papulosquamous disorders

8/12/2019 Papulosquamous Disorders

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PAPULOSQUAMOUS DISORDERS

DEPT OF DERMATOLOGYDR. Akreti SobtiK. J. Somaiya Hospital


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Introduction

Etiologically unrelated group of disorders

Common clinical features papules or

plaques covered with scales Includes :

Psoriasis

Lichen planus

Pityriasis rosea

Seborrhoeic dermatitis


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PSORIASIS

Chronic, non-infectious, inflammatory skindisorder characterized by well definederythematous plaques covered with silverywhite scales mainly on the extensor aspectsof the body

Course is unpredictable but usually chronic

with exacerbations and remissions


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ETIOPATHOGENESIS

Precise cause unknown

There is a genetic predispositionand an obviousenvironmental trigger


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Genetic predisposition : Determined by a large no of genes each of which

have a low penetrance

If no parents affected : 2% If no parents but 1 sibling: 8%

If 1 parent and 1 sibling : 16%

If both parents and 1 sibling : 50%

HLA association Cw6 : strong association (10 fold risk)

B27 : Psoriatic Arthritis


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EPIDERMAL CELL KINETICS

Increased epidermopoeisis

Increased recruitment of cells from the

resting phase to the growth phase The growth fraction approaches 100%

compared with 30% in normal

Epidermal turn-over time is shortened toapprox 10 days as compared to 60 days innormal


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PRECIPITATING FACTORS

Trauma : Physical, chemical, electrical, surgical

Koebnersphenomenon

Infection : tonsillitis caused by hemolyticstreptococci can trigger guttate psoriasis

Hormonal : improves in pregnancy but relapses

post-partum

Sunlight : Improves most patients (10% worsen)

Seasonal : winter exacerbation, summer

improvement


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Drugs : NSAIDS, blockers, antimalarials,lithium and sudden withdrawal of systemiccorticosteroids

Hypocalcaemia

Stress

Alcohol intake AIDS


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CLASSIFICATION

MORPHOLOGICAL DISTRIBUTION

Classical plaque type

Guttate Pustular

Erythrodermic

Follicular

Linear

Annular

Classical (extensors)

Inverse (flexures) Scalp

Palmo-plantar

Nails

Joints


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CHRONIC PLAQUE TYPE

Well defined salmon pink plaque coveredwith silvery white scales distributedsymmetrically over extensor surface of thebody

Can involve the scalp, nails, palms and soles

Removal of scales causes pinpoint bleedingAuspitz Sign

Koebnerization present

Morphological variants linear, annular..


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GUTTATE PSORIASIS

Seen in children and adolescent

Often triggered by streptococcal tonsillitis

Sudden eruption of rain drop-like scalypapules on the trunk

Spontaneous remission

Treatment with anti-streptococcal antibiotics Good prognosis


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SCALP PSORIASIS

Psoriasis Seborrheic Dermatitis

Silvery white scales

Extends beyond the hairmargin (Corona Psoriatica)

Auspitzs sign +ve

Psoriatic lesions elsewhere

Yellowish greasy scales

Does not extend beyondthe scalp margin (CoronaSeborrheica)

Carpet-Tack sign +ve

Lesions in Seborrheic areas


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NAIL PSORIASIS

Nail Matrix Nail Bed Nail Pits

Splinter Hemorrhages

Anonychia (Pustular Ps)

Onycholysis

Subungual hyperkeratosis

Oil-drop sign

Pits : Five or more nail pits in one nail or 20 or more pits in all 20 nails

D/D: Alopecia Areata, Traumatic, Rieters, Idiopathic, Chronic Eczema


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ERYTHRODERMIC PSORIASIS

Rare but important complication

Diffuse redness and scaling involving >90% BSA

Precipitated by sudden withdrawal of systemiccorticosteroids, use of anthranil or coal tar, stress,pregnancy or acute infection (unstable)

Chronic plaque type disease progressing to

involve entire body surface area will also result inerythroderma (stable)


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Chronic protein loss

Dermatopathic enteropathy

Anemia (iron deficiency & megaloblastic) Poikilothermia Shivering

Fluid and electrolyte imbalance

Rare High output cardiac failure


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PUSTULAR PSORIASIS

Localised Generalised Acrodermatitis continua of

Hallopeau

Palmoplantar Pustulosis(thenar-hypothenar)

Von Zumbusch

Pregnancy Associated

Impetigo Herpetiformis Juvenile Associated

Localised variant ofGeneralised Ps

Circinate & Annular Variant


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INVESTIGATIONS

Skin biopsy

Throat swab in guttate psoriasis

Skin scraping & nail clipping to exclude fungalinfections

Radiological Ix & RA factor

HIV in severe recalcitrant cases


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TREATMENT

Counseling plays a VERY important role

Psoriasis is not contagious

Not a systemic disease

Treatable but not curable

Treatment aimed at inducing remission or makingthe condition more tolerable

Stress free life goes a long way in achieving and/ormaintaining disease free periods


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TREATMENT

TOPICAL SYSTEMIC

Emollients

Keratolytics Topical steroids

Vit-D Analogues (calcipotriol)

Topical Retinoids

Diathranol Intralesional Steroids

Topical PUVA (Paint & bathPUVA)

Systemic PUVA

Systemic Retinoids

(Acitretin) Methotrexate

Hydroxyurea

Cyclosporin

Azathioprine Mycophenolate Mofetil

Biologicals (Etanercept,Imfliximab)

MaxEPA


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PITYRIASIS ROSEA

Etiology is unknown

Proposed HHV 7

seasonal variation h/o fever and sore throat

spontaneous resolution

Affects children and young adults

Six week disease


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Morphology Herald Patch/Mother patch

Large eryhtematous plaque with a collarette of

scales Precedes all lesions

Followed by multiple smaller similar plaques onphotoprotected (trunk & proximal extremities)

areas Long axis parallel to the ribs giving a Christmas

Fir-Tree pattern

Associated with variable itching


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LICHEN PLANUS

DEFINITION:-

Inflammatory, pruritic disease of the skin and

mucus membranes characterized bydistinctive papules with a predilection forflexures and trunk


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CLINICAL FEATURES

Characteristic lesion Pruritic Plane (flat topped) Purple (violaceous) Polygonal Papule

Magnifying glass Wickhams striae (network of greyish streaks on skin

surface) Koebnerisation

Lesions heal with hyperpigmentation


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LP OF NAILS

Subungual papules Thickening &malformation of nails

Pterygium formation : Fibrosis of the nailmatrix resulting in the fusion of proximal nailfold with the proximal nail bed

Longitudinal grooves & ridges

20 nail dystrophy


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LP OF ORAL CAVITY

Common

Sites:

Buccal mucosa, palate, lips and tongue Pin-head sized white papules coalesce to

form lacy pattern

Ulcerative lesions may occur

Cancer may rarely develop at site ofulceration


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LP OF PALMS & SOLES

Firm, yellowish papules on the margins of thepalms and soles

Heperkeratosis and fissures

Half the patients have classical LP lesions onthe wrist


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GRAHAM-LITTLE-PICCARDI-

LASSUEUR SYNDROME Patchy cicatricial alopecia of the scalp

Patchy non-cicatricial alopecia in the axillaand pubic area

Follicular LP on trunk and extremities


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ETIOLOGY

Unknown

Immunologically mediated (CMI)

Can occur in families ( HLA B7)

Drug induced lichenoid reactions Penicillamine, anti-malarials, arsenic, gold,

quinidine, B-blockers, INH, Streptomycin,Ethambutol, Captopril, Thiazide diuretics

Oral LP can occur secondary to dental filling


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TREATMENT

TOPICALSYSTEMIC ORAL LP

Potent steroids

Tacrolimus

TarILS

Steroids

Dapsone

GriseofulvinPUVA

Retinoids

Cyclosporin

Cyclophosphamide

Azathioprine

MetronidazoleHydroxychloroquine

Steroid mouth-washes

(betnesol)

Triamcinolone in a specialbase

Orabase

TESS gel

ILS


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