🧴 PSORIASIS - Simple Explanation with Examples

mkdir -p /home/daytona/workspace/psoriasis-study-guide && ls /home/daytona/works…

~/psoriasis-study-guide/generate_pdf.py

from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm, mm
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, KeepTogether, PageBreak
)
from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY
from reportlab.platypus import Flowable

# ── Colour palette ──────────────────────────────────────────────────────────
NAVY      = colors.HexColor("#1A3A5C")
TEAL      = colors.HexColor("#0D7C8C")
ORANGE    = colors.HexColor("#E87722")
LIGHT_BG  = colors.HexColor("#EAF4F6")
YELLOW_BG = colors.HexColor("#FFF8E1")
GREEN_BG  = colors.HexColor("#E8F5E9")
RED_BG    = colors.HexColor("#FFEBEE")
WHITE     = colors.white
GREY_LINE = colors.HexColor("#CCCCCC")

# ── Document setup ───────────────────────────────────────────────────────────
OUTPUT = "/home/daytona/workspace/psoriasis-study-guide/Psoriasis_Study_Guide.pdf"
doc = SimpleDocTemplate(
    OUTPUT, pagesize=A4,
    leftMargin=1.8*cm, rightMargin=1.8*cm,
    topMargin=2*cm, bottomMargin=2*cm
)

# ── Styles ────────────────────────────────────────────────────────────────────
base = getSampleStyleSheet()

def S(name, parent="Normal", **kw):
    return ParagraphStyle(name, parent=base[parent], **kw)

cover_title  = S("CoverTitle", fontSize=32, textColor=WHITE,
                 fontName="Helvetica-Bold", alignment=TA_CENTER, leading=38)
cover_sub    = S("CoverSub",   fontSize=14, textColor=colors.HexColor("#D0ECF0"),
                 fontName="Helvetica", alignment=TA_CENTER, leading=20)
cover_meta   = S("CoverMeta",  fontSize=10, textColor=colors.HexColor("#B0D8E0"),
                 fontName="Helvetica", alignment=TA_CENTER)

h1 = S("H1", fontSize=16, textColor=WHITE, fontName="Helvetica-Bold",
       spaceBefore=6, spaceAfter=4, leading=20)
h2 = S("H2", fontSize=13, textColor=NAVY, fontName="Helvetica-Bold",
       spaceBefore=10, spaceAfter=4, leading=16)
h3 = S("H3", fontSize=11, textColor=TEAL, fontName="Helvetica-Bold",
       spaceBefore=8, spaceAfter=3, leading=14)
body = S("Body", fontSize=9.5, fontName="Helvetica",
         leading=14, spaceAfter=3, alignment=TA_JUSTIFY)
bullet = S("Bullet", fontSize=9.5, fontName="Helvetica",
           leading=14, spaceAfter=2, leftIndent=12, firstLineIndent=-12)
small = S("Small", fontSize=8.5, fontName="Helvetica",
          leading=12, textColor=colors.HexColor("#444444"))
caption = S("Caption", fontSize=8, fontName="Helvetica-Oblique",
            textColor=colors.HexColor("#666666"), alignment=TA_CENTER)
note_style = S("Note", fontSize=9, fontName="Helvetica-Oblique",
               textColor=colors.HexColor("#5D4037"), leading=13)
tip_style  = S("Tip",  fontSize=9, fontName="Helvetica-Bold",
               textColor=colors.HexColor("#1B5E20"), leading=13)

# ── Helper flowables ──────────────────────────────────────────────────────────
def section_header(text, bg=NAVY):
    """Full-width coloured section banner."""
    data = [[Paragraph(text, h1)]]
    t = Table(data, colWidths=[17.4*cm])
    t.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), bg),
        ("TOPPADDING",    (0,0), (-1,-1), 8),
        ("BOTTOMPADDING", (0,0), (-1,-1), 8),
        ("LEFTPADDING",   (0,0), (-1,-1), 12),
        ("RIGHTPADDING",  (0,0), (-1,-1), 12),
        ("ROUNDEDCORNERS", [6]),
    ]))
    return t

def info_box(text, bg=LIGHT_BG, border=TEAL):
    data = [[Paragraph(text, note_style)]]
    t = Table(data, colWidths=[17.4*cm])
    t.setStyle(TableStyle([
        ("BACKGROUND",   (0,0), (-1,-1), bg),
        ("LEFTPADDING",  (0,0), (-1,-1), 10),
        ("RIGHTPADDING", (0,0), (-1,-1), 10),
        ("TOPPADDING",   (0,0), (-1,-1), 8),
        ("BOTTOMPADDING",(0,0), (-1,-1), 8),
        ("LINEAFTER",    (0,0), (0,-1), 3, border),   # left accent bar trick — use LINEBEFORE
        ("LINEBEFORE",   (0,0), (0,-1), 4, border),
        ("ROUNDEDCORNERS", [4]),
    ]))
    return t

def tip_box(text):
    return info_box("💡 " + text, bg=GREEN_BG, border=colors.HexColor("#388E3C"))

def warning_box(text):
    return info_box("⚠️  " + text, bg=RED_BG, border=colors.HexColor("#C62828"))

def hr():
    return HRFlowable(width="100%", thickness=0.5, color=GREY_LINE, spaceAfter=6, spaceBefore=6)

def sp(h=6):
    return Spacer(1, h)

def bul(text):
    return Paragraph(f"• {text}", bullet)

# ── Table helpers ─────────────────────────────────────────────────────────────
HDR_STYLE = TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), NAVY),
    ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
    ("FONTNAME",      (0,0), (-1,0), "Helvetica-Bold"),
    ("FONTSIZE",      (0,0), (-1,0), 9.5),
    ("BOTTOMPADDING", (0,0), (-1,0), 7),
    ("TOPPADDING",    (0,0), (-1,0), 7),
    ("ALIGN",         (0,0), (-1,-1), "LEFT"),
    ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
    ("FONTNAME",      (0,1), (-1,-1), "Helvetica"),
    ("FONTSIZE",      (0,1), (-1,-1), 9),
    ("ROWBACKGROUNDS",(0,1), (-1,-1), [WHITE, LIGHT_BG]),
    ("TOPPADDING",    (0,1), (-1,-1), 5),
    ("BOTTOMPADDING", (0,1), (-1,-1), 5),
    ("LEFTPADDING",   (0,0), (-1,-1), 8),
    ("RIGHTPADDING",  (0,0), (-1,-1), 8),
    ("GRID",          (0,0), (-1,-1), 0.4, GREY_LINE),
    ("ROUNDEDCORNERS", [4]),
])

def make_table(headers, rows, col_widths=None):
    data = [[Paragraph(f"<b>{h}</b>", S("th", fontSize=9.5, textColor=WHITE,
                        fontName="Helvetica-Bold", leading=13)) for h in headers]]
    for row in rows:
        data.append([Paragraph(str(c), small) for c in row])
    t = Table(data, colWidths=col_widths, repeatRows=1)
    t.setStyle(HDR_STYLE)
    return t

# ════════════════════════════════════════════════════════════════════════════════
# BUILD CONTENT
# ════════════════════════════════════════════════════════════════════════════════
story = []

# ── COVER PAGE ────────────────────────────────────────────────────────────────
cover_data = [[
    Paragraph("PSORIASIS", cover_title),
    Paragraph("Complete Study Guide", cover_sub),
    Paragraph("Types · Pathogenesis · Clinical Features · Investigations · Treatment", cover_sub),
    Spacer(1, 10),
    Paragraph("Chapter 19 — Dermatology, Venereology and Leprosy", cover_meta),
]]
cover_table = Table([[item] for item in [
    Paragraph("PSORIASIS", cover_title),
    Spacer(1, 8),
    Paragraph("Complete Study Guide", cover_sub),
    Spacer(1, 6),
    Paragraph("Types · Pathogenesis · Clinical Features · Treatment", cover_sub),
    Spacer(1, 14),
    Paragraph("Chapter 19 — Dermatology, Venereology & Leprosy", cover_meta),
    Spacer(1, 6),
    Paragraph("Based on standard medical textbook content", cover_meta),
]], colWidths=[17.4*cm])
cover_table.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), NAVY),
    ("TOPPADDING",    (0,0), (-1,-1), 14),
    ("BOTTOMPADDING", (0,0), (-1,-1), 14),
    ("LEFTPADDING",   (0,0), (-1,-1), 20),
    ("RIGHTPADDING",  (0,0), (-1,-1), 20),
    ("ROUNDEDCORNERS", [10]),
]))
story.append(Spacer(1, 60))
story.append(cover_table)
story.append(Spacer(1, 30))

# small decorative strip
strip_data = [["QUICK FACTS"]]
strip = Table(strip_data, colWidths=[17.4*cm])
strip.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), TEAL),
    ("TEXTCOLOR",     (0,0), (-1,-1), WHITE),
    ("FONTNAME",      (0,0), (-1,-1), "Helvetica-Bold"),
    ("FONTSIZE",      (0,0), (-1,-1), 11),
    ("ALIGN",         (0,0), (-1,-1), "CENTER"),
    ("TOPPADDING",    (0,0), (-1,-1), 6),
    ("BOTTOMPADDING", (0,0), (-1,-1), 6),
]))
story.append(strip)
story.append(Spacer(1, 8))

facts = [
    ["Prevalence", "Affects ~2-3% of world population"],
    ["Peak onset", "Bimodal: 16-22 yrs (early) and 57-60 yrs (late)"],
    ["Genetics", "9 susceptibility genes (PSORS1-9); most important: PSORS1"],
    ["Key lesion", "Well-defined silvery-scaled erythematous plaque on extensor surfaces"],
    ["Hallmark sign", "Auspitz sign (pinpoint bleeding on scale removal)"],
    ["Most common type", "Plaque psoriasis (Psoriasis Vulgaris) — 90% of cases"],
]
facts_table = Table(facts, colWidths=[5*cm, 12.4*cm])
facts_table.setStyle(TableStyle([
    ("FONTNAME",      (0,0), (-1,-1), "Helvetica"),
    ("FONTSIZE",      (0,0), (-1,-1), 9),
    ("FONTNAME",      (0,0), (0,-1), "Helvetica-Bold"),
    ("TEXTCOLOR",     (0,0), (0,-1), NAVY),
    ("ROWBACKGROUNDS",(0,0), (-1,-1), [WHITE, LIGHT_BG]),
    ("TOPPADDING",    (0,0), (-1,-1), 5),
    ("BOTTOMPADDING", (0,0), (-1,-1), 5),
    ("LEFTPADDING",   (0,0), (-1,-1), 8),
    ("GRID",          (0,0), (-1,-1), 0.3, GREY_LINE),
]))
story.append(facts_table)
story.append(PageBreak())

# ── SECTION 1: ETIOLOGY ───────────────────────────────────────────────────────
story.append(section_header("1. ETIOLOGY"))
story.append(sp(8))
story.append(Paragraph("The exact etiology of psoriasis is not known. It results from a combination of genetic predisposition and environmental triggers.", body))
story.append(sp(6))

etio_data = [
    ["Factor", "Details", "Memory Tip"],
    ["Genetic\n(Polygenic)", "Complex polygenic inheritance. Positive family history in >50% of patients.\n9 susceptibility genes: PSORS1–PSORS9.\nMost important: PSORS1 (chromosome 6p21.3).",
     "\"9 PSORS genes\" — think 9 players in a team"],
    ["Environmental\nTriggers", "Infections (bacterial/viral)\nStress & physical injury / trauma\nSmoking, alcohol, drugs",
     "\"STAID\" — Stress, Trauma, Alcohol, Infections, Drugs"],
]
story.append(make_table(etio_data[0], etio_data[1:], col_widths=[3.5*cm, 9.5*cm, 4.4*cm]))
story.append(sp(10))

# ── SECTION 2: PATHOGENESIS ───────────────────────────────────────────────────
story.append(section_header("2. PATHOGENESIS", bg=TEAL))
story.append(sp(8))
story.append(Paragraph("<b>Core concept:</b> Psoriasis results from interactions between genetic factors and environmental triggers, leading to immune activation and accelerated keratinocyte proliferation.", body))
story.append(sp(6))

story.append(Paragraph("Step-by-step pathway:", h3))
steps = [
    ("1", "Environmental trigger activates antigen-presenting cells (Dendritic / Langerhans cells)"),
    ("2", "These activate CD4+ TH1 and TH17 cells via IL-12 and IL-23 respectively"),
    ("3", "T-cells enter skin and accumulate in epidermis"),
    ("4", "T-cells secrete mediators: TNF-α, IFN-γ (TH1) • IL-17A, IL-17F, IL-22 (TH17)"),
    ("5", "Mediators activate keratinocytes → produce antimicrobial peptides (β-defensins), cytokines (TNF-α, IL-1β, IL-6) and chemokines"),
    ("6", "Result: shortened cell cycle (36 hrs vs 311 hrs normal) and turnover (4 days vs 27 days normal)"),
]
step_table = Table(
    [[Paragraph(f"<b>{n}</b>", S("sn", fontSize=11, textColor=WHITE, fontName="Helvetica-Bold", alignment=TA_CENTER)),
      Paragraph(d, small)] for n, d in steps],
    colWidths=[1.2*cm, 16.2*cm]
)
step_table.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (0,-1), TEAL),
    ("BACKGROUND",    (1,0), (1,-1), WHITE),
    ("ROWBACKGROUNDS",(1,0), (1,-1), [WHITE, LIGHT_BG]),
    ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
    ("TOPPADDING",    (0,0), (-1,-1), 7),
    ("BOTTOMPADDING", (0,0), (-1,-1), 7),
    ("LEFTPADDING",   (0,0), (0,-1), 4),
    ("LEFTPADDING",   (1,0), (1,-1), 10),
    ("GRID",          (0,0), (-1,-1), 0.3, GREY_LINE),
]))
story.append(step_table)
story.append(sp(8))
story.append(tip_box("Key cytokines to remember: TNF-α, IL-17, IL-22, IL-23, IL-12, IFN-γ. Biologic drugs target many of these!"))
story.append(PageBreak())

# ── SECTION 3: PATHOLOGY ─────────────────────────────────────────────────────
story.append(section_header("3. PATHOLOGY (Histology)"))
story.append(sp(8))

path_data = [
    ["Histological Feature", "Description", "Significance"],
    ["Hyperproliferation of keratinocytes", "Increased epidermal cell proliferation", "Explains thick scaly plaques"],
    ["Dilated tortuous blood vessels", "In dermal papillae, surrounded by mixed neutrophilic & lymphohistiocytic infiltrate", "Explains Auspitz sign (bleeding)"],
    ["Munro's microabscesses", "Polymorphonuclear abscesses within parakeratotic stratum corneum", "Pathognomonic for psoriasis"],
    ["Spongiform pustules", "PMN abscesses within mildly spongiotic foci of superficial epidermis", "Seen in pustular psoriasis"],
    ["Parakeratosis", "Nuclei retained in stratum corneum (incomplete keratinization)", "Explains silvery scale"],
]
story.append(make_table(path_data[0], path_data[1:], col_widths=[4.5*cm, 7.5*cm, 5.4*cm]))
story.append(sp(10))

# ── SECTION 4: CLINICAL FEATURES ─────────────────────────────────────────────
story.append(section_header("4. CLINICAL FEATURES", bg=TEAL))
story.append(sp(8))

story.append(Paragraph("Key characteristics of psoriatic lesions:", h3))
features = [
    "Well-defined pink-red, sharply demarcated macules, papules, or rounded plaques",
    "Covered by silvery scales with a whitish halo around lesions (Woronoff's sign)",
    "Predominantly affects extensor surfaces (elbows, knees) and scalp",
    "Usually covered by silvery scales; has a chronic fluctuating course",
    "Increased association with HIV infection",
]
for f in features:
    story.append(bul(f))
story.append(sp(8))

story.append(Paragraph("Classic Signs — The Auspitz Sign (Step-by-Step):", h3))
auspitz = [
    ["Step", "Action", "Finding", "Term"],
    ["Step 1", "Gently scrape lesion with glass slide", "Silver scales fall off more prominently", "Grattage test positive"],
    ["Step 2", "Continue scraping (remove all scales)", "Glistening white adherent membrane appears", "Berkeley's membrane"],
    ["Step 3", "Remove the membrane", "Pinpoint bleeding points become visible", "Auspitz sign ✓"],
]
story.append(make_table(auspitz[0], auspitz[1:], col_widths=[2*cm, 5.5*cm, 6*cm, 3.9*cm]))
story.append(sp(6))

other_signs = [
    ["Sign", "Description"],
    ["Woronoff's sign", "Whitish halo around psoriatic lesion"],
    ["Koebner phenomenon", "New psoriatic lesion appears at site of skin trauma/injury in susceptible individuals"],
    ["Candle grease / Wax spot sign", "Scraping plaque causes silvery scales to fall off like scraping a wax candle"],
    ["Last membrane phenomenon", "Wet layer adhered to lesion is last layer of dermal papillae — pathognomonic of psoriasis"],
]
story.append(make_table(other_signs[0], other_signs[1:], col_widths=[5*cm, 12.4*cm]))
story.append(PageBreak())

# ── SECTION 5: TYPES ──────────────────────────────────────────────────────────
story.append(section_header("5. TYPES OF PSORIASIS"))
story.append(sp(8))

types_data = [
    ["Type", "Key Features", "Special Notes / Memory"],
    ["Plaque (Psoriasis Vulgaris)\n★ MOST COMMON", 
     "90% of cases. Symmetrically distributed thick silvery plaques on elbows, knees, scalp, lower back. 1-10 cm diameter, raised, well-defined margins.",
     "Think: 'Vulgaris = Very common'\nKoebner phenomenon can occur"],
    ["Guttate Psoriasis",
     "Small rain-drop shaped (0.5-2 cm) lesions scattered over trunk. Often follows streptococcal throat infection in children/young adults.",
     "'Gutta' = drop (Latin)\nTrigger: Strep throat"],
    ["Inverse (Flexural) Psoriasis",
     "Affects skin folds: axillae, groin, submammary, perianal. Smooth, red, shiny lesions — minimal or NO scales (moisture prevents scaling).",
     "Inverse = opposite location to plaque\nNo silvery scales!"],
    ["Localized Pustular Psoriasis",
     "Pustules localized to palms and soles (palmoplantar pustulosis). Chronic, relapsing course.",
     "Palms + Soles\n= Palmoplantar pustulosis"],
    ["Generalized Pustular Psoriasis\n(Von Zumbusch)",
     "Acute onset. Widespread sterile pustules on erythematous base. Fever, malaise, leucocytosis. Medical emergency.",
     "Von Zumbusch = Very severe\nMEDICAL EMERGENCY"],
    ["Erythrodermic Psoriasis",
     "Entire body surface (>90%) becomes red, inflamed, scaling. Can be life-threatening. Causes: withdrawal of systemic steroids, infection.",
     "Erythro = red, Derma = skin\nMEDICAL EMERGENCY"],
    ["Palmoplantar Psoriasis",
     "Involves palms and soles. Hyperkeratotic plaques; can be debilitating.",
     "Difficult to treat; consider systemic therapy early"],
]
story.append(make_table(types_data[0], types_data[1:], col_widths=[4*cm, 7.5*cm, 5.9*cm]))
story.append(sp(8))
story.append(warning_box("Erythrodermic psoriasis and Von Zumbusch generalized pustular psoriasis are both MEDICAL EMERGENCIES requiring urgent hospitalization."))
story.append(PageBreak())

# ── SECTION 6: NAIL & JOINT FEATURES ─────────────────────────────────────────
story.append(section_header("6. NAIL CHANGES & PSORIATIC ARTHROPATHY", bg=TEAL))
story.append(sp(8))

story.append(Paragraph("Nail Involvement (up to 50% of patients):", h2))
nail_data = [
    ["Nail Change", "Description", "Analogy"],
    ["Thimble pitting", "Tiny pits/depressions on nail surface", "Like a sewing thimble surface"],
    ["Onycholysis", "Distal separation of nail plate from nail bed", "Like a floor tile lifting off"],
    ["Oil drop sign", "Yellow-brown discoloration under nail plate", "Looks like an oil drop under nail"],
    ["Subungual hyperkeratosis", "Thickening of tissue under nail", "Nail stuffed with thick material"],
    ["Onychodystraphy", "Thickened, deformed nail overall", "Complete nail destruction"],
]
story.append(make_table(nail_data[0], nail_data[1:], col_widths=[4.5*cm, 7*cm, 5.9*cm]))
story.append(sp(6))
story.append(info_box("For diagnosis of nail psoriasis: >6 nails must be involved, each nail having >20 pits.", bg=YELLOW_BG, border=ORANGE))
story.append(sp(10))

story.append(Paragraph("Psoriatic Arthropathy:", h2))
story.append(bul("Occurs in 5-10% of psoriatic patients"))
story.append(bul("Usually develops several years after skin lesions appear"))
story.append(bul("Most patients will have nail changes"))
story.append(bul("It is a form of chronic seronegative spondyloarthropathy (see Chapter 8)"))
story.append(PageBreak())

# ── SECTION 7: INVESTIGATIONS ────────────────────────────────────────────────
story.append(section_header("7. INVESTIGATIONS & DIAGNOSIS"))
story.append(sp(8))
story.append(info_box("In most cases, the diagnosis can be made based on history and physical examination alone. Biopsy is seldom necessary.", bg=GREEN_BG, border=TEAL))
story.append(sp(8))

story.append(Paragraph("Associated Comorbidities to Screen For:", h3))
comorbidities = [
    "Metabolic syndrome",
    "Ulcerative colitis",
    "Crohn's disease",
    "Coronary artery disease",
    "Lymphoma",
    "HIV infection (increases association and severity)",
]
for c in comorbidities:
    story.append(bul(c))
story.append(PageBreak())

# ── SECTION 8: TREATMENT ──────────────────────────────────────────────────────
story.append(section_header("8. MANAGEMENT OF PSORIASIS"))
story.append(sp(8))
story.append(Paragraph("Treatment is divided into 4 broad categories:", body))
story.append(sp(4))
cats = Table([
    [Paragraph("<b>(1) Topical Agents</b>", S("c", fontSize=10, textColor=WHITE, fontName="Helvetica-Bold", alignment=TA_CENTER)),
     Paragraph("<b>(2) Phototherapy (UV)</b>", S("c2", fontSize=10, textColor=WHITE, fontName="Helvetica-Bold", alignment=TA_CENTER)),
     Paragraph("<b>(3) Systemic Agents</b>", S("c3", fontSize=10, textColor=WHITE, fontName="Helvetica-Bold", alignment=TA_CENTER)),
     Paragraph("<b>(4) Biologics</b>", S("c4", fontSize=10, textColor=WHITE, fontName="Helvetica-Bold", alignment=TA_CENTER)),
    ]
], colWidths=[4.35*cm, 4.35*cm, 4.35*cm, 4.35*cm])
cats.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (0,0), TEAL),
    ("BACKGROUND",    (1,0), (1,0), ORANGE),
    ("BACKGROUND",    (2,0), (2,0), NAVY),
    ("BACKGROUND",    (3,0), (3,0), colors.HexColor("#6A1B9A")),
    ("TOPPADDING",    (0,0), (-1,-1), 10),
    ("BOTTOMPADDING", (0,0), (-1,-1), 10),
    ("ALIGN",         (0,0), (-1,-1), "CENTER"),
    ("ROUNDEDCORNERS", [4]),
    ("INNERGRID",     (0,0), (-1,-1), 1, WHITE),
]))
story.append(cats)
story.append(sp(10))

# STEP 1
story.append(Paragraph("STEP 1 — Topical Treatments (First-line for mild-moderate disease)", h2))
step1_data = [
    ["Drug", "Mechanism / Notes", "Use"],
    ["Emollients / Moisturizers\n(Petroleum jelly, thick creams)", "Hydrate skin; reduce scaling\nMost effective after hydrating bath/shower", "All severity levels — baseline therapy"],
    ["Topical Corticosteroids\n(e.g. Betamethasone 0.5%)", "Anti-inflammatory; mainstay of treatment\nHigh-potency for thick plaques on extensor surfaces\nLow-potency (e.g. 0.05% fluocinonide) for face/folds", "First-line for most cases"],
    ["Coal Tar", "Anti-inflammatory and antiproliferative\nUsually combined with steroids", "Mild-moderate; also used in phototherapy regimens"],
    ["Calcipotriene / Calcitriol\n(Vitamin D3 analog)", "Affects growth and differentiation of keratinocytes\nSlows down cell overproduction", "Good alternative or add-on to steroids"],
    ["Tazarotene\n(Topical retinoid)", "Vitamin A derivative; normalizes keratinocyte differentiation", "Moderate plaque psoriasis"],
    ["Topical Calcineurin Inhibitors\n(Tacrolimus, Pimecrolimus)", "Immunosuppressant; blocks T-cell activation", "Face and intertriginous areas (sensitive skin)"],
    ["Salicylic Acid", "Keratolytic — softens and removes scales\nAllows other topical meds to penetrate better", "Always use BEFORE other topicals"],
    ["Topical Anthralin", "Antiproliferative; reduces keratinocyte turnover", "Short-contact therapy for scalp"],
]
story.append(make_table(step1_data[0], step1_data[1:], col_widths=[4.5*cm, 8.5*cm, 4.4*cm]))
story.append(sp(10))

# STEP 2
story.append(Paragraph("STEP 2 — Phototherapy (Moderate-extensive disease)", h2))
story.append(info_box("Mechanism: Effect likely through immunomodulatory properties (induces apoptosis of T-cells, reduces inflammatory cytokines)", bg=LIGHT_BG, border=TEAL))
story.append(sp(6))
step2_data = [
    ["Modality", "Details", "Key Points"],
    ["Sunlight", "Careful sun exposure may improve psoriasis", "Sunburn may exacerbate!"],
    ["UVB (295-320 nm) Broadband", "Erythema-inducing doses 3-5x/week until remission", "Moderate to extensive disease"],
    ["UVB Narrow Band (311 nm)", "More effective than broadband; induces T-cell apoptosis", "Preferred over broadband; fewer sessions"],
    ["PUVA\n(Psoralen + UVA 320-400 nm)", "Oral psoralen (8-MOP) then UVA exposure.\nPsoralen intercalates DNA; UVA cross-links DNA strands → stops cell division.\n75% patients show marked improvement.\n⚠ Risk: cataract, pigmentation, premature ageing, skin cancer", "Used when UVB fails (moderate-severe)\nOther uses: vitiligo, mycosis fungoides, atopic dermatitis"],
    ["Excimer Laser (308 nm)", "High-energy laser targeting only involved skin", "Treats only plaques; spares normal skin"],
    ["Goeckerman Regimen", "UVB + Coal tar", "Classic combination therapy"],
    ["Ingram Regimen", "Coal tar + UVB + Dithranol", "Second classic regimen"],
]
story.append(make_table(step2_data[0], step2_data[1:], col_widths=[4*cm, 9*cm, 4.4*cm]))
story.append(sp(8))
story.append(tip_box("PUVA memory: P = Psoralen (plant drug) | U = Ultraviolet | V = Very effective (75%) | A = UVA light (320-400 nm)"))
story.append(PageBreak())

# STEP 3
story.append(section_header("STEP 3 — Systemic Therapy (Severe / Refractory disease)", bg=colors.HexColor("#6A1B9A")))
story.append(sp(8))
step3_data = [
    ["Drug", "Class / Mechanism", "Indications", "Key Side Effects / Notes"],
    ["Methotrexate", "Folate antagonist; inhibits rapidly dividing cells", "Severe psoriasis, psoriatic arthritis, nail disease, erythrodermic & pustular variants", "Teratogen! Hepatotoxicity. Can combine with UVB/PUVA"],
    ["Acitretin", "Vitamin A analog (retinoid); regulates keratinocyte growth & differentiation", "Severe psoriasis, especially pustular and erythrodermic types", "Teratogen — contraindicated in pregnancy and for 3 years after stopping. Avoid excess sun/alcohol"],
    ["Cyclosporine", "T-cell suppressor; calcineurin inhibitor", "Severe psoriasis not responding to other agents", "Nephrotoxicity, hypertension; short-term use"],
    ["Apremilast", "Phosphodiesterase-4 (PDE4) inhibitor; reduces inflammatory signals", "Moderate-to-severe plaque psoriasis", "Oral; GI side effects initially. No lab monitoring required"],
]
story.append(make_table(step3_data[0], step3_data[1:], col_widths=[3*cm, 4.5*cm, 5*cm, 4.9*cm]))
story.append(sp(8))
story.append(warning_box("Both Methotrexate and Acitretin are TERATOGENS. Always confirm the patient is not pregnant before prescribing."))
story.append(sp(10))

# Biologics box
story.append(Paragraph("STEP 4 — Biological Therapies (targeting specific cytokines)", h2))
bio_data = [
    ["Drug Class", "Targets", "Examples"],
    ["TNF-α inhibitors", "Tumor necrosis factor-alpha", "Etanercept, Infliximab, Adalimumab"],
    ["IL-12/23 inhibitors", "IL-12 and IL-23 (p40 subunit)", "Ustekinumab"],
    ["IL-17 inhibitors", "IL-17A", "Secukinumab, Ixekizumab"],
    ["IL-23 inhibitors", "IL-23 (p19 subunit)", "Guselkumab, Risankizumab"],
]
story.append(make_table(bio_data[0], bio_data[1:], col_widths=[5*cm, 6*cm, 6.4*cm]))
story.append(PageBreak())

# ── SECTION 9: QUICK REVISION ─────────────────────────────────────────────────
story.append(section_header("9. QUICK REVISION — MNEMONICS & MEMORY TABLES"))
story.append(sp(8))

story.append(Paragraph("PSORIASIS Mnemonic:", h2))
mnemo = [
    ["Letter", "Stands For"],
    ["P", "Plaques — silvery, well-defined"],
    ["S", "Scalp, Skin, nails involved"],
    ["O", "On extensor surfaces (elbows, knees)"],
    ["R", "Red base under silvery scales"],
    ["I", "Immune-mediated (T-cells + cytokines)"],
    ["A", "Auspitz sign — hallmark sign (pinpoint bleeding)"],
    ["S", "Speeds up cell turnover (4 days vs 27 days normal)"],
    ["I", "Itchy (sometimes); chronic fluctuating course"],
    ["S", "Silvery scales — hallmark feature"],
]
story.append(make_table(mnemo[0], mnemo[1:], col_widths=[2*cm, 15.4*cm]))
story.append(sp(10))

story.append(Paragraph("Key Numbers to Remember:", h2))
numbers = [
    ["Value", "What it represents"],
    ["90%", "Plaque psoriasis (psoriasis vulgaris) accounts for 90% of all cases"],
    ["4 days", "Epidermal turnover time in psoriasis (vs. 27 days normal)"],
    ["36 hours", "Cell cycle time for keratinocytes in psoriasis (vs. 311 hours normal)"],
    [">50%", "Patients with positive family history"],
    ["9", "Number of susceptibility genes (PSORS1-PSORS9)"],
    ["6p21.3", "Chromosome location of the most important gene PSORS1"],
    ["5-10%", "Patients who develop psoriatic arthropathy"],
    [">6 nails, >20 pits", "Criteria for diagnosing nail psoriasis"],
    ["75%", "Patient improvement rate with PUVA therapy"],
    ["3 years", "Duration after stopping Acitretin before pregnancy is safe"],
]
story.append(make_table(numbers[0], numbers[1:], col_widths=[4.5*cm, 12.9*cm]))
story.append(PageBreak())

# ── SECTION 10: EXAM TIPS ─────────────────────────────────────────────────────
story.append(section_header("10. HIGH-YIELD EXAM POINTS", bg=ORANGE))
story.append(sp(8))

exam_points = [
    "Auspitz sign = pathognomonic for psoriasis (pinpoint bleeding after scale removal)",
    "Last membrane phenomenon = pathognomonic (last wet layer adherent to lesion = deepest layer of dermal papillae)",
    "Munro's microabscesses on histology = pathognomonic for psoriasis",
    "PSORS1 on chromosome 6p21.3 = most important susceptibility gene",
    "Koebner phenomenon: also seen in vitiligo, lichen planus, warts — but classic for psoriasis",
    "Guttate psoriasis is triggered by Streptococcal throat infection (most common trigger in children)",
    "Von Zumbusch (generalized pustular) and Erythrodermic psoriasis = MEDICAL EMERGENCIES",
    "Methotrexate is teratogenic — contraindicated in pregnancy",
    "Acitretin: pregnancy contraindicated for 3 years after stopping (due to long half-life)",
    "PUVA = Psoralen (8-methoxypsoralen) + UVA (320-400 nm); risk of skin cancer with long-term use",
    "Goeckerman regimen = UVB + Coal tar | Ingram regimen = Coal tar + UVB + Dithranol",
    "For nail psoriasis diagnosis: >6 nails involved, each with >20 pits",
    "Psoriatic arthropathy = chronic seronegative spondyloarthropathy (RF negative)",
    "PUVA also used for: vitiligo, mycosis fungoides, atopic dermatitis, senile pruritus",
    "Inverse psoriasis = NO silvery scales (moisture in skin folds prevents scaling)",
]
for i, pt in enumerate(exam_points, 1):
    story.append(Paragraph(f"<b>{i}.</b> {pt}", bullet))
    story.append(sp(2))

story.append(sp(10))
story.append(hr())
story.append(Paragraph("Study Guide prepared from Chapter 19: Dermatology, Venereology and Leprosy — Standard Medical Textbook", caption))
story.append(Paragraph("For educational purposes only. Always refer to current clinical guidelines for patient care.", caption))

# ── BUILD PDF ─────────────────────────────────────────────────────────────────
doc.build(story)
print(f"PDF created: {OUTPUT}")

cd /home/daytona/workspace/psoriasis-study-guide && python generate_pdf.py 2>&1

ls -lh /home/daytona/workspace/psoriasis-study-guide/Psoriasis_Study_Guide.pdf