis
Severity Index (NAPSI), but it has not been
widely utilized.
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Psoriatic Plaques
Symmetric Distribution
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Childhood Psoriasis
Palmoplantar Psoriasis
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Genital Psoriasis
Guttate psoriasis
 More in children & adolescents.
 Preceded by upper respiratory tract
infection.
 Elevated antistreptolysin O titre indicating
recent respiratory tract infection in more
than 50 % of cases.
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Guttate psoriasis
Erythrodermic Psoriasis
 Characterized by generalized erythema and
scaling.
 Gradual or acute onset.
 Although there are many causes of
erythroderma clues to the diagnosis of
psoriatic erythroderma include previous
plaques in classic locations, characteristic
nail changes, and facial sparing.
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Erythrodermic Psoriasis
Pustular Variants
Generalized Pustular Psoriasis
 The infiltration of neutrophils dominates
the histologic picture, while erythema and
the appearance of sterile pustules dominate
the clinical picture .
 Triggering factors include pregnancy, rapid
tapering of corticosteroids (or other
systemic therapies), hypocalcemia,
infections.
 Generalized pustular psoriasis during
pregnancy is also referred to as impetigo
herpetiformis.
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Patterns of Generalized
Pustular Psoriasis
I- Von Zumbusch pattern.
 This is a generalized eruption starting
abruptly with erythema and pustulation.
 The skin is painful during this phase.
 The patient has a fever and feels ill.
 After several days, the pustules usually
resolve and extensive scaling is observed.
Von Zumbusch pattern
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2- Annular pattern
 The eruption is characterized by annular
lesions, consisting of erythema and scaling
with pustulation at the advancing edge .
 The lesions enlarge by centrifugal
expansion over a period of hours to days,
while healing occurs centrally .
Annular Psoriasis
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3- Exanthematic type
 This is an acute eruption of small pustules,
abruptly appearing and disappearing over a
few days.
 It usually follows an infection or specific
medications e.g. lithium.
 No systemic symptoms .
 Also referred to as acute generalized
exanthematous pustulosis .
4- Localized pattern
 Sometimes pustules appear within or at the
edge of existing psoriatic plaques.
 This can be seen during the unstable phase
of chronic plaque psoriasis and following
the application of irritants e.g. tars.
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Localized Pustular Psoriasis
Pustulosis of Palms & Soles
 Sterile pustules of palmoplantar surfaces
admixed with yellow brown macules & scaly
erythematous plaques.
 A minority of patients have chronic plaque
psoriasis elsewhere.
 Unlike generalized pustular psoriasis,
pustules remain localized to palms & soles
with chronic course.
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Pustulosis of Palms & Soles
Acrodermatitis continua of
Hallopeau
 Rare manifestation of psoriasis.
 Pustules at distal portion of fingers and toes .
 Followed by scaling and crusting .
 Pustules in nail bed and nail shedding may
occur .
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Acrodermatitis continua of
Hallopeau
Special Locations
Scalp psoriasis
 One of the commonest sites of psoriasis.
 Discrete lesions in contrast to the less well
defined lesions of seborrhoeic dermatitis .
 However it is not possible to differentiate the
two diseases in most cases and sometimes
they coexist .
 Lesions advance on periphery of face,
retroauricular areas and upper neck .
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Scalp Psoriasis
Scalp Psoriasis
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Pityriasis amiantacia
Sometimes in scalp psoriasis, scales may
have asbestos like appearance attached to
scalp hair.
 Although it can be seen in seborrheic
dermatitis, infected atopic dermatitis and
tinea capitis, yet psoriasis is the commonest
cause of pityriasis amiantacia.
Flexural psoriasis
 Flexural lesions are characterized by shiny,
pink to red, sharply demarcated thin
plaques.
 There is much less scale than plaque
psoriasis.
 Often a central fissure is seen.
 When flexural areas are the only sites of
involvement, the term “inverse” psoriasis is
sometimes used.
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Flexural Psoriasis
Oral mucosa
Migratory annular erythematous lesions
with hydrated white scales (annulus
migrans).
 In patients with acrodermatitis continua of
Hallopeau and generalized pustular
psoriasis .
 Tongue is the commonest location .
 Clinical and pathological appearance
similar to geographic tongue .
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Nail psoriasis
 The fingernails are more often affected than
the toenails.
 Patients with nail involvement appear to
have an increased incidence of psoriatic
arthritis.
 Psoriasis affects the nail matrix, nail bed and
hyponychium.
Nail Psoriasis
 Small parakeratotic foci in the proximal
portion of the nail matrix lead to pits in the
nails .
 Leukonychia and loss of transparency are
due to involvement of the mid portion of the
matrix.
 If the whole nail matrix is involved, a whitish,
crumbly, poorly adherent “nail” is seen.
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Nail Psoriasis
 Psoriatic changes of the nail bed result in the
“oil spot” or “oil drop” phenomenon, which
reflects exocytosis of leukocytes beneath the
nail plate.
 Splinter hemorrhages are the result of
increased capillary fragility, and subungual
hyperkeratosis and distal onycholysis are due
to parakeratosis of the distal nail bed.
Nail Psoriasis
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Psoriatic Arthritis
 Occur in 5–30 % of patients with cutaneous
psoriasis.
 10–15 % present with arthritis before
appearance of skin lesions.
 Classification :
1- Mono & asymmetric oligoarthritis
(commonest)
2- Arthritis of distal interpharyngeal joints
3- Rheumatoid arthritis like presentation
4- Arthritis mutilans (least common)
5- Spondylitis & sacroiliitis
Disorders Related to Psoriasis

Few disorders share important
clinical and histological features with
psoriasis.
 Distinct entities because they have
different genetic, epidemiologic or
clinical features .
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I- Inflammatory
linear verrucous
epidermal nevus (ILVEN)
 ILVEN is characterized by linear
psoriasiform lesions (i.e. scaling and
erythematous plaques) that follow the lines
of Blaschko .
 Based upon its chronicity and resistance to
therapy, ILVEN is thought to be an entity
separate from linear psoriasis.
(ILVEN)
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II- Reactive arthritis
(Reiter’s disease)
This syndrome features urethritis,
arthritis, ocular findings and oral ulcers,
in addition to psoriasiform skin lesions.
The lesions on the plantar surface usually
have thick yellow scale and are often
pustular (keratoderma blennorrhagicum).
 Psoriatic plaques on the penis are
referred to as balanitis circinata
Reactive arthritis (Reiter’s
disease)
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III- Sneddon–Wilkinson disease
(subcorneal pustular dermatosis)
 This disorder is characterized by annular or
polycyclic lesions, starting in the flexures .
 Very superficial (subcorneal) sterile pustules are
the hallmark of Sneddon–Wilkinso disease, hence
its second name.
 There may be a gravity-induced demarcation in
some vesiclopustules, with clear fluid superiorly
and pus inferiorly.
 Its response to dapsone, combined with subcorneal
pustules, provide support for this condition being a
disease entity distinct from pustular psoriasis.
Sneddon–Wilkinson disease
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Differential Diagnosis
 Plaques of psoriasis on shins may be
misdiagnosed as lichen planus, but
characteristic violaceous lesions elsewhere and
mucosal involvement usually point to the correct
diagnosis.
 Palmoplantar plaque psoriasis can be confused
with keratotic eczema of the palms and soles, as
both may have scaling and fissures. Sharp
margination of the lesions favors psoriasis and
examination of the remainder of the skin surface
can differentiate both diseases.
Differential Diagnosis
 Although seborrheic dermatitis is in the
differential diagnosis of psoriasis, it is
important to remember that it can coexist
with psoriasis.
 Single or limited number of erythematous
plaques, especially if they are treatment
resistant, the possibility of SCC in situ (e.g.
Bowen’s disease, erythroplasia of Queyrat)
needs to be excluded via histologic
examination.
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Differential Diagnosis
 Sometimes a biopsy is necessary to
distinguish chronic plaque psoriasis from the
mycosis fungoides . Clinical features
suggestive of the latter include wrinkling due
to epidermal atrophy and progression to
infiltrated plaques.
 Dermatomyositis can involve the scalp,
elbows and knees, as well as the hands, and
initially may be diagnosed as psoriasis.
Differential Diagnosis
 Other causes of erythroderma :
Sézary syndrome , pityriasis rubra pilaris
and drug reactions .
 In the case of guttate psoriasis, the
differential diagnosis may include small
plaque parapsoriasis , pityriasis lichenoides
chronica , secondary syphilis and pityriasis
rosea . The lesions of guttate psoriasis
rarely involve the palms or soles and are
often more erythematous than those of
parapsoriasis.
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Differential Diagnosis
 Psoriasis of the flexures is one cause of
intertrigo.
 Other etiologies include seborrheic
dermatitis, cutaneous candidiasis, tinea
incognito, necrolytic migratory erythema,
extramammary Paget’s disease, Bowenoid
papulosis and contact dermatitis.
Differential Diagnosis
 In infants the possibility of Langerhans cell
histiocytosis needs to be considered. In
these patients, there may also be scalp
involvement with scaling and crusts.
 Occasionally, tinea capitis is in the
differential diagnosis of scalp psoriasis.
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