Case Presentation……

Dr. Aravindakshan. G. K.

A 35 year man CC of itching of whole skin of about 12 years. The skin appears like as whitish scaly lesions got aggravated by sun exposure, night and during sleep. He also complaints of right knee joint pain since 3 months got aggravated from rising from seat, walking and ameliorated by rubbing and lying on bed.

On enquiry complaints started as lesions on knee joint as pustules and scaly lesions on anterior part of leg, scalp, hands and face. PMH suggests about allopathic treatment but only temporary relief.

PH suggests about bronchial asthma from childhood, before 1 year as hepatomegaly.

FH suggests about mother died due to D.M & H.T.

O/E, pulse rate: 78/min.resp. rate: 18/min.B.P: 98/68 mm of Hg.mild pallor.H.S: S1 long and dull, S2 normal.

Psychic features as indecsessive, use abuse words, disappointed when others say wrong about him, desires solitude.

Regional features as scaly eruptions as whole body, nails in all toes as yellowish tiny pittings and kollionychia. He also has palilalia and slurring of speech.

Other investigations report as on colour doppler study as mitral valve and tricupsid valve reguritation.

Individualistic features as1. scrapping with knife.2. always wants to be neat.3. worries about little matters.4. worries about his family.5. when anger use abuse words.

Medicine prescribed as Ars. Alb 0/6 / 1D.

the remaining days as SL..

Diagnosed as Psoriasis

A papulosquamous disorder….

Definition…..

It is a chronic inflammatory skin disorder clinically characterized by well defined erythematous, sharply demarcated papules and rounded plaques, covered by silvery scale and a chronic fluctuating course.

The patches are most common on the knees, elbows, scalp, tailbone, and back, but they may be anywhere on the body (including the fingernails, palms, and soles of the feet).

Psoriasis is not contagious. The exact cause of psoriasis is not known, but the body's natural defense system (immune system) is believed to be involved. The condition tends to run in families

Doctors believe that the immune system is

a factor in the development of psoriasis. This is because increased numbers of white blood cells are present between

the abnormal layers of skin and because psoriasis responds to drugs that suppress the immune system.

The patches (called plaques) are made up

of dead skin cells that form thick layers. The body replaces normal skin cells

every 28 days, but in psoriasis, skin cells are replaced every 3 to 6 days.

The histological changes of psoriasis are two key pathophysiological features.› The keratinocytes hyperproliferate with a

grossly increased mitotic index and an abnormal pattern of differentiation, leading to the retention of nuclei in the stratum corneum, not normally present as the stratum corneum cells are dead.

› There is a large inflammatory cell infiltrate.

The T-cell infiltrates in psoriasis have a non-random patterns of migration including CD8+T cells present in the epidermis, and CD4+ T cells in the dermis.

Besides T cells, other immu-nocyte subsets include increased numbers of neutrophils, dermal dendritic cells, macro-phages, and mast cells.

Especially in chronic plaque lesions, a marked epidermal thickening is observed This thickening is a result of hyperplasia of basal and suprabasal keratinocytes. At the same time, abnormal keratinocyte differentiation with marked PARAKERATOSIS (nuclei in the stratum corneum)and an absent granular layer is demonstrated.

Neutrophilsinvade the epidermis and accumulate as small spongiform Kogoj pustules or migrate up to the stratum corneum forming Munro’smicroabscesses.

Munro’s microabscesses are found only inparakeratotic areas of the epidermis.

Infiltration of neutrophils is striking in pustular and in guttate psoriasis.

The number of epidermal lymphocytes of the psoriatic lesion is significantly increased and comprises both CD8+ (killer) T lymphocytes and CD4+ (helper) T lymphocytes,

Langerhans cellsand a macrophage subpopulation called non-Langerhans dendritic cells represent the epidermal dendritic cells.

In psoriasis, fully mature Langerhans cells are increased in number and have enhanced antigen-presenting capacity due to overexpression of HLA class II molecules

Neoangiogenesis is characteristic of psoriatic plaque formation, and in lesional skin increased numbers of dilated, tortuous vesselsare thus encountered.

Indeed, a four-fold increase in endothelium of the superficial, but not of the deeper, microvasculature in lesional skin is reported

Psoriasis vulgarisAlso known as "plaque psoriasis," it is the

type that affects 80% to 90% of people with the disease. Psoriasis vulgaris can be recognized by the presence of raised, red, scaly patches (or "plaques"), usually on the elbows, knees, scalp, chest, nails, and lower back and associated with fever, malaise, diarrhea, and arthralgias. These may vary in size. The scales may be thick and silvery.

Guttate psoriasisThis form is less common; only about

10% of patients have this type. Guttate psoriasis often appears after someone suffers from strep throat. It commonly starts in childhood or adolescence with the sudden appearance of drop-sized patches (guttate means drop-like).

These lesions may spread to cover large areas of the upper body, legs, arms, and scalp.

Pustular psoriasis• This is a rare form of psoriasis. It may be

localized (usually appears on the palms of the hands and the soles of the feet), or generalized over the entire body.Localized pustular psoriasis can be quite painful, making it difficult to use your hands or walk normally. Most commonly, skin becomes red and swollen, with small, pus-filled pimples that dry to form brown dots; some people may have scaly patches

Inverse psoriasis• This form is also called skin-fold, flexural,

or genital psoriasis, because smooth, red, dry patches often occur in the folds of the skin (known as flexures). Inverse psoriasis may concentrate in the genital area, as well as under the breasts and in the armpits, and is more common in people who are overweight. It is characterized by increased sensitivity to friction and sweating. The affected skin can cause great discomfort, and this can make sexual relations difficult.

Erythrodermic psoriasis• Also known as exfoliative psoriasis, this

is a form of psoriasis that covers almost the entire body. It is characterized by severe redness and scaling, which is often accompanied by itching and pain. Because symptoms are so widespread over the body, this form can be extremely serious.

Erythrodermic psoriasis can cause the body temperature to fluctuate, especially in extremely hot or cold weather. It can also complicate heart disease and cause heart failure, because the heart rate may accelerate due to increased blood flow to the inflamed skin

Psoriatic arthritis: a related condition• Psoriatic arthritis is an arthritic condition—a condition related to the joints. The most common symptoms are inflammatory arthritis, and dry, scaly, thick, and inflamed skin. However, the skin symptoms and the arthritis symptoms frequently appear at different times, often years apart, so their connection may not be obvious

Psoriatic arthritis usually involves the joints of the hands and feet, knees, and ankles, which can become painful, swollen, hot, red, and stiff. Pain and stiffness can also develop in the lower back, buttocks, neck, and upper back. Psoriasis skin symptoms may include pitting and ridges in the fingernails and toenails. Nearly one quarter of people with psoriasis have psoriatic arthritis.

NUMMULAR PSORIASIS

FLEXURAL PSORIASIS

GUTTATE PSORIASIS

PALMAR PSORIASIS

PUSTULAR PSORIASIS

ERYTHRODERMIC PSORIASIS

Symptoms……

Tiny areas of bleeding when skin scales are picked or scraped off (Auspitz's sign). • Mild scaling to thick, crusted plaques on the scalp. • Itching, especially during sudden flare-ups

or when the psoriasis patches are in body folds, such as under the breasts or the buttocks. • Nail disorders. Nail disorders are common, especially in severe psoriasis.

Nail symptoms include: Tiny pits in the nails (not found with

fungal nail infections). • Yellowish discoloration of the toenails and possibly the fingernails. • Separation of the end of the nail from the nail bed. • Less often, a buildup of skin debris under the nails

Differential Diagnosis…..

SECONDARY SYPHILIS.

Lichen.

Eczematids….

Pityriasis rubra pilaris. ….

Fungoid mycosis

Sézary syndrome. ….

Prognosis…..

• Psoriasis is usually long-lasting, returns often (chronic), and can be unpredictable. Symptoms may come on suddenly (flare) and then improve and go away (remission). This cycle continues over and over. In some cases, psoriasis may go away without treatment. However, in moderate to severe cases, it is best to treat psoriasis so that it does not get worse.

Psoriasis can cause significant stress and lowered self-esteem. In one study, people with psoriasis reported a reduction in functioning similar to that of people with cancer, arthritis, heart disease, depression, and other serious conditions.

Management….

Initial treatment• Treatment for mild psoriasis,

characterized by a few isolated raised patches, begins with skin care, which includes keeping your skin moist and lubricated.

1. Creams, ointments, and lotions, to lubricate the skin. 2. Shampoos, oils, and sprays,to treat psoriasis of the scalp.3. Some exposure to sunlight.4. Keep away from all the trigerring

factors.5. Stress, skin injury, infection, and use

of alcohol can all contribute to symptom flare-ups.

Arsenicum album: People likely to respond to this remedy

usually are anxious, restless, and compulsively neat and orderly. They are often deeply chilly, experience burning pains with many physical complaints, and become exhausted easily. The skin is dry and scaly and may tend to get infected. Scratching can make the itching worse, and applying heat brings relief

This remedy is suited to people who are easily fatigued by exertion, sluggish physically, chilly with clammy hands and feet, and often overweight. Skin problems tend to be worse in winter. Typically solid and responsible, these people can be overwhelmed by too much work and stress. Anxiety, claustrophobia, and fear of heights are common. Cravings for sweets and eggs are often also seen when Calcarea is needed.

Calcarea carbonica:

Graphites:

People needing this remedy often have a long-term history of skin disorders. The skin looks tough or leathery skin with cracks and soreness. Itching is often worse from getting warm, and the person may scratch the irritated places till they bleed. Trouble concentrating, especially in the morning, is also often seen when this remedy is needed

Mercurius solubilis:

People who seem introverted and formal—but are very intense internally, with strong emotions and impulses—may benefit from this remedy. They tend to have swollen lymph nodes and moist or greasy-looking skin, and are very sensitive to changes in temperature. The areas affected by psoriasis may become infected easily.

Mezereum:

A person who needs this remedy usually is serious, and often feels strong anxiety in the region of the stomach. Scaly plaques may itch intensely, thickening or crusting over if the person scratches them too much. Cold applications relieve the itching (although the person feels generally chilly and improves with warmth). People who need this remedy often have a craving for fat, and feel best in open air.

Petroleum:

This remedy is often indicated for people whose physical problems are aggravated by stressful emotional experiences. It is especially suited to individuals with extremely dry skin, and problems that involve the palms and fingertips. The person may feel a cold sensation after scratching, and the skin is easily infected and may look tough and leathery. Itching will be worse at night, and from getting warm in bed. People who need this remedy may also have a tendency toward motion sickness.

Rhus toxicodendron:

When this remedy is indicated for a person with psoriasis, the skin eruptions are red and swollen, and often itch intensely. Hot applications or baths will soothe the itching—and also muscle stiffness, toward which these people often have a tendency. The person is restless, and may pace or constantly move around. A craving for cold milk is often seen when a person needs this remedy.

Sepia:

This remedy may be helpful to a person who feels dragged out and irritable, often with little enthusiasm for work or family life. The person’s skin may be look dry and stiff. Psoriasis may appear in many places on the body, including the nails and genitals. Signs of hormonal imbalance are often seen (in either sex), and problems with circulation are common. Exercise often helps this person’s energy and mood.

Staphysagria:

This remedy may be helpful to individuals whose psoriasis has developed after grief or suppressed emotions. Any part of the body can be involved but the scalp is often affected. People who need this remedy often seem sentimental, meek and quiet, and easily embarrassed — but often have a strong internal anger or deeply-buried hurt.

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Sulphur:

Intensely burning, itching, inflamed eruptions that are worse from warmth and bathing suggest a need for this remedy. Affected areas often look bright red and irritated, with scaling skin that gets inflamed from scratching. This remedy is sometimes helpful to people who have repeatedly used medications to suppress psoriasis (without success).

CORALLIUM RUBRUM

Coral-colored. Red, coppery spots. Psoriasis of palms and soles. Worse in open air ,changing from a

warm to cold room.

CLEMATIS ERECTA

Eruptions red and moist with increasing moon, dry and pale with decreasing

moon. burning, stinging, itching, agg. heat of bed, washing, esp. cold. Great sleepiness during daytime,

sleepless at night

CHRYSAROBINUM

Dry, scaly eruption, especially aroundeyes and ears, scabs with pus

underneath.

Violent itching

Bacillus morgan-Gaertner

Erythemato-squamous eruptions in round plaques on elbows, knees, integument, sacral region even on nails and heels.

Aggravation: In company, after meals, before menses, by the heat of bed, at night.

Amelioration: By movement, by passing flatus, by eructation.

THYROIDINUM

Psoriasis associated with adiposity worse night. Cold hands and feet. Itching without eruption, worse night.

Sarracenia purpurea

Pustular psoriasis.

X-RAY

Dry, itching eczema. Erythema around roots of nails. Skin dry, wrinkled. Painful cracks. Nails thicken.

Modalities.-Worse, in bed, afternoon, evening and night; open air.

KALIUM ARSENICOSUM

Burning eruptions. Eczema. Itching agg. Cold, undressing.

KALIUM SULPHURICUM

Scaly eruptions. Desquamating. Agg: HEAT. Overheated. Warm room. Amel: COLD, OPEN AIR. Agg: Evening.

USTILAGO

Nails exfoliate, falling out. Eruptions, coppery spots.

Carbolic acid

Itching. amel. rubbing, with burning pain

afterwards.

PHYTOLACCA

Agg: COLD, WET WEATHER. Agg: Night, motion. amel. Warm and dry, rest. Eruptions begin on scalp and spreds all

over body.

MANGANUM-ACT.

Chronic eczema, with amenorrhoea, agg. menses or menopause.

Radium .brom

Itching all over body, burning of skin, as if a fire.

ICTHYOLUM

Heat and irritation; itching. Scaly and itching eczema. Crops of boils. Purities of pregnancy.

RUMEX

Intense itching of skin, especially of lower extremities; worse, exposure to cold air when undressing.

Worse, in evening, from inhaling cold

air; left chest; uncovering.

KALI.BROM

Worse on chest shoulders and face. Anesthesia of skin. Modalities :better when

occupied ,mentally or physically.

iris Pustular eruptions. Agg :night.

Miasms….

Psoriasis = “marriage of all the miasms”

predominantly Psoric and sycotic

Dr. R.P. Patel says…..

more of Psora

a pinch of sycosis

a lot of syphilis

The psoric manifestations…..

dryness predominates fine, thin scales Tendency for recurrence Skin cannot endure water

Sycotic manifestations….

Fish scale eruptions Pruritus with thickening of the skin pigmentation < change of weather(damp) < meat

Syphilitic manifestations……

nails - paper like, spoon shaped, bending tearing easily

mentally - dull, heavy, stupid, stubborn, sullen, morose

Tubercular miasm…..

• nails - irregular , brittle, breaks, split easily

• with many hang nails • also spotted with white specks

Miasm of this patient as

Psoric and syphilitic.. From the state of lesions and mental

behaviors.

Management from your part….suggestions…