Neurodermatitis in Baquba City, Diyala Governorate/Iraq Clinical and histopathological study

Background : Many patients that have itchy thickened skin lesions are lichenified, it's located on the extremities namely on the knees, feet, dorsum of the hands, and /or elbows was being seen bilaterally and may be symmetrically. Objective: To evaluate clinical and histopathological features of neurodermatitis with some similarities to psoriasis in Iraqi patients. Patients and Methods: Twenty-Five patients with neurodermatitis attending Department of Dermatology, Baquba Teaching Hospital were enrolled in this study in time between 1 st January 2020 to 31 th January 2021. All patients were being examined and full history was taken, including age of the patients, onset and duration of the disease, severity and type of itching. A full examination was done to identify the character, colour, shape, site, and involvement of other body site of lesion. Incisional biopsy specimens from both lesion and adjacent normal skin were obtained from 9 patients and submitted to histological assessment. Results: Ten of the patients (40%) were male and fifteen (60%) were females, their age ranged from 29-70 years, with a mean of 49.5 years. The average duration ranged from one month-15 years with median 7.5 years. Clinically; patients have severe itchy plaques that distributed bilaterally like those of psoriasis, involvement of the knees (56%), dorsum of the both hands, feet, and elbows, also having ( lichenification ,that is characterized by thickening of the skin and exaggeration of the skin lines ) which characteristic of the individual lesion of lichen simplex chronicus, these plaques were symmetrical, well defined, sharper, more keratotic, violaceous pigmentation, marked accentuation and thickening of skin. Psoriatic scales are not present typically on the plaques of these patients. These plaques mainly located on extremities. Nine specimens' taken for histopathologiacl findings showed hyperkeratosis, acanthosis, dermal papilomatosis, suprapapillary epidermal thinning. All patients mentioned a severe itching which was paroxysmal in typing, more severe in the evening. Conclusion: ( Lichenified psoriasis) Psoriatic neurodermatitis might be lichen simplex chronicus as a result to repetitive itching and scratching of plaque psoriasis. This was typical neurodermatitis and not psoriasis.


Introduction
Psoriasis is a common, and chronic, recurrent inflammatory disease of the skin, in which both genetic and environmental factors have and play critical role. The most characteristic lesion consist of circumscribed erythematous, well demarcated, scaling plaques, present particularly over extensor surfaces of the body and scalp [1].The incidence of disease, has been estimated to be 60 individual per 100000 per year [2].A recent US study has suggested that the annual incidence of psoriasis has doubled in the 30 years between 1970 and 2000 [3].Both sex are affected equally. The first peak occurrence of plaque psoriasis is in people aged 16-22 years old, the second peak between 57-62 years old [4]. Psoriasis was much greater amongst the first and the second degree relatives of patients than unaffected control subjects [5]. Studies of twin siblings have shown that there is concordant disease in 20%of monozygotic twins compared with 9% in dizygotic twins, corresponding to an estimated heritability of 68% [6]. several putative genetic susceptibility regions have also been identified, including psoriasis susceptibility 1(PSOR1) on chromosome 6p, and other loci (PSOR 2, PSOR3, PSOR4, PS0R5, PSOR6, PSOR7) have been identified [7,8].Inflammatory mechanisms are immune based and most likely initiated and maintained primarily by memory_ T cells in the dermis [9]. Cytokines, predominantly of the Th1 milieu, including TNF-ɑ, interferon Ɣ, IL6, and IL2 are over expressed in individual with psoriasis. IL-17, IL22, IL23 are over expressed in psoriatic plaques [10]. A wide range of recognized of injurious local stimuli, including physical, chemical, surgical has been recognized to elicit psoriatic lesions isomorphic (koebner phenomenon) [11]. Acute guttate type of psoriasis is strongly associated with preceding or concurrent streptococcal infection, particularly (streptococcal pharyngitis) [12]. There are many drugs also were reported to be responsible for the onset or exacerbation of psoriasis , chief amongst these are Captopril, antimalarial , B-blocker agents, non-steroidal anti-inflammatory drugs [13].Early changes on histopathology there is vasodilation, papillary dermal edema and leukocyte infiltrates apper to precede epidermal changes in early developing lesions [14] .While in fully developed plaques there is confluent parakeratosis associated with focal orthokeratosis and munro micro abscess formation with in stratum corneum, granular layer is absent focally , spongiform pustules in the spinous layer of Kogoj [15]. The first and early manifestation of psoriasis may occur at any age, and the tendency for female to develop of psoriasis earlier than male. Duration of the disease may vary from a few weeks to a whole lifetime, also the course unpredictable with relapse and remission [15].
Psoriasis neurodermatitis; there are several patients with itchy indurated plaques distributed bilaterally resembling the plaques of psoriasis in its distribution and involvement of the elbows, knees and /or dorsum of the hands and feet, and also having lichenification (well-defined lichenified lesion ) like lichen simplex chronicus, that consist of one or more lichenified patches or plaques on the skin that results from the ORIGINAL RESEARCH Published: 30 June 2023 Doi: 10.26505/DJM.24026730721 chronic itching and scratching cycle causes exaggeration of the normal skin marking creases . However, these plaques have not shown typical characteristics scales of psoriasis, most patients with psoriatic neurodermatitis either mentioned having a more severity of itching while comforting or the severity of itching not different significantly between resting and being working. There is no significant difference in frequencies of scratching in these lesions of these patients from those in patients with typical lichen simplex chronicus. Previously the similar of these cases have been described as lichenified psoriasis or 'psoriatic neurodermatitis' [16].

Study protocol
Twenty-five patients with psoriatic neurodermatitis attending Dep. of Dermatology , Baquba teaching hospital were enrolled in this study during the period" between 1 st January 2020 to 31 th January 2021 Study population: Inclusion criteria: presence of itchy plaques that were lichenified and located on the elbows, knees, and / or dorsum of the hands and feet (bilaterally); absence of auspitzs' sign, no adherent abundant scales in these plaques; and no previously or recently typical psoriatic lesions on other site.
Exclusion criteria: criterion for psoriatic neurodermatitis was a clear causal relationship between the contactants and the plaques. A skin examination was done completely for the plaques and any other skin problems also, like dryness or eczematous plaques if present. Severity of the changes in the plaques was graded as evident, subtle or none .The changes in plaques were erythema, sharp border, any scaling present, keratosis, lichenification and any excoriation. Also for papules, or tiny vesicles and if there is any secondary changes to such vesicles around these plaques. Types of the papules were recorded if it is follicular, or lichenoid, and prurigo-like ".

Study Design
All patients were being examined, and a full history was taken including age, onset and duration, type and severity of itching. A full examination was done to identify the character, color, shape, site and involvement of other body sites. For histological study an incisional biopsy specimens from both lesion and adjacent normal skin were obtained from (9) patients. An elliptical incision was made using surgical blade. The biopsy specimens stained with haematoxylin and eosin stains, and submitted to histological assessment under light microscop.

Statistical Analysis
Excell 2010, SPSS version 20 statistical program used for analysis.

Results
Clinical findings: 25 patients were assessed, 10(40%) were males and 15(60%) females. Their ages ranged from 29-70 years mean (49.5) years Table (1). The average duration ranged from one month-15 years median (7.5) years. Patients that presented with severe itchy plaques like those of psoriasis in its distribution and with the bilateral involvement of knees, feet, dorsum of hands, and/ or elbows, and also having lichenification. However, characteristics of psoriasis scale not shown typically in these plaques. These plaques are located on extremities (knees 56 %) involvement were present for both the knees and dorsum of the feet in 6 patients, for both the knees and both elbows in 4 patients, for the knees and dorsum of the hands in 2 patients, for the dorsum of feet in 3 patients, the knees in 2 patients, and only for the elbows in one patient, involvement of other body sites are reported in 2 patients (sacrum). All patients have had a more severe itching which was paroxysmal in nature and more severe in evening. Histological findings (H and E stain) 9 biopsies shown hyperkeratosis, acanthosis , dermal papillomatosis , suprapapillary epidermal thinning , also there is parakeratosis and hypogranulosis , and there is focal epidermal inflammatory cells collections (Kogoj).

Discussion
Psoriasis is a common (about 2%-3% of the population), chronic, scaly rash that affects people of all ages. It is not contagious and not due to allergy. Patients with psoriasis often have relatives with disease i.e. it tends to run in families. It affects men and women equally; it may or may not itchy. In this study, we observed that although ours cases with so-called psoriatic neurodermatitis there is no typical scales that present in psoriatic plaques, and not having typical psoriatic lesions on other body sites, while the histopathological changes in their plaques were its highly suggestive for diagnosis of psoriasis. Hyperkeratosis more frequently occurences, and near absence of granular layer, confluent parakeratosis in the plaques of the patients with PN that clinically being more keratotic. In addition to these changes, Auspitz' sign corresponding to histopathological changes; as regular acanthosis and thinning of the supra_papillary epidermis were also more frequent in that plaques of patients with PN. However, the last change contrary to expectation was notable to produce its clinical counterpart that made for excoriation [17,18]. This lichenified psoriasis (psoriasis neurodermatitis) that has been described as psoriatic plaques that increase skin markings and lichenification on their surfaces [16].Two theories for the pathogenesis of lichenification of these plaques; first explanation as a result of koebner phenomenon that result from frequent trauma, rubbing, the second one itchy psoriasis may be superimposed by lichen simplex chronicus,infact long duration of the disease in PN were severely itchy and keratotic more and less excoriated . S Gunasti et al, found that; the PN was located on extremities and the females almost exclusively was affected more, in the patients with PN, depression and suicide was found more frequently than generalized anxiety disorder which is less, and LSC on the itchy psoriasis may be the so-called psoriatic neurodermatitis [19].

Conclusions
Psoriatic neurodermatitis more frequently in females patients Severity of itching was more in the evening usually.LSC secondary to plaque psoriasis maybe it's the PN.The term psoriatic neurodermatitis may be replaced of lichenified psoriasis.These were typical neurodermatitis with some clinical similarity to psoriasis.

So as
to emphasized not only the similarities of the cases to both the psoriasis and lichen simplex chronicus, and the relationship between severity of itching and the psychic and neural differences in psoriasis, need more studies and investigations such patch test.

Acknowledgment
Authors would like to thanks the management of hospital and all patients participate in this study.

Source of funding:
The current study was funded by our charges with no any other funding sources elsewhere.

Ethical clearance: The agreements of
Baquba Teaching hospital were taken. All patients were informed about the study's objective and the convenience was taken.