WordNet
- a chronic skin disease characterized by dry red patches covered with scales; occurs especially on the scalp and ears and genitalia and the skin over bony prominences
PrepTutorEJDIC
- 乾癬(かんせん)(慢性の非伝染性皮膚病)
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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2015/12/07 18:41:33」(JST)
wiki en
| Psoriasis | |
|---|---|
|
Back and arms of a person with psoriasis
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| Classification and external resources | |
| Pronunciation | /sɵˈraɪ.əsɨs/ (psora + -iasis) |
| Specialty | Dermatology |
| ICD-10 | L40 |
| ICD-9-CM | 696 |
| OMIM | 177900 |
| DiseasesDB | 10895 |
| MedlinePlus | 000434 |
| eMedicine | emerg/489 plaque derm/365 |
| MeSH | D011565 |
Psoriasis is a long-lasting autoimmune disease characterized by patches of abnormal skin.[1] These skin patches are typically red, itchy, and scaly. They may vary in severity from small and localized to complete body coverage.[2] Injury to the skin can trigger psoriatic skin changes at that spot, which is known as Koebner phenomenon.[3]
There are five main types of psoriasis: plaque, guttate, inverse, pustular, and erythrodermic.[1] Plaque psoriasis, also known as psoriasis vulgaris, makes up about 90% of cases. It typically presents with red patches with white scales on top. Areas of the body most commonly affected are the back of the forearms, shins, around the belly button, and the scalp.[4] Guttate psoriasis has drop-shaped lesions.[1] Pustular psoriasis presents with small non-infectious pus-filled blisters.[5] Inverse psoriasis forms red patches in skin folds.[1] Erythrodermic psoriasis occurs when the rash becomes very widespread, and can develop from any of the other types. Fingernails and toenails are affected in most people at some point in time. This may include pits in the nails or changes in nail color.[4]
Psoriasis is generally thought to be a genetic disease which is triggered by environmental factors.[2] In twin studies, identical twins are three times more likely to both be affected compared to non-identical twins; this suggests that shared genetic risk factors predispose to psoriasis. Symptoms often worsen during winter and with certain medications such as beta blockers or NSAIDs.[4] Infections and psychological stress may also play a role.[1][2] Psoriasis is not contagious. The underlying mechanism involves the immune system reacting to skin cells. Diagnosis is typically based on the signs and symptoms.[4]
There is no cure for psoriasis. However, various treatments can help control the symptoms.[4] These treatments may include steroid creams, vitamin D3 cream, ultraviolet light, and immune system suppressing medications such as methotrexate.[1] About 75% of people can be managed with creams alone.[4] The disease affects 2–4% of the population.[6] Both males and females are affected with equal frequency.[1] Psoriasis is associated with an increased risk of psoriatic arthritis, lymphomas, cardiovascular disease, Crohn's disease, and depression.[4] Psoriatic arthritis affects up to 30% of individuals with psoriasis.[5]
Contents
- 1 Signs and symptoms
- 1.1 Plaque
- 1.2 Pustular
- 1.3 Other skin lesions
- 1.4 Psoriatic arthritis
- 1.5 Nail changes
- 1.6 Medical signs
- 2 Causes
- 2.1 Genetics
- 2.2 Lifestyle
- 2.3 HIV
- 2.4 Medications
- 3 Mechanism
- 4 Diagnosis
- 4.1 Classification
- 4.1.1 Morphological
- 4.1.2 Pathogenetic
- 4.1.3 Severity
- 4.1 Classification
- 5 Management
- 5.1 Topical agents
- 5.2 Phototherapy
- 5.3 Systemic agents
- 5.4 Surgery
- 5.5 Alternative therapy
- 6 Prognosis
- 6.1 Cardiovascular disease
- 6.2 Other diseases
- 7 Epidemiology
- 8 History
- 8.1 Etymology
- 9 Society and culture
- 10 Research
- 11 References
- 12 Further reading
- 13 External links
Signs and symptoms
Plaque
Psoriatic plaque, showing a silvery center surrounded by a reddened border.
Psoriasis vulgaris (also known as chronic stationary psoriasis or plaque-like psoriasis) is the most common form and affects 85%–90% of people with psoriasis.[7] Plaque psoriasis typically appears as raised areas of inflamed skin covered with silvery-white scaly skin. These areas are called plaques and are most commonly found on the elbows, knees, scalp, and back.[7][8] Psoriatic erythroderma (erythrodermic psoriasis) involves widespread inflammation and exfoliation of the skin over most of the body surface. It may be accompanied by severe itching, swelling, and pain. It is often the result of an exacerbation of unstable plaque psoriasis, particularly following the abrupt withdrawal of systemic glucocorticoids.[9] This form of psoriasis can be fatal as the extreme inflammation and exfoliation disrupt the body's ability to regulate temperature and perform barrier functions.[10]
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Plaques of psoriasis
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A person's arm covered with plaque psoriasis
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Psoriasis of the palms
Pustular
See also: Generalized pustular psoriasis
Severe pustular psoriasis.
Pustular psoriasis appears as raised bumps filled with noninfectious pus (pustules).[11] The skin under and surrounding the pustules is red and tender.[12] Pustular psoriasis can be localized, commonly to the hands and feet (palmoplantar pustulosis), or generalized with widespread patches occurring randomly on any part of the body. Acrodermatitis continua is a form of localized psoriasis limited to the fingers and toes that may spread to the hands and feet.[12] Pustulosis palmaris et plantaris is another form of localized pustular psoriasis similar to acrodermatitis continua with pustules erupting from red, tender, scaly skin found on the palms of the hands and the soles of the feet.[12]
Generalized pustular psoriasis (pustular psoriasis of von Zumbusch), also known as impetigo herpetiformis during pregnancy,[13] is a rare and severe form of psoriasis that may require hospitalization. The development of generalized pustular psoriasis is often caused by an infection, abrupt withdrawal of topical corticosteroid treatment, pregnancy, hypocalcemia, medications, or following an irritating topical treatment for plaque psoriasis.[12] This form of psoriasis is characterized by an acute onset of numerous pustules on top of tender red skin. This skin eruption is often accompanied by a fever, muscle aches, nausea, and an elevated white blood cell count.[12] Annular pustular psoriasis (APP), a rare form of generalized pustular psoriasis, is the most common type seen during childhood.[13] APP tends to occur in women more frequently than in men, and is usually less severe than other forms of generalized pustular psoriasis such as impetigo herpetiformis.[13] This form of psoriasis is characterized by ring-shaped plaques with pustules around the edges and yellow crusting.[13] APP most often affects the torso, neck, arms, and legs.[13]
Other skin lesions
Example of guttate psoriasis
An example of psoriasis affecting the penis. The white spots are psoriasis lesions.
Additional types of psoriasis affecting the skin include inverse psoriasis, guttate psoriasis, oral psoriasis, and seborrheic-like psoriasis.[14]
Inverse psoriasis (also known as flexural psoriasis) appears as smooth, inflamed patches of skin. The patches frequently affect skin folds, particularly around the genitals (between the thigh and groin), the armpits, in the skin folds of an overweight abdomen (known as panniculus), between the buttocks in the intergluteal cleft, and under the breasts in the inframammary fold. Heat, trauma, and infection are thought to play a role in the development of this atypical form of psoriasis.[15] Napkin psoriasis is a subtype of psoriasis common in infants characterized by red papules with silver scale in the diaper area that may extend to the torso or limbs.[16] Napkin psoriasis is often misdiagnosed as napkin dermatitis (diaper rash).[17]
Guttate psoriasis is characterized by numerous small, scaly, red or pink, droplet-like lesions (papules). These numerous spots of psoriasis appear over large areas of the body, primarily the trunk, but also the limbs and scalp. Guttate psoriasis is often triggered by a streptococcal infection, typically streptococcal pharyngitis.[15] The reverse is not true.
Oral psoriasis is very rare,[18] in contrast to lichen planus, another common papulosquamous disorder that commonly involves both the skin and mouth. When psoriasis involves the oral mucosa (the lining of the mouth), it may be asymptomatic,[18] but it may appear as white or grey-yellow plaques.[18] Fissured tongue is the most common finding in those with oral psoriasis and has been reported to occur in 6.5–20% of people with psoriasis affecting the skin. The microscopic appearance of oral mucosa affected by geographic tongue (migratory stomatitis) is very similar to the appearance of psoriasis.[19] However, modern studies have failed to demonstrate any link between the two conditions.[20]
Seborrheic-like psoriasis is a common form of psoriasis with clinical aspects of psoriasis and seborrheic dermatitis, and may be difficult to distinguish from the latter. This form of psoriasis typically manifests as red plaques with greasy scales in areas of higher sebum production such as the scalp, forehead, skin folds next to the nose, skin surrounding the mouth, skin on the chest above the sternum, and in skin folds.[16]
Psoriatic arthritis
See also: Psoriatic arthritis
Psoriatic arthritis is a form of chronic inflammatory arthritis that has a highly variable clinical presentation and frequently occurs in association with skin and nail psoriasis.[21][22] It typically involves painful inflammation of the joints and surrounding connective tissue and can occur in any joint, but most commonly affects the joints of the fingers and toes. This can result in a sausage-shaped swelling of the fingers and toes known as dactylitis.[21] Psoriatic arthritis can also affect the hips, knees, spine (spondylitis), and sacroiliac joint (sacroiliitis).[23] About 30% of individuals with psoriasis will develop psoriatic arthritis.[7] Skin manifestations of psoriasis tend to occur before arthritic manifestations in about 75% of cases.[22]
Nail changes
Psoriasis of a fingernail, with visible pitting.
A photograph showing the effects of psoriasis on the toenails.
Psoriasis can affect the nails and produces a variety of changes in the appearance of finger and toe nails. Nail psoriasis occurs in 40–45% of people with psoriasis affecting the skin and has a lifetime incidence of 80–90% in those with psoriatic arthritis.[24] These changes include pitting of the nails (pinhead-sized depressions in the nail is seen in 70% with nail psoriasis), whitening of the nail, small areas of bleeding from capillaries under the nail, yellow-reddish discoloration of the nails known as the oil drop or salmon spot, thickening of the skin under the nail (subungual hyperkeratosis), loosening and separation of the nail (onycholysis), and crumbling of the nail.[24]
Medical signs
In addition to the appearance and distribution of the rash, specific medical signs may be used by medical practitioners to assist with diagnosis. These may include Auspitz's sign (pinpoint bleeding when scale is removed), Koebner phenomenon (psoriatic skin lesions induced by trauma to the skin),[16] and itching and pain localized to papules and plaques.[15][16]
Causes
The cause of psoriasis is not fully understood, but a number of theories exist.
Genetics
See also: List of human leukocyte antigen alleles associated with cutaneous conditions
Around one-third of people with psoriasis report a family history of the disease, and researchers have identified genetic loci associated with the condition. Identical twin studies suggest a 70% chance of a twin developing psoriasis if the other twin has the disorder. The risk is around 20% for nonidentical twins. These findings suggest both a genetic susceptibility and an environmental response in developing psoriasis.[25]
Psoriasis has a strong hereditary component, and many genes are associated with it, but it is unclear how those genes work together. Most of the identified genes relate to the immune system, particularly the major histocompatibility complex (MHC) and T cells. Genetic studies are valuable due to their ability to identify molecular mechanisms and pathways for further study and potential drug targets.[26]
Classic genome-wide linkage analysis has identified nine loci on different chromosomes associated with psoriasis. They are called psoriasis susceptibility 1 through 9 (PSORS1 through PSORS9). Within those loci are genes on pathways that lead to inflammation. Certain variations (mutations) of those genes are commonly found in psoriasis.[26] Genome-wide association scans have identified other genes that are altered to characteristic variants in psoriasis. Some of these genes express inflammatory signal proteins, which affect cells in the immune system that are also involved in psoriasis. Some of these genes are also involved in other autoimmune diseases.[26]
The major determinant is PSORS1, which probably accounts for 35%–50% of psoriasis heritability.[27] It controls genes that affect the immune system or encode skin proteins that are overabundant with psoriasis. PSORS1 is located on chromosome 6 in the major histocompatibility complex (MHC), which controls important immune functions. Three genes in the PSORS1 locus have a strong association with psoriasis vulgaris: HLA-C variant HLA-Cw6,[28] which encodes a MHC class I protein; CCHCR1, variant WWC, which encodes a coiled protein that is overexpressed in psoriatic epidermis; and CDSN, variant allele 5, which encodes corneodesmosin, a protein which is expressed in the granular and cornified layers of the epidermis and upregulated in psoriasis.[26]
Two major immune system genes under investigation are interleukin-12 subunit beta (IL12B) on chromosome 5q, which expresses interleukin-12B; and IL23R on chromosome 1p, which expresses the interleukin-23 receptor, and is involved in T cell differentiation. Interleukin-23 receptor and IL12B have both been strongly linked with psoriasis.[28] T cells are involved in the inflammatory process that leads to psoriasis.[26] These genes are on the pathway that up-regulate tumor necrosis factor-α and nuclear factor κB, two genes involved in inflammation.[26] Recently, the first gene directly linked to psoriasis has been identified. A rare mutation in the gene encoding for the CARD14 protein plus an environmental trigger was enough to cause plaque psoriasis (the most common form of psoriasis).[29][30]
Lifestyle
Conditions reported as accompanying a worsening of the disease include chronic infections, stress, and changes in season and climate.[28] Others include hot water, scratching psoriasis skin lesions, skin dryness, excessive alcohol consumption, cigarette smoking, and obesity.[28][31][32]
HIV
The rate of psoriasis in HIV-positive individuals is comparable to that of HIV-negative individuals, however, psoriasis tends to be more severe in people infected with HIV.[33] A much higher rate of psoriatic arthritis occurs in HIV-positive individuals with psoriasis than in those without the infection.[33] The immune response in those infected with HIV is typically characterized by cellular signals from Th2 subset of CD4+ helper T cells,[34] whereas the immune response in psoriasis vulgaris is characterized by a pattern of cellular signals typical of Th1 subset of CD4+ helper T cells and Th17 helper T cells.[35][36] It is hypothesized that the diminished CD4+-T cell presence causes an overactivation of CD8+-T cells, which are responsible for the exacerbation of psoriasis in HIV-positive people. Psoriasis in those with HIV/AIDS is often severe and may be untreatable with conventional therapy.[37]
Medications
Drug-induced psoriasis may occur with beta blockers,[5] lithium,[5] antimalarial medications,[5] non-steroidal anti-inflammatory drugs,[5] terbinafine, calcium channel blockers, captopril, glyburide, granulocyte colony-stimulating factor,[5] interleukins, interferons,[5] lipid-lowering drugs,[14]:197 and paradoxically TNF inhibitors such as infliximab or adalimumab.[38] Withdrawal of corticosteroids (topical steroid cream) can aggravate psoriasis due to the rebound effect.[39]
Mechanism
Psoriasis is characterized by an abnormally excessive and rapid growth of the epidermal layer of the skin.[40] Abnormal production of skin cells (especially during wound repair) and an overabundance of skin cells result from the sequence of pathological events in psoriasis.[12] Skin cells are replaced every 3–5 days in psoriasis rather than the usual 28–30 days.[41] These changes are believed to stem from the premature maturation of keratinocytes induced by an inflammatory cascade in the dermis involving dendritic cells, macrophages, and T cells (three subtypes of white blood cells).[7][33] These immune cells move from the dermis to the epidermis and secrete inflammatory chemical signals (cytokines) such as tumor necrosis factor-α, interleukin-1β, interleukin-6, interleukin-36 and interleukin-22.[26][42] These secreted inflammatory signals are believed to stimulate keratinocytes to proliferate.[26] One hypothesis is that psoriasis involves a defect in regulatory T cells, and in the regulatory cytokine interleukin-10.[26]
Gene mutations of proteins involved in the skin's ability to function as a barrier have been identified as markers of susceptibility for the development of psoriasis.[43][44]
DNA released from dying cells acts as an inflammatory stimulus in psoriasis[45] and stimulates the receptors on certain dendritic cells, which in turn produce the cytokine interferon-α.[45] In response to these chemical messages from dendritic cells and T cells, keratinocytes also secrete cytokines such as interleukin-1, interleukin-6, and tumor necrosis factor-α, which signal downstream inflammatory cells to arrive and stimulate additional inflammation.[26]
Dendritic cells bridge the innate immune system and adaptive immune system. They are increased in psoriatic lesions[40] and induce the proliferation of T cells and type 1 helper T cells (Th1). Targeted immunotherapy as well as psoralen and ultraviolet A (PUVA) therapy can reduce the number of dendritic cells and favors a Th2 cell cytokine secretion pattern over a Th1/Th17 cell cytokine profile.[26][35] Psoriatic T cells move from the dermis into the epidermis and secrete interferon-γ and interleukin-17.[46] Interleukin-23 is known to induce the production of interleukin-17 and interleukin-22.[40][46] Interleukin-22 works in combination with interleukin-17 to induce keratinocytes to secrete neutrophil-attracting cytokines.[46]
Diagnosis
A diagnosis of psoriasis is usually based on the appearance of the skin. Skin characteristics typical for psoriasis are scaly, erythematous plaques, papules, or patches of skin that may be painful and itch.[15] No special blood tests or diagnostic procedures are needed to make the diagnosis.[12][47]
The differential diagnosis of psoriasis includes dermatological conditions similar in appearance such as discoid eczema, seborrhoeic eczema, pityriasis rosea (may be confused with guttate psoriasis), nail fungus (may be confused with nail psoriasis) or cutaneous T cell lymphoma (50% of individuals with this cancer are initially misdiagnosed with psoriasis).[39] Dermatologic manifestations of systemic illnesses such as the rash of secondary syphilis may also be confused with psoriasis.[39]
If the clinical diagnosis is uncertain, a skin biopsy or scraping may be performed to rule out other disorders and to confirm the diagnosis. Skin from a biopsy will show clubbed epidermal projections that interdigitate with dermis on microscopy. Epidermal thickening is another characteristic histologic finding of psoriasis lesions.[12][48] The stratum granulosum layer of the epidermis is often missing or significantly decreased in psoriatic lesions; the skin cells from the most superficial layer of skin are also abnormal as they never fully mature. Unlike their mature counterparts, these superficial cells keep their nucleus.[12] Inflammatory infiltrates can typically be visualized on microscopy when examining skin tissue or joint tissue affected by psoriasis. Epidermal skin tissue affected by psoriatic inflammation often has many CD8+ T cells while a predominance of CD4+ T cells make up the inflammatory infiltrates of the dermal layer of skin and the joints.[12]
Classification
Morphological
| Psoriasis Type | ICD-10 Code |
|---|---|
| Psoriasis vulgaris | L40.0 |
| Generalized pustular psoriasis | L40.1 |
| Acrodermatitis continua | L40.2 |
| Pustulosis palmaris et plantaris | L40.3 |
| Guttate psoriasis | L40.4 |
| Psoriatic arthritis | L40.50 |
| Psoriatic spondylitis | L40.53 |
| Inverse psoriasis | L40.8 |
Psoriasis is classified as a papulosquamous disorder and is most commonly subdivided into different categories based on histological characteristics.[2][5] Variants include plaque, pustular, guttate, and flexural psoriasis. Each form has a dedicated ICD-10 code.[49] Psoriasis can also be classified into nonpustular and pustular types.[50]
Pathogenetic
Another classification scheme considers genetic and demographic factors. Type 1 has a positive family history, starts before the age of 40, and is associated with the human leukocyte antigen, HLA-Cw6. Conversely, type 2 does not show a family history, presents before age 40, and is not associated with HLA-Cw6.[51] Type 1 accounts for about 75% of persons with psoriasis.[52]
The classification of psoriasis as an autoimmune disease has sparked considerable debate. Researchers have proposed differing descriptions of psoriasis and psoriatic arthritis; some authors have classified them as autoimmune diseases[12][28][53] while others have classified them as distinct from autoimmune diseases and referred to them as immune-mediated inflammatory diseases.[26][54][55]
Severity
Distribution of severity
There is no consensus about how to classify the severity of psoriasis. Mild psoriasis has been defined as a percentage of body surface area (BSA)≤10, a Psoriasis Area Severity Index (PASI) score ≤10, and a dermatology life quality index (DLQI) score ≤10.[56] Moderate to severe psoriasis was defined by the same group as BSA >10 or PASI score >10 and a DLQI score >10.[56] The DLQI is a 10 question tool used to measure the impact of several dermatologic diseases on daily functioning. The DLQI score ranges from 0 (minimal impairment) to 30 (maximal impairment) and is calculated with each answer being assigned 0–3 points with higher scores indicating greater social or occupational impairment.[57]
The psoriasis area severity index (PASI) is the most widely used measurement tool for psoriasis. PASI assesses the severity of lesions and the area affected and combines these two factors into a single score from 0 (no disease) to 72 (maximal disease).[58] Nevertheless, the PASI can be too unwieldy to use outside of research settings, which has led to attempts to simplify the index for clinical use.[59]
Management
Schematic of psoriasis treatment ladder
While no cure is available for psoriasis,[39] many treatment options exist. Topical agents are typically used for mild disease, phototherapy for moderate disease, and systemic agents for severe disease.[60]
Topical agents
Topical corticosteroid preparations are the most effective agents when used continuously for 8 weeks; retinoids and coal tar were found to be of limited benefit and may be no better than placebo.[61] Greater benefit has been observed with very potent corticosteroids when compared to potent corticosteroids. Vitamin D analogues such as paricalcitol were found to be significantly superior to placebo. Combination therapy with vitamin D and a corticosteroid was superior to either treatment alone and vitamin D was found to be superior to coal tar for chronic plaque psoriasis.[62]
Moisturizers and emollients such as mineral oil, petroleum jelly, calcipotriol, and decubal (an oil-in-water emollient) were found to increase the clearance of psoriatic plaques. Emollients have been shown to be even more effective at clearing psoriatic plaques when combined with phototherapy.[63] However, certain emollients have no impact on psoriasis plaque clearance or may even decrease the clearance achieved with phototherapy. The emollient salicylic acid is structurally similar to para-aminobenzoic acid (PABA), commonly found in sunscreen, and is known to interfere with phototherapy in psoriasis. Coconut oil, when used as an emollient in psoriasis, has been found to decrease plaque clearance with phototherapy.[63] Medicated creams and ointments applied directly to psoriatic plaques can help reduce inflammation, remove built-up scale, reduce skin turnover, and clear affected skin of plaques. Ointment and creams containing coal tar, dithranol, corticosteroids (i.e. desoximetasone), fluocinonide, vitamin D3 analogs (for example, calcipotriol), and retinoids are routinely used. The use of the finger tip unit may be helpful in guiding how much topical treatment to use.[31][64]
Vitamin D analogues may be useful with steroids; however, alone have a higher rate of side effects.[65] They may allow less steroids to be used.[66]
Another topical therapy used to treat psoriasis is a form of balneotherapy, which involves daily baths in the Dead Sea. This is usually done for four weeks with the benefit attributed to sun exposure. This is cost-effective and it has been propagated as an effective way to treat psoriasis without medication.[67] Decreases of PASI scores greater than 75% and remission for several months have commonly been observed.[67] Side-effects may be mild such as itchiness, folliculitis, sunburn, poikiloderma, and a theoretical risk of nonmelanoma skin cancer or melanoma has been suggested.[67] However, more recent studies have determined that there does not appear to be increased risk of melanoma in the long-term.[68] Data are inconclusive with respect to nonmelanoma skin cancer risk, but support the idea that the therapy is associated with an increased risk of benign forms of sun-induced skin damage such as, but not limited to, actinic elastosis or liver spots.[68] Dead Sea balneotherapy is also effective for psoriatic arthritis.[68]
Phototherapy
Phototherapy in the form of sunlight has long been used for psoriasis.[60] Wavelengths of 311–313 nanometers are most effective, and special lamps have been developed for this application.[60] The exposure time should be controlled to avoid over exposure and burning of the skin. The UVB lamps should have a timer that will turn off the lamp when the time ends. The amount of light used is determined by a person's skin type.[60] Increased rates of cancer from treatment appear to be small.[60] Narrow band UVB light (NBUVB) phototherapy has been demonstrated to have similar efficacy to PUVA.[69]
A major mechanism of NBUVB is the induction of DNA damage in the form of pyrimidine dimers. This type of phototherapy is useful in the treatment of psoriasis because the formation of these dimers interferes with the cell cycle and stops it. The interruption of the cell cycle induced by NBUVB opposes the characteristic rapid division of skin cells seen in psoriasis.[69] The activity of many types of immune cells found in the skin is also effectively suppressed by NBUVB phototherapy treatments. The most common short-term side effect of this form of phototherapy is redness of the skin; less common side effects of NBUVB phototherapy are itching and blistering of the treated skin, irritation of the eyes in the form of conjunctival inflammation or inflammation of the cornea, or cold sores due to reactivation of the herpes simplex virus in the skin surrounding the lips. Eye protection is usually given during phototherapy treatments.[69]
Psoralen and ultraviolet A phototherapy (PUVA) combines the oral or topical administration of psoralen with exposure to ultraviolet A (UVA) light. The mechanism of action of PUVA is unknown, but probably involves activation of psoralen by UVA light, which inhibits the abnormally rapid production of the cells in psoriatic skin. There are multiple mechanisms of action associated with PUVA, including effects on the skin's immune system. PUVA is associated with nausea, headache, fatigue, burning, and itching. Long-term treatment is associated with squamous cell carcinoma (but not with melanoma).[32][70] A combination therapy for moderate to severe psoriasis using PUVA plus acitretin resulted in benefit, but acitretin use has been associated with birth defects and liver damage.[71]
Systemic agents
Pictures of a patient with psoriasis (and psoriatic arthritis) at baseline and 8 weeks after initiation of infliximab therapy.
Psoriasis resistant to topical treatment and phototherapy may be treated with systemic therapies including oral medications or injectable treatments.[72] Patients undergoing systemic treatment must have regular blood and liver function tests to check for medication toxicities.[72] Pregnancy must be avoided for most of these treatments. The majority of people experience a recurrence of psoriasis after systemic treatment is discontinued.
Non-biologic systemic treatments frequently used for psoriasis include methotrexate, ciclosporin, hydroxycarbamide, fumarates such as dimethyl fumarate, and retinoids.[73] Methotrexate and ciclosporin are drugs that suppress the immune system; retinoids are synthetic forms of vitamin A. These agents are also regarded as first-line treatments for psoriatic erythroderma.[9]
Biologics are manufactured proteins that interrupt the immune process involved in psoriasis. Unlike generalised immunosuppressive drug therapies such as methotrexate, biologics target specific aspects of the immune system contributing to psoriasis.[73] These medications are generally well-tolerated and limited long-term outcome data have demonstrated biologics to be safe for long-term use in moderate to severe plaque psoriasis.[73][74] However, due to their immunosuppressive actions, biologics have been associated with a small increase in the risk for infection.[73] Professional guidelines regard biologics as third-line treatment for plaque psoriasis following inadequate response to topical treatment, phototherapy, and non-biologic systemic treatments.[74] The safety of biologics during pregnancy has not been assessed. European guidelines recommend avoiding biologics if a pregnancy is planned; anti-TNF therapies such as infliximab are not recommended for use in chronic carriers of the hepatitis B virus or individuals infected with HIV.[73]
Several monoclonal antibodies target cytokines, the molecules that cells use to send inflammatory signals to each other. TNF-α is one of the main executor inflammatory cytokines. Four monoclonal antibodies (MAbs) (infliximab, adalimumab, golimumab, and certolizumab pegol) and one recombinant TNF-α decoy receptor, etanercept, have been developed to inhibit TNF-α signaling. Additional monoclonal antibodies have been developed against pro-inflammatory cytokines interleukin-12, interleukin-23 and interleukin-17[75] and inhibit the inflammatory pathway at a different point than the anti-TNF-α antibodies.[26] IL-12 and IL-23 share a common domain, p40, which is the target of the recently FDA-approved ustekinumab.[28]
Two drugs that target T cells are efalizumab and alefacept. Efalizumab is a monoclonal antibody that specifically targets the CD11a subunit of LFA-1.[73] It also blocks the adhesion molecules on the endothelial cells that line blood vessels, which attract T cells. Efalizumab was voluntarily withdrawn from the European market in February 2009 and from the US market in June 2009 by the manufacturer due to the medication's association with cases of progressive multifocal leukoencephalopathy.[73] Alefacept also blocks the molecules that dendritic cells use to communicate with T cells and even causes natural killer cells to kill T cells as a way of controlling inflammation.[26]
Individuals with psoriasis may develop neutralizing antibodies against monoclonal antibodies. Neutralization occurs when an antidrug antibody prevents a monoclonal antibody such as infliximab from binding antigen in a laboratory test. Specifically, neutralization occurs when the antidrug antibody binds to infliximab's antigen binding site instead of TNF-α. When infliximab no longer binds tumor necrosis factor alpha, it no longer decreases inflammation, and the psoriasis may worsen. Neutralizing antibodies have not been reported against etanercept, a biologic-drug that is a fusion protein composed of two TNF-α receptors. The lack of neutralizing antibodies against etanercept is probably secondary to the innate presence of the TNF-α receptor, and the development of immune tolerance.[76]
Surgery
Limited evidence suggests removal of the tonsils may benefit people with chronic plaque psoriasis, guttate psoriasis, and palmoplantar pustulosis.[77][78]
Alternative therapy
Uncontrolled studies have suggested that individuals with psoriasis or psoriatic arthritis may benefit from a diet supplemented with fish oil rich in eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA).[79] Conflicting evidence exists indicating that there may be an increased incidence of psoriasis in people with celiac disease. Psoriatic disease severity decreased after 3 months of a gluten free diet in patients with anti-gliadin antibodies.[79]
Prognosis
Most people with psoriasis experience nothing more than mild skin lesions that can be treated effectively with topical therapies.[61]
Psoriasis is known to have a negative impact on the quality of life of both the affected person and the individual's family members.[28] Depending on the severity and location of outbreaks, individuals may experience significant physical discomfort and some disability. Itching and pain can interfere with basic functions, such as self-care and sleep.[41] Participation in sporting activities, certain occupations, and caring for family members can become difficult activities for those with plaques located on their hands and feet.[41] Plaques on the scalp can be particularly embarrassing, as flaky plaque in the hair can be mistaken for dandruff.[80]
Individuals with psoriasis may feel self-conscious about their appearance and have a poor self-image that stems from fear of public rejection and psychosexual concerns. Psoriasis has been associated with low self-esteem and depression is more common among those with the condition.[2] People with psoriasis often feel prejudiced against due to the commonly held incorrect belief that psoriasis is contagious.[41] Psychological distress can lead to significant depression and social isolation; a high rate of thoughts about suicide has been associated with psoriasis.[17] Many tools exist to measure the quality of life of patients with psoriasis and other dermatological disorders. Clinical research has indicated individuals often experience a diminished quality of life.[81] Children with psoriasis may encounter bullying.[82]
Several conditions are associated with psoriasis. These occur more frequently in older people. Nearly half of individuals with psoriasis over the age of 65 have at least three comorbidities, and two-thirds have at least two comorbidities.[83]
Cardiovascular disease
Psoriasis has been associated with obesity[2] and several other cardiovascular and metabolic disturbances. The incidence of diabetes is 27% higher in people affected by psoriasis than in those without the condition.[84] Severe psoriasis may be even more strongly associated with the development of diabetes than mild psoriasis.[84] Younger people with psoriasis may also be at increased risk for developing diabetes.[83][85] Individuals with psoriasis or psoriatic arthritis have a slightly higher risk of heart disease and heart attacks when compared to the general population. Cardiovascular disease risk appeared to be correlated with the severity of psoriasis and its duration. There is no strong evidence to suggest that psoriasis is associated with an increased risk of death from cardiovascular events. Methotrexate may provide a degree of protection for the heart.[32][83]
The odds of having hypertension are 1.58 times higher in people with psoriasis than those without the condition; these odds are even higher with severe cases of psoriasis. A similar association was noted in people who have psoriatic arthritis—the odds of having hypertension were found to be 2.07 times greater when compared to odds of the general population. The link between psoriasis and hypertension is not currently understood. Mechanisms hypothesized to be involved in this relationship include the following: dysregulation of the renin-angiotensin system, elevated levels of endothelin 1 in the blood, and increased oxidative stress.[85][86] The incidence of the heart rhythm abnormality atrial fibrillation is 1.31 times higher in people with mild psoriasis and 1.63 times higher in people with severe psoriasis.[87] There may be a slightly increased risk of stroke associated with psoriasis, especially in severe cases.[32][88] Treating high levels of cholesterol with statins has been associated with decreased psoriasis severity, as measured by PASI score, and has also been associated with improvements in other cardiovascular disease risk factors such as markers of inflammation.[89] These cardioprotective effects are attributed to ability of statins to improve blood lipid profile and because of their anti-inflammatory effects. Statin use in those with psoriasis and hyperlipidemia was associated with decreased levels of high-sensitivity C-reactive protein and TNFα as well as decreased activity of the immune protein LFA-1.[89] Compared to individuals without psoriasis, those affected by psoriasis are more likely to satisfy the criteria for metabolic syndrome.[12][87]
Other diseases
The rates of Crohn's disease and ulcerative colitis are increased when compared with the general population, by a factor of 3.8 and 7.5 respectively.[2] Few studies have evaluated the association of multiple sclerosis with psoriasis, and the relationship has been questioned.[2][90] Psoriasis has been associated with a 16% increase in overall relative risk for non-skin cancer.[32] People with psoriasis have a 52% increased risk cancers of the lung and bronchus, a 205% increase in the risk of developing cancers of the upper gastrointestinal tract, a 31% increase in the risk of developing cancers of the urinary tract, a 90% increase in the risk of developing liver cancer, and a 46% increase in the risk of developing pancreatic cancer.[32] The risk for development of non-melanoma skin cancers is also increased. Psoriasis increases the risk of developing squamous cell carcinoma of the skin by 431% and increases the risk of basal cell carcinoma by 100%.[32] There is no increased risk of melanoma associated with psoriasis.[32]
Epidemiology
Psoriasis is estimated to affect 2–4% of the population of the western world.[6] The rate of psoriasis varies according to age, gender, region and ethnicity; a combination of environmental and genetic factors is thought to be responsible for these differences.[6] It can occur at any age, although it most commonly appears for the first time between the ages of 15 and 25 years. Approximately one third of psoriasis patients report being diagnosed before age 20.[91] Psoriasis affects both sexes equally.[51]
People with inflammatory bowel disease such as Crohn's disease or ulcerative colitis are at an increased risk of developing psoriasis.[38] Psoriasis is more common in countries farther from the equator.[38] Persons of white European ancestry are more likely to have psoriasis and the condition is relatively uncommon in African Americans and extremely uncommon in Native Americans.[39]
History
Scholars believe psoriasis to have been included among the various skin conditions called tzaraath (translated as leprosy) in the Hebrew Bible, a condition imposed as a punishment for slander. The patient was deemed "impure" (see tumah and taharah) during their afflicted phase and is ultimately treated by the kohen.[92] However, it is more likely that this confusion arose from the use of the same Greek term for both conditions. The Greeks used the term lepra (λεπρα) for scaly skin conditions. They used the term psora to describe itchy skin conditions.[92] It became known as Willan's lepra in the late 18th century when English dermatologists Robert Willan and Thomas Bateman differentiated it from other skin diseases. Leprosy, they said, is distinguished by the regular, circular form of patches, while psoriasis is always irregular. Willan identified two categories: leprosa graecorum and psora leprosa.[93]
Psoriasis is thought to have first been described in Ancient Rome by Cornelius Celsus. The disease was first classified by English physician Thomas Willan. The British dermatologist Thomas Bateman described a possible link between psoriasis and arthritic symptoms in 1813.[94]
The history of psoriasis is littered with treatments of dubious effectiveness and high toxicity. In the 18th and 19th centuries, Fowler's solution, which contains a poisonous and carcinogenic arsenic compound, was used by dermatologists as a treatment for psoriasis.[92] Mercury was also used for psoriasis treatment during this time period.[92] Sulfur, iodine, phenol were also commonly used treatments for psoriasis during this era when it was incorrectly believed that psoriasis was an infectious disease.[92] Coal tars were widely used with ultraviolet light irradiation as a topical treatment approach in the early 1900s.[92][95] During the same time period, psoriatic arthritis cases were treated with intravenously administered gold preparations in the same manner as rheumatoid arthritis.[95] All of these treatments have been replaced with modern topical and systemic therapies.
Etymology
The word psoriasis is from Greek ψωρίασις, meaning "itching condition" or "being itchy"[96] from psora, "itch" and -iasis, "action, condition".
Society and culture
The International Federation of Psoriasis Associations (IFPA) is the global umbrella organization for national and regional psoriasis patient associations and also gathers the leading experts in psoriasis and psoriatic arthritis research for scientific conferences every three years.[97] The Psoriasis International Network, a program of the Fondation René Touraine, gathers dermatologists, rheumatologists and other caregivers involved in the management of psoriasis. Non-profit organizations the National Psoriasis Foundation in the United States, the Psoriasis Association in the United Kingdom, and Psoriasis Australia offer advocacy and education about psoriasis in their respective countries.
Research
The role of insulin resistance in the pathogenesis of psoriasis is currently under investigation. Preliminary research has suggested that antioxidants such as polyphenols may have beneficial effects on the inflammation characteristic of psoriasis.[98]
Many novel drugs being researched target the Th17/IL-23 axis,[98] particularly IL-23p19 inhibitors, as IL-23p19 is present in increased concentrations in psoriasis skin lesions while contributing less to protection against opportunistic infections.[99] Other cytokines such as IL-17 and IL-22 also have been targets for inhibition as they play important roles in the pathogenesis of psoriasis.[99] Another avenue of research has focused on the use of vascular endothelial growth factor inhibitors to treat psoriasis.[53] Oral agents being investigated as alternatives to medications administered by injection include Janus kinase inhibitors, protein kinase C inhibitors, mitogen-activated protein kinase inhibitors, and phosphodiesterase 4 inhibitors, all of which have proven effective in various phase 2 and 3 clinical trials.[98][99] However, these agents have potentially severe side-effects due to their immunosuppressive mechanisms.[99]
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- ^ a b c Habif, Thomas P. (2010). "8". Clinical dermatology a color guide to diagnosis and therapy (5th ed.). Edinburgh: Mosby Elsevier. ISBN 978-0-323-08037-8.
- ^ a b Shlyankevich J, Mehta NN, Krueger JG, Strober B, Gudjonsson JE, Qureshi AA, Tebbey PW, Kimball AB (December 2014). "Accumulating Evidence for the Association and Shared Pathogenic Mechanisms Between Psoriasis and Cardiovascular-related Comorbidities". Am J Med 127 (12): 1148–53. doi:10.1016/j.amjmed.2014.08.008. PMID 25149424.
- ^ a b Armstrong AW, Harskamp CT, Armstrong EJ (January 2013). "Psoriasis and the risk of diabetes mellitus: a systematic review and meta-analysis". JAMA Dermatol 149 (1): 84–91. doi:10.1001/2013.jamadermatol.406. PMID 23407990.
- ^ Armstrong AW, Harskamp CT, Armstrong EJ (2013). "The association between psoriasis and hypertension: a systematic review and meta-analysis of observational studies". J Hypertens 31 (3): 433–42. doi:10.1097/HJH.0b013e32835bcce1. PMID 23249828.
- ^ a b Tablazon IL, Al-Dabagh A, Davis SA, Feldman SR (February 2013). "Risk of cardiovascular disorders in psoriasis patients: current and future". Am J Clin Dermatol 14 (1): 1–7. doi:10.1007/s40257-012-0005-5. PMID 23329076.
- ^ "Psoriasis Linked to Stroke Risk". BBC. August 2011.
- ^ a b Ghazizadeh R, Tosa M, Ghazizadeh M (2011). "Clinical Improvement in Psoriasis with Treatment of Associated Hyperlipidemia". Am J Med Sci 341 (5): 394–8. doi:10.1097/MAJ.0b013e3181ff8eeb. PMID 21233693.
- ^ Hsu LN, Armstrong AW. (November 2012). "Psoriasis and autoimmune disorders: a review of the literature". J Am Acad Dermatol 67 (5): 1076–9. doi:10.1016/j.jaad.2012.01.029. PMID 23062896.
- ^ Benoit S, Hamm H (2007). "Childhood Psoriasis". Clinics in Dermatology 25 (6): 555–562. doi:10.1016/j.clindermatol.2007.08.009. PMID 18021892.
- ^ a b c d e f Gruber F, Kastelan M, Brajac I (2004). "Psoriasis treatment—yesterday, today, and tomorrow". Acta Dermatovenereol Croat 12 (1): 30–4. PMID 15072746.
- ^ Meenan FO (March 1955). "A note on the history of psoriasis". Ir J Med Sci (351): 141–2. PMID 14353580.
- ^ Benedek TG (June 2013). "Psoriasis and psoriatic arthropathy, historical aspects: part I". J Clin Rheumatol 19 (4): 193–8. doi:10.1097/RHU.0b013e318293eaeb. PMID 23669809.
- ^ a b Benedek TG (June 2013). "Psoriasis and psoriatic arthropathy: historical aspects: part II". J Clin Rheumatol 19 (5): 267–71. doi:10.1097/RHU.0b013e31829d4ad4. PMID 23872545.
- ^ Ritchlin, Christopher; Fitzgerald, Oliver (2007). Psoriatic and Reactive Arthritis: A Companion to Rheumatology (1st ed.). Maryland Heights, Miss.: Mosby. p. 4. ISBN 978-0-323-03622-1.
- ^ International Federation of Psoriasis Associations. Ifpa-pso.org. Retrieved on 2013-06-08.
- ^ a b c Dubois Declercq S, Pouliot R. (July 2013). "Promising new treatments for psoriasis". ScientificWorldJournal 2013 (980419). doi:10.1155/2013/980419. PMC 3713318. PMID 23935446.
- ^ a b c d Patel M, Day A, Warren RB, Menter A (December 2012). "Emerging Therapies for the Treatment of Psoriasis". Dermatol There (Heidelb) 2 (1): 16. doi:10.1007/s13555-012-0016-4. PMC 3510410. PMID 23205338.
Further reading
- Baker, Barbara S. (2008). From Arsenic to Biologicals: A 200 Year History of Psoriasis. Beckenham UK: Garner Press. ISBN 0-9551603-2-4.
External links
| Wikimedia Commons has media related to Psoriasis. |
- Psoriasis at DMOZ
- "Guidelines for the assessment and management of psoriasis". U.S. National Guideline Clearinghouse.
- Questions and Answers about Psoriasis - US National Institute of Arthritis and Musculoskeletal and Skin Diseases
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UpToDate Contents
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- 1. 乾癬の治療 treatment of psoriasis
- 2. 乾癬の疫学、臨床症状、および診断 epidemiology clinical manifestations and diagnosis of psoriasis
- 3. 膿疱性乾癬：病因、臨床症状、および診断 pustular psoriasis pathogenesis clinical manifestations and diagnosis
- 4. 滴状乾癬 guttate psoriasis
- 5. 乾癬における合併疾患 comorbid disease in psoriasis
English Journal
- Aryl-Acetic and Cinnamic Acids as Lipoxygenase Inhibitors with Antioxidant, Anti-inflammatory, and Anticancer Activity.
- Hadjipavlou-Litina D1, Pontiki E.
- Methods in molecular biology (Clifton, N.J.).Methods Mol Biol.2015;1208:361-77. doi: 10.1007/978-1-4939-1441-8_26.
- Cinnamic acids have been identified as interesting compounds with cytotoxic, anti-inflammatory, and antioxidant properties. Lipoxygenase pathway, catalyzing the first two steps of the transformation of arachidonic acid into leukotrienes is implicated in several processes such as cell differentiation
- PMID 25323520
- The A3 Adenosine Receptor: History and Perspectives.
- Borea PA1, Varani K2, Vincenzi F1, Baraldi PG1, Tabrizi MA1, Merighi S2, Gessi S1.
- Pharmacological reviews.Pharmacol Rev.2015 Jan;67(1):74-102.
- By general consensus, the omnipresent purine nucleoside adenosine is considered a major regulator of local tissue function, especially when energy supply fails to meet cellular energy demand. Adenosine mediation involves activation of a family of four G protein-coupled adenosine receptors (ARs): A1,
- PMID 25387804
- A pilot study examining mindfulness-based cognitive therapy in psoriasis.
- Fordham B1, Griffiths CE, Bundy C.
- Psychology, health & medicine.Psychol Health Med.2015 Jan;20(1):121-7. doi: 10.1080/13548506.2014.902483. Epub 2014 Apr 1.
- A sub-population of people with psoriasis have strong causal beliefs about stress, high levels of emotional distress (anxiety and depression) and an impaired quality of life (QoL). Mindfulness-based cognitive therapy has been found to reduce levels of stress and distress and to improve QoL. This pil
- PMID 24684520
- Two cases of renal cell cancer during immunobiologic therapy for psoriasis.
- Zarur FP, d'Almeida LF, Mafort MS, Gusmão PR, Avelleira JC.
- Anais brasileiros de dermatologia.An Bras Dermatol.2014 Dec;89(6):1017-8.
- Immunobiologic therapy is indicated for severe forms of psoriasis, resistant to conventional therapy. There is growing concern about their safety profile and possible association with cancer development. This article documents two cases of renal cell cancer during treatment with biologic therapy, re
- PMID 25387517
Japanese Journal
- 症例報告 Crohn病患者に投与されたインフリキシマブによって誘発された膿疱性乾癬様皮疹
- 山口 隼人,森木 睦,市川 仁美 [他]
- 臨床皮膚科 = Japanese journal of clinical dermatology 68(7), 505-510, 2014-06
- NAID 40020118911
- 症例報告 アダリムマブ導入後に高血圧の改善がみられた尋常性乾癬の1例
- 石井 健,西村 千尋,五味 博子 [他]
- 臨床皮膚科 = Japanese journal of clinical dermatology 68(6), 403-406, 2014-05
- NAID 40020099340
- 妊娠に際してinfliximabを中止しGMA/GCAPを,出産後はinfliximab再投与を行った妊婦膿疱性乾癬の1例
- 扇谷 咲子,土橋 人士,平澤 祐輔 [他]
- 日本皮膚科学会雑誌 = The Japanese journal of dermatology 124(6), 1127-1133, 2014-05
- NAID 40020065419
- 高齢者での乾癬治療 (特集 最近のトピックス2014 Clinical Dermatology 2014) -- (皮膚疾患治療のポイント)
- 梅澤 慶紀,中川 秀己
- 臨床皮膚科 68(5), 99-103, 2014-04
- NAID 40020075247
Related Links
- Find information about the types of psoriasis and their symptoms, and the treatments available to help manage your condition. ... To get the best possible experience using our website, we recommend updating your browser to a ...
- The National Psoriasis Foundation works to find a cure for psoriasis and psoriatic arthritis and to eliminate their devastating effects through research, advocacy and education. ... National Psoriasis Foundation provides you with the ...
- What Is Psoriasis? Unpredictable and irritating, psoriasis is one of the most baffling and persistent of skin disorders. It's characterized by skin cells that multiply up to 10 times faster than normal. As underlying cells reach the skin's ...
Related Pictures
★リンクテーブル★
| リンク元 | 「乾癬」「ヒト白血球抗原」「psoriatic」 |
| 拡張検索 | 「psoriasis arthropathica」 |
「乾癬」
概念
- 慢性再発性難治性の炎症性角化症
- 代表的炎症性疾患のひとつで原因は不明：遺伝因子＋環境因子(生活習慣、気候、薬物) → HLA-B27と関連していることからautoimmune diseaseとも考えられている。
- 青年から中年に好発。厚い銀白色の麟屑を伴った紅斑・丘疹が出没、表皮の炎症と表皮細胞のターンオーバーの亢進を認める。
乾癬の階層
病型
- 四肢で著名で厚い麟屑を付着した紅斑
- 背部に散在する軽度の麟屑を伴う紅斑、丘疹 Gibertばら色粃糠疹との区別が重要
- 先行感染(溶連菌)や慢性経過の乾癬が存在していることが多い。
- 広範囲の皮膚の潮紅 紅潮皮膚の上に環状に配列する無菌性膿疱
- 通常尋常性乾癬を伴う 長期間のコントロールが必要
- 難病指定
- 膜様の麟屑を伴う 全身皮膚潮紅
- 関節炎を伴う
- 爪の租造化
- 爪の租造化は水虫でも見られる
- 手指の関節の著名な変形
- 尋常性乾癬を伴うことがある
病因
- 遺伝的+誘発因子, 悪化因子
- 誘発因子、悪化因子(外傷、感染症、日光、薬剤、低Ca血症、肥満、妊娠、アルコール摂取、ストレス)
遺伝的背景
- 家族内発症率→多因子遺伝が発症に関与
- 両親が乾癬：50%、片親：16.4%、家族歴：4倍
- HLA-Cw6と相関
- HLA-A1, HLA-B13, HLA-BW16, HLA-B17, HLA-B37, HLA-CW6, HLA-DR7も関連
- HLA-B27
疫学
- 初発年齢：20歳前後に大きなピーク。60歳代に小さなピーク。
- 白人1-2%(5%に達する国もある), 日本人0.1% ←人種者あり
病変形成＆病理
- keratinocyteとlymphocyteの相互作用
- 乾癬患者と正常者の角化細胞を比べると、乾癬患者の方がT細胞の増殖への影響が大きい
- 乾癬患者のT細胞は正常者の表皮に乾癬を生じさせた
- 表皮細胞の遊走能などをTNF-α、IL-8などによって促進
- 炎症部位に好中球や樹上細胞などを呼び寄せるようなケモカインが出される
- 血管増殖因子を出す
- transglutaminaseが感染患者では表皮全てで発現？
- keratinocyteの分化に関わる
- 通常は顆粒層のみで発現
- 樹状細胞の関与？
病理組織像
- 表皮肥厚 acanthosis：規則的に波打っている
- 顆粒層消失 → ケラトヒアリン顆粒を作らないうちに角層に移行するため。
- 錯核化 parakeratosis：角質層に核が残る
- ムンロ微小膿瘍（好中球による無菌性膿瘍）
- 真皮上層までリンパ球浸潤。好中球、樹状細胞の浸潤が認められる。
- 病変部、非病変部移行部のkeratin16発現
- keratinocyteの最終分化に関与
- ケラチン16は炎症がひどいときに発現する
症状
- 角化性丘疹が癒合した大小さまざまな紅色の局面を特徴とし、表面には典型的な鱗屑が付着
診断
検査
- 蝋片現象陽性：皮疹の爪を爪などでこすった際に白色鱗屑が見られる
- Auspitz現象陽性：鱗屑を剥がすと点状出血を認める(顆粒層減少と毛細血管拡張による)
- Kobner現象陽性：しヒンのない部位に外傷などの刺激が加わるとそこに乾癬の皮疹ができる。
治療
- 完全に治癒することはなく慢性に経過し、悪化・軽快の反復。日常生活に支障がなくなる程度まで直す。
軽症
- 外用療法(つまり、局所療法)
- 第一選択薬は活性型ビタミンD3 → 再発までの期間を延長できる
- ボンアルファ、ボンアルファハイ、カルシポトリオール(ボネックス)、オキサロール
- 効果が不十分な場合はステロイド外用も考慮
- ただし、very strong以上のステロイドを漫然と投与することは避けるべき
- 少量のステロイドとビタミンD3の併用療法がトレンドらしい？
- ビタミンD3による高カルシウム血症に注意
- 全身療法
- 紫外線照射、ビタミンA酸誘導体内服、免疫抑制薬内服
中等症
- 紫外線治療(PUVA、narrow band UVB）
- 作用メカニズム；表皮角化細胞の増殖抑制、免疫抑制作用
- 副作用；火傷、発癌作用（ほかの免疫抑制剤との併用禁忌）、色素沈着(UVAの場合、まだら模様になりうる→narrow band UVBなら防ぐことができる)
重症
- 全身療法
-
- 作用メカニズム:T cellの活性化抑制
- 副作用:腎機能障害（血清クレアチニンが30％以上上昇した場合、投与量を少なくするか、投与を中止することが必要）。紫外線療法との併用は禁忌(発癌リスク↑)
- 作用メカニズム:分化誘導作用
- 副作用；催奇形性（女性2年、男性6ヶ月の避妊が必要）、骨形成阻害（小児への長期投与は慎重に）、肝機能障害、高脂血症。(高頻度)口唇炎、手指の落屑。
- 副作用が強いので最後の手段として使用する。
- 作用メカニズム:表皮角化細胞の増殖抑制
- 副作用:肝機能障害
日常生活治療、指導、補助
- 痒みに対する処置～抗ヒスタミン剤、入浴、食べ物(刺激の強い食べ物)
- 肥満、糖尿病、高脂血症の予防
- アルコールの抑制、肝機能障害
- スキンケア
- 角化傾向が強い場合はサリチル酸
参考
- 1. [charged] Epidemiology, pathophysiology, clinical manifestations, and diagnosis of psoriasis - uptodate [1]
- 2.
USMLE
- Q book p.289 9
- A 30-year-old woman has chronic, silver-white, scaly patches with an erythematous border on the skin of her knees and elbows.
「ヒト白血球抗原」
- 英
- human leucocyte antigen, HLA
- 同
- ヒト白血球型抗原、HLA抗原 HLA antigen、ヒト組織適合性白血球抗原 human histocompatibility leukocyteantigen
- 主要組織適合抗原 MHC ← 免疫との関連はこちらを参照
- 関
- 骨髄バンク、HLA抗原
疾患との関連
出典不明
| 強直性脊椎炎 | B27 |
| 関節リウマチ | DR4 |
| 重症筋無力症 | DR9,DQ3 |
| 尋常性天疱瘡 | A26,DR4 |
| バセドウ病 | DR5 |
| I型糖尿病(インスリン依存性糖尿病) | B54,DR4,DR9,DR53,DQ4 |
| グレーブス病 | DR5 |
| ベーチェット病 | B51 |
| 原田病 | DR4,DR53 |
| 潰瘍性大腸炎 | B52,DR2 |
| クローン病 | DR4,DQ3 |
| 高安病 | B52,DR2,DQ1 |
| バージャー病 | B52,DR2,DQ1 |
| ナルコレプシー | DR2 |
first aid step1 2006 p.191
| HLA-B27 | psoriasis, ankylosing spondylitis, inflammatory bowel disease, Reiter's syndrome. |
| HLA-B8 | Graves' disease, celiac sprue. |
| HLA-DR2 | multiple sclerosis, hay fever, SLE, Goodpasture's syndrome. |
| HLA-DR3 | diabetes mellitus type 1. |
| HLA-DR4 | rheumatoid arthritis, diabetes mellitus type 1. |
| HLA-DR5 | pernicious anemia → B12 deficiency, Hashimoto's thyroiditis. |
| HLA-DR7 | steroid-responsive nephrotic syndrome. |
まとめ
「psoriatic」
- adj.
- 乾癬性の、乾癬の