Psoriasis and lichen презентация

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Psoriasis and Lichen Ruber Planus.

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Psoriasis.
Pathogenesis.
Psoriasis is a chronic inflammatory disease of unknown cause. It is now considered to be due to T-lymphocytes mediated disease of abnormal keratinocyte proliferation in genetic predisposed subject.

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Etiopathogenesis
Genetic Factors. Multifactorial inheritance mechanisms and etiologies without any genetic component have not yet been ruled out, though many families appear to exhibit autosomal dominant patterns of inheritance with decreased penetrance.

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Etiopathogenesis
Environmental Factors - Infection and a number of physical agents (eg, HIV infection, alcoholism, smoking UV light) all can affect the course, duration, and clinical appearance of plaque psoriasis.

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Etiopathogenesis.
Local factors
Trauma - All types of trauma have been associated with the development of plaque psoriasis (eg, physical, chemical, electrical, surgical, infective, and inflammatory types of injury).
Sunlight - Most patients generally consider sunlight to be beneficial for their psoriasis.

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Etiopathogenesis.
Systemic factors
Infection - Pharyngeal streptococcal infections have been shown to produce a clinically distinctive disease flare known as guttate psoriasis.
HIV - An increase in psoriasis activity has been observed in patients who are or become infected with HIV.
Drugs - A number of medications have been shown to cause an exacerbation of psoriasis.
Psychogenic/emotional - Many patients report an increase in the psoriasis severity with psychological stress.
Smoking - An increased risk of chronic plaque psoriasis exists in cigarette smokers.
Alcohol - Alcohol is considered a risk factor for psoriasis, particularly in young to middle-aged males.
Endocrine - Psoriasis severity has been noted to fluctuate with hormonal changes.

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Season Forms of Psoriasis
According to the climatic and meteorological factors winter (intensification in the cold period of the year), summer and mixed forms are differentiated. Winter type of psoriasis is found more often than other forms.

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Stages
Stages. In the progress of clinical development three stages of inflammatory process are distinguished: progressive, hospital and regressive.
For the progressive stage characteristic features are intensive itching, development of new papules, peripheral growth of old papules, presence of the inflammatory crown around the papule, Köbner’s phenomenon. (Fig. 6.)
At the hospital stage fresh lesions do not develop, the peripheral crowns are absent, Köbner’s phenomenon is not seen.
At the regressive stage the lesions are compressed, get pale, the desquamation decreases or stops, depigmentation of the crown takes place around the papule (pseudoatrophied Woron’s crown) and resolution of the lesions.

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Clinical classification
Non-pustular Psoriasis
Chronic Plague type
Acute Guttate
Inverse, flexural
Erythrodermic
Regional: palms and soles, nails
Sebo-psoriasis

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Clinical classification
Pustular Psoriasis
Generalized Pustular psoriasis (von Zumbusch)
Localized pustular psoriasis of palms & soles
Psoriasis with Arthropathy
oligoarticular asymmetrical arthritis, symmetrical involving small joints of fingers likes rheumatoid arthritis, classical distal arthropathy involving distal interphalangeal joints, destructive arthritis mutilans and psoriatic spondyloarthropathy which is similar to ankylosing spondylitis.

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Clinical Features
The commonest form of psoriasis is the chronic plague type which usually presents as brightly erythematous scaly plagues at the predisposed areas i.e. the extensor aspect, the tip of elbows, knees, sacral area, the scalp. They may be associated with no symptoms to moderate pruritus. Excessive dandruff and scaling from the lesional area may be an early complaint.

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Koebner’s Phenomena.
Three interesting phenomena occur in Psoriasis.
Any form of trauma may result in psoriasis appearing in the traumatized areas which is known as Koebner phenomenon or isomorphic response.

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Woronoff
phenomena.
Well-circumscribed margins - Psoriatic plaques are well defined and have sharply demarcated boundaries. Psoriatic plaques occasionally appear to be immediately encircled by a paler peripheral zone referred to as the halo or ring of Woronoff.

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Auspitz phenomena
Psoriatic triad consists of three consequent phenomena, appearing after scratching psoriatic papulae.
a) intense desquamation with silver-white scaling reminding stearine (“stearine macula” phenomenon);
b) shiny surface after the removal of scales (“terminal” or psoriatic film phenomenon);
c) drop bleeding in further scratching (phenomenon of drip bleedin

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Chronic Plague type
Plaque psoriasis, the most common type of the disease, is characterized by raised, thickened patches of red skin covered with silvery-white scales. Well-circumscribed margins - Psoriatic plaques are well defined and have sharply demarcated boundaries.
Symmetry - Psoriatic plaques tend to be symmetrically distributed over the body.

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Acute Guttate
Guttate psoriasis is characterized by small, drop-like lesions
The small guttate maculopapular scaly lesion still have the characteristic feature of psoriasis and hence there will be no diagnostic problem.

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Inverse, flexural
Flexural psoriasis may lack the prominent silvery scaling because the flexural areas affected usually appear as brightly erythematous, homogenous, well defined and sharply demarcated plaque or patch with or without super-infection with Candida

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Erythrodermic psoriasis
Erythrodermic psoriasis is characterized by intense redness and swelling of a large part of the skin surface. It results from unfavourable external factors, irritating treatment and can be noted in 1-3% of patients with psoriasis, in whom there is usually a decrease in immunological indicators and high allergic reactivity. Due to this the whole skin takes a bright red colour with severe edema. In different places edema and infiltration are unequally marked. High desquamation, falling out of hair, enlargement of lymph nodes, destruction of nails, and suppurative paronychia are observed.

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Regional
Nails
Nail involvement is commonly seen in all types of psoriasis which can affect the nail matrix and nail bed leading to pitting, discoloration, subungual hyperkeratosis, onycholysis, splinter hemorrhage. Circular area of discoloration of nail bed resembling an oil drop underneath the nail - oil drop sign is most characteristic for psoriatic nail.

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Seborrheic psoriasis
Many doctors may not consider the existence of this condition: sebo-psoriasis or seborrheic psoriasis. Very often, we can encounter conditions in which both psoriatic and seborrheic eczema features are present. We consider this a separate entity because it is not rare. Genetically constituted psoriatics can develop seborrhoeic eczema lesions at the scalp, eyebrows and regions of ears with characteristic morphology of psoriasis.

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Pustular
Psoriasis
Generalized pustular psoriasis can present in a psoriatic prone patient who is given systemic steroid for other conditions and upon sudden withdrawal of the steroid, generalized pustular psoriasis will be precipitated for the first time. Occasionally, it develops from the unstable nummular psoriasis or acrodermatitis continua after inappropriate irritant therapy or withdrawal of extensive topical steroid.

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Pustular
Psoriasis
Localized pustular psoriasis of palms and soles usually present as symmetrical, monomorphic eruption of small sterile pustular eruption on hands and feet. They are painful rather than pruritic. Very often, brownish thick wall pustules are found. They are resistant to treatment and will be quite disabling. Another form of local pustular psoriasis is asymmetrical involvement affecting distal phalanx with nail destruction.

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Psoriasis with
Arthropathy
Radiological examination of the affected joints may confirm the psoriatic arthropathy. The following findings are characteristic signs of psoriatic arthropathy: 1) destructive distal interphalangeal arthropathy with bony ankylosis of the interphalangeal joints 2) abnormally wide joint spaces and well demarcated adjacent bony surfaces 3) bony proliferation of distal phalanx in great toe 4) resorption of tufts of distal phalanges of hands & feet.

Investigation
The typical histopathology of psoriasis:
1) regular elongation of the rete ridges with thickening in their lower portion.
2) elongation and edema of the papillae.
3) thinning of the suprapapillary portions of the stratum malpighii with the occasional presence of a very small spongiform pustule.
4) the absence of granular layer
5) parakeratosis
6) presence of Munro microabscesses.

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Differential
diagnoses

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Lichen Ruber
Planus. Etiology
Etiology and pathogenesis. There is an opinion that the disease is inflectional by nature as it is successfully treated with antibodies and viruses are revealed inside the cells. Other specialists consider it to be of neurogenic genesis and think that the stress condition may be the reason of the disease, as hypnotism and reflex segment therapy is successful in some patients, situation of the lesions along the course of the nerves. Attention is paid to the hormonal deviation and metabolic upset in patients with plane red lichens. Family hereditary predisposition is observed.

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Lichen Ruber
Planus. Course.
Lichen planus may cause a small number of skin lesions or less often affect a wide area of the skin and mucous membranes. In 85% of cases it clears from skin surfaces within 18 months but it may persist longer especially when affecting the mouth or genitals.

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Classification
Classical lichen planus
Oral lichen planus
Lichen planus of nails
Atypical lichen planus
Hypertrophic, or verrucose form
Atrophic and sclerotic forms
Pemphigoid or bullous form
Lichen ruber moniliformis
Acuminate, perifollicular form
Annular form
Lichen planus pigmentosa
Actinic lichen planus

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Clinical features
Classical Form.
Classical lichen planus is characterized by shiny, flat-topped, firm papules (bumps) varying from pin point size (‘guttate’) to larger than a centimetre. They are a purple colour and often are crossed by fine white lines (called ‘Wickham's striae’). They may be close together or widespread, or grouped in lines (linear lichen planus) or rings (annular lichen planus). Linear lichen planus can be the result of scratching or injuring the skin. Although sometimes there are no symptoms, it is often very itchy.
Wickham's striae

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Clinical features. Hyperpigmentation.
New lesions may appear while others are clearing. As the lichen planus papules clear they are often replaced by areas of greyish-brown discolouration, especially in darker skinned people. This is called postinflammatory hyperpigmentation and can persist for months.

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Oral
lichen planus
The mouth is involved In 50% of cases and is often the only affected area. The usual areas affected are the inside of the cheeks and the sides of the tongue, but the gums and lips may also be involved.

Oral lichen planus
The most common features are:
Painless white streaks in a lacy or fern-like pattern
Painful and persistent ulcers (erosive lichen planus)
Diffuse redness and peeling of the gums (desquamative gingivitis)
In some cases oral lichen planus affecting the gums is due to contact allergy to mercury in amalgam fillings on nearby teeth. The cause can be confirmed by patch testing. In these patients the lichen planus may resolve on replacing the fillings with composite material. If the lichen planus is not due to mercury allergy removing amalgam fillings is very unlikely to result in cure.

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Lichen planus
of nails
Lichen planus affects one or more nails in 10% of cases, sometimes without involving the skin surface – if all nails are abnormal and nowhere else is affected it is called twenty nail dystrophy. The nail plate tends to thin and may become grooved and ridged. The nail may darken, thicken up or lift off the nail bed (onycholysis). Sometimes the cuticle is destroyed and forms a scar. The nails may shed, stop growing altogether and rarely, completely disappear.

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Atrophic and
sclerotic forms
Atrophic or sclerotic changes may occur after the papules and plaques resolve. Because of its light colour, the bleached-like cicatricial atrophy is called lichen albus; it may be localized on the neck, wrists, chest and abdomen. Microfocal atrophic alopecia may develop on the scalp in case of pseudopelade which is accompanied with symptoms of follicular keratosis on the extensor surfaces of the limbs (Little-Lassauer's syndrome).

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Lichen planus.
Hypertrophic form
Lichen planus may affect any area, but is most often seen on the front of the wrists, lower back, and ankles. On the palms and soles the papules are firm and yellow. Very thick scaly patches are particularly itchy and are most likely to arise around the ankles (hypertrophic lichen planu).

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Lichen ruber moniliformis. Acuminate, perifollicular form.
Is characterized by large, cherrystone in size, lesions threaded like the beads of a necklace. The pustules are domelike, rounded, wax-like, keloid-like and are arranged like beads, which creates the impression of narrow keloid bands. In some cases the lesions resemble a necklace without keloid-like strands.
Follicular lichen planus, also known as lichen perifollicularis, results in tiny red spiny papules around a cluster of hairs. Rarely, blistering occurs in the lesions. Permanently bald patches may develop. Sometimes no follicular scaling or inflammation is present but bald areas of scarring slowly appear, often looking rather like footprints in the snow. This is known as ‘pseudopelade’.

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Other forms of
lichen planus
Bullous lichen planus is rare; blisters appear within lichen planus papules or by themselves, generally on the lower legs.
Actinic lichen planus only affects sun exposed sites such as face, neck and the backs of the hands.
Lichen planus pigmentosa. In some patients oval greyish brown marks appear on the face and neck or trunk and limbs without an inflammatory phase.
In the all forms of lichen planus we can see the Koebner’s symptom.