Exudative psoriasis is a severe type of psoriasis characterized by the severity of the exudative component against the background of immune disorders and endocrine pathology. Clinically manifested by the formation of foci of inflammation from plaques impregnated with exudate, with dense crusts on the surface in the absence of primary erythema. When the plaques are removed, erosions are exposed, a secondary infection joins. In the diagnostic triad, there is no phenomenon of stearin stain, terminal film remains, drip bleeding. The diagnosis is made on the basis of the clinic and the patient’s immune status, various instrumental techniques are used to identify complications (radiography, arthroscopy, etc.). Anti-inflammatory treatment with the connection of antihistamines, vitamin therapy, UVI.
Exudative psoriasis is a chronic inflammatory dermatosis of non–infectious origin with a predominance of the exudative component. It accounts for about 1% of all cases of psoriasis. Taking into account the fact that psoriasis is considered one of the most common skin diseases in the world (according to some authors, up to 7% of all inhabitants of the planet suffer from this pathology), 1% of exudative psoriasis in the general structure of morbidity provides a sufficiently high population prevalence of the pathological process.
Climate, skin color do not predetermine the occurrence of dermatosis, while exudative psoriasis is genotypic. For example, in the USA, dermatosis is almost not registered among Indians and African Americans, and it occurs quite often among representatives of other races with different skin colors. The disease has no gender component and no age restrictions. The urgency of the problem is associated with a violation of the quality of life, the severity of the course, the possibility of a fatal outcome.
Most dermatologists consider dermatosis to be a bi-etiological disease arising from the combined action of a genetic factor and autoimmune disorders. Currently, there are about three thousand genes associated with the occurrence of dermatosis, 9 loci associated with psoriasis (PSORS 1-9). Mutations of the first locus provoke exudative psoriasis in 50% of cases. It is known that the PSORS1 gene is associated with corneodesmosin, a substance responsible for desquamation (exfoliation) of the epithelium.
The low penetrance of PSORS1 and the fact that the mechanism of hereditary gene transfer in exudative psoriasis does not fit into Mendel’s laws does not allow us to consider genetic disorders as the main cause of pathology. Therefore, modern dermatologists consider autoimmune disorders to be the main mechanism of the development of exudative psoriasis.
Dermatologists note the association of exudative psoriasis with bad habits – smoking and overeating, which probably explains its highest incidence in highly developed countries with an atherogenic nutrition profile. The provoking moments are:
- allergic mood of the body;
- frequent hypothermia;
- endocrine pathology.
Provoking factors, the most common of which are stress and pathogenic microorganisms, act as foreign antigens, activate cells of the immune system that begin the production of cytokines. In parallel with the hyperactivation of lymphocytes of the immune system, damaged keratinocytes of the epidermis are included in the work. They become a kind of target cells. Pathogenic antigens tend to displace keratinocytes, trying to replace epidermal cells.
An autoimmune reaction begins, as a result of which cytokines Th1 and Th17 trigger the process of inflammation with the predominance of an exudative component that permeates all layers of the epidermis. Therefore, in the clinic of exudative psoriasis, there is no manifestation of the onset of an inflammatory reaction – erythema, and foci consisting of exudative plaques immediately form. The inflammation and proliferation of the epidermis increase metabolic disorders and endocrine pathology, which indirectly worsen the trophism of the dermis.
American dermatologist Gerald Kruger, professor at the University of Utah College of Medicine, proposed the most significant classification of exudative psoriasis by the type of primary elements. In modern dermatology, practitioners are guided by it, prescribing adequate therapy of dermatosis in order to avoid the development of inverse drug psoriasis, which occurs as a secondary type of inflammation provoked by a new trigger against the background of an already existing inflammatory reaction of a different etiology. Distinguish:
- Thick-plaque exudative psoriasis associated with obesity. Mostly men suffer. Such psoriasis has an unfavorable prognosis, a severe course with nail damage and the development of psoriatic polyarthritis. When supervising patients, it is necessary to determine the body mass index (BMI), it is mandatory to connect to therapy means that correct fat metabolism, and anti-rheumatoid therapy.
- Thin-plaque exudative psoriasis associated with diabetes mellitus and other endocrine disorders, eczema, teardrop psoriasis. The supervision of such patients requires constant monitoring with the determination of the quality of life index (QIQ), which takes into account the clinic and the patient’s subjective feelings (itching, bleeding, prodromal phenomena), so as not to miss a possible malignancy
Clinical manifestations of the pathological process are specific. On unchanged skin without initial hyperemia and papules, small bright pink plaques appear, which, merging, form foci of inflammation of considerable size (up to 10-20 cm in diameter) with clear boundaries. There is no infiltration in the foci of exudative psoriasis, the skin is hot to the touch. There is no peeling characteristic of other types of psoriasis.
Due to the prevailing exudative component of inflammation, the focus swells, the elements are soaked with liquid, instead of thin scales consisting of horn cells of the surface layer of the epidermis, plaques in the focus are covered with thick scales-crusts of dirty gray or dirty yellow color. When trying to remove the scaly crust from the surface of the plaque, spot bleeding occurs, the wet surface is exposed. At this stage, a secondary infection often joins exudative psoriasis.
Dried crusts float on top of each other, cracks appear on them, their uneven edges touch clothes, causing significant discomfort to patients, especially if the process is localized on the skin of the hands. The joined burning sensation, itching cause insomnia and neurosis.
The pathological process can be localized on any part of the skin, but most often exudative psoriasis is located in the folds of the skin and on the lower extremities, accompanying varicose veins. If the focus of the pathological process is injured, healing is very slow. This is due to the fact that exudative psoriasis is active throughout the life of patients, its course is characterized by relapses and exacerbations, but even during remission, latent inflammation continues in the skin. During the period of exacerbations, the manifestations of concomitant somatic diseases increase.
The diagnosis is made by a dermatologist based on anamnesis and clinical manifestations. The presence of concomitant pathology, complications of exudative psoriasis, first of all, the involvement of joints in the pathological process is taken into account. The immune status of the patient is determined to assess the severity of the course of the disease, the appointment of adequate therapy. In addition, consultation with a rheumatologist, surgeon, endocrinologist is mandatory. The basis of the diagnosis is:
- Laboratory tests. Immunohistochemical studies are carried out, the cytokine profile, the level of IgG, IgA, IgM immunoglobulins are determined. In histological diagnostics, it is important to identify microabsesses of Munro in the epidermis, characteristic of exudative psoriasis.
- Instrumental techniques. X-ray examination is used. Sonographic ultrasound and arthroscopy are used, bone density is measured (densitometry).
Differentiate exudative psoriasis with other forms of psoriasis and dermatoses:
- a pustular variety of psoriasis,
- palmar-plantar psoriasis,
- teardrop-shaped psoriasis,
- psoriatic arthropathy,
- psoriatic arthritis,
- seborrheic psoriasis,
- seborrheic eczema,
- psoriatic erythroderma,
- atopic dermatitis.
The purpose of therapy is to suppress inflammation, prolong remission. Treatment of exudative psoriasis is divided into local and general. Corticosteroids, retinoids, ointments based on tar and vitamins, salicylic ointments, herbal infusions are used locally. General therapeutic measures consist in the appointment of detoxification therapy, vitamin therapy, hepatoprotectors, retinoids, antihistamines, diuretics, cytostatics, antimetabolites, short courses of corticosteroids. In rare cases (due to side effects), antagonists of tumor necrosis factor alpha (Anti-TNF), NSAIDs are used for the purpose of anesthesia.
With exudative psoriasis, UVI, PUVA therapy is effective. In severe cases, hemosorption and plasmapheresis are carried out, paraffin applications are used. In modern dermatology, laser therapy of exudative psoriasis is used. The combination of photomechanical, photochemical, and photothermal effects of the excimer laser system is considered the most effective.
Prognosis and prevention
With this type of psoriasis, daily prevention is necessary. There are a number of rules that should be followed by patients with exudative psoriasis. You should only take a shower, do not use coarse sponges, do not rub the skin with a towel, moisturize the skin and the room daily, wear clothes made of natural materials and cotton underwear, while sunbathing, use means with a high filter against UVI, exclude bad habits, heavy physical exertion, fatigue and atherogenic nutrition profile, avoid stress and infections. A complete cure is considered impossible, the prognosis is uncertain.