Psoriasis vulgaris

Dandruff, psoriasis, psori

Chronic inflammatory systemic disease associated with scaly skin changes, joint complaints, nail changes and internal complications.

• Prevalence: 2-3% (Central Europe)
• Women = men

• Genetic factors:
  • Polygenetic disease, at least 40 genetic loci are involved. The strongest risk factor for psoriasis (p value is < 10^-200) is HLA-Cw6
    • HLA-Cw6: PSORS1 (gene locus: 6p21.3)
• Exacerbation due to medication:
  • Lithium
  • Antimalarials
  • NSAIDs
    • Naprofen
    • Diclofenac
    • Indometacin
  • Beta blockers, ACE inhibitors (recently questioned by large cohort study)
  • Ca++ channel blockers
  • Rarely systemic glucocorticoids (rebound after discontinuation or even pustular exacerbation)
  • Antibiotics
    • Macrolides
  • Trigger factors :
    • Mechanical factors (Köbner phenomenon)
    • Infections
    • Stress
    • Alcohol and nicotine consumption

• Nail infestation: occurs in approx. 80% of cases
• Joint infestation: occurs in approx. 20% of cases
  • CAVE: this also includes patients who are only seen by a rheumatologist

• Particularly on the elbows, capillitium, knees, trunk, face, palms, soles, nails and genital area, there are sharply defined, erythematous, fine to coarse lamellar scaling plaques. Patients show both chronically stable plaques and intermittent skin lesions.

• Köbner phenomenon: Delayed triggering of psoriasis changes due to mechanical pressure.
• Candle spot phenomenon: Recognition of the lamellar scaling is possible by scratching, a whitish mass appears.
• Phenomenon of the last cuticle: After scraping off the scales, only a thin epidermal layer remains.
• Scaling sign: "bleeding dew". Punctate haemorrhages appear as soon as the last epidermal layer has been scraped off, due to injury to the dilated capillaries high in the papillary ends of the stratum papillare of the dermis.

• Seborrhoea: Joint occurrence of psoriasis and seborrhoeic eczema.

• Mucosal changes:
  • Exacerbation may occur on the glans penis due to mechanical stress (Köbner phenomenon)
  • The oral mucosa is usually only seen in the context of generalised pustular psoriasis.

• Anamnesis
  • Family medical history
  • Joint complaints
  • Nail changes
  • Improvement with UV exposure
  • Bacterial infections (tonsillitis, especially in guttate psoriasis)
  • Medication
• Clinical findings
  • Marginal erythema
  • Silvery scaling
  • Infiltrated plaques
• Biopsy if necessary
  • Distinguishing dermatopathologically between nummular eczema and psoriasis vulgaris is very difficult and not always possible. The clinical findings carry more weight here.
  • Psoriasis palmoplantaris and palmoplantar eczema can also be difficult to distinguish. The determination of NOS2 and CCL27 can be helpful here (Quaranta et al. Sci Trans 2014).

Most common localisation: scalp, then elbow extensor sides and knees, as well as sacral. But can also occur all over the rest of the body.

Family history often positive

• Hyperparakeratosis
• Neutrophil granulocytes in the str. spinosum (Kogoj pustule) and in the area of hyperparakeratosis (Munro microabscesses)
• Focal loss of the str. granulosum
• Acanthosis with elongated narrow retele ridges
• Ectatic capillaries
• Papillomatosis
• Perivascular, CD4-positive lymphohistiocytic infiltrates

• Poriatic arthritis
• Coronary heart disease
• Metabolic syndrome
• M. Crohn's disease, ulcerative colitis
• Uveitis
• Depression
• Multiple sclerosis

Relubricating the skin can reduce or prevent plaques.

Chronic disease, progresses in episodes

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