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Dermatology
Psoriasis
Built from Dermatology, 5th Edition
What’s inside
12 sections · 183 slides
Introduction and History
What psoriasis is, and how it came to be understood
- Roadmap of this topic
- What is psoriasis
- A systemic disease, not just skin-deep
- History of psoriasis
Epidemiology and Genetics
Who gets psoriasis, and why it runs in families
- How common is psoriasis
- Onset, course, and associated changes
- 41%
- Twin studies confirm a genetic link
- HLA-Cw6 and type I versus type II psoriasis
- Genome-wide association studies
- Psoriasis susceptibility genes
- Examples of psoriasis susceptibility genes
- Examples of psoriasis susceptibility genes (continued)
- Examples of psoriasis susceptibility genes (continued)
- Examples of psoriasis susceptibility genes (continued)
- Functional genomics and pustular psoriasis genetics
Pathogenesis
How the immune system builds a psoriatic plaque
- From 'skin disease' to 'immune disease'
- T cells and dendritic cells drive the disease
- How the plaque begins and grows
- Immunopathogenesis of psoriasis: initiation phase
- Why interferon-alpha starts the fire
- Neutrophils and blood vessel growth
- The T helper cytokine picture
- A self-amplifying feedback loop
- STAT3 drives keratinocyte overgrowth
- Innate immunity and the keratinocyte's own defenses
- Chemokines: the traffic signals of inflammation
- Disease memory: why psoriasis returns to the same spot
- External triggers: the Koebner phenomenon
- Systemic triggers: infection
- Endocrine, stress, and drug triggers
- Lifestyle triggers: alcohol, smoking, and weight
Clinical Features
What psoriasis looks like, site by site
- The spectrum of psoriasis
- Two classic bedside signs
- Chronic plaque psoriasis
- Annular plaques from central clearing
- Multiple large, symmetric plaques
- Psoriasis of the palms and soles
- Palmoplantar psoriasis
- Genital psoriasis
- Plaque psoriasis: sharp demarcation and scale
- Plaque psoriasis with typical scale
- Common plaque psoriasis sites
- Plaque psoriasis in an adolescent
- Large chronic plaques on the legs
- Symmetric plaque distribution
- Psoriasis of the fingers with nail disease
- Plantar psoriasis with hyperkeratosis
- Plantar psoriasis in darker skin
- Diffuse plantar psoriasis
- Genital plaques with scale
- Penile psoriasis patterns
- Measuring severity: the PASI score
- PASI: scoring redness, thickening, and scale (0-4 each region)
- PASI: area involved and regional correction factor
- Guttate psoriasis
- Guttate lesions of varying scale
- Symmetric guttate and plaque distribution
- Erythrodermic psoriasis
- CARD14-associated papulosquamous eruption
- Pustular psoriasis: an overview
- Four patterns of pustular psoriasis
- Generalized pustular psoriasis (von Zumbusch)
- Advancing pustular border
- Annular pustular psoriasis
- Annular pustular plaques enlarging
- Annular pustular psoriasis with moist desquamation
- Annular pustular rim around a plaque
- Localized pustules on a psoriatic plaque
- Pustulosis of the palms and soles
- Acrodermatitis continua of Hallopeau
- Acrodermatitis continua with nail involvement
- Special locations: the scalp
- Childhood scalp psoriasis
- Pityriasis amiantacea
- Bazex syndrome mimicking psoriasis
- Flexural (inverse) psoriasis
- Inverse psoriasis of the major folds
- Inframammary inverse psoriasis
- Oral involvement: annulus migrans
- Nail psoriasis
- Nail pitting and onycholysis
- Psoriatic arthritis: the basics
- Where psoriatic and reactive arthritis strike
- The 'sausage digit' of psoriatic arthritis
- Five major types of psoriatic arthritis
- Disorders related to psoriasis
- Linear psoriasis along the lines of Blaschko
- Reactive arthritis (formerly Reiter disease)
- Sneddon-Wilkinson disease
- Sneddon-Wilkinson annular plaques
- A single subcorneal pustule
- Differential diagnosis of subcorneal/intraepidermal pustules
- Differential diagnosis of subcorneal/intraepidermal pustules (continued)
Associations and Differential Diagnosis
Diseases that travel with psoriasis, and look-alikes to rule out
- Associations with other skin diseases
- The itch-scratch-Koebner vicious cycle
- Infection and cancer associations
- Comorbidities of moderate-to-severe psoriasis
- Cardiovascular disease and metabolic syndrome
- Fatty liver disease and bowel disease
- Differential diagnosis: general skin lesions
- Keratotic eczema resembling palmar psoriasis
- Differential diagnosis: erythroderma, guttate, and folds
- Differential diagnosis: pustular presentations
Pathology
What a psoriatic plaque looks like under the microscope
- From first papule to fully active lesion
- The active, diagnostic lesion
- The stable, established plaque
- Pustular psoriasis under the microscope
- Reflectance confocal microscopy of a plaque
Topical Treatment
Creams, ointments, and other treatments applied to the skin
- General treatment philosophy
- Topical corticosteroids
- Indications and contraindications: topical corticosteroids
- Vitamin D3 analogues
- Vitamin D3 analogues used in psoriasis
- Anthralin (dithranol)
- Indications and contraindications: anthralin
- Topical retinoids: tazarotene
- Indications and contraindications: topical tazarotene
- Other topical treatments
Phototherapy and Classic Systemic Drugs
Light-based and whole-body treatments for wider disease
- Phototherapy and photochemotherapy
- Indications and contraindications: photo(chemo)therapy
- Methotrexate: mechanism and dosing
- Indications and contraindications: methotrexate
- Methotrexate side effects
- Side effects of methotrexate: blood and skin
- Side effects of methotrexate: liver, lung, and fetus
- Side effects of methotrexate: cancer risk and severe reactions
- Side effects of methotrexate: infection and other effects
- Cyclosporine
- Indications and contraindications: cyclosporine
- Systemic retinoids: acitretin
- Indications and contraindications: acitretin
- Acitretin: monitoring before and during treatment
- JAK and TYK2 inhibitors
- Apremilast and additional systemic drugs
- Additional systemic therapies for psoriasis
Targeted Immunomodulators
'Biologic' drugs that block one specific inflammatory signal
- What targeted immunomodulators do
- Where biologic drugs act on the inflammatory pathway
- Commercially available biologic agents for psoriasis
- Commercially available biologic agents for psoriasis (continued)
- Newer drugs work better, short term
- Estimated short-term (12-16 week) PASI response rates
- Estimated short-term (12-16 week) PASI response rates (continued)
- Long-term efficacy and real-world data
- Indications and contraindications: targeted immunomodulators
Therapeutic Management
Choosing and combining treatments in practice
- Assessing a patient before choosing treatment
- A stepped-care ladder for psoriasis
- International Psoriasis Council severity criteria
- Managing with topical agents
- Managing with phototherapy and classic systemics
- Managing with targeted immunomodulators
- Combining treatments
- Managing childhood psoriasis
- Managing comorbidities: choosing a systemic drug
- Choosing systemic therapy by comorbidity
- Managing psoriasis at specific body sites
- Topical treatment and UVB phototherapy with comorbidities
- Psoriasis and pregnancy
- Topical and phototherapy safety in pregnancy
- Systemic therapy safety in pregnancy
- Treatment in older patients
Summary
The essential picture of psoriasis
- Key takeaways: disease
- Key takeaways: treatment
References
Sources cited in this chapter
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- Dermatology, 5th Edition (2-Volume Set)