**2.1 Addictions and Psoriasis**

Association between Psoriasis and addictive disorders is a longtime suspect and several studies are supporting association of Psoriasis and alcohol, and of Psoriasis and tobacco. Association between Psoriasis and alcohol seems not to be influenced by gender and shows a dose-effect relation. The most striking link between cigarette smoking and Psoriasis has been established in Palmo-Plantar Pustulosis (PPP). This link also seems to exist for other forms of Psoriasis with a dose-effect relation.

The relationship between cigarette smoking and Psoriasis has been the subject of several studies. It was showed that cigarette smoking represents a significant risk factor for appearance of Psoriasis, especially in women, in a case about five, and it has been pointed out that risk increases with the number of cigarettes consumed per day and increases in those who smoke 20 or more daily. The risk would increase further in those who have a family history of this disease. Also for PPP seems to be a relation to cigarette smoking, with a risk factor 7.2 times higher in smokers than in non smokers. The report is based on leukocyte neutrophil counts: PPP is a neutrophilic dermatosis and cigarette smoke increases peripheral neutrophil counts and alters it in morphological and functional way.

Cigarette smoking may be involved in the high prevalence of lung and oral cancer and cardio-vascular disorders in psoriatic patients. The association between alcohol and development of plaque-type Psoriasis is complex and confusing because many of the initial studies did not control for confounding factors such as tobacco use.

There are a number of difficulties in the assessment of the correlation between Psoriasis, cigarette smoking and alcohol, and even more so in establishing a causal or etiologic relationship between the three because of several confusing factors (Meyer &al., 2008).

Alcohol-controlled studies suggest that women who are smokers have an up to 3.3-fold increased risk of developing plaque-type Psoriasis. Men who are smokers do not exhibit such an increased risk, but studies have shown that smoking more than 10 cigarettes per day by men who are Psoriasis patients may be associated with a more severe expression of disease in their extremities. In addition, smoking among both men and women who are Psoriasis patients has been shown to reduce improvement rates.

Dermatologists are not only the sentinels for early diagnosis of psoriatic arthritis, but also for metabolic complications such as dyslipidemia or diabetes. Moreover, they need to keep in mind interactions between (systemic) anti-psoriatic drugs and the co-medication of their patients as well as possible consequences of these co-medications on the course of Psoriasis (Behnam & al., 2005).

Head and Neck Psoriasis 83

involvement of the auricle but also by the involvement of external auditory canal by heaps of scales that can stamp it. Diagnosis of SeboPsoriasis, that is characterised by the presence of yellowish-white unctuous scales can be put when psoriasiform lesions are localized exclusively in seborrheic areas of the face (naso-labial fold, glabella and eyebrows, auricle and retroauricular fold) and are associated with similar lesions of the hairline and the presternal area. This clinic form, on the border between Psoriasis Vulgaris and Seborrheic Dermatitis, is considered a Psoriasis arisen on patches of Seborrheic Dermatitis because of

Family history may predispose patients to scalp Psoriasis. In an analysis of Psoriasis genes in an Icelandic patient population, 296 of 1,000 Psoriasis patients experienced onset of Psoriasis on the scalp. Cluster analysis (Karason & al., 2005) of this subset of patients determined that 198 patients fit within 79 families and determined a linkage to chromosome 10. The familial nature of Psoriasis has long been recognized with evident intra and interfamilial variability. Thirty nine individual with Psoriasis (25 men and 14 women) from 9 Tunisian unrelated multiplex families (in Tunisian population the estimated prevalence of Psoriasis is of 3%) were investigated during a study period of 1 year (Ammar & al., 2009). The common form of Psoriasis was discovered in 37 cases. The nails, the scalp, the mucous membranes were involved respectively in 21, 12 and 13 cases.

Methods used to diagnose scalp Psoriasis vary in sensitivity, reproducibility, and invasiveness. Recently has been introduced a videodermoscopy scalp Psoriasis severity index (VSCAPSI) for evaluation of scalp Psoriasis (Rossi &al., 2011). This index is particularly useful in mild and moderate forms that often are not clinically appreciable. VSCAPSI takes into account extension of the area of the scalp affected, the presence and morphology of vascular patterns, erythema and desquamation. Videodermoscopy images obtained between November 2009 to June 2010 from 900 participants with various scalp and hair disorders were reviewed for distinguishing features. During the 2010 Italian congress on Psoriasis, in order to assess the reproducibility and efficacy of the VSCAPSI, 146 dermatologists were asked to evaluate 16 videodermoscopy images of scalp Psoriasis using the VSCAPSI. Of the 900 patients, 85 new cases of scalp Psoriasis were diagnosed. The other 815 patients were found to be suffering from different scalp and hair diseases. Of 146 dermatologists, 28 did not recognize erythema, 15 desquamation and 7 the vascular patterns. The VSCAPSI provides an important tool for early diagnosis, differential diagnosis

Head and neck Psoriasis (in the form of the so-called Psoriasis vulgaris or plaque type of Psoriasis and guttate Psoriasis) commonly involves the skin surface of the scalp and the face (eyebrow, nose, upper lip, forehead, and hairline) and presents as papules, well-demarcated erythematous plaques with a scaly surface or as papulo-squamous lesions covered by fine silvery-white and loosely adherent scales. The amount and thickness of the scales is variable such are the plaques, ranging in size from few to several centimeters, with coalescence of smaller plaques into larger and sometimes fissured lesions. On the other hand, less thick plaques and less scaly lesions are commonly encountered in children with face psoriatic localization compared with adults. Pustular forms of Psoriasis are rarely described on the

the Koebner phenomenon.

The Psoriasis was severe in 11 cases.

and follow-up and screening.

**3.1 Histology of head and neck Psoriasis: Gross findings** 

The association between Psoriasis and alcoholism represents one of the major psychodermatological issues where a multidisciplinary approach (including dermatologist, psychiatrist, psychologist and others) is crucial for optimal outcome. Psoriasis is associated with an increased risk of comorbidity and mortality compared to the general population. It appears that patients with Psoriasis have a higher prevalence of metabolic disorders such as diabetes, hypertension, obesity, and hyperlipidemia, as well as a higher frequency of cigarette smoking. These concomitant diseases can complicate the treatment of Psoriasis.
