psoriasis

Symptoms and signs

According to the characteristics of skin lesions, clinical psoriasis is divided into four types, namely, vulgaris, joint disease, erythroderma and pustular.

1. Psoriasis vulgaris is the most common clinical type. The typical damage in the initial stage is red papules or maculopapular rash. The size of the needle to mung bean is clear. The boundary is clear. It is covered with multiple layers of silver-white or mica-like scales. The scales are easy to scrape off. After scraping, a bright reddish film is formed on the substrate. , continue to scratch the surface of the erythema, a small bleeding point, that is, point bleeding, also known as the Auspitz sign (Figure 1, 2). Membrane phenomena and Auspitz signs are characteristic of psoriasis vulgaris. Can slowly expand or fuse into brown-red plaques with varying degrees of itching. Skin lesions occur in the extremities, elbows, knees, scalp and lower back. The disease has a long course and can last for several years to several decades. According to the development of the disease, the disease can be divided into the onset period, the stable period and the regression period.

(1) Progression period: for the acute attack stage, new skin lesions continue to appear, old skin lesions continue to expand, inflammation is obvious, and there may be a homomorphic reaction, that is, the Koebner phenomenon refers to the normal appearance of the skin in trauma, scratch, injection or acupuncture. After the same stimulation, the skin lesions with the same nature as the primary disease usually have skin lesions within 3 to 18 days of injury. Therefore, the occurrence of stripe scaly lesions in the scratch or surgical incision should consider the possibility of psoriasis.

(2) Stabilization period: the lesion stops developing, inflammation is reduced, and no new skin lesions occur.

(3) Degenerative period: inflammation subsides, scales decrease, skin lesions shrink, flatten, disappear, and residual pigmentation or pigmentation spots. In addition to skin lesions, nail lesions are also a common manifestation of psoriasis. Psoriasis may be the most common disease associated with nail lesions. 80% to 90% of patients with psoriasis have a nail involvement in their lifetime, and nail lesions are higher than nails. Lesions (Figures 3, 4). Psoriasis A disease varies according to the pathological changes. Common manifestations include a point-like depression, mediastinum, furrow, thickening, oil droplets, discoloration, dissection, lobular hemorrhage, brittle fracture, shedding, and hypotenuse Excessive, hypertrophy of the nail bed. A point-like depression, mediastinum and furrow are caused by psoriasis involving the parent material. Oil droplets, discoloration, exfoliation, hyperkeratosis, etc. are caused by nail bed lesions.

In the development of the disease, psoriasis vulgaris lesions can have multiple manifestations. 1 Map-like psoriasis: adjacent small lesions merge with each other to form plaques with marginal maps. 2 gyrus psoriasis: the lesion spreads to both sides or several plaques fuse to form a ridge that bends back and forth. 3 ring psoriasis: damage to the central regression or healing and ring shape (Figure 5). 4 Coin-like psoriasis: The lesions are large and round and flat, like a coin. 5 generalized psoriasis: the number of lesions is large, and the distribution range is wide and even affects the whole body. 6 follicular psoriasis: damage occurs in the hair follicles, adult type is mainly found in women, follicular lesions are part of the generalized psoriasis, symmetrically distributed in the abdomen; children's follicular lesions aggregate into asymmetric plaques It occurs in the trunk and armpits. 7 sputum psoriasis: The skin lesions continue to expand to the surrounding area, making it squat. 8 crust-like psoriasis: lesions smashed, exuded, contaminated brown scaly sputum accumulation, like a clam shell. 9 verrucous psoriasis: the surface of the lesion is sputum-like, more common in the calf. 10 spots of psoriasis: early onset, common in young people, often have upper respiratory tract infection before the onset, damage to small papules, scattered in the body around the body, generally occurs in the upper part of the trunk and limbs end. Seborrheic psoriasis: Skin damage is similar to seborrheic dermatitis, yellowish red, unclear borders, overgrown greasy scales, often located in the area of ​​sebum spillage. Eczema-like psoriasis: manifested between eczema and psoriasis. Photosensitive psoriasis: It is called photosensitivity psoriasis after the onset of sun exposure or increased skin lesions. Skin lesions occur in exposed areas such as the face, back of the hand, forearms and calves, and there is a small amount of damage in non-exposed areas. Reverse psoriasis: Skin lesions are confined to large skin folds such as the armpits, groin, and neck. Skin lesions are clearly defined erythema and have no scales. Scalp psoriasis: scalp psoriasis is very common (Figure 6), manifested as thick scaly lesions and plaques, clear lesion boundaries, widespread or clustered, usually without hair loss and dislocation, a small number of patients Hair loss and baldness appear. Mucosal psoriasis: common in glans, lips and buccal mucosa, is a red patch with clear edges, dry surface, can have silvery white scales. Diaper psoriasis: caused by an allergic reaction caused by ammonia generated when urea is decomposed in urine. 12% to 55% of cases have a family history of psoriasis. More common in infants, buttocks and abdomen first rash, dark red or brownish red patches, covered with silvery white scales, surrounded by psoriasis-like papules, damage can spread to the trunk and proximal extremities.

2. erythrodermic psoriasis is a rare type of specific inflammation of psoriasis. Often involved in more than 75% of the body surface, can affect all parts, including face, hands and feet, armor, torso and limbs. It can be developed for sudden onset or chronic psoriasis. Inflammation, lesions, and ineffective control of instability Psoriasis vulgaris or psoriasis vulgaris suddenly stops topical potent glucocorticoids, systemic glucocorticoids or MTX, associated with other systemic diseases, infections, or Emotional depression and generalized pustular psoriasis are prone to develop erythrodermic psoriasis. The clinical features are diffuse large erythema, edema, and desquamation in the whole body. The erythema is most obvious, and there are often small pieces of normal skin with clear boundaries (Fig. 7). Eyelid valgus can occur when it occurs on the face. It is often accompanied by systemic symptoms such as fever, chills, fatigue, and depression. Patients may have increased white blood cells and left nuclear shift, electrolyte imbalance, hypoproteinemia, dehydration, and occasional abnormal liver function.

3. Pustular psoriasis

(1) Acute generalized pustular psoriasis (Zumbusch type): Patients may have several years of history of psoriasis vulgaris, followed by pustular psoriasis. Both men and women can be affected. Local irritation, pregnancy, taking birth control pills, infection, and discontinuation of glucocorticoids are all contributing factors. The clinical features are sudden high fever, general malaise, and joint swelling that lasts for several days, followed by systemic erythema, edema, and generalized yellowish-white, shallow, aseptic needles to miliary-sized pustules. Pustules are usually located on the skin that is obviously reddening. They begin to be small pieces and later merge into a pus. The erythema surrounding the pustules often expands and fuses, which can cause erythroderma-like changes (Figures 8-10). In addition to the formation of nail pustules and complete loss of nails, fingertip atrophy may occur in patients with longer course of disease. Other systemic manifestations include weight loss, leukocytosis, hypocalcemia, and increased erythrocyte sedimentation rate. Patients may experience severe systemic disease, congestive heart failure, and secondary infection. Short-term fever and pustule formation are periodic, and general treatment is difficult to work. It can last for several months or longer, but the skin lesions can also spontaneously resolve.

(2) ring-shaped pustular psoriasis: lesions occur in the onset of psoriasis or in the course of generalized pustular psoriasis, tend to expand and form an enlarged ring, appearing on the ring erythema Pustules are their main feature.

(3) Localized pustular psoriasis: This type of psoriasis lacks systemic symptoms, including two types: palmoplantar pustular psoriasis and continuous acrodermatitis. Psoriasis pustular psoriasis occurs in women, and the age of onset is usually 40 to 60 years old. Symptoms of erythema, scaly plaques with recurrent episodes of persistent aseptic pustules appearing symmetrically, pustules appear in batches and turn into brown desquamative rash within 1 to 2 weeks. The course of the disease is chronic and recurrent.

(4) herpes-like impetigo: more often in the middle and late pregnancy. The course of the disease can last for several weeks after delivery. The clinical features are similar to acute generalized pustular psoriasis, with severe systemic symptoms and death from thermoregulatory disorders and organ failure.

4. Arthritic psoriasis, also known as psoriatic arthritis, is an autoimmune inflammatory disease mainly involving ligaments, tendons, fascia and joints. It is a serologically negative spondyloarthropathy. Upper extremity joint involvement is more common, and the incidence in patients with psoriasis is 5% to 8%. The age of onset is generally 35 to 45 years old, and the incidence is less common in 20 years old. There is no significant gender difference in adult cases. Adults with a higher incidence of devastating arthritis are more likely to have a poor prognosis, but arthritis in children is often a benign course. Usually slow onset, but less than one-third of patients have a very sudden onset. Systemic symptoms are rare and generally only seen in outbreaks of extensive joint involvement. Clinically, according to the patient's bone and joint involvement, psoriatic arthritis is currently divided into five clinical types, namely, mainly involving distal toe joint type, disabling arthritis type, symmetrical polyarthritis type, and asymmetry. Sexual arthritis and spondylitis (with or without peripheral arthritis).

(1) Skin lesions: The incidence of arthritis is generally positively correlated with the degree of skin involvement. The incidence of arthritis is increased when the skin is severely affected. It is more likely that extensive skin involvement will be destroyed or disfigured arthritis, but Remission or exacerbation of joint lesions has little to do with improvement or deterioration of skin diseases. In most patients, skin lesions often occur before arthritis, but arthritis occurs first in about 1 in 7 cases. Some patients have mild skin involvement, which is characterized by minor damage to the back of the ear, gluteal folds, or a few nail recesses. Psoriasis-like skin lesions caused by HIV infection are more serious. HLA-B27-positive patients may have pustular psoriasis or intermediate syndrome with some features of Reite syndrome.

(2) Joint lesions: peripheral arthropathy and its accompanying nail disease, tenosynovitis, start and end point disease and axial bone disease are characteristics of psoriatic arthritis. More than 80% of patients present with peripheral asymmetry of arthritis, which can affect the small joints of the hands and feet, large joints of the lower extremities or large and small joints. The involvement of the hands and feet is characterized by stiffness, inflammation, arthritis and contracture, and approximately 5% of cases have a selective involvement of the distal toe joint. One or more arthritic lesions of the digits have diagnostic value for the disease. Different degrees of involvement of the distal and distal metatarsophalangeal joints of the hands and feet is a common manifestation, usually accompanied by metacarpophalangeal or metatarsophalangeal arthritis. Only a few joints are characterized by this disease. One or more joints are also strong and straight. One of the characteristics, toe stiffness is sometimes the initial performance or the only performance. The major joints that can be involved in this disease include hip, knee and ankle joints. Generally, there are only unilateral hip or knee joint lesions. Most of them are misdiagnosed as degenerative arthritis or traumatic arthritis. The age of onset is small and asymmetric. Involved in the diagnosis of psoriatic arthritis. About 15% of cases can cause symmetry involvement in the hand and foot joints, similar to rheumatoid arthritis. The main point of differentiation is that psoriatic arthritis has the following characteristics: joint involvement is not completely symmetrical, distal toe arthritis, one or more joints are stiff, other associated lesions such as axonal disease, tenosynovitis start and end point disease and A disease. About 5% of patients have obvious damage to the affected joints, called disfigured arthritis. The vast majority of cases show non-uniformity damage of one or several joints, and very few cases have extensive joint involvement. 25% of patients with mutilatory arthritis have pustular psoriasis. Nearly 20% of patients with peripheral arthritis are associated with spinal involvement, which can form ankle arthritis or an inferior ligament callus that is irregularly distributed along the spine. Pediatric psoriatic arthritis is often similar to that of adults, but isolated tenosynovitis and single joint involvement are more common, with few generalized involvement.

Medication treatment

The purpose of psoriasis treatment is to prevent each episode and to extend its remission time as much as possible. Treatment must be selected on a case-by-case basis, the most important being different depending on the clinical type, stage, severity and location of the lesion. Avoid all possible causes. In the acute phase, stimulation therapy such as strong topical drugs and ultraviolet radiation should be avoided to prevent trauma, avoiding scratching and hot water scalding. The lighter is mainly used outside the drug, and the severe one can be treated according to the condition. The pros and cons should be weighed when choosing treatment, and close observation of adverse reactions is required. After the disease is controlled, the treatment should be consolidated to avoid sudden withdrawal of the drug.

1. External medications In the acute phase, mild protective agents and glucocorticoid preparations should be used. Stabilization and remission periods may be more effective than prednisone drugs, such as keratinogens and immunosuppressants, but should start at low concentrations. When the skin lesions are extensive, they should be used in a small area. Topical drugs usually use glucocorticoid preparation, 0.1% to 2% Yulin ointment, tar preparation (including 2% to 10% coal tar, pine tar, black soybean oil and retort), 0.05% to 0.1-cis retinoic acid Cream, 0.005% calcipotriol (calcium triol) ointment, 0.005% to 0.01% mustard gas ointment, 5% fluorouracil (5-Fu) ointment, etc., usually 1 or 2 times / d, combined with sub- erythema UV irradiation Can enhance the efficacy. The above-mentioned topical medicine can cause irritant dermatitis, which is characterized by burning, itching, erythema, desquamation, and the like. Scalp psoriasis can be combined with selenium sulfide (selenium sulfide), 2% ketoconazole lotion and 6% salicylic acid solution for external use. Local application of glucocorticoids mainly involves contracting blood vessels, anti-inflammatory and reducing epidermal mitosis. In general, at least intermediate glucocorticoids are needed to effectively improve or eliminate skin lesions. Potent glucocorticoids can only be used for a limited period of time, generally should not exceed 3 months, and are prohibited from skin wrinkles such as the face, underarms, and groin. Side effects of the drug site appear skin atrophy, telangiectasia, folliculitis and steroid dermatitis, usually appear after 1 to 2 months of medication, so the facial medication time is recommended not more than 2 weeks is appropriate.

2. Systemic treatment Clinically, erythrodermic psoriasis, generalized pustular psoriasis and arthritic psoriasis are serious, and it is difficult to treat with topical drugs alone. Systemic treatment is needed.

(1) Glucocorticoids: Psoriasis vulgaris and psoriatic arthritis should be avoided in the system. For erythrodermic psoriasis and generalized pustular psoriasis, which cannot be controlled by other therapies, the dose is usually 40-60 mg/d of prednisone. Glucocorticoids can only be used as a temporary drug, and should not be used alone. It should be combined with a drug that gradually improves the long-term control of the disease. It should be noted that the topical or systemic glucocorticoids should be gradually withdrawn, and a combination of acitretin (etretete), methotrexate and cyclosporine may be used.

(2) Immunosuppressant: 1 methotrexate (MTX): according to the dose of 10 ~ 25mg / week, intravenous or intramuscular injection, usually starting 7.5 ~ 10mg / week, gradually increased to the commonly used effective dose of 15 ~ 25mg /week. Studies have shown that methotrexate (MTX) has a good clinical effect on all types of psoriasis, the complete response rate can reach 50%, and the partial response rate is 30%. Abnormal liver and kidney dysfunction, anemia, and infection are prohibited. Alcohol, non-steroidal anti-inflammatory drugs, salicylic acid drugs, bone marrow inhibitors and hepatotoxic drugs can increase the toxicity of methotrexate (MTX), so try not to use other drugs at the same time. Nausea, general weakness, and headache are common side effects, and complete cytopenia, acute dermal toxicity, allergic pneumonia, severe gastrointestinal reactions, and hypersensitivity reactions are rare. Long-term use of methotrexate (MTX) can cause liver fibrosis and cirrhosis, and patients are generally recommended for liver biopsy when the total amount reaches 1.5 to 2.5 g.

Preventive care

1. Remove possible causes such as improving immunity, preventing tonsillosis or upper respiratory tract infections.

2. Early diagnosis, early treatment. Don't over-examine the curative effect, treat the disease correctly, and maintain a good attitude.

Pathological cause

The cause of psoriasis has not yet been elucidated. The clinical heterogeneity of psoriasis and the obvious multi-gene inheritance pattern indicate that the combination of many factors participates in its development, including genetic factors, infection, stress, environmental factors such as drugs, and immune factors.

Disease diagnosis

Psoriasis vulgaris should be differentiated from pityriasis rosea, secondary syphilis, red pityriasis, psoriasis, and head lice. The erythrodermic psoriasis should be differentiated from other causes such as erythroderma caused by red pityriasis, eczema, malignant tumors, and the like. Generalized pustular psoriasis should be differentiated from acute generalized rash pustulosis. Arthritic psoriasis should be differentiated from diseases such as rheumatoid arthritis, Reiter disease and gout

complication

Patients with psoriasis may have kidney damage, and may also be associated with liver, eye, gastrointestinal tract, cardiovascular and other organ diseases.