Psoriatic Plaques Research Articles

Juvenile arthritis with cutaneous lesions – diagnostic pitfalls

Psoriatic arthropathy (AP) is an inflammatory arthropathy with a prevalence between 0.1% and 1%, occurring in approximately one third of the patients suffering from psoriasis, having an equal gender distribution. Psoriatic arthritis is recognized to have erosive and destructive potential in approximately 40-60% of patients, with progressive evolution from the first year of diagnosis. According to the ILAR criteria, the diagnosis of juvenile psoriatic arthritis requires the simultaneous presence of arthritis and a classic psoriatic rash or, if a rash is absent, the coexistence of arthritis and any two of the following: family history of psoriasis in a first-degree relative, dactylitis and nail pitting or onycholysis. Articular involvement varies from symmetrical small-joint arthritis to asymmetrical lower-extremity large-joint arthritis, and finally may progress to polyarthritis, mimicking seropositive rheumatoid arthritis. In general, arthritis of metacarpophalangeal, proximal interphalangeal and distal interphalangeal joints of one or more fingers forms the “sausage-like” fingers, known as dactylitis. Typically, psoriatic plaques are seen on the extensor sides of joints, haired skin, the umbilicus and the perineum. Nail changes, including nail dystrophy, subungual hyperkeratosis and onycholysis are common among patients with psoriasis. Dermatologic manifestations appear before the manifestations of arthritis in about 75% of patients. Increased acute phase markers, chronic anaemia and thrombocytosis could be seen. Antinuclear antibodies (ANA) are found in low or moderate titres in a significant proportion of patients. HLA B27 positivity accounts for 30%. Psoriasis is associated with an increased risk of other autoimmune disorders like ulcerative colitis, Crohn’s disease, and autoimmune thyroiditis.

Multiple Lentigines Arising in Sites of Resolving Psoriatic Plaques after Treatment with Ustekinumab.

Multiple Lentigines Arising in Sites of Resolving Psoriatic Plaques after Treatment with Ustekinumab.

Co-occurrence of psoriasis, vitiligo, and lichen planus in a single patient

Psoriasis is a common autoimmune skin disease affecting around 2%–3% of the world population. The disease has an autoimmune and complex genetic background. It may be associated with other autoimmune diseases such as vitiligo, lichen planus, discoid lupus erythematosus, and alopecia areata as reviewed in the literature. There are few case reports about the co-occurrence of one or two autoimmune diseases. Many speculations have been put forward about the pathogenesis of these conditions, but T-cell-mediated autoimmunity and true Koebner phenomenon background play a common etiological cause of co-occurrence of psoriasis, lichen planus, and vitiligo. We report a 9-year-old female patient who presented with psoriasis, lichen planus, and vitiligo lesions. Interestingly, she developed psoriatic plaques on the vitiligo patches in the knee. Histopathological diagnosis was consistent with the concurrence of psoriasis, lichen planus, and vitiligo.

Differential effects of Wnt5a on the proliferation, differentiation and inflammatory response of keratinocytes.

The predominant role of Wnt family member 5A (Wnt5a) is to induce non-canonical Wnt signalling pathways, including the Wnt‑Ca2+ and Wnt‑planar cell polarity pathways. Enhanced Wnt5a expression is involved in the formation of psoriatic plaques; however, its mechanistic role remains to be determined. In the present study, the effects of Wnt5a expression on HaCaT keratinocytes were investigated. HaCaT cells were cultured in medium supplemented with 0, 40 or 80ng/ml Wnt5a for 24h. Cell proliferation, the cell cycle, gene expression and inflammatory responses were investigated using Cell‑Counting Kit‑8 assays, flow cytometry analyses, reverse transcription‑quantitative polymerase chain reaction analyses and enzyme‑linked immunosorbent assays, respectively. Wnt5a treatment was revealed to suppress cell proliferation in HaCaT cells. Furthermore, Wnt5a was also demonstrated to increase the proportion of HaCaT cells arrested at the G2/M phase of the cell cycle, but reduce the proportion of HaCaT cells arrested at G0/G1 phase cells. In addition, the expression levels of the differentiation markers, including filaggrin, keratin 1 and keratin 10 were revealed to be downregulated in HaCaT cells. Expression of the canonical Wnt signalling genes (β‑catenin and cyclin D1) and proliferation markers, such as Ki‑67 and proliferating cell nuclear antigen in HaCaT cells were also revealed to be downregulated. However, the expression levels of inflammatory response markers (interferon‑γ, interleukin‑8 and interleukin‑17A) were revealed to be upregulated in HaCaT cells following Wnt5a treatment. These findings suggest that Wnt5a expression may be involved in the inhibition of cell differentiation and the induction of an inflammatory response in patients with psoriasis.

IL-17–Secreting γδ T Cells Are Completely Dependent upon CCR6 for Homing to Inflamed Skin

mAbs that neutralize IL-17 or its receptor have proven efficacious in treating moderate-to-severe psoriasis, confirming IL-17 as an important driver of this disease. In mice, a rare population of T cells, γδT17 cells, appears to be a dominant source of IL-17 in experimental psoriasis. These cells traffic between lymph nodes and the skin, and are identified by their coexpression of the TCR variable regions γ4 and δ4. These cells are homologous to the Vγ9Vδ2 T cell population identified in human psoriatic plaques. In this study we report that a potent and specific small molecule antagonist of the CCR6 chemokine receptor, CCX2553, was efficacious in reducing multiple aspects of psoriasis in two different murine models of the disease. Administration of CCX2553 ameliorated skin inflammation in both the IL-23-induced ear swelling model and the topical imiquimod model, and significantly reduced the number of γδT17 cells in inflamed skin. γδT17 cells were greatly reduced in imiquimod-treated skin of CCR6-/- mice, but adoptively transferred wild-type (CCR6+/+) γδT17 cells homed normally to the skin of imiquimod-treated CCR6-/- mice. Our data suggest that γδT17 cells are completely dependent on CCR6 for homing to psoriasiform skin. Thus, CCR6 may constitute a novel target for a mechanistically distinct therapeutic approach to treating psoriasis.

Aggravation apparente d’un psoriasis révélant un surdosage en méthotrexate

Methotrexate (MTX) is an antimetabolite drug used in the treatment of cancers and autoimmune diseases and frequently in dermatology for cutaneous and/or arthritic psoriasis. Toxicities due to MTX overdosage are mainly cutaneous, hepatic and hematologic. Herein, we report a case of MTX overdosage presenting as an erosive and an inflammatory flare of preexisting psoriatic plaques and with new palmar lesions. A 51-year-old male with a 6-year history of plaque psoriasis resistant to topical corticosteroids was started for the first time on MTX 20mg weekly. One week later, he presented with fever, general weakness and mucocutaneous ulcerations. Physical examination revealed inflammatory, erythematous and partially erosive annular plaques strictly confined to preexisting psoriatic lesions, along with keratotic psoriatic palmar plaques. Further questioning indicated that the patient was taking MTX 20mg daily. Investigations revealed neutropenia (1040/mm3) and skin histology showed prominent dystrophic keratinocytes and confirmed the diagnosis of methotrexate toxicity. Clinical and biological improvements were observed after cessation of MTX and treatment with folinic acid, IV hydration and urine alkalization. Skin lesions due to acute MTX toxicity are rare, but they herald later-onset pancytopenia. Identification of these cutaneous lesions might enable earlier treatment initiation. The predilection of MTX toxicity for preexisting lesions or the de novo appearance of palmoplantar pustules should not lead to the erroneous diagnosis of psoriasis flare.

USE OF AUTOFLUORESCENCE DERMATOSCOPY IN PATIENTS WITH PSORIASIS

Results of autofluorescence dermatoscopy using videodermatoscope «EcoSkin» in patients with different dermatologic diseases are represented. The study included 64 patients, 27 of them had different types of psoriasis, 11 – acne, 3 – rosacea, 5 – eczema, 3 – mite-induced dermatitis, 4 – superficial mycosis of the glabrous skin, 7 – atopic dermatitis, 4 – seborrheic dermatitis. The major changes of autofluorescence were detected in pathological foci in patients with psoriasis. Authors suppose that increased autofluorescence of porphyrins in psoriatic plaques in the study is associated with enhanced prolyferation in pathological tissues and with liver dysfunction. The analysis of autofluorescence images in patients with rosacea, eczema, atopic and mite-induced dermatitis did not show significant difference in autofluorescence images of affected skin comparing with intact skin in same patients. In patients with acne a pattern of spot red-orange autofluorescence of skin in seborrheic areas corresponding with location of openings of pilosebaceous apparatus was detected that was associated by authors with Propionibacterium acnes infection.

385 IL-17E activates M2 macrophages to produce IL-8 in a p38 dependent manner and favor the recruitment of neutrophils in psoriatic skin

Psoriasis vulgaris is a common chronic recurrent immune-mediated skin disease. We have recently found that IL-17E (i.e IL-25), a member of the IL-17 cytokine family, is over-expressed in lesional psoriatic skin when compared to non lesional and healthy donors. Within the psoriatic plaque, macrophages having a mixed M1/M2 phenotype internalize IL-17E in a receptor induced clathrin-mediated mechanism. In this study we investigated the biological effects of IL-17E in psoriasis. In vitro M2-polarized macrophages, but not M1, responded to IL-17E by producing inflammatory cytokines (e.g. TNF and IL-6) and chemokines (e.g. IL-8 and MCP-1) typical expressed by M1 cells. Nuclear factor-kappa B (NF- κB), p38 and STAT3 were required for generating the IL-17E-dependent effects. Of note, IL-17E did not stimulate the production of cytokines/chemokines involved in T cell polarization and recruitment. Supernatants of IL-17E-stimulated M2 macrophages contained high levels of IL-8 and favored the attraction of neutrophils to a higher extent compared to supernatants of resting macrophages. Chemical p38 inhibition impaired IL-8 production and neutrophil chemotaxis in vitro. In vivo, intra-dermal injection of rmIL-17E in BALB/c mice induced severe dermal inflammation as assessed by immunohistological and FACS analysis, with increased neutrophil/eosinophil infiltration and reduced T-cell recruitment, compared to saline control group. Neutralization of IL-17E by intra-peritoneal injection of anti-IL-17E antibodies reduced the infiltration of neutrophils in a tape-stripping model. Consistent with the in vivo and in vitro data, the number of IL-17E+ cells in lesional skin correlated with the number of neutrophils, while being inversely proportional to the number of infiltrating T cells. Together, our data show that IL-17E favors the preferential recruitment of neutrophils via macrophage activation and define a novel pro-inflammatory role of IL-17E in psoriasis.

European consensus statement on phenotypes of pustular psoriasis.

Pustular psoriasis (PP) is a group of inflammatory skin conditions characterized by infiltration of neutrophil granulocytes in the epidermis to such an extent that clinically visible sterile pustules develop. Because of clinical co-incidence, PP is currently grouped with psoriasis vulgaris (PV). However, PP and PV are phenotypically different, respond differently to treatments and seem to be distinct on the genetic level. In contrast to PV, the phenotypes of PP are not well defined. Descriptions of each form of PP are discordant among standard dermatology textbooks [Saurat Dermatologie 2016, Rook's Dermatology 2016, Fitzpatrick's 2012 and Braun-Falco 2012], encumbering the collection of phenotypically well-matched groups of patients as well as clinical trials. The European Rare and Severe Psoriasis Expert Network (ERASPEN) was founded to define consensus criteria for diagnosis, deeply phenotype large groups of PP patients, analyse the genetics and pathophysiology and prepare for prospective clinical trials. This work reviews historical aspects of these conditions, new genetic findings and presents our initial considerations on the phenotypes of PP and a consensus classification of clinical phenotypes that will be used as a baseline for further, prospective studies of PP. Generalized pustular psoriasis (GPP) is defined as primary, sterile, macroscopically visible pustules on non-acral skin (excluding cases where pustulation is restricted to psoriatic plaques). GPP can occur with or without systemic inflammation, with or without PV and can either be a relapsing (>1 episode) or persistent (>3months) condition. Acrodermatitis continua of Hallopeau (ACH) is characterized by primary, persistent (>3months), sterile, macroscopically visible pustules affecting the nail apparatus. Palmoplantar pustulosis (PPP) has primary, persistent (>3months), sterile, macroscopically visible pustules on palms and/or soles and can occur with or without PV.

Tissue hemostasis is shifted toward thrombogenesis in the psoriatic plaques

BackgroundPsoriasis is a common autoimmune disease of unknown etiology. Recently, much attention has been paid to evidence that a local hypercoagulable state is an important contributing factor to the development of inflammatory skin diseases. Thus, the aim of this study was to characterize the local hemostasis in the affected skin of patients with psoriasis. MethodsSkin biopsies of psoriatic plaques were obtained from 73 consecutive patients (48M, 25F, average age 45 years) with at least a one year history of the disease. The studied patients had not received any specific systemic treatment for at least 4 weeks before the biopsy was done. As a control, normal skin biopsies were obtained from 16 healthy subjects. For immunohistological study, the En-Vision method (DAKO EnVision Kit ®/Alkaline Phosphatase detection system), and monoclonal antibodies anti-tissue factor (TF), anti-thrombomodulin (TM) and anti-von Willebrand Factor (vWF) were used. All these molecules were assessed semi-quantitatively in the frozen sections. ResultsClinically, the Body Surface Area index ranged between 1–90% and the Psoriasis Area Severity Index score ranged from 1.6 to 47. Immunohistochemistry revealed redistribution of TF antigens from the upper to lower layers of the epidermis as compared to the control. It was collaborated with the number of TF-positive cells in the psoriatic skin sections (78.3%) as compared with the healthy subjects (34.4%; P<0.001). In addition, TF was uniformly and moderately expressed on capillary endothelial cells of the plaque sections in 43 out of 73 patients (58.9%). As far as the thrombomodulin is concerned, TM was clearly down-regulated and localized mainly in the upper layers of the psoriatic epidermis. It was collaborated with the number of TM positive cells in the psoriatic skin sections (38.9%) as compared with the healthy subjects (66.7%; P<0.001). All capillary vessels found in the biopsy sections were positive for TM and vWF staining, with similar expression (≥2+) in both groups. In the current study, no relationship was found between the TF, TM and vWF expression and the PASI and BAS (NS). ConclusionsA local procoagulable state found in psoriatic plaques suggests a significant role of local tissue hemostasis in pathogenesis of the disease. These findings indicate another potential target for a therapeutic approach in patients with psoriasis, although further research would help elucidate the exact mechanisms.

Liposphere mediated topical delivery of thymoquinone in the treatment of psoriasis

Thymoquinone (TMQ) is reported with good anti-psoriatic activity; however, the hydrophobicity, poor aqueous solubility, light and pH sensitive nature of TMQ hinder its delivery to target site. To address these delivery challenges of TMQ, lipospheres were explored. The topical use of lipospheres offers an effective mean of penetration along with stability and scalability. TMQ lipospheres of particle size below 70 nm were prepared and evaluated. These lipospheres resulted in deeper skin penetration, slow release and skin compatibility. Anti-inflammatory and anti-psoriatic potential of lipospheres was determined using in vitro cell lines and imiquimod induced psoriatic plaque model. Cell lines studies indicated reduction in the level of nitric oxide and IL-2, IL-6, IL-1β, TNF-α, whereas in vivo results indicated improvement in the phenotypic, histopathological features and reduced level of IL-17 and TNF-α in psoriatic skin. These results suggest the potential of TMQ lipospheres in the management of psoriasis.

Skin-infiltrating, interleukin-22–producing T cells differentiate pediatric psoriasis from adult psoriasis

Evidence from adult psoriasis studies implicates an imbalance between regulatory and effector T cells, particularly TH-17-producing T cells, in the pathogenesis of psoriasis. Little is known about the immunopathology of psoriasis in children. We sought to functionally characterize the inflammatory cell profiles of psoriatic plaques from pediatric patients and compare them with healthy, age-matched controls and adult psoriasis patients. Skin samples from pediatric psoriasis patients and healthy controls were analyzed by multiparameter flow cytometry to determine the dominant immune cell subsets present and cytokines produced. Lesional tissue from pediatric psoriasis patients had significantly increased interleukin (IL) 22 derived from CD4+ and CD8+ cells compared with the tissues from healthy pediatric controls and adult psoriasis patients. Tissue from pediatric psoriasis patients had significantly less elevation of IL-17 derived from CD4+ and CD8+ cells compared with the tissue from adult psoriasis patients. In contrast with the lesions from adult patients, lesional skin in pediatric patients with psoriasis did not have increases in regulatory T cells. This is a pilot study, thus the sample size is small. Significant differences in IL-17 and IL-22 expression were observed in the pediatric psoriasis patients compared with pediatric healthy controls and adult psoriasis patients. IL-22 might be relevant in the pathogenesis of pediatric psoriasis and represents a potential treatment target unique to pediatric psoriasis.

Basic and Translational Science: A Report from the GRAPPA 2016 Annual Meeting.

Rapid advances in effective treatments for psoriasis and psoriatic arthritis (PsA) have emerged from improved understanding of cell subsets and critical mediators that promote tissue inflammation and destruction. More specifically, increased knowledge of innate immunity and the important involvement of cytokines in the interleukin (IL)-23-IL-17 axis as key mediators of psoriatic plaque and joint inflammation in both psoriasis and PsA have led to new theories of immunopathogenesis. Herein we summarize recent discussions on IL-17-related pathways and their relationship to psoriasis and PsA.

Psychosis and psoriasis, the skin talks the truth

IntroductionIt is well known about relation between skin and mind, not only due to their mutual origin, but also by their illness expression parallelism. We report a case to show that reciprocity.Personal antecedentsWoman, 42-year-old, single. She only suffers from a skin disease; mild psoriasis guttata placed in both elbows and knees. She treated it with local treatment (cortisone cream) during seasonal prutius and the lesions did not grow or expand. She was hospitalized due to psychotic symptoms (paranoid delusions with her colleagues) and started antipsychotics treatment (risperidone 12 mg per day and olanzapine 10 mg per night). By the same time, she suffered a psoriasis crisis. Her psoriatic plaques increased their sizes and her chest and both thighs were affected too. She complained about grave pruritus. All her medical test results were normal. After that, the patient improved her psychotics’ symptoms, but she started with agoraphobic signs and seclusion at home. Psoriasis were even worse than before and she needed metrotexate to treat it. Being introduced to escitalopram 15 mg per day, anxiety and depression symptoms disappeared and her grave psoriasis became the mild one that she knew.ConclusionSchizophrenia was associated with a greater variety of autoimmune diseases than was anticipated. Studies found evidence for a shared genetic etiology between schizophrenia and psoriasis. Despite that, we think that the study of psychopathology can amplify our understanding about the etiopathogenesis of psoriasis and associated mental disorders.Disclosure of interestThe authors have not supplied their declaration of competing interest.

The role of intradermal proliferation of T-cells in the pathogenesis of psoriasis

BACKGROUNDPsoriasis is a common immune-mediated chronic inflammatory disease of the skin and joints, affecting 1-3% of the population. It is generally accepted that the pathogenesis of psoriasis involves accumulation of effector T-cells within lymph nodes and their subsequent migration into the skin through the blood system. Here we provide evidence that psoriatic plaque itself may serve as a source of inflammatory T-cells.OBJECTIVEWe examined the intradermal proliferation of T-cells and the number of effector/memory (CD45RO+) T-cells in the skin of psoriatic patients at different periods of the disease.METHODSSkin samples were obtained from 41 patients with progressive psoriatic lesions; 18 of these patients also donated skin specimens during the remission of the disease. The control group consisted of 16 healthy subjects. Ki-67 immunohistochemical staining was applied to detect proliferating cells, CD3ε served as a T-cell marker, and CD45RA and CD45RO antibodies were utilized to discriminate between naive and effector/memory T-cells, respectively.RESULTSProgressive psoriatic lesions demonstrated Ki67 staining both in keratinocytes and in the CD3ε+ cells of dermal infiltrate. Median count of CD45RO+ cells per microscopic field was 15 in healthy controls, 59 in patients in remission and 208 in progressive psoriatic plaques. The observed differences demonstrated high level of statistical significance.STUDY LIMITATIONSLimited number of analyzed patients.CONCLUSIONProgressive phase of psoriasis is characterized by intradermal proliferation of T-cells. Spots of regressed psoriatic lesions contain high number of CD45RO+ cells, which are likely to render an immunological memory.

JCLMM: A finite mixture model for clustering of circular-linear data and its application to psoriatic plaque segmentation

The hue and chroma components of an image pixel carry crucial information that can be exploited to perform segmentation. However, due to its directional property, a circular distribution is required to characterize the hue component. In this article, we propose a mixture of bi-variate circular–linear distributions, for modelling hue and chroma information. The proposed model incorporates a joint distribution of a circular and a linear variable by means of circular copula and offers a flexible architecture that deals with heterogeneous margins for different mixture components. We apply this model for psoriatic plaque segmentation in skin images, using the hue and the chroma information. We observe that the chroma exhibits a heterogeneous distribution in a skin image. Moreover, the joint distribution of hue and chroma possesses multi-modal characteristics. Our model is suitable to perform segmentation under such circumstances. After segmentation, we perform automatic plaque localization by means of a statistical model that exploits hue information of the segmented regions. We conduct the experiments on a set of 75 psoriasis skin images. Both segmentation and localization performances are evaluated with respect to a number of commonly used criteria. The experimental results show that the proposed segmentation model outperforms several competing supervised and unsupervised methods in detecting psoriatic plaque regions in skin images.

Receptor for advanced glycation end products is overexpressed in psoriatic plaques independent of disease severity.

Enhanced expression and excitation of the receptor for advanced glycation end products is considered to play a role in the regulation of many pro-inflammatory genes involved in the pathogenesis of psoriasis. We investigated the expression of receptor for advanced glycation end product in various cell types, in lesional and peri-lesional skin of patients with psoriasis, and its correlation with disease severity. Paraffin-embedded punch biopsy tissue taken from psoriatic plaques and peri-lesional normal appearing skin tissue of twenty patients with psoriasis, and normal skin samples of eleven healthy participants, were enrolled in the study. The sections were stained immunohistochemically with anti-receptor for advanced glycation end product antibody. The intensity of receptor for advanced glycation end product expression was assessed semi-quantitatively on epidermal cells, microvascular endothelium, dermal fibroblasts and inflammatory cells. They were graded as follows: 0 (no staining), 1 (weak), 2 (moderate) and 3 (strong) intensity. Receptor for advanced glycation end product expression on epidermis, microvascular endothelium, inflammatory cells and fibroblasts in the psoriatic plaques was more intense than perilesional and normal tissue (all P < 0.05). It did not correlate with disease severity. The main limitation of our study is that this was a semi-quantitative assessment, detected immunohistochemically in skin biopsies. Receptor for advanced glycation end product expression may have an important role in psoriasis pathogenesis, independent of disease severity.

Clinical pearls in anesthesia for excision and reconstructive surgery for cauliflower carcinoma on psoriatic plaques

Meticulous preoperative evaluation and planning is essential in psoriasis patients presenting for surgery as the airway and axial skeleton may both be involved in addition to extensive integumentary involvement. Difficult airway as well as difficult neuraxial block may be encountered due to psoriatic arthropathy. Widespread skin lesions may not spare free space for intravenous cannulation, invasive arterial/central venous lines, spinal/epidural block, and electrode placement for electrocardiogram, bispectral index, or peripheral nerve stimulator. Noninvasive techniques such as pleth variability index for guiding fluid therapy are encouraged to avoid instrumentation induced fresh psoriatic lesions. Psoriasis therapy (steroids, methotrexate, psoralens, and antidepressants) has side effects including malignant transformation of multiple psoriatic plaques which merit consideration. Drugs known to aggravate psoriasis (benzodiazepines, clonidine, beta blockers, and nonsteroidal anti-inflammatory drugs) and slightest trauma to skin need to be avoided. Anesthetic challenges in a psoriatic patient and their successful management have been described here.

Expression of Angiogenic Factors in Psoriasis Vulgaris.

Psoriasis is a chronic inflammatory skin disease characterized by epidermal hyperproliferation, abnormal differentiation and inflammatory infiltration in the dermis. The dermal microvascular expansion associated with abnormal orientation and dilatation of capillaries in the biopsies of the psoriatic skin suggest that the disease is dependent on angiogenesis. To analyze and compare the immunohistochemical expression of angiogenic factors - Vascular Endothelial Growth Factor (VEGF), von Willebrand Factor (vWF) and CD 34 in skin biopsies of psoriasis cases with control skin samples; and to correlate the expression of angiogenic factors with Psoriasis Area and Severity Clinical Index (PASI SCORE). This was a prospective case control study conducted over a period of 15 months. Thirty-two psoriasis cases and thirty control skin samples were included in the study. Skin biopsy specimen was taken from clinically diagnosed psoriasis cases who did not receive any treatment. The diagnosis of psoriasis vulgaris was confirmed after microscopic examination. Immunohistochemical expression for VEGF, vWF and CD 34 was studied. VEGF expression in epidermis was significantly higher in cases when compared to control skin (p <0.01). CD 34 expression was significantly upregulated in cases when compared to controls (p<0.01). Von Willebrand factor expression was weak in both the cases and the controls. Significant correlation between the expression of VEGF and PASI score (r=0.944; p<0.01), and expression of CD 34 and PASI score was observed (r=0.942; p<0.01). In the present study, significant overexpression of VEGF and CD 34 was noted in cases when compared to controls. The keratinocytes in the psoriatic skin lesions were recognized as a source of pro-angiogenic cytokines namely the VEGF and other growth factors which promotes angiogenesis in psoriatic plaque. Angiogenesis plays an important role in genesis and development of psoriasis vulgaris. Therefore, development of targeted anti-angiogenic therapy might be beneficial for this chronic disabling dermatological disease.

Topical Therapies in Psoriasis.

Topical therapy as monotherapy is useful in psoriasis patients with mild disease. Topical agents are also used as adjuvant for moderate-to-severe disease who are being concurrently treated with either ultraviolet light or systemic medications. Emollients are useful adjuncts to the treatment of psoriasis. Use of older topical agents such as anthralin and coal tar has declined over the years. However, they are cheaper and can still be used for the treatment of difficult psoriasis refractory to conventional treatment. Salicylic acid can be used in combination with other topical therapies such as topical corticosteroids (TCS) and calcineurin inhibitors for the treatment of thick limited plaques to increase the absorption of the latter into the psoriatic plaques. Low- to mid-potent TCS are used in facial/flexural psoriasis and high potent over palmoplantar/thick psoriasis lesions. The addition of noncorticosteroid treatment can also facilitate the avoidance of long-term daily TCS. Tacrolimus and pimecrolimus can be used for the treatment of facial and intertriginous psoriasis. Tazarotene is indicated for stable plaque psoriasis usually in combination with other therapies such as TCS. Vitamin D analogs alone in combination with TCS are useful in stable plaques over limbs and palmoplantar psoriasis. Topical therapies for scalp psoriasis include TCS, Vitamin D analogs, salicylic acid, coal tar, and anthralin in various formulations such as solutions, foams, and shampoos. TCS, vitamin D analogs, and tazarotene can be used in the treatment of nail psoriasis.