Psoriasis symptoms diagnosis therapy yellow list

PsoriasisPsoriasis is a non-contagious inflammatory chronic dermatologic disease. In addition to the cutaneous manifestation, other organs may also be affected.

Psoriasis is a non-contagious inflammatory chronic dermatological disease. It usually progresses in relapses. Apart from cutaneous involvement, other organs may also be affected. Here, the joints (psoriatic arthritis), the eyes (uveitis), the vascular system, the heart, as well as the genitals are particularly worth mentioning.

Type 1 Psoriasis

Psoriasis is familial in about 40% of cases. An association with features of the human leukocyte antigen (HLA) system (HLA-Cw6, HLA -DR7, HLA-B17, HLA-B57) has been shown. All these genes are located on the short arm of chromosome 6. The age of onset of this form of psoriasis is in the second and third decade of life.

Type 2 psoriasis

In type 2 psoriasis, no familial clustering has been found. The association with HLA traits is at best slight. The age of first manifestation here is in the fifth to sixth decade of life. Thus clearly later in comparison to the type 1 form.

Psoriasis patients usually suffer from a significant reduction in their quality of life. According to studies, this limitation is comparable to that of patients suffering from malignancies, heart disease or diabetes mellitus. This can lead to an increased suicidal tendency, a higher incidence of depressive disorders or an increased alcohol consumption.

Epidemiology

The prevalence of psoriasis in Germany is 2.1%. This corresponds to about 2 million affected patients. Psoriasis thus represents one of the most common chronic inflammatory diseases. About 80% of psoriasis patients suffer from psoriasis vulgaris, which is often also called plaque type.

Causes

The disposition to develop psoriasis is inherited. The risk is particularly high if both parents are affected by psoriasis (60-70%). The etiology also includes autoimmune reactions. Is not conclusively clarified.

Pathogenesis

Pathophysiologically, a dysregulation of immune cells is at the center of the disease. It has been shown that an increased stimulation of T-helper cells by dendritic cells occurs in psoriasis patients, especially during the initial manifestation and during disease flares. The dendritic cells produce cytokines z.B. TNF-alpha, IFN-gamma, IL-17.

In addition, the cell cycle of the keratinocytes is severely shortened. While the keratinocytes in healthy individuals are approx. 28 days for maturation and migration from the basal layer to the horny layer of the skin, in psoriasis patients it is only three to five days. The production of new epidermal cells can be increased up to 30-fold.

Trigger factors

Numerous trigger factors for psoriasis have been identified, some of which are listed below:

– Physical, chemical and inflammatory skin irritation, e.g. B. Injuries, sunburn, scratching, surgery – Hormonal influences: Menstruation, pregnancy, menopause – Stress – Immunodeficiency, e.g. B. HIV infections, z. B. By streptococci and staphylococci – Medications: ACE inhibitors, beta blockers, folic acid, lithium salts, NSAIDs (nonsteroidal anti-inflammatory drugs), tetracyclines, etc. – Alcohol abuse.

Symptoms

The typical skin changes in psoriasis are sharply defined erythrosquamous plaques covered with silvery scales. About two-thirds of patients suffer from itching, some of which is severe.

Psoriasis vulgaris

Predilection sites of psoriasis vulgaris are the hairy head, the extensor sides of the elbows and knees, and the sacral region with anal fold involvement. In children, the face is often affected as well.

Psoriasis guttata

Psoriasis guttata is a rather acute eruptive form of psoriasis. This is typically characterized by very small plaques.

Psoriasis intertriginosa

In intertriginous psoriasis, the inflammatory scaly foci are found in the intertriginous regions of the body (axillae, groin, submammary).

Pustular psoriasis

In this special form of psoriasis, pustules are formed in addition to the typical plaques. These may be limited to the palms of the hands and feet (pustolosis palmoplantaris) or may be generalized. In acrodermatitis continua suppurativa, the end phalanges of the fingers or toes are affected by pustular inflammation and the nails are also affected.

About 30% of psoriasis patients suffer from nail psoriasis, which can be accompanied by punctate nail defects (spotted nails), whitish changes (leukonychia) and even dystrophy of the nail plate.

Severity classification

Psoriasis can be clinically classified as mild, moderate, and severe based on the Psoriasis Area and Severity Index (PASI). This score includes the symptoms of erythema, infiltration, scaling, and the extent of involvement of the four body regions: head, trunk, arms, and legs. In addition, a simple approach to measure the percentage of diseased body surface is the "body surface area" (BSA).

In addition, the health-related quality of life is evaluated by means of questionnaires. The "Dermatology Life Quality Index" (DLQI) has proven to be useful here. Mild psoriasis is present with a PASI of 10, BAS>10, or a DLQI> 10 from.

Other points should also be considered when assessing the severity of affected individuals:

– Response to previous therapies – Infestation of visible areas (including scalp and nails) or the genital area – Presence of itching

Disease activity

In addition to the severity classification of the disease, the disease activity should also be included in the therapeutic decision-making process. In this case, the occurrence of new lesions at short intervals, the spread of existing lesions and the tendency to recurrence after therapy are indicative of high disease activity.

Diagnostics

Medical history and clinical examination

After taking a detailed history, the patient's complete skin is examined. Psoriasis typically presents with sharply demarcated erythematous plaques covered with white to silvery scales. These silvery lamellar scales are formed by aged skin cells and have a sebaceous consistency resembling candle wax.

In addition, increased itching is observed in the affected persons. This often leads to scratching, which makes the scales more prominent. When scratching, the loosely adherent scales now fall off, resembling candle wax. This phenomenon is therefore called candle (drop) phenomenon. When scratching continues, the outer layer of the skin also falls away and a thin layer of the epidermis is exposed, the last cuticle. If this is scratched off, a punctiform bleeding results, which is called the Auspitzphanomen ("bloody dew").

Biopsy

In case of doubt, a sample biopsy of the skin may be indicated for differential diagnosis. In the histopathological examination, a thickening of the epidermis is observed in psoriasis. The stratum granulosum is absent or markedly narrowed. The keratinocytes remain immature. The epithelial layer is covered by inflammatory cells, v. a. CD8+ and CD4+ T cells, infiltrated.

Therapy

The essential goal in psoriasis therapy is the absence of cutaneous symptoms. According to the current AWMF guideline, the minimum requirement for therapy is the achievement of a PASI 50 response, i.e., at least a 50% reduction in the initial clinical findings compared to the pre-therapeutic state. In addition, a DLQI The importance of meeting this minimum requirement is underlined by the amption that long-term adequate control of disease activity can lead to a reduction in cardiovascular comorbidity. In mild to moderate psoriasis, topical therapy may achieve sufficient therapeutic success. Moderate to severe forms of psoriasis usually require a systemic therapy approach.

Topical therapy

The cornerstone of topical therapy for psoriasis is topical corticosteroids of potency II and III. The duration of therapy with topical corticosteroids should be limited to 6 weeks to avoid adverse drug reactions. A second topical drug used in psoriasis therapy are the vitamin D analogs (calcipotriol, tacalcitol). A combination preparation of a vitamin D3 analogue (calcipotriol). A moderately potent corticosteroid is often used in first-line therapy.

Light therapy

Light therapy is indicated in moderately severe forms of psoriasis or when there is no response to topical therapy alone. It can be applied in the form of selective ultraviolet phototherapy (SUP), narrow spectrum ultraviolet therapy, balneo-phototherapy as well as photochemotherapy (PUVA). The goal is to achieve remission of the disease. Light therapy is not suitable as maintenance therapy, as it would be associated with an increased risk of skin cancer.

Systemic therapy

From moderately severe psoriasis, as well as for patients with high disease activity or frequent recurrences, systemic therapy may be considered. Various drugs are available as first-line systemic therapy. The most important of these are fumaric acid esters, ciclosporin, retinoids such as z. B. Acitretin. Methotrexate. Acitretin and methotrexate.

If therapy is not sufficiently successful, the use of biologicals may be considered. These are either surface molecule fusion proteins (etanercept) or monoclonal antibodies (e.g. B. Infliximab, Adalimumab). Examples of biologicals are infliximab, adalimumab, etanercept, secukinumab, ustekinumab and apremilast. Therapeutic antibodies directed against TNF-alpha (infliximab and adalimumab), for example. With approved biologicals, there is an increased risk of infection during therapy use.

In addition, studies have shown a slightly increased risk for the development of lymphoproliferative disorders and non-melanocytic skin tumors during therapy with TNF-alpha inhibitors (infliximab, adalimumab and etanercept). Likewise, for the long-term application of ciclosporin A. PUVA has been shown to increase the incidence of non-melanocytic skin tumors.

Consideration should also be given in the selection of appropriate therapy to the individual pre-existing degree of skin damage, the patient's lifestyle (cumulative UV dose at the end of a year), and skin type (v. a. Skin type 1) of the patient.

Other therapies

The use of climatic therapies, z. B. at the Dead Sea, are recommended in the context of psoriasis therapy.

Patients should be directed to self-help groups and, if appropriate. participate in patient education. In the case of psychological impairment, it is possible to refer patients to the appropriate specialists.

Prognosis

Psoriasis is a chronic disease, which progresses in phases. The disease itself is not curable. There are numerous therapy concepts for psoriasis. Patients with psoriasis often suffer from comorbidities that can limit life expectancy. Psoriasis patients have an increased risk of developing metabolic syndrome, arterial hypertension, diabetes mellitus, and dyslipidemia. Most importantly, the increased incidence of cardiovascular disease, z. B. myocardial infarction and apoplexy, are of importance. The better the disease is treated, the more likely possible cardiovascular disease can be reduced.

Prophylaxis

The development of psoriasis strongly depends on the individual disposition. It is not possible to carry out targeted measures for prophylaxis for the initial manifestation. Relapses can be postponed or delayed.

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