PAPULOSQUAMOUS DISORDERS

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PAPULOSQUAMOUS DISORDERS

• DR.V.SUJA
• PROFESSOR
• DERMATOLOGY VENEREOLOGY

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PAPULES, PLAQUES SCALING

• EPIDERMOPOIESIS

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PAPULOSQUAMOUS DISORDERS

• Psoriasis
• Lichen planus
• Lichen nitidus
• Lichen striatus
• Expoliative dermatitis
• Pityrasis rosea
• Seborrhec dermatitis
• DOS
• Secondary syphilis
• Durg reactions
• Fungal infections

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PSORIASIS

• 3 PREVALENCE
• VARIED PRESENTATION
• VARIED TREATMENT MODALITIES
• TREATMENT SHOULD BE INDIVIDUALISED
• PATIENT EDUCATION IMPORTANT

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DEFINITION

• Chronic disorder
• Affects skin joints
• Multifactorial etiology
• Unpredictable course
• Remissions exacerbations
• Most prevalent t cell mediated
• Inflammatory disorder of skin

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AETIOPATHOGENISIS

• Exact cause-unknown
• Genetic predisposition
• Precipitating factors

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AETIOPATHOGENISIS

• Epidermal Factors
• Transit Time lt13 Days To 2 Days
• SCAg Leaks Bind To SCAbgtAg/Ab Complexes Bind
  To Complementgt PMNL Infiltration To Epidermisgt
  Epidermopoiesis
• Dermal Factors

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AETIOPATHOGENISIS

• Dermal factors
• capillary changes
• arterial capillaries to venous capillaries
• Leakage of PMNL to epidermisgtrapid epidermopoiesis

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GENTIC FACTORS

• Especially in arthropathic type
• Multilocus model of inheritance
• HLA-cw6 locus
• Genetic code is critical in the devt of disease
• Susceptible individuals in latent
  phenotype-prepsoriasis
• Transmission to children varies

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AETIOPATHOGENISIS

• TRIGGER FACTORS
• INFECTION
• TRAJUMA
• DRUGS
• BETA BLOCKERS
• ANTMALARIALS
• LTHUM
• NSAIDS
• INTERLENION ON
• PREGNACNY
• HIV
• SEASONAL

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AETIOPATHOGENISIS

• There is an aberration through the skin of
  patients with psoriasis that is modified to
  disease expression by circulating factors

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AETIOPATHOGENISIS

• ACTIVATED T CELLS ENTER SKIN
• RELEASE CYTOKINES CHEMOKINGE
• LEADS TO INFLAMMATION
• COB CD4 CELLS MEDIATE EPIDERMAL HYPERPLASIA

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AETIOPATHOGENISIS

• EPIDERMAL KERATINOCYTES DERIVED CYTOKINGES
• T CELL ACTIVATION
• T CELL ACTIVATION (ANTIGEN PROCESSED BY
  LANGERHANS CELLS). CYTOKINES
• ACTIVATE EPIDERMAL KERTINOCYTIES
• CDS(KILLER) TLYM-AUTOREACTIVE WITH EPIDERMAL
  KERATINOCYTIES
• EPIDERMAL ACTIVATION

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AETIOPATHOGENISIS

• ACTIVATEDSKIN HOMING PATHOGENIC T CELL
  POPULATION
• LIBERATES CYTOKINES AND CHEMOKINES LEADS TO
• INFLAMMATORY INFLTRATE EPSISRMAL
  PROLIERATION WIH ABNORMAL KERATNOCYTE
  DIFFERENTIAATION

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CLINICAL LFEATURES

• Psora-to itch
• Extensor predilection
• Varied presentation
• Nail lesions common
• Oral lesions rare
• Joint
• Pustular lesions
• Exploitive dermatitis
• Koebner phenomenon
• Auspitiz sign

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TYPES OF PSORIASIS

• PS VULGARIS
• FLXEURAL PS OR INVERSE PS
• GUTTATE PS
• SEBO PS
• FOLLICULAR PS
• EXFOLIATIVE PS
• NAIL LPS
• PALMOPLANTAR PS

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NAIL CHANGES

• PITTING
• SUBUNGUAL HYPER KERATOSIS
• ONYCHOLYSIS
• YELLOWISH DISCOLORATION
• OIL DROP SIGN

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PS ARTHROPATHY-TYPES

• DISTAL INTERPHALANGEAL
• MONO/OLIGOARTICULAR
• POLYARTICULAR
• SACROILIATIS
• RHEUMATOID ARTHRITIS TYPE
• MUTLANS

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COMPLICATIONS

• PSYCHOLOGICAL STRESS
• ARTHROPATHY
• EXRFOLIATIVE DERMATITIS
• PUSTULAR PS
• LOCALISED
• GENERALISED-VON-ZUMBUSCH
• TYPE-EMERGENCY

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TREATMENT
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CHRONIC OR STABLE PS

• TOPICL LKERATOLYTIC ANITIMITIOTICS
• SYSTEMIC DRUGS AS TETRACYCLINES,OMEGA
  TRGLYDERIDES dapsone clofazimine
• PHOTOTHERAPY
• SYSTEMIC IMMUNOSUPPRESSANTS
• METHOTREXATE,CYCLOSPORIN
• RETINOIDS
• PEPUVA
• OTHER DRUGS AS HYDROXY UREA
• BILOGICALS

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TOPICAL AGENTS

• TAR
• CRUDE COAL TAR IN PETROLATUM
• IN STABLE PS
• MECHANISM
• PHOTODYNAMIC
• ANTIMITOTIC

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APPLICATIONS OF TAR

• SCALP-ALCOHOLIC EXTRACTS /TAR SHAMPOSS
• USE VEGETABLE OL ON SCALP 1 hr PRIOR TO
  APPLICATION OF TAR
• PALMOPLANTAR-TAR BATH OR OINTMENT (CURDE COAL TAR
  TO SOFT PARAFFIN 6-12) SALYCYLIC ACID
• SALYCILIC ACID-3 gm
• CRUDE COAL TAR -6 gm
• VASELINE LUPTO-100gm

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TAR

• TAR BATH-LIQUOR LPICIS CARE 6-12 ml TO AGLAS OF
  WATER HALF LAN HOUR BATH AND EXPOSE TO SUN LIGHT
  FOR 20 MIN DAILY
• AVOID TAR IN FACE INTERIGINOUS AREAS
• GOKERMAN THERAPY
• APPLY CRUDE COAL TAR FOLLOED BY UVB
• HOSPITALISE
• PRIOR TESTING IS NEEDED-3 OINT AS LOPEN PATCH
  TEST IN ABD WALL -24 hrs

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TAR

• COMPLICATIONS
• PRIMARY IRRITATION
• FOLLICULITIS
• TAR ACNE
• REVERSIBLE PIGMENTATION
• EXDACERBATION OF LEWSIONS
• BURNING
• CARCINOGENICITY

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TAR-CI

• ERYTHRODERMA
• PUSTULAR PS
• UNSTABLE PS
• FLEXURAL, SCROTAL FACE LESIONS
• IRRITATION-GIVE TOPICAL STEROIDS

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DITHRANOL

• CIGNOLIN OR ANTHRALINE
• CHRYAORABIN FROM ARAROBA TREE (TAWNY COLORED)-GOA
  POWDER
• HIGHLY UNSTABLE-HYDROXY FREE RADICALS PRODUCED
  (ACT ON THE STEM CELL POPULLATION OF EPIDERMIS)
  THERAPEUTIC EFFECT/ STAINING
• YELLOW LTO PURPLE BROWN STAINING
• USE WITH CAUTION- BURNING

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DITHRANOL

• START WITH LOW CONC JUST FEELING OF WARMTH
• ltCONTACT TIME OR COC
• DONT APPLY TO NORMAL SKIN
• FLEXURAL ARES-0.1-0.25 CREAM
• CI IN MOIST AND INFLAMMED LESIONS

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DITHRANOL

• INGRAM REGIME
• COAL LTAR BATH DRY
• UVB
• APPLY DITHRANCL LO.42 IN LASSERS PASTE TO
  STIFFEN
• COVER WITH POWDER, STOCIKINET DRESSING
• AFTER 24 HRS REMOVE IT VEG RPT
• SHORT CONTACT THERAPY
• 0-1-0.OR 2 CONC FOR SHOR PERIOD OF CONTACH
• COMBINATOIN THERAPY
• DITHRANOL CALCIPOTROIN/STEROIDS/STEROIDS/TAZAAROT
  ENE

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TOPICAL RETINOIDS

• SYNTHETIC / NATURAL COMPOUNDS WITH VITA ACTIVITY
• TOPICAL RETINOIDS IN MINOR TYPE OF LPS
• SYSTEMIC RETINOIDS IN SEVRE PS
• 1990- TAZAROTENE
• MODULATE EXPRESSION OF GENS THAT REGULATE CELL
  PROLIFERATION DIFFERENTIATION
• SYSTEMIC ABS MINIMAL
• CARCINOGENIC EFFECT RARE

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TOPICAL RETINOIDS

• INDICATIONS
• CHRONIC STABLE PLAUE TYPEON TRUNK OR LIMBS UP TO
  20 OF BODY AREA
• CL-PREGNANCY ECZEMATOUS LESIONS, ALLERGY SUNBURNS
• MONOTHERAPY -0.5,0.1
• COMBINATION THERAPY
• ALTERNATIVE LWITH TOPICAL LSTEROIDS
• UBV/UNA

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VIT D3 ANALOGUES

• VIT HORMONE
• 1.25 (OH )2 D3 INHIBITS KERATIONOCYTE
  PROLIFERATION HELPS IN DIFFERENTIATION
• CALCIPOTROIL-SYNTHETIC ANALOGUE OF
• CALCITRIOL LESS ACTION IN CA METABOLISM
• 550MI CROMGM/GIN AN OINTMENT IS SUFFIVCIENT
• CAN BE USED IN FLEXURAL SITES ALSO ORIETMENT
  CREAM SOLUTION
• AVODN IN PREGINANCY

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SALICYLIC ACID

• KERATOLYTIC ltCORNECYUITE ADHESION
• WINTER GREENLEAVES
• THICK HEPERKERATOTIC LESIONS
• INSCALP,PALM SOLE
• CAN BE COMBINED WITH STEROIDS , TAR
• OTHER TOPICAL AGENTS
• METHOTREXATE 0.25
• ALLANTION

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PHOTO/PHOTOCHEMOTHERAPY

• PUVA ORAL LPSORALENUVA- PUVASOL
• EYE CHECKYR CATARACT, MALIGNANCIES
• 8-MOP 0.6 MG/KG 2 HRS PRIOR
• 5 MOP1.2MG/KG 1 HR PRIOR
• 11AM FOR 12 MIN
• THRICE A WEEK
• RESPONSED BY 20 TREATMENTS
• TWICE A WEEK FOR 1 MON ONCE WEEKLY FOR ONE MON
• CONTINUE FOR 2 MORE MONTHS
• THEN TREATMENT FREE PERIOD OF 3 MON
• BATH PVA-20 MIN IN 0.5 MG/L WATER SOLUTION OF 8-
  MOP DRY SKIN X EXPOSE TO UVA
• CREAM PUVA

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NARROW BAND UVB (31 NM) THERAPY

• PHOTOTHERAPY OF CHOICE
• REMISSIONOF SKIN LESIONS
• LARGER PERIOD LOF REMISSION
• CAN BE USED IN PREGENANCY CHILDREN, NO POST
  TRETMENT EYE
• PROTECTION NEEDED
• START WITH 0.7 MED
• LATER gt BY 20-40 OF THE DOSE

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METHOTREXATE

• ERYTRODERMA PUSTULAR PS, ARTHROPATHY gt40 BOBY
  AREA INVT, FAILURE LOF OTHER MODES
• DOSEAGE-
• 12 HR APRT WEELY DOSE OF 7.5 TO 22.5 MG
• SINGLE WEEKLY ORAL 25-37.5MG
• WEEKLY PARENTERAL IM/IV 15-50MG

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METHOTREXATE

• CI-PREGNANCY RENAL D/S RECENT HEPATITIS LIVER
  CIRRHOSIS FIBROSIS, ALCOHOLISM PEPTIC ULCER,
  SEVERE INFECTIONS SEVERE ANEMIA LEUCOPENIA,
  THROMBOCYTOPENIA, UNWILLING TO ADOPT
  CONTRACEPTION
• CUMULATIVE DOSE 1.5 GM LIVER BIOPSY

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SYSTEMIC RETINOIDS

• PROLIFERATION NORMALISES DIFFERENTIATION,
  IMMUNOMODULATION
• ACT THROUGH CYTOPLASMIC NULEAR RETINOID
  RECEPTORS REGULATING GENE EXPRESSION
• ETRETINATE
• ACITRETIN-METABOLITE OF ETRETINATE

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ACITRETIN ETRETINATE

• STANDARD TREATMENT FOR MODERATE TO SEVERE PS
• CHRONOC PLAQUES PS -COM,BINATION OF A/E WITH
  DIRANOL OR VIT D3 ANALOUES/TAR
• ERYTHRODERMIC/SVERE PUSTULAR PS MONOTHERAPY
• ALSO FOR MAINTENANCE THERAPY

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ACITRETIN ETRETINATE

• SIDE EFFECTS
• CHELITIS DRYNESSOF MUCOSA EPISTAXIS, THIRST
  XEROSIS, PRURITUS, HAIR LOSS-ALL REVERSIBLE
  ONSTOPPING THERAPY
• gtTRIGLYCERIDES, SOLOW FAT, LOW CHO DIET
• DISH
• CONTRACEPTION MUST BE BEGUN 1 MON BEFORE STRATING
  AND SHOULD BE CONTINUED FOR AT LEAST 2 YRS AFTER
  STOPPAGE IN WOMEN

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ACITRETIN ETRETINATE

• CI-SEVERE LIVER /RENAL D/S
• DIABETES MELLITUS., HYPERILIPIDEMIAS
• REGENANCY LACTATIONOR PLANNIN GOF PREG WITHIN 2
  YRS OF STOPPING THE DURG
• DOSE ACITRETIN -0.25.0.6 MG/KG/DAY
• ONCE CLEAREANCE-LOWER DOSE TO 0.2-0.4 MG/KG/DAY
  FOR 3-6 MON
• CAN BE USED IN IMMUNOCOMPROMISED ALSO

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ACITRETIN ETRETINATE

• DRUG INTERACTIONS
• TETRACYCLINES, PHENYTION, BARBITURATES, NSAIDS,
  KETOCONAZOL
• E AND CYCLOSPORIN
• SYSTEMIC CORTICOSTEROIDS
• NO ROLE IN CHRONIC PLAQUE PS
• SEVER PUSTULAR PS- ESPE IN PREG
• ERYTHRODERMA WITH SVERE
• SYSTEMIC COM

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BALNEOTHERAPY BALNEOPHOTOTHERAPY

• SALT WATER BATHgt EXPOSE TO SUNLIGHT
• gt20 SALT WATER WATER BATHgtUVB
• SEA WATER BATH NATURAL UUV EXPOSURE CLIMATO
  THERAPY
• DEAD SEA TREATMET IN ISRAEL LASERS
• STUBBORN PS PLAQUES NOT RESPONOING -308 NM
  EXCIMER LASERS

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NAIL PS

• TOPICAL LDIPS IN COAL TAR
• IONTOPHERISIS OF MIX
• TOPICAL CORTICOSTEROIDS UNDER OCCLUSION
• TOPICAL 1 5 FUL/l TRIAMCINOLONE
• PUVA
• TAZAROTENE TOPICAL

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IMMUNE ALTERING BIOLOGICAL THERAPY

• PROTEINS THAT BIND TO EXTRACELLULAR TARGETS,
  BLOCK MOLECULAR ACTIVATION
• CLASS 1 MONOCLONAL ANTIBODIES
• CLASS 2 ANTIBODY LIKE FUSION
• PROTEINS FUSED SEGMENTS OF
• MOUSE AND HUMAN Ab
• ALEF ACEPT ETANERCEPT

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ALEFACEPT, ETANERCEPT

• ALEFACEPT BLOCK MHC MOLECULE
• COMPETIVE INHIBITOR OF INF-A
• APPROVED BY USFDA
• DOSE -25 MG TWICE WEEKLY BY S/C INJ FOR 12 WEEKS
• COMPLICATIONS AS MULITIPLE SCLEROSIS , SKING CA,
  LUPUS, ARE SEVR

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BIOLOGICALS

• BIOLOGICALS LAREA A DISTANT HORIZON IN TE OF PS
• EXFOLIVATIVE DERMATITIS
• DERMATOLOGIC CAUSES
• SYATEMIC DISEASE
• IDIOPATHIC