​Kembara Xtra - Medicine - Psoriasis

​Kembara Xtra - Medicine - Psoriasis 
Chronic inflammatory condition with variable phenotypes and severity that is frequently characterized by cutaneous erythematous plaques with silvery scale
Medical phenotypes
Plaque (vulgaris): the most prevalent form (about 80% of cases); well-defined, crimson plaques with silvery scale; typically distributed on the scalp, extensor surfaces, and trunk.
- Guttate: Presents suddenly with 1- to 10-mm droplet-shaped erythematous papules with fine scale throughout the trunk and extremities; typically in patients under 30 years old. It is frequently preceded by group A -hemolytic streptococcal infection two to three weeks prior.
Most situations end on their own.
- Reverse: affects flexural surfaces and intertriginous areas; pink to crimson plaques with little scale; distinct from candidiasis by the lack of satellite pustules.
- Erythrodermic: widespread erythema and scaling that covers 90% or more of the body's surface area (BSA); it is also accompanied by desquamation, hair loss, nail dystrophy, and systemic symptoms such fever, chills, malaise, lymphadenopathy, and/or high-output cardiac failure.
Pustular psoriasis comes in a variety of forms, including generalized pustular psoriasis, localized pustular psoriasis, and impetigo herpetiformis (during pregnancy). The generalized kind can lead to potentially fatal bacterial superinfections.
- Pitting, oil patches, and onycholysis in the nails; up to 50% of psoriasis patients have nails affected by the condition, which has an 80–90% lifetime incidence; higher correlation with psoriatic arthritis

Prevention Incidence
Females outnumber men in terms of predominate sex, and there are two incidence peaks between the ages of 20 and 30 and 50 and 60.
The most frequently affected demographic group in the United States is non-Hispanic Caucasian, with a prevalence of 2-4%.

Pathophysiology and Etiology 

When environmental triggers combine with a polygenic predisposition to develop psoriasis, a complex immune-mediated disorder with interactions between dendritic cells, T lymphocytes, neutrophils, and keratinocytes results. Relapsing flares linked to systemic, psychological, infectious, and environmental factors are also common.
Genetics
HLA-C*06 is most significantly connected with early-onset psoriasis. Genetic predisposition (polygenic): 40% of first-degree relatives have psoriasis. Multiple susceptibility loci contain genes implicated in immune system regulation.

Risk factors include: HIV, streptococcal infection, family history, obesity, local trauma, local irritability (Koebner phenomenon), stress (which may exacerbate the condition), medications (including lithium, antimalarials, -blockers, interferon, TNF- inhibitors, and steroid withdrawal), smoking, and alcohol misuse.

Prevention 

the management of cardiovascular risk factors. avoiding stress, trauma, sunburns, smoking, certain drugs, alcohol, and other triggers.

Accompanying Conditions 

 Cardiovascular illness, atherosclerotic disease, obesity, metabolic syndrome, diabetes, chronic renal disease, psoriatic arthritis, seborrheic dermatitis,
Other autoimmune illnesses include Crohn's disease, ulcerative colitis, and ankylosing spondylitis. Psychiatric/psychological conditions include depression, anxiety, suicidal ideation, low self-esteem, emotional stress, alcoholism, and sexual dysfunction.


Diagnosis May include: aggravation of existing plaques, particularly on extensor surfaces and scalp; abrupt emergence of sharply delineated, erythematous plaques with overlaying silvery scales. usually no or minimal itching. Recent streptococcal infection or trauma are examples of triggers.
 A history of the same condition in the family


clinical assessment 

Salmon pink to crimson erythematous papules and plaques with clearly defined borders and silvery scale
Distribution favors the scalp, auricular conchal bowls, and postauricular region, as well as the extensor surface of the extremities, particularly the knees and elbows, umbilicus, lower back, and nails. Nail findings include pitting, oil spots, and onycholysis.
Woronoff ring is a pale blanching ring that may be seen around a psoriatic lesion. Sebopsoriasis: Psoriasis can overlap with seborrheic dermatitis as greasy scales on the scalp, eyebrows, nasolabial folds, postauricular, and presternal areas. Koebner phenomenon: New psoriatic lesions arising at sites of skin injury/trauma.

Differential diagnosis: Plaque; seborrheic dermatitis (may coexist); nummular eczema; atopic dermatitis; contact dermatitis; lichen simplex chronicus (may coexist); tinea; pityriasis rubra pilaris; dermatomyositis; squamous cell carcinoma in situ; reactive arthritis; pityriasis rosea; lichen planus
Pityriasis rosea, pityriasis lichenoides chronica, secondary syphilis, and tiny plaque parapsoriasis are guttate; tinea, seborrheic dermatitis, contact dermatitis, and cutaneous candidiasis are inverse.
Pustular conditions include folliculitis, acute generalized exanthematous pustulosis, subcorneal pustulosis, and cutaneous T-cell lymphoma. Erythrodermic conditions include pityriasis rubra pilaris and drug-induced erythroderma.


Laboratory Results 
Initial examinations (lab, imaging)
 Clinical diagnosis based on physical examination and history.
Lab tests are typically not required, though KOH might be useful to rule out tinea, particularly in inverse psoriasis.
Consider getting a skin biopsy if the diagnosis is unclear.
If joint discomfort is reported, have x-rays done to rule out psoriatic arthritis.

Other/Diagnostic Procedures
The BSA involvement and overall severity of psoriasis are assessed using the PASI.
Interpretation of the Dermatology Life Quality Index (DLQI) Test
Biopsy results: Elongation, thickening, and clubbing of rete ridges; dilated tortuous capillary loops in the dermal papillae; perivascular lymphocytic infiltrate; Munro microabscesses: neutrophils in stratum corneum; thickening of the stratum corneum (hyperkeratosis) with retention of nuclei (parakeratosis);

Management 
Elimination of triggers, adequate topical hydration (emollients), and weight loss

First Line of Medicine

Assess for concurrent psoriatic arthritis and, if it exists, start with psoriasis and psoriatic arthritis treatments, even if skin symptoms are minor, to reduce the risk of joint damage from psoriatic arthritis.
Mild to moderate illness
Emollients: petrolatum/ointments help keep skin hydrated, reduce itching, and lower the risk of koebnerization
- Corticosteroid creams
 Vasoconstrictive, immunosuppressive, antiproliferative, and anti-inflammatory actions
 Skin shrinkage, hypopigmentation, striae, acne, folliculitis, and purpura are local side effects. Symptoms throughout the body: Pregnancy Category C; risk is increased when higher potency formulations are applied over a large surface for an extended length of time.
Applications are frequently made twice daily until lesions flatten or disappear, after which PRN use is tapered off for maintenance.
Shampoos and sprays are also available. Scalp: high potency in solution or foam vehicle. Face, intertriginous areas, and infants: low potency corticosteroids: 1% hydrocortisone
Adults should begin treatment with daily doses of medium-potency corticosteroids (0.1% mometasone or triamcinolone), strong-potency corticosteroids (0.05% betamethasone or fluocinonide), and super-potent corticosteroids (clobetasol, halobetasol) that are reserved for recalcitrant plaques.
-Calcipotriene 0.005% cream, which is a vitamin D analogue, should not be used with treatments that can change pH (such as topical lactic acid). It may be combined with a superpotent corticosteroid. local side effects include erythema, edema, peeling, and burning; Topical retinoids: tazarotene 0.05% or 0.1% (Tazorac) daily; may be taken with corticosteroids; pregnancy Category C; local irritability and photosensitivity are side effects. Topical calcineurin inhibitors for use during pregnancy Category X: Tacrolimus 0.1% or pimecrolimus 1% may be used as steroid-sparing medications, particularly in face and intertriginous areas.
- Evaluation of topical treatments: For body plaques, vitamin D analogues function more gradually than topical corticosteroids but have longer disease-free periods; for the scalp, powerful and superpotent steroids work better (2)[A].
- Combining super-effective steroids and vitamin D mimics is more effective than using either one alone.
Serious illness: possible need for combined therapy
- UVB (broad/narrow band [BB, NB]) light therapy or PUVA: Skin type influences treatment regimens.
PUVA can be used as an adjuvant therapy; it has GI SE, photosensitivity, and an elevated risk of nonmelanoma skin malignancies.
- Systemic oral medications
 Methotrexate: Start with a 5-mg test dosage, then increase to 7.5 to 15.0 mg/week IV, PO, IM, or SC, and then add 2.5 mg every two to three weeks, up to 25 mg; use caution in women of reproductive age and avoid pregnancy; take folic acid supplements.
1 mg/day baseline chest x-ray, monitor LFTs, renal function, CBC, testing for latent tuberculosis (TB); consider liver biopsy when cumulative dose reaches 3.5 to 4.0 g; avoid alcohol and medications that interfere with folic acid metabolism including trimethoprim—sulfamethoxazole (Bactrim), NSAIDs, sulfamethoxazole, or hepatotoxic agents (e.g., retinoids).
Start with 2.5 mg/kg/day of cyclosporine; if there is still no improvement after 4 weeks, increase by 0.5 mg/kg/day; and repeat every 2 weeks (maximum dose: 5 mg/kg/day); Limit use to 6 months to 1 year during pregnancy Category C; adverse effects include renal damage and hypertension: Utilize Mg2+, CBC, lipids, and blood pressure to track renal function and electrolytes.
○ Acitretin (Soriatane): Start at 10 to 25 mg/day; effective for pustular psoriasis and as a maintenance therapy after stabilization with other agents; pregnancy Category X: pregnancy test before starting; two forms of contraception 1 month before, during, and for at least 3 years after treatment; avoid alcohol ; side effects: alopecia, xerosis, cheilitis, hepatotoxicity, hyperlipidemia, cataracts; monitor LFTs, renal function, lipid profile, CBC, regular eye exams.
 Apremilast (Otezla): 10 mg PO; titrate up by 10 mg/day on days two through five to a maintenance dose of 30 mg BID beginning on day six. Regular lab monitoring is not necessary. The most typical SE include GI issues, depression, and pregnancy.
Obtain remission for individuals with moderate to severe illness. Category C - Biologics. Safety information and costly and long-term effects are unavailable (4).[A].
 Basic principles: Avoid live immunizations, screen for latent TB at baseline and annually, run a hepatitis panel at baseline, and monitor CBC with differential for infections, heart failure, cancer, drug-induced lupus, and demyelinating disorders. All must to be regarded as first-line, efficient therapies; pregnancy Category B
TNF-inhibitors: also approved for psoriatic arthritis treatment. Etanercept (Enbrel), adalimumab (Humira), and infliximab (Remicade) are available options.
Ustekinumab (Stelara), an IL-12/IL-23 antagonist, is also authorized for the treatment of psoriatic arthritis.
Secukinumab (Cosentyx) and brodalumab (Siliq) are IL-17 antagonists. Psoriatic arthritis therapy has also been authorized. Patients with inflammatory bowel illness should not consume.
Next Line
Azathioprine, hydroxyurea, 6-thioguanine, and fumaric acid esters are immunosuppressive drugs.
Topicals include coal tar, anthralin, and salicylic acid


Referral 

Patients with pustular psoriasis, psoriatic arthritis, severe extremities involvement, or illness not improving with topical therapy should be referred.

Surgical Techniques 

Postoperative wound healing may be affected by psoriasis and psoriatic medicines.

Alternative Therapies 
climatotherapy, balneotherapy, and stress reduction techniques

Admission 

To rule out sepsis, restore the skin's barrier function with cleansing and bandaging, start systemic therapy, use aggressive topical corticosteroid therapy, and manage electrolytes

BSA involvement as a follow-up measure to assess how well the therapy is functioning; if no improvement is shown, modify the therapy or add an agent.

Exercise and a well-balanced diet to reduce cardiovascular risk factors


Prognosis 
Chronic plaque type is lifelong with intermittent spontaneous remissions and exacerbations; the guttate form may be self-limited and remit after months; the erythrodermic and generalized pustular forms may be severe and persistent.

Cardiovascular disease, widespread pustular psoriasis, and erythrodermic psoriasis are complications.

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