Review Status: Internally reviewed
1.Psoriasis of the scalp
2a.Psoriasis of the scalp
2b.Psoriasis of the scalp
3.Psoriasis : Trunk
- Figure 5a.Psoriasis: Back
- Figure 7a.Psoriasis: Back
10a.Psoriasis: Thigh and Knee
10b.Psoriasis: Thigh, posterior view
12a.Psoriasis: Ankle, anterior view
12b.Psoriasis: Ankle, anterior view
12c.Psoriasis: Ankle, anterior view
- A common, genetically determined, inflammatory and proliferative disease
of the skin, the most characteristic lesions consisting of chronic, sharply demarcated,
dull-red scaly plaques, particularly on the extensor prominences and in the scalp. The
disease is enormously variable in duration and extent and morphological variants are
Incidence and prevalence:
1.Racial and ethnic variations:
- --1~1.4％in USA
- --1.43~2.9％in North Europe
- --0％in Latin American Indian
- In Singapore, India, Chinese and Malays Age of onset:
- --early at 16~22 years
- --later at 57~60 years
Patients with a family history of psoriasis tend to have
an earlier age of onset.
Familial tendency for psoriasis:
Psoriasis in parents
- Sex ratio:
Etiology and pathogenesis:
- Single gene autosomal dominant inheritance.
- Some studies showed the inheritance may be multi-factorial.
- HLA phenotype most strongly associated with psoriasis.
- Enviromental factors also contribute to the etiology.
Provocation and exacerbation:
- Koebner and reverse Koeber phenomenon.
- All-or-none phenomenon
- Streptococcal infection, especially in the throat, in provoking acute
- Continuing, subclinical streptococcal infection might be responsible for
refractory chronic plaque psoriasis. --Additional administration of rifampicin with
penicillin or erythromycin has been shown to markedly improve the skin lesions of all of
patients with streptococcus-associated psoriasis unresponsive to penicillin or
- Peaks of incidence at puberty and at the menopause.
- Improve in pregnancy, worse in postpartum.
- Generalized pustular psoriasis may be provoked by pregnancy and may
exacerbate premenstrually, and may also be provoked by high dose estrogen therapy.
4.Climate (sunlight / temperature):
- Sunlight is generally beneficial, but small minority of psoriatics are
provoked by strong sunlight and suffer summer exacerbations in exposed skin.
- The prevalence of photosensitivity was estimated at 5.5％.?--Photosensitivity
in psoriasis was significantly associated with skin type I, advanced age and female sex.
- The most frequent associations included the administration of lithium, β-adrenergic
blocking agents and antimalarials, calcium channels blockers, and the withdrawal of
systemically administered corticosteroids.
- The possible exacerbating effect of NSAID is of particular importance,
but they still don*t have an obvious direct adverse effect on psoriasis.
- There is evidence that the severity of psoriasis may depend on prior
- Heavy drinking at a level liable to be detrimental to health was found
significantly more commonly in male patients with severe psoriasis than in other psoriasis
sufferers. It is possible that excessive alcohol consumption may lead to reduced
therapeutic compliance, and also that it is a symptom of stress caused by severe skin
9.Acquired immunodeficiency syndrome (AIDS):
- The prognosis of AIDS in patients with psoriasis also appeared poor, but
the mechanism is still unclear.
1.Hyper-epidermopoiesis, rapid DNA synthesis:
- --decrease cAMP, increase cGMP or cGMP/cAMP ratio.
- --certain regulatory subunits (RI and RII respectively) of cAMP-dependent
protein kinases I and II in fibroblasts from psoriatic versus nornal subjects.
- Calmodulin:?Increased biologically active or immunoreative calmodulin
(low calcium) has been found in samples from lesional psoriasis skin by several groups.
- Growth factors:
- --increase TGF-α, EGF receptor, IL-6
- --there is shortening of the epidermal germinative cell cycle, an
increase in the number of cells in the proliferative pool, and marked shortening of the
epidermal turnover time in psoriatic lesions.
- --The increased expression in psoriatic lesional extracts of RNA for the
proto-oncogenes Ki-ras, myc, fos, and abl has been reported.
- Leucocyte attractants in psoriasis:
- --Arachidonic cascade :LTB4 elicits the formation of intra-epidermal
- --It may induce epidermal proliferation in vivo, and the activity of
ornithine decarboxylase (ODC), the rate-limiting enzyme in the synthesis of the
polyamines, is increased by proliferative stimuli such as the tumor-promoting phorbol
ester, UVB irradiation and hair plucking.
- --Some proteolytic enzymes such as plasminogen activator, may play a role
in cellular activation, division and escape from contact inhibition.
- --Phosphatidylinositol (PI) specific phospholipase C activity was found
to be elevated in psoriatic lesional samples.
- --PIP2 =＞DAG+IP3
- intracellular calcium release
- activation of PKC
- --PKC activity has been reported to be significantly decreased in
- Activated T-cell expressing surface HLA-DR molecules and IL-2 receptors.
- Lymphocytes attracted by locally produced chemotactic factors may release
γ-interferon which in turn may induce the expression of HLA-DR and ICAM-1 on
keratinocytes.=＞mononuclear cells bind to keratinocyte=＞cytokine release and result
- l Irregular epidermal proliferation and increased mitotic figures in
keratinocytes, superficial vascular dilatation and proliferation, and infiltration of
lesions with leucocytes including neutrophils, lymphocytes and monocyte / macrophages.
- Diffuse parakeratosis
- Hypogranulosis poor differentiation
- Regular acanthosis rapid mitosis
- Tortuous, dilated vessels
- Spongiosiform pustules of Kogoj
- Microabscess of Munro
- Clinical features:
- 1. Modes of onset:
- Acute guttate psoriasis: children or young adult.
- Most forms of psoriasis: before the fourth decade.
- Pustular psoriasis of the palms and soles is extremely rare before adult
- Post traumatic from: young, athletic men
- Flexural lesions: obese, middle-aged subjects or pre-existing intertrigo.
- Psoriasis which limited to the groins, perineal and perianal regions: men
in the 20~50 age group.
- 2. Particular clinical signs:
- 3. The morphology of the common chronic stable plaque (psoriasis
vulgaris, nummular psoriasis)
- Erythema which is full, rich red (salmon-pink) to orange-brown --D/D:
eczema, seborrheic dermatitis, lichen simplex, lichen planus.
- Silver white scale(Figure
11 , Figure 12a , Figure 12b , Figure 12c)
- Well -defined, with a sharply delineated edge
- Thickening characteristic of the psoriasis causes the lesions to be
raised from the adjoining skin and easily palpable.
- Hue/opacity papules
- Discs and plaques of varying sizes are often found on the trunk and limbs(Figure 4a , Figure 5a , Figure 11).
There may be any number of lesions or only a single one.
- Pustules may appear
- Clinical variants:
- 1. Guttate psoriasis:
- Children and young adults who after acute streptococcal infections.
- Shower of small lesions, appearing more or less generally over the body.
- Often appear on the trunk and proximal part of the limbs, rarely on the
- Tendency of regression and recurrence.
--nature of the scaling
- D/D: multiple small scaling:
- --psoriasiform drug eruption
- --secondary syphilis
- --pityriasis rosea
- 2. Rupioid, elephantine and ostraceous psoriasis: Plaques associated with
- 3. Erythrodermic psoriasis:
Type 1: Extensive chronic plaque psoriasis
- --Erythroderma may occur as initial manifestation of psoriasis, or
gradually or suddenly developed in a pre-existed psoriasis
- --May follow sensitivity / irritation to topical reaction
- --Widespread of follicular lesions during regression may indicating an
Type 2: Unstable psoriasis
- --May occurred at any time, unexpected
- --Frequently in arthropathic type, or general pustular psoriasis, induced
by infection, hypocalcemia, tar or corticosteroids.
- --Frequent relapse is the feature
- --The patient is febril and ill, the course is often tumultuous or
prolonged, and there is an appreciable mortality.
- --Severe itching
- Metabolic complications of erythroderma:
- --Universal inflammation as exfoliative dermatitis may induce the
- heat loss and leading to hypothermia.
- hypohidrotic or anhidrotic, urine outpet tends to drop
- compensatory increases in body heat production
- skin blood flow, blood volume and cardiac output may all be increased and
lead to failure of the cardiovascular system
- malabsorption =＞dermatogenic enteropathy
- loss of protein =＞hypoalbuminemia =edema
- loss of iron =＞mild anemia
- Modification by site:
- 1. Scalp:
- Usually no hair loss, except in erythroderma
- Pityriasis amiantacea or rupioid
- Very thick plaques develop, especially at the occiput.
- Diffuse involved or multiple discrete plaques of varying size.
- Hair line usually predominant.
- A solitary patch on the glans of the uncircumcised male lacks scales, but
its color and well-defined edge are usually distinctive.
- Need biopsy to R/O erythroplasia or Zoon's plasma cell balanitis.
3. Flexural (inverse) psoriasis:
- Groins, vulva, axilla, submammary folds, gluteal cleft and other body
folds is commoner in older adults than children.
- Scaling is greatly reduced or absent.
- The surface has a glazed hue and fissuring at the depth of the fold is
- The edges are usually well defined unless secondary infection or
- D/D with infective or seborrheic dermatitis when the lesions are on the
retro-auricular fold or the external auditory meatus.
4. Hands and feet:
- Typical scaly patches on which a fine silvery scale.
- Relationship to trauma or occupational irritants.
- D/D with lichen simplex, hyperkeratotic eczema, pustulosis. Psoriasis has
a sharply defined edge and absence of vesiculation.
- Frequently in psoriasis arthropathica.
- Pitting in 25~50％or more.
- Spots of "oil-drop"
- Discoloration, subungual hyperkeratosis, ridges / grooves, onycholysis
- Atypical forms:
- 1. Linear and zonal lesions
- 2. Seborrhoeic psoriasis
- 3. Mucosal lesions
- 4. Ocular lesions
- 1. Other skin diseases:
- seborrheic dermatitis
- lichen simplex l lichen planus
- actinic reticuloid
- P-J syndrome
- viral warts
- 2. Arthritis
- 3. Gout
- 4. Hypocalcemia
- 5. Intestinal disease and malabsorption
- 6. Cardiovascular disease
- 1. Infection
- 2. Arthritis
- 3. Alcoholism
- 4. Nephritis and renal failure
- 5. Hepatic failure
- 6. Apical pulmonary fibrosis
- 7. Amyloidosis
- Differential diagnosis:
- 1. Seborrheic dermatitis
- 2. Eczema
- 3. Lichen planus
- 4. Lichen simplex
- 5. Pityriasis lichenoides chronica
- 6. Candidiasis
- 7. Tinea cruris
- 8. Pityriasis rubra pilaris
- 9. Secondary syphilis
- 10. Porokeratosis
- 11. Bowen's and Paget's disease
- 12. Penile erythroplasia
- 13. Erythema annulare centrifugum
- 14. The annular migratory necrolytic erythema associated with carcinoma
of the pancreas
- 15. Subcorneal pustular dermatosis
- 16. Psoriasiform drug eruptions
- 17. Parakeratosis pustulosa
- Course and prognosis:
- 1. Guttate attacks carry a better prognosis than the others.
- 2. An early onset and a family history of the disease appear to worsen
- 1. Relapse is the rule, however completely the lesions are treated and by
- 2. Severe cases can be maintained in prolonged remission by the use of
MTX, PUVA or cyclosporin.
- 1. Local therapy:
- Tar therapy
- Daily application of 2~5％crude tar, combined with a tar bath and UV
light, has been a mainstay of in-patient treatment.
- Tar alone is certainly active in psoriasis as is UVB alone.
- Coal tar seems to sensitize the skin to UVA but not to UVB and
pototoxicity is of photodynamic type.
- A combination of 5％crude coal tar and dithranol was found to be as
effective as dithranol alone when used in short contact treatment of psoriasis.
- Folliculitis is the commonest side-effect.
- There was a significantly greater risk of skin cancer in psoriatic
patients treated with high exposure coal tar and UV light therapy, than in matched
patients treated with smaller dose therapy. The increased incidence of malignancy may,
therefore, depend on exposure to high dose UVB.
- --erythrodermic or generalized pustular psoriasis
- --pre-existing folliculitis
- --severe acne
- Dithranol (anthralin):
- Tar bath =＞ suberythema UVB =＞ dithranol paste (combine therapy is
better than single therapy)
- Dithranol past is not suitable for the head and neck, flexures or
genitalia, where it is liable to spread and is too irritant. Short contact therapy (10 min
daily) may be effective and less irritant.
- The drug has the great virtue of lacking systemic toxicity.
- Leaving deep brown staining.
- Side-effect: folliculitis
- Choose to use on face and neck, flexures and genitalia. They are also
used in unstable, erythrodermic and generalized pustular psoriasis in preference to tar or
- The merits are ease of application and removal, lack of irritancy and the
absence of staining of skin or linen.
- The hazards: topical steroids under occlusion do have a limited place in
the management of recalcitrant psoriasis of the scalp, hands, feet and other areas.
- Plasma cortisol levels are easily suppressed by the most potent
preparations or high doses.
- CPotent ones are likely to be needed on the scalp and knuckles
particularly. onversely, the flexures and inner thighs need much weaker products.
- # Intralesional corticosteroid therapy:
- Triamcinolone hexacetonide or triamcinolone acetonide can be infiltrated
intradermally into localized psoriasis lesions by needle injection. It is used in
troublesome small, resistant lesions on the backs of hands, especially the knuckles,
intensely pruritic small plaques or lichenoid lesions.
- Treatment of the scalp:
- Tar-containing shampoos =＞ cream formulations of dithranol =＞ if
fail, corticosteroid scalp lotion or gels should be drenched overnight with a coconut oil
based tar and salicylic acid pomade which is shampooed out once or even twice daily.
- Topical or intralesional cytostatic therapy:
- Alkylating agent lomustine
- Topical MTX
Dialysis and related procedures:
- The clearing of incidental psoriasis during hemodialysis for uremia was
reported in 1976. Dialysis could favorably influence psoriasis in patients with normal
- Peritoneal dialysis is more effective than hemodialysis.
- Cardiopulmonary bypass oxygenation
- Extensive exchange with fresh frozen plasma
- Occlusive dressing alone:
- Prolonged occlusion with various tape products including Band-Acid.
- Prolonged application of the adhesive hydrocolloid occlusive dressing.
- Side-effects: hyperpigmentation, pain on removal of dressings, Koebner
response or offensive odor.
- It is the management of limited psoriasis.
- Goeckerman first thoroughly documented the ability of crude coal tar
applications followed by exposure to UV radiation to clear psoriasis.
- Continued maintenance UVB therapy after initial clearance with UVB
significantly increased the duration of disease control. An average of six treatments per
- Selective UVB phototherapy (SUP) was introduced in Europe using UV
sources with peak effective output in the 300~320 nm range. The excluded shorter
wavelengths are also those most capable of causing DNA damage so the carcinogenic hazard
may be reduced.
- Low intensity SUP (LISUP) -home use
- Fluorescent lamps with negligible UVC emission
- In relation to possible carcinogenic hazards.
- Side effects: therapeutic doses of UVB impair delayed hypersensitivity
responses to dinitrochlorobenzene and mechlorethamine and may increase urinary excretion
of mutagens. Prevalence of senile cataract is correlated with climatic UV exposure.
- Very large doses of UVA alone may improve paoriasis and enhancement of
UVB responses by UVA has been claimed.
- UVB therapy is valuable for discoid psoriasis and may be especially
valuable in guttate and seborrheic patterns.
2. Systemic therapy
- The fluorinated forms such as triamcinolone and betamethasone have more
effect on psoriasis than prednisolone.
- Withdrawal the drug will induce psoriasis to relapseor may rebound. The
rebound may take the form of widespread amall-patterned eruprive psoriasis often involving
the face and backs of hands.
- Systemic steroids should not be used in the routine care of psoriasis.
- Orally, intramuscularly or intravenously.
- --competitive inhibition of dihydrofolate reductases, exerting a stronge
antimitotic action on the epidermis.
- --inhibits PMN chemotaxis
- MTX may be given as a single weekly oral dose, occasionally fortnightly.
- During or after therapy, the renal, hepatic and marrow function tests are
- --anemia, thrombocytopenia and leucopenia, active infection, peptic
ulceration, ulcerative colitis, alcoholism, immunodeficiency, pregnancy, lactation and an
- --transient anorexia, nausea and dyspeptic pain.
- --bursting headaches
- --burning sensations in the psoriasis plaques --on the marrow:
leucopenia, thrombocytopenia, folate-deficient megaloblastic anemia.
- --modest thrombocytopenia, low to normal WBC count
- --hetapotoxic, causing fibrosis and cirrhosis
- --oligospermia in men
- --abortifacient and teratogenic in early pregnancy
- Risk factors:
- --liver disease
- --impaired renal function
- --increased age
- It is particularly valuable in the chronic erythrodermic and generalized
- In the event of accidental overdosage or unexpected acute toxicity,
folinic acid should be given intramuscularly in full dosage.
- Combined with:
- --folinic acid
- in order to reduce dosage and toxicity of each modality.
- It blocks the conversion of ribonualeotides to deoxyribonucleotides by
interfering with the enzyme ribonucleosidediphosphate reductase.
- Marrow toxicity.
- Less effective than MTX.
- Indication: patients needing systemic treatment and who are resistant to
MTX or develop side-effect.
- Virtue: less frequent cause of anorexia, nausea and hepatotoxicity.
- --fall in hemoglobin
- --cutaneous vasculitis
- --diffuse hyperpigmentation
- --actinic psoriasis
- --psychological effcts
- It affects only cells in the mitotic cycle, acting in the late premitotic
and mitotic phases. It is capable of normalizing the vasculature of certain proliferating
tumors. Initial response is rapid and optimal response may take 2 to 3 months.
- --bone marrow toxicity (microcytotic anemia)
- --GI intolerance
- --hair loss
- --leg ulceration
- --association with AML, SCC, multiple BCC, B-cell lymphoma
- # Etretinate:
- --psoriasis vulgaris
- --pustular psoriasis
- --erythrodermic psoriasis
- --exfoliative and plaque psoriasis
- Psoriasis vulgaris may be less responsive and is often combine with :
- --etretinate and long-term MTX
- --corticosteroid cream
- --selective UVB phototherapy (SUP)
- --lipophilic and progressively accumulates in the subcutis
- --radiographic spinal changes
- --dryness of the lips, nose, eyes, mouth, throat or vagina
- --painful exfoliative cheilitis, urethritis, balanitis, gingivitis,
peeling of the finger-tips and corneal ulceration.
- --rhagades, palmoplantar desquamation, burning sensations in the skin.
- --joint stiffness and synovitis
- --night blindness
- Etretinate is very valuable in generalized pustular psoriasis.
- --active liver disease
- --pre-existing hyperlipidemia
- # Isotretinoin (13-cis-retinoic acid):
- Improve generalized pustular psoriasis
- Less effective than etretinate in the treatment of chronic plaque
- # Acitretin (formerly etretin):
- Effective: acitretin=etretinate
- Tolerance: etretinate>acitretin
- There is an advantage in combining a retinoid with PUVA.
- Successful use of oral 8-methoxypsoralen (8-MOP) and UVA led to intense
interest and the coining of the terms "photochemotherapy" and "PUVA".
- --It is arbitrary.
- --Liquid form produce higher, earlier peak levels of drug in the plasma
and more reproducible plasma concentrations.
- --Absorption being delayed and reduced by a fat-rich meal.
- --Treatment is given two to four times weekly.
- Eye protection
- Patient selection:
- --Contra-indications: renal, hepatic or severe cardiovascular disease,
cataract formation, pregnancy, children under 18 years, or pre-existing light-aggravated
disease such as SLE or porphyria.
- PUVA should only be considered as a primary treatment in those patients
over 55 years where psoriasis covers at least 20％of the body surface, and who cannot be
controlled by conventional topical therapy.
- --excellent in discoid psoriasis vulgaris.
- --PUVA is also of value in generalized pustular psoriasis, erythrodermic
psoriasis, chronic palmoplantar pustular psoriasis and nail psoriasis, but succuss rates
are much lower in these atypical patterns of disease.
- Patient monitoring:
- --regular blood count
- --renal and liver function tests
- --eye examination
- Combined therapy:
- --etretinate or acitretin
- --topical corticosteroids
- --cytotoxic drug
- Adverse effects of PUVA:
- --Erythema and frank sunburn are the commonest effects.
- --Immune function abnormaly (reduce T-cell and its function, inhibition
of lymphocyte DNA synthesis, delayed hypersensitivity responses)
- --mild facial dermatitis
- --bullae of generalized pemphigoid
- --hypertrichosis in females
- --lichenoid eruptions
- --actinic keratosis
- --superficial actinic porokeratosis
- --LE-like syndrome
- The carcinogenic hazard of PUVA:
- --It is undisputed that solar UV radiation is a major etiological factor
in SCC, BCC and malignant melanoma in humans. Psoralens are known to be mutagenic and DNA
damage has been induced by PUVA.
- --PUVA may induce AML and a preleukemic state.
PUVA using other psoralens:
PUVA therapy with topically applied psoralens:
- --Advantage: avoidance of nausea
- --Disadvantage: risk of severe local phototoxic reactions with
blistering, and the production of unsightly, patchy pigmentation.
- Cyclosporin (Cyclosporin A, CyA):
- Its inhibitory effects on T-cells, a possibility which has substantially
affected attitudes towards pathogenic mechanism in psoriasis.
- It is active orally and it should be given only to patients with
sufficiently severe disease.
- --renal dysfunction
- --uncontrolled hypertension
- --past or present malignancy
- --history of epilepsy
- --acute infection
- --immunosuppressive therapy
- --concomitant therapy with nephrotoxins
- --previous serious side-effect from CyA and known ----hypersensitivity
- Relative contra-indication:
- --abnormal liver function
- --drug or alcohol abuse
- Withdrawal =＞severe psoriasis relapse within weeks
- --dose-related hypertension
- --increase the risk of malignancy
- Miscellaneous oral and topical agents:
- Vitamin D3 (effctive: orally=topical)
- --inducing keratinocates differentiation and inhibition of T-cell
- 5-Lipoxygenase inhibitors
- Fish oil
- --interference with arachidonic acid metabolism.
- Zidovudine (azidothymidine)
- Systemic therapy for severe psoriasis: conclusions
- Pustular forms of psoriasis:
- 1. Definition:
- Neutrophilic accumulation in the epidermis is characteristic of all types
and patterns of psoriasis and histologically all psoriasis is "pustular".
- 2. A convenient classification is as follows:
- Localized pustular psoriasis:
- chronic palmoplantar
- acute palmoplantar (pustular bacterid)
- acrodermatitis continua
- Generalized pustular psoriasis:
- of pregnancy
- infantile and juvenile
- localized (not hands and feet)
- Localized pustular psoriasis:
- 1. Chronic palmoplantar pustular psoriasis (PPP)
- A common condition in which erythematous and scaly plaques studded with
sterile pustules persist on the palms or soles. The disease is chronic and very resistant
- Maybe association with psoriasis vulgaris or has family history of it.
- HLA-B13 (-)
- HLA-B17 (-)
- Provocative factors:
- Tonsils is a site of relevant focal infection.
- Clinical features:
- Adults, starts in the fifth or sixth decade or earlier
- A modest preponderance of women.
- one or more well-defined plaques
- Hands: thenar eminence > hypothenar eminence or central palm or distal
- Feet: instep, the medial or lateral border of the foot at the level of
the instep or the sides or back of the heel
- Symmetrical on the hands or feet is common
- Dusty red and often scaly
- Pustules are present, the desiccated pustule is exfoliated.
- Differential diagnosis:
- Secondary infection of eczema
- Chronic allergic contact dermatitis
- Chronic acropustulosis
- The usual course is prolonged.
- Temporary spontaneous remission
- 2. Acute palmoplantar pustular psoriasis:
- Rare, acute, monomorphic eruption of sterile pustules occurring on all
aspects of the hands and feet.
- palms, soles, and palmoplantar aspects of digits or dorsa of the hands
- The term "bacterid" implies that the eruption is provoked by a
remote bacterial infection.
- D/D: acute leucocytoclastic vasculitis with immune complex deposition.
- 3. Acrodermatitis continua
- A chronic sterile pustular eruption affecting initially the tips of
fingers or toes which tends slowly to extend locally but which, in adults, may evolve into
generalized pustular psoriasis.
- Clinical features:
- Children, female is common
- starts on finger or thumb more often than on a toe
- Koebner phenomena or infection induced
- bordered by a fringe of undermined epidermis, irregular, often sodden and
preceded by a line of vesiculopustules.
- slow proximal extension
- The nail plate may be completely destroyed.
- osteolysis of the tuft of the distal phalanx
- digits' end may become wasted and tapered, like scleroderma.
- Cold weather may be exacerbation
- evolve into generalized pustular psoriasis, especially in the elderly.
- Differential diagnosis:
- pulp infection
- herpetic whitlow
- contact dermatitis
- Intra-epidermal pustule packed with neutrophils.
- --tar-impregnated occlusive bandages
- --topical corticosteroid
- --oral corticosteroid
- Generalized pustular psoriasis:
- Generalized pustular psoriasis (GPP) is an uncommon variant of psoriasis
vulgaris in which an acute, subacute or occasionally chronic eruption has sterile
pustulosis as its central feature.
- Relationship to psoriasis vulgaris:
- Patients may have phases of ordinary psoriasis before or after the GPP.
- Provocation factors:
- Von Zumbusch's (acute) original patient was provoked by irritating
- coal tar and dithranol
- drug: especially corticosteroid
- Withdraw of systemic steroid
- The inflammation is more intense in acute GPP than the other types.
- lymphocytes infiltration
- vessels edema
- spongioform pustule formation (Kogoj)
- acanthosis with elongation of rete ridges.
1. Acute generalized pustular psoriasis (von Zumbusch):
- Clinical features:
- Typical type: early onset, develops into pustular psoriasis after some
years, after provocation by steroid withdrawal.
- Atypical type: later onset, acral or flexural in distribution. A rapid
and apparently spontaneous progression to the generalized pustular form follows.
- Burning erythema that spreads in hours to result in large areas of
- pin-point pustules =＞clusters
- lakes of pus, isolated pustules, circinate lesions, plaques of erythema
with pustular collarettes or a generalized erythroderma.
- fever, generalized weakness, severe malaise, leukocytosis
- Nails: thickened or separated by subungual lakes of pus.
- buccal mucosa and tongue may be involved.
- Remission occurs within days or weeks, but relapses are common.
- hypoalbuminemia =＞hypocalcemia
- liver damage or even jaundice
- deep vein thrombosis =＞fatal pulmonary embolism
- staphylococcal infection
- inflammatory polyarthritis
- gross hair loss
- telogen effluvium
- Laboratory findings:
- absolute lymphopenia
- PMN reduce
- plasma albumin, zinc and calcium may low
- ESR is usually raised.
- hyperlactatemia (secondary to hyperproliferation).
2. Generalized pustular psoriasis of pregnancy:
- A rare eruption, occurring especially in pregnancy with the features of
generalized pustular psoriasis but with a tendency to be symmetrical and grouped and often
starting in the flexures.
- before MC
- progesterone or clomiphene will produce pustular exacerbation.
- Impetigo herpetiformis with hypocalcemia is an entity separate from GPP
occurring in pregnancy.
- Clinical features:
- last trimester but may be earlier in the first month of pregnancy
- Risk of placental insufficiency leading to stillbirth, neonatal death of
the child or fetal abnormalities.
- Laboratory findings:
- lowered levels of vitamin D
- mestranol/ethynodiol combinition orally
3. Infantile and juvenile pustular psoriasis:
- male preponderance
- Systemic symptoms are often absent and spontaneous remissions occur.
- 2~10 years at onset
- Zumbusch pattern but annular and circinate forms are seen.
- The prognosis is variable but the disease may terminate spontaneously or
develop into more tractable psoriasis vulgaris.
- 4. Circinate and annular pustular psoriasis:
- more characteristic of the subacute or chronic forms of widespread
- discrete areas of erythema which become raised and edematous.
- slow centrifugal spread may mimic erythema annulare centrifugum.
- pustules appear peripherally on the crest of the advancing edge.
- 5. Localized forms of generalized pustular psoriasis:
- palmoplantar pustulosis
- napkin psoriasis
- psoriasis vulgaris following prolonged irritant topical therapy.
- subcorneal pustular dermatosis
- pustular lesions in Reiter's disease
- acute pemphigus foliaceus
- migratory necrolytic eruption of glucagonoma
- bowel by-pass syndrome
- Sweet's syndrome
- Behcet's syndrome
- rampant impetigo
- pustular drug druption
- Management of generalized pustular psoriasis
- Admission to hospital
- Withdrawal of provocative factors
- General measures:
- --conservative treatments such as bedrest, sedation, bland local
application, fluid and protein replacement, adequate ambient temperature.
- Topical therapy:
- --completely bland creams or lotions
- --weak corticosteroid cream
- --contra-indication: tar and dithranol
- Systemic therapy:
- --dapsone or sulphapyridine
- --corticosteroid (oral, parenteral, topical)
- --etretinate alone or combine with PUVA
- Von Zumbusch psoriasis: prognosis good
- GPP developing from acropustulosis: the worst prognosis
- GPP of childhood: prognosis good GPP which onset late: poor prognosis,
death is due to cardiac failure or resperatory infection.
- Patients with preceding ordinary psoriasis had a better prognosis than
those with atypical prepustular psoriasis.
- Arthropathic psoriasis (Psoriatic arthritis):
- 1. 0.02~0.1％in population, 2~25％of psoriatics
- 2. Definition:
- The association of psoriasis of the skin and/or nails with a peripheral
and/or spinal arthropathy, and usually a negative serological test for rheumatoid factor.
- 3. Etiology and pathogenesis:
- usually association with HLA-B27
- enviromental factors
- 4. 40~60 years is the peak age
- 5. Clinical patterns:
- asymmetrical DIP joints
- arthritis mutilans with osteolysis of phalanges and metacarpals
- symmetrical polyarthritis (RA-like)
- oligoarthritis with tenosynovitis of hands
- D/D: ankylosing spondylitis, psoriasis arthritis may with peripheral
- nail dystrophy
- 1. ROOK WILKINSON EBLING TEXTBOOK OF DERMATOLOGY by R.H. CHAMPION J.
L.BURTON K. J.G. EBLING
- 2. COLOR ATLAS AND SYNOPSIS OF CLINICAL DERMATOLOGY by THOMAS B.
FITZPATRICK RICHARD ALLEN JOHNSON KLAUS WOLFF MACHIEL K. POLANO DICK SUURMOND
Suggestion to this case
- Editor: 林育佳,蔡文仁,黃建元,李文瑞
- Text: 蔡宏彬
- Supervisor: Yu-Chuan Li, M.D., Ph.D.