Psoriasis: Diagnosis and Management

00:01 The clinical manifestations very typical very very typical on extensor surfaces mostly elbows and knees.

00:08 But it also can occur on scalp and around the umbilicus.

00:11 And in the gluteal cleft are these well-defined salmon color.

00:16 They're classically called salmon color.

00:18 But in fact they're erythematous plaques.

00:20 They're raised, they're itchy.

00:22 They have silvery scales on the surface.

00:25 And, uh, what you're seeing there is absolutely, very, very, very typical.

00:30 And they're itchy. Pruritic.

00:32 Uh, you can have variations on this theme.

00:35 They, they get different names.

00:36 They're treated all the same.

00:38 They're the same disease.

00:39 They just have slightly different manifestations on the skin.

00:43 So guttate psoriasis or drop -like psoriasis, small little papules that are not the big plaques, but small little papules found on the same kind of trunk and proximal extremities.

00:55 And these tend to be more associated with certain bacterial infections, such as Streptococcus.

01:00 Pustular psoriasis kind of an accentuation of that Monroe's microabscess neutrophil recruitment.

01:08 So in those patients you're getting a much stronger, uh, acute inflammatory neutrophilic infiltrate the patches because of the neutrophils releasing reactive oxygen species and proteases and stuff.

01:21 They tend to be more painful.

01:23 Uh, and typically in pustular psoriasis, you see the involvement of the palms and the soles. So plantar and palmer involvement.

01:31 Other systemic manifestations.

01:33 Remember that this can be a systemic disease.

01:36 And the most characteristic one is psoriatic arthritis.

01:40 And this is again associated with HLA-B27.

01:43 In about 30% of patients with psoriasis, they will have joint involvement as well. Can look very much like rheumatoid arthritis.

01:52 It's an autoimmune inflammatory response affecting the joints.

01:56 Uh, there's ocular involvement, the blepharitis.

02:00 And you can see that poor individual, it's very itchy, more common in men than women.

02:04 But it can occur in both.

02:06 With conjunctivitis or uveitis as well.

02:09 The diagnosis, pretty much clinical history.

02:12 And that physical exam finding.

02:13 You see those silver plaques or salmon-colored plaques with silver kind of flakiness. You made the diagnosis, but you can do a biopsy.

02:23 And I always, as a pathologist, want to advocate for getting tissue because tissue is the issue. But we want to see that parakeratosis the neutrophilic microabscesses, we want to see a thinned or absent granular cell layer because we're having abnormal maturation of the keratinocytes.

02:41 And then clearly we're going to see the dermal epidermal infiltrates and inflammatory cells as well as dilated vessels because in fact this is an inflammatory process. How do we manage this.

02:53 Well this is where living in the 21st century, we've got some benefits because now we have drugs that we can treat it.

02:59 In my era, it was previously called the heartbreak of psoriasis because there was very little we can do for it. Well, that's different now.

03:06 So for mild to moderate disease, topical immunosuppression, corticosteroids, it turns out that some vitamin D drugs can modify the immune response by changing kind of the the cytotoxic T-cell more to a suppressor or a regulatory T-cell kind of uh, milieu. And topical retinoids also by affecting then the proliferation of epithelial cells and a little bit of an effect on the inflammatory infiltrate.

03:36 So that's all useful for mild to moderate disease.

03:39 For severe disease, we can do systemic retinoids or methotrexate. Cyclosporin.

03:46 Kind of systemic autoimmune or immune suppressive drugs.

03:51 And then you see a variety of others.

03:52 And now there are monoclonal antibodies that are also involved.

03:56 And phototherapy for really severe disease just to make people feel better, you can have them just give emollients, just, you know, something that makes the skin more smooth and supple and more lubricated. And because there can be exogenous stimuli, including smoking, just stress, maybe it's trauma, recurrent trauma because of what people do.

04:20 You can try lifestyle modifications.

04:23 And with that, hopefully you won't have the heartbreak of psoriasis anymore.

04:26 You will have a very good understanding of why this is happening, and then the multiple ways as doctors that you can now treat it.

04:34 Thanks.