Psoriasis Disease

DESCRIPTION

Genetically determined (sporadic) common, chronic, epidermal proliferative disease. Clinically characterized by erythematous, dry scaling patches, recurring remissions and exacerbations. Flares may be related to systemic and environmental factors. Usual course - acute, chronic; unpredictable.

Clinical forms:
- Discoid or plaque psoriasis - most common, patches appear on scalp, trunk and limbs, nails may be pitted and/or thickened
- Guttate psoriasis - occurs most frequently in children, numerous small papules over wide area of skin, but greatest on the trunk
- Pustular psoriasis - small pustules over the body or confined to one area (i.e., palms and soles) or arranged in annular patterns (especially children)
- Inverse, flexural psoriasis - affects the flexural areas, lesions are moist and without scales (common in older people)
- Erythroderma (exfoliative psoriasis or red man syndrome) - patients skin turns red, may result from a flare of pre-existing dermatosis
- Ostraceous - grossly hyperkeratotic
System(s) affected: Skin/Exocrine
Genetics:
- Genetic predisposition (probably polygenic)
- Type I psoriasis - young, strong family history = more aggressive disease
- Type 2 psoriasis - older, no family history = more stable disease
- Higher incidence in Caucasians and atopic families
- Increased incidence of human leukocyte antigens (HLA antigens)
Incidence/Prevalence in USA: 1000-2000 cases/100,000 people in the U.S.
Predominant age: Two peaks of onset, age 16-22 and age 57-60; can develop in infants
Predominant sex: Male = Female

SIGNS AND SYMPTOMS

Arthritis
Pruritus
Silvery scales on red plaques
Knee-elbow-scalp distribution
Stippled nails and pitting
Positive Auspitz sign (underlying pinpoints of bleeding following scraping)
Koebner's phenomenon (psoriatic response in previously unaffected area 1-2 weeks after skin injury)

CAUSES

Possible genetic error in mitotic control. Activation of lymphocytes (antigen? autoimmune?). Epidermal cell cycle 10 times shorter than normal, leading to epidermal hyperproliferation.

RISK FACTORS

Local trauma; local irritation
Infection (streptococcal pharyngitis can stimulate acute guttate psoriasis, HIV)
Endocrine changes
Stress (physical and emotional)
Sudden withdrawal of systemic and/or potent topical steroids
Alcohol use
Obesity

LABORATORY

Negative rheumatoid factor
Latex fixation test
Leukocytosis and increased sedimentation rate often seen, especially in pustular psoriasis
Fungal studies - may show a superimposed infection
Uric acid increases in 10-20%
In severe cases, anemia, B12, folate and iron deficiency can be present

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

Parakeratosis (focal), especially with neutrophils
Hyperkeratosis
Hypogranulosis
Epidermal hyperplasia
Elongation and thickening of rete ridges
Thin epidermis above dermal papillae
Spongiform pustule of Kogoj
Munro's microabscess
Abnormal mitoses
Dilated tortuous capillary loops
"Squirting" papillae

SPECIAL TESTS

Biopsy

IMAGING

N/A

DIAGNOSTIC PROCEDURES

Usually diagnosis accomplished by inspection, occasionally biopsy required

APPROPRIATE HEALTH CARE

Outpatient usually
May require inpatient for severe or resistant cases. Emergency: Severe and unstable forms like acute pustular psoriasis (Von Zumbusch's) or acute erythroderma.

GENERAL MEASURES

Solar radiation
Mild disease - ultraviolet radiation (UVA, UVB)
Medication to soften scale, followed by soft brush while bathing
Oatmeal baths for itching
Tar shampoos
Avoid excessive sun exposure
Desert climates provide a favorable effect for some patients
Wet dressings may help relieve pruritus
For extensive, recalcitrant psoriasis, a referral to a specialist in psoriatic therapy is suggested

SURGICAL MEASURES

N/A

ACTIVITY

No restrictions

DIET

No special diet

PATIENT EDUCATION

Provide patient reassurance and anxiety relief to the extent possible
Assurance to patient and family the condition is non-contagious
For a listing of sources for patient education materials favorably reviewed on this topic, physicians may contact: American Academy of Family Physicians Foundation, 11400 Tomahawk Creek Parkway, Leawood, KS, 66211, (800)274-2237, ext. 4406
National Psoriasis Foundation, Suite 300, 6600 S.W. 92nd Avenue, Portland, OR 97223, (503)244-7404; toll free (800)723-9166; fax (503)245-0626; E-mail 76135.2746@comserve.com

PREVENTION/AVOIDANCE

Avoid alcoholic beverages
Avoid irritating drugs
Avoid stimulating drugs (lithium, ACE inhibitors, beta-adrenergic blockers, tetracycline, NSAIDs, amiodarone, morphine, procaine, potassium iodide, salicylates, sulfapyridine, sulfonamides and penicillin. Pustular flares may occur with steroids).
Avoid antimalarial medications (aminoquinolone compounds)

POSSIBLE COMPLICATIONS

Pustular psoriasis
Exfoliative erythrodermatitis
Rebound of the psoriatic process after corticosteroids are discontinued
Topical corticosteroids may cause thinning of skin, striae, masking local infection, hypopigmentation and tachyphylaxis (reduce tachyphylaxis by a corticosteroid-free interval or lower potency once improved)
Hypercalcemia with excessive calcipotriene
Salicylism possible in children with high dose topical salicylic acid.

EXPECTED COURSE AND PROGNOSIS

Usually benign
Life-threatening forms do occur
May be refractory to treatment

ASSOCIATED CONDITIONS

Extensive erythrodermic psoriasis may accompany AIDS
Arthritis
Psoriatic arthritis
Myopathy
Enteropathy
Spondylitic heart disease
Acute anterior uveitis

AGE-RELATED FACTORS

Pediatric:

Onset common <10, rarely <3
Disease may be atypical in its course

Geriatric:

About 3% of psoriasis patients acquire the disease after age 65
Detailed drug history important, since many drugs (e.g., beta-blockers) can exacerbate psoriasis
If using cytotoxic medications for treatment of psoriasis, closely follow hepatic and renal functions, and creatinine clearance
Elderly patients may have difficulty with application of topicals over all affected body parts

Others: N/A

PREGNANCY

Unpredictable effect on disease. Avoid tars, topical corticosteroids, calcipotriene, and systemic therapies. Etretinate is fetotoxic.

OTHER NOTES

N/A

ABBREVIATIONS

N/A

Clinical Investigations

ROLE OF HOMOEOPATHY

Holistic healing that treats the person, not just the disease. Experience gentle, lasting wellness with expert constitutional care.