Psoriasis

Introduction to psoriasis Psoriasis, commonly known as "psoriasis", is a common chronic inflammatory skin disease that is prone to recurrence. The characteristic lesion is red papules or plaques covered with multiple layers of silvery white scales. The incidence of young adults is the highest, males are more likely than females, and the north is more than the south. It is prone to increase or aggravate in spring and winter, and more relieved in summer and autumn. The etiology and pathogenesis are not completely clear. The study found that the pathogenesis of this disease is related to genetic factors, streptococcus infection, immune dysfunction, metabolic disorders and endocrine changes. There are four types of clinical: vulgaris, pus, erythrodermic and arthritic. Psoriasis vulgaris is the most common, milder, the disease is chronic, and it is easy to relapse after healing. basic knowledge The proportion of illness: 0.005% Susceptible people: no special people Mode of infection: non-infectious Complications: erythroderma

Causes of psoriasis

Infection (25%):

Especially bacterial infections can induce or aggravate psoriasis. Induced infection can be found in 45% of patients with psoriasis. Streptococcal infections, especially pharyngitis, are the most common cause. Streptococcus can be isolated from periodontal abscesses, perianal cellulitis, and impetigo. Streptococcal infections can cause the onset of psoriasis, especially in children and adolescents. It can also cause pustular psoriasis or aggravate plaque psoriasis. Sometimes, sinus, respiratory, gastrointestinal, and genitourinary infections can also cause an increase in psoriasis. HIV infection can also aggravate psoriasis.

Endocrine (20%):

Hypocalcemia is a cause of pan-type pustular psoriasis. Although vitamin D3 derivatives can improve psoriasis, vitamin D3 deficiency does not cause psoriasis. Psoriasis is improved in 50% of pregnant patients. However, some pregnant patients develop rash pustulosis (which is also considered to be a pustular psoriasis).

Neuropsychiatric stress (15%):

The relationship between mental stress and psoriasis is well defined, and it can both induce the onset of psoriasis and exacerbate existing psoriasis. Aggravation often occurs weeks to months after mental stimulation.

Drugs (15%):

Lithium preparations, interferons, beta-blockers and antimalarials can exacerbate psoriasis. Rapid dose reduction of hormones can cause widespread psoriasis or lead to pustular psoriasis.

Drinking, smoking and obesity (10%):

Obesity, excessive drinking, and smoking have all been reported to be associated with psoriasis. But some studies have shown that obesity and excessive drinking may also be a result of psoriasis.

The etiology of this disease is not completely clear. In recent years, most scholars believe that it is related to genetic, infection, metabolic disorders, immune dysfunction, endocrine disorders, trauma, trauma or surgery. Some scholars have found that dampness is also one of the pathogenic factors of psoriasis, and whether fish and shrimp are the predisposing factors of psoriasis needs further study.

Pathogenesis

Psoriasis was originally thought to be an epidermal disease caused by biochemical or cellular defects in keratinocytes. In the early 1980s, some biochemical mediators, enzymes, and pathways were found to be abnormal in psoriasis, including c AMP, eicosanoids, protein kinase C, phospholipase C, polyamines, and transforming growth factor alpha.

When it was discovered that drugs such as cyclosporine that have been T cells can improve psoriasis, people's attention begins to shift to T cells. For the past 20 years, psoriasis has been considered a T cell-driven disease. Intensive studies have been conducted on lymphocyte subsets and cytokines involved in chemotaxis, homing, and activation of inflammatory cells, and new therapeutic approaches have been developed. Some reports even suggest that psoriasis is an autoimmune disease, but true autoantibodies have not yet been found in patients with psoriasis.

However, recent findings have shown that psoriasis as a multi-gene (see Table 1) disease, some genetic polymorphisms involving the immune system and keratinocyte abnormalities can be the cause of psoriasis. It is now believed that the epidermis is also an important active part of the innate immune response and can affect the activation of the adaptive immune system. Therefore, psoriasis can be caused by abnormalities in the adaptive immune system or by abnormal immune function of epidermal cells.

Psoriasis prevention

The occurrence and recurrence of psoriasis are affected by many factors. Some patients develop from upper respiratory tract infections, some patients suffer from excessive mental stress, and some patients suffer from dampness and cold, which requires patients. Learn to summarize and explore the law of the disease.

First, prevention of infection: local infection is an important cause of psoriasis, especially after a cold, complicated with tonsillitis, bronchitis, need active treatment, try to shorten the course of the disease, tonsil repeated inflammation, and closely related to the onset of psoriasis For tonsillectomy, this is especially important for adolescents.

Second, allergic factors: is one of the important causes of psoriasis, due to diet or medication, or contact with a substance and allergies, often can induce psoriasis, patients need to carefully recall each time after relapse When you take something, or touch a substance, it makes the skin itchy, and then erythema, then this substance should be avoided in the future, for example, some seafood, beef and mutton, spicy things and other substances.

3. Dampness and cold : There are many psoriasis induced by wind and cold. Due to the damp environment and cold weather, the disease may occur or worsen. Therefore, patients should try to avoid large heat and heat, and keep the room ventilated. dry.

Fourth, mental factors: daily life due to work pressure, rest is not good, mental over-stress, resulting in emotional instability, anxiety and anger, and can not reasonably adjust the skin or long-term diet irregular, overeating, eat more Exciting the wind, excessive drinking and drinking tea, and external causes of colds, fever, inflammation of the tonsils, low immune function, lack of resistance, resulting in the onset and recurrence of psoriasis, excessive mental stress, temperament, depression, etc. Psychic factors are the cause, accounting for the first cause of other causes, accounting for 18.6% of the total incidence of psoriasis in China, excessive mental stress, can produce a series of psychological or physiological reactions, promote neuroendocrine disorders, damage the body's immune defense system, and The metabolic disorder of certain enzymes promotes the occurrence of psoriasis. Therefore, in the event of irresistible or unpredictable emergencies, patients should try to control their emotions, maintain a calm mood, and ensure adequate sleep time. Take an appropriate amount of sedative.

5. Use the following controlled drugs with caution: What kind of drugs are used for the first time to treat psoriasis, which plays a key role in the efficacy and recurrence of the disease. In a period of time, the medical community is studying the direction of treating psoriasis. , to a considerable extent, into the misunderstanding, mainly in: when psoriasis patients began to appear papular erythema, this time indicates that the patient's immune system is reduced, endocrine dysfunction, microcirculation loss caused by skin excretion dysfunction, The endotoxin that should be excreted in the body accumulates under the skin, and the drugs used are not used to improve immunity, restore the normal metabolic function of the skin, excrete endotoxin, but use hormones, immunosuppressants to suppress immunity and control skin excretion function. As a result, the more severe the treatment, the more serious the disease is, the more difficult it is to treat. Therefore, as a patient, there should be a basic understanding of such drugs. Currently, the drugs commonly used to control psoriasis are corticosteroids and anti-tumor.

In short, there are many reasons for the induction of psoriasis. Only patients pay more attention to their daily lives, pay attention to environmental hygiene, and actively eliminate predisposing factors such as avoiding alcohol, avoiding spicy, fish, shrimp, seafood, mutton and cockroaches. The tonsils are inflamed, the disease must be treated in the formal medical department, and some controlled drugs should be used with caution to reduce the chance of recurrence.

Psoriasis complications Complications

The disease is often complicated by liver and kidney damage, and can be life-threatening due to secondary infection, electrolyte imbalance or failure.

Symptoms of psoriasis Common symptoms Skin scaly skin redness System diffuse flushing pruritus scaly polymorphic erythematous rash erythema scaly large amount of skin desquamous lymph nodes swollen point bleeding

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 early 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 with a small bleeding point, that is, point bleeding, also known as the Auspitz sign (Figure 1, 2). Thin film 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 progress period, the stabilization 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 stimulus, 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 take into account the possibility of psoriasis.

(2) Stabilization period: the lesion stops developing, the inflammation is relieved, 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, exfoliation, lobular hemorrhage, brittle fracture, shedding, and hypokeratosis. Excessive, hypertrophy of the nail bed. A point-like depression, mediastinum and furrow are caused by psoriasis involving the parent material. Oil droplet phenomenon, 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, the distribution range is wide and even affect 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, making it squat. 8 crust-like psoriasis: lesions smashed, oozing, stained brown scaly sputum accumulation, like a clam shell. 9 verrucous psoriasis: the surface of the lesion is blemish, the calf is more common. 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, yellow-red, unclear borders, overgrown with greasy scales, often located in areas 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, hand, foot, armor, torso and limbs. It can be developed for sudden onset or chronic psoriasis. Inflammation, extensive 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 slices of normal skin with clear boundaries (Fig. 7). It can have an eyelid valgus when it occurs on the face. 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 triggering factors. The clinical features are sudden high fever, general malaise, and joint swelling that lasts for several days, followed by systemic erythema, edema, generalized invasive yellow-white, shallow, aseptic needles to small miliary 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 a maternal pustule 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. Palmoplantar 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 repeated.

(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 to cause damage or disfiguring arthritis in people with extensive skin involvement, but The relief or aggravation of joint lesions has little to do with the 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 proximal and distal digits of the hand and foot are common manifestations, 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 difference between the two 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 axial bone 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 have 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.

Psoriasis examination

1, pathological examination

Psoriasis is in the epidermis, and skin biopsy of psoriasis patients can be used to determine the type of skin lesions in patients with psoriasis. Histopathological examination of lesions in patients with atypical clinical manifestations is helpful in confirming the diagnosis.

2, dirty function check

By observing the treatment of patients with psoriasis, it is found that a considerable number of patients with psoriasis have disorders of visceral function. This is in complete agreement with the Chinese medicine on the etiology of psoriasis. Examination of the visceral function of patients with psoriasis facilitates the development of a treatment plan based on the patient's physical condition. B-ultrasound helps to understand changes in the shape of organs such as liver and kidney; problems with the heart can be reflected by electrocardiogram and echocardiography.

3. Targeted inspection

Liver function should be checked for patients suspected of having liver damage or when drugs affecting liver function should be used, and regular review should be conducted; in addition to urine tests, kidney function and blood acid and alkali and electrolyte levels should be checked.

4, routine laboratory inspection

Blood routines include hemoglobin content and red blood cells, white blood cells, and platelet counts; urine routines include pH, urine sugar, protein, various cells, etc.; stool routines include traits, cell counts, and occult blood. This is the three major routines that hospitalized patients have to do, and outpatients are subject to need.

5, X-ray inspection

Arthritic psoriasis requires X-ray examination (perspective, filming, etc.) to determine the location, type, degree of joint damage, and response and outcome after treatment. Inpatients also routinely perform chest fluoroscopy to see if there is an infection with a combined respiratory tract.

Psoriasis diagnosis and identification

diagnosis

According to the clinical manifestations of the disease, especially the characteristics of the rash and the characteristics of histopathology, it is generally not difficult to diagnose.

Differential diagnosis

Should be identified with the following diseases:

1. The margin of damage of seborrheic dermatitis is not obvious, the basal infiltration is lighter, the scales on the rash are sick, no Ausspitz's sign, seborrheic dermatitis in the scalp is often accompanied by hair loss, and the hair is not bundled.

2. Rose pityriasis damage mainly occurs in the trunk and the proximal extremities. The long axis of the rash is consistent with the skin pattern. The scales are small and thin, and the course of disease is short.

3. Lichen planus damage occurs in the limbs. It is a purple-red polygonal flat papule with waxy luster on the surface. Wickham pattern is visible. The mouth is often damaged. It is often itchy in different degrees and histopathology is specific.

4. The red pityriasis of the hair occurs mostly in the extremities of the extremities. In the early stage, the keratotic papules of the follicles are still visible. The keratotic papules of the follicles are still visible around the lesions of the late patches, especially the keratotic papules of the first phalanx follicles. According to the characteristics of the disease, the lesions are covered with fine scales and are not easily exfoliated, often accompanied by hyperkeratosis of the palmar.

5. The psoriatic lesions are covered with fine scales, no multi-layered scales, no film phenomenon, no Auspitz's sign, and no self-conscious symptoms.

6. Head lice need to be differentiated from head psoriasis. Head lice are caused by pathogenic fungi. At the beginning of the damage, the red small papules surrounding the hair shaft gradually expanded to the periphery, forming one to several pieces of desquamation plaques. The boundary was clear, the hair in the patch was tarnished, and it was easy to break at 2 to 4 cm from the scalp. The fungus was positive. More common in children.

7. Exfoliative dermatitis Psoriasis erythroderma (exfoliative dermatitis), with a history of psoriasis, mostly caused by improper treatment of psoriasis vulgaris. This can be distinguished from erythroderma (exfoliative dermatitis) caused by other causes.

8. Chronic eczema and eczema itching severe, blister exudation, erosion, crusting in the acute phase or early stage, hypertrophy in the chronic phase, lichen-like changes and pigmentation.

9. Neurodermatitis dermatitis is a cluster of mossy papules or mossy plaques with significant itching. It occurs in the parts of the extremities, the posterior neck and the cercariae, which are easy to rub and easy to grasp, symmetrically distributed, and the lesions are obviously thick. The skin is bulging and the skin is thick. Intense itching. The affected part was scratched at all times, but in addition to scratches and small areas of exudate scars, the damaged surface was always dry and no blisters occurred.

10. Rheumatoid arthritis psoriatic arthropathy needs to be differentiated. Psoriatic arthropathy occurs in small joints, especially in the end of the toe joint, serum rheumatoid factor test is negative, and may be accompanied by psoriasis lesions and nail changes.

Other differential diagnosis of diseases include sweat herpes eczema, discoid lupus erythematosus and the like.

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