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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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Thank you
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