DEPT OF DERMATOLOGY DR. Akreti Sobti K. J.

Somaiya Hospital

PAPULOSQUAMOUS DISORDERS

Introduction
Etiologically unrelated group of disorders
Common clinical features papules or

plaques covered with scales Includes :

Psoriasis Lichen planus

Pityriasis rosea
Seborrhoeic dermatitis

PSORIASIS
Chronic, non-infectious, inflammatory skin disorder characterized by well defined erythematous plaques covered with silvery

white scales mainly on the extensor aspects of the body Course is unpredictable but usually chronic with exacerbations and remissions

 EPIDEMIOLOGY
Prevalence : 1-3 % of the population Male : females equal but females develop it earlier

Bimodal peak : 2nd decade and then 5th decade

 ETIOPATHOGENESIS
Precise cause unknown There is a genetic predisposition and an obvious

environmental trigger

 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

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 to approx 10 days as compared to 60 days in normal

PRECIPITATING FACTORS
Trauma : Physical, chemical, electrical, surgical Koebners phenomenon
Infection : tonsillitis caused by hemolytic

streptococci can trigger guttate psoriasis Hormonal : improves in pregnancy but relapses post-partum Sunlight : Improves most patients (10% worsen) Seasonal : winter exacerbation, summer improvement

 Drugs : NSAIDS, blockers, antimalarials, lithium and sudden withdrawal of systemic corticosteroids Hypocalcaemia
Stress Alcohol intake AIDS

CLASSIFICATION
MORPHOLOGICAL
Classical plaque type
Guttate Pustular

DISTRIBUTION
Classical (extensors)
Inverse (flexures) Scalp

Erythrodermic
Follicular Linear Annular

Palmo-plantar
Nails Joints

CHRONIC PLAQUE TYPE

Well defined salmon pink plaque covered with silvery white scales distributed symmetrically over extensor surface of the

body Can involve the scalp, nails, palms and soles Removal of scales causes pinpoint bleeding Auspitz Sign Koebnerization present Morphological variants linear, annular..

GUTTATE PSORIASIS
Seen in children and adolescent
Often triggered by streptococcal tonsillitis Sudden eruption of rain drop-like scaly

papules on the trunk Spontaneous remission Treatment with anti-streptococcal antibiotics Good prognosis

SCALP PSORIASIS
Psoriasis
Silvery white scales
Extends beyond the hair

Seborrheic Dermatitis
Yellowish greasy scales
Does not extend beyond

margin (Corona Psoriatica)

Auspitzs sign +ve Psoriatic lesions elsewhere

the scalp margin (Corona Seborrheica) Carpet-Tack sign +ve Lesions in Seborrheic areas

NAIL PSORIASIS
Nail Matrix Nail Pits Splinter Hemorrhages Anonychia (Pustular Ps) Nail Bed 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

ERYTHRODERMIC PSORIASIS
Rare but important complication

Diffuse redness and scaling involving >90% BSA

Precipitated by sudden withdrawal of systemic

corticosteroids, 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 in erythroderma (stable)

 Chronic protein loss

Dermatopathic enteropathy Anemia (iron deficiency & megaloblastic) Poikilothermia Shivering Fluid and electrolyte imbalance Rare High output cardiac failure

PUSTULAR PSORIASIS
Medical Emergency (Acute GPP)
Provocative factors : Irritant topical therapy,

hypocalcemia, infections, pregnancy, sudden withdrawal of systemic steroids High grade fever with burning sensation and tenderness of skin Lakes of pus on erythematous base Skin failure, septicemia Death

PUSTULAR PSORIASIS
Localised Acrodermatitis continua of Hallopeau Palmoplantar Pustulosis (thenar-hypothenar) Generalised Von Zumbusch Pregnancy Associated Impetigo Herpetiformis Juvenile Associated Localised variant of Generalised Ps Circinate & Annular Variant

PSORIATIC ARTHROPATHY
Sero-negative Arthritis
1. Mono or Asymmetrical Oligo-Arthritis 2. Predominantly DIP Arthritis 3. RA-Like Symmetrical 4. Axial Arthritis (spondylitis &/or sacroiliitis) 5. Arthritis Mutilans

INVESTIGATIONS
Skin biopsy
Throat swab in guttate psoriasis Skin scraping & nail clipping to exclude fungal

infections Radiological Ix & RA factor HIV in severe recalcitrant cases

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 making

the condition more tolerable Stress free life goes a long way in achieving and/or maintaining disease free periods

TREATMENT
TOPICAL
Emollients
Keratolytics Topical steroids Vit-D Analogues (calcipotriol)
Topical Retinoids

Diathranol Intralesional Steroids Topical PUVA (Paint & bath

PUVA)

SYSTEMIC Systemic PUVA Systemic Retinoids (Acitretin) Methotrexate Hydroxyurea Cyclosporin Azathioprine Mycophenolate Mofetil Biologicals (Etanercept, Imfliximab) MaxEPA

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

 Morphology
Herald Patch/Mother patch Large eryhtematous plaque with a collarette of scales Precedes all lesions Followed by multiple smaller similar plaques on

photoprotected (trunk & proximal extremities) areas Long axis parallel to the ribs giving a Christmas Fir-Tree pattern Associated with variable itching

LICHEN PLANUS
DEFINITION:Inflammatory, pruritic disease of the skin and mucus membranes characterized by distinctive papules with a predilection for flexures and trunk

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

CLASSIFICATION
According to CONFIGURATION Linear LP Annular LP According to SITE Classical (flexural) LP on scalp Palms & Soles LP on Nails Mucus Membranes According to MORPHOLOGY Classical Follicular (Lichen planopilaris) Atrophic Hypertrophic Ulcerative Bullous LP Actinic LP Pemphigoides LP-LE overlap Hepatitis associated LP LP pigmentosus

According to ONSET

Acute Widespread LP Chronic Localised LP

LP OF NAILS
Subungual papules Thickening & malformation of nails
Pterygium formation : Fibrosis of the nail

matrix resulting in the fusion of proximal nail fold with the proximal nail bed Longitudinal grooves & ridges 20 nail dystrophy

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 of

ulceration

LP OF PALMS & SOLES

Firm, yellowish papules on the margins of the palms and soles
Heperkeratosis and fissures

Half the patients have classical LP lesions on the wrist

GRAHAM-LITTLE-PICCARDILASSUEUR SYNDROME
Patchy cicatricial alopecia of the scalp
Patchy non-cicatricial alopecia in the axilla

and pubic area Follicular LP on trunk and extremities

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

TREATMENT
TOPICAL SYSTEMIC ORAL LP Steroid mouth-washes (betnesol) Triamcinolone in a special base Orabase TESS gel ILS

Potent steroids Tacrolimus Tar ILS

Steroids Dapsone Griseofulvin PUVA Retinoids Cyclosporin Cyclophosphamide Azathioprine Metronidazole Hydroxychloroquine

 Thank you