Psoriasis


Article Author:
Pragya Nair


Article Editor:
Talel Badri


Editors In Chief:
Susan Johnson
Alexandra Caley


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
11/18/2018 8:42:05 PM

Introduction

Psoriasis is a chronic proliferative and inflammatory condition of the skin. It is characterized by erythematous plaques covered with silvery scales particularly over the extensor surfaces, scalp, and lumbosacral region.[1][2][3]

Etiology

Psoriasis has a prevalence[4] ranging from 0.2% to 4.8%. The exact etiology is unknown, but it is considered to be an autoimmune disease mediated by T lymphocytes. There is an association of HLA antigens seen in many psoriatic patients particularly in various racial and ethnic groups. Familial occurrence suggests its genetic predisposition. Injury in the form of mechanical, chemical, and radiational trauma induces lesions of psoriasis. Certain drugs like chloroquine, lithium, beta-blockers, steroids, and NSAIDs can worsen psoriasis. Generally, summer improves psoriasis while winter aggravates it. Apart from above factors infections, psychological stress, alcohol, smoking, obesity, and hypocalcemia are other triggering factors for psoriasis.[5]

Epidemiology

Psoriasis occurs worldwide, and its prevalence varies. In the United States, about 2% of the population is affected. High rates of psoriasis have been reported in the Faroe Islands. The prevalence of psoriasis is low in Japan and may be absent in Aboriginal Australians and Indians from South America.

Psoriasis can present at any age. A bimodal age of onset has been recognized. The mean age of onset for the first presentation of psoriasis can range from 15 to 20 years of age, with a second peak occurring at 55 to 60 years. [6][7]

Pathophysiology

The pathophysiology of psoriasis involves infiltration of the skin by activated T cells which stimulate proliferation of keratinocytes. This dysregulation in keratinocyte turnover results in the formation of thick plaques. Other associated features include epidermal hyperplasia and parakeratosis. In addition, the epidermal cells fail to secrete lipids which results in flaky and scaly skin, which is typical of psoriasis.[8]

History and Physical

Psoriasis presents as well defined erythematous plaques covered with silvery scales commonly over the scalp, extensors of extremity particularly over knees and elbows and lumbosacral region. Psoriasis is classified into two types. Type 1 psoriasis, which has a positive family history, starts before age 40 and is associated with HLA-Cw6; while type 2 psoriasis does not show a family history, presents after age 40, and is not associated with HLA-Cw6Psoriasis can present with different morphology in the form of plaque, guttate, rupioid, erythrodermic, pustular, inverse, elephantine, and psoriatic arthritis. Variation in a site is seen with the involvement of scalp, palmoplantar region, genitals, and nails. Any injury to the skin in patients with psoriasis in the form of either mechanical, chemical or radiational trauma induces lesions of psoriasis at that site which is called Koebner phenomenon. It indicates the activeness of disease.

Plaque psoriasis typically presents as erythematous plaques with silvery scales most commonly over extensors of extremities, i.e., on the elbows, knees, scalp, and back.  It is the most common type of psoriasis which affects 85% to 90% patients. On successive removal of psoriatic scales pinpoint bleeding points are seen. This is called Auspitz sign which is used to confirm the diagnosis clinically.

Guttate psoriasis also called as eruptive psoriasis is commonly seen in children after an upper respiratory tract infection with the streptococcal organism. It presents with erythematous and scaly raindrop-shaped lesions mainly over trunk and back. It is the type of psoriasis having the best prognosis.

Pustular psoriasis presents with small non-infectious pus-filled lesions with erythema surrounding it. It is of two types localized and generalized. Generalized pustular psoriasis is associated with hypocalcemia and presents with sterile pustules on an erythematous plaque involving the whole body.

Erythrodermic psoriasis presents with widespread inflammation in the form of erythema and exfoliation of the skin covering more than 90% of the body area. It is associated with severe itching, swelling, and pain. It is the result of an exacerbation of unstable plaque psoriasis, following the abrupt withdrawal of systemic steroids. Complications of erythroderma include impairment in barrier functions of skin, disturbance in basal metabolic rate, increased cutaneous circulation in turn affecting the heart with cardiac failure.   

Nail changes in psoriasis are seen as pitting, oil spots, subungual hyperkeratosis, nail dystrophy, and anchylosis.

Fissured tongue is the most common finding of oral psoriasis and has been reported to occur in 6.5% to 20% of people with psoriasis affecting the skin.

Inverse psoriasis is also called as flexural psoriasis or intertriginous psoriasis. It appears as smooth, erythematous and sharply demarcated patches affecting intertriginous areas like groins, armpits, intergluteal region, inframammary region. The skin may be moist, macerated, may contain fissures which may be malodorous, pruritic, or both.   It needs to be differentiated from dermatophyte infection affecting these sites, which presents with central clearing and the active border with scales, vesicles, and pustules at the margin.

Sebopsoriasis is a form of psoriasis which typically manifests as red plaques with greasy scales. It commonly affects areas with increased sebum production such as the scalp, forehead, nasolabial folds, sternum, and retro-auricular folds.

Psoriatic arthritis is a form of chronic inflammatory arthritis which affects 30% patients with psoriasis. It commonly occurs in association with skin and nail psoriasis. It typically involves painful inflammation of the joints and connective tissue commonly affecting the joints of the fingers and toes. It leads to sausage-shaped swelling of the fingers and toes known as dactylitis. Psoriatic arthritis can also affect the hips, knees, spine presenting as spondylitis and sacroiliac joints with sacroiliitis.

Ocular features: psoriasis also affects the eyelid, conjunctiva, and cornea giving rise to trichiasis, ectropion, conjunctivitis, and corneal dryness. The most common eye feature is blepharitis which can lead to cicatricial ectropion, madarosis, and trichiasis. In some cases, anterior uveitis may be seen.[3][9]

Evaluation

Usually, diagnosis is made by clinical morphology and site of lesions. Histopathology is rarely necessary but may help to differentiate psoriasis from another dermatosis if the diagnosis is not easy. Characteristic changes in biopsy show parakeratosis, micro-abscess, the absence of granular lesions, regular elongation of ridges in the form of camel foot appearance, spongiform pustules of Kogoj with dilated and tortuous capillaries in dermal papilla.[10][11]

Treatment / Management

Psoriasis Area Severity Index (PASI) is the most widely used measurement tool which assesses the severity of the condition and allows to evaluate the treatment efficiency.  Topical therapy is used in mild to moderate psoriasis. Emollients and moisturizers may help in improving barrier function and retain the hydration of stratum corneum. Topical agents used are coal tar, dithranol, corticosteroids, vitamin D analog, and retinoids. [12][13][14]

Phototherapy includes PUVA therapy which combines psoralen with exposure to ultraviolet light (UVA), as well as NBUVB (Narrowband UVB light) with a range of 311 nanometers to 313 nanometers. NBUVB  is equally effective without the side effects of psoralen like gastrointestinal upset, cataract formation, and carcinogenic effect. It can safely be given to children, pregnant and lactating females and even elderly.

Systemic drugs are used in extensive cases, the involvement of nails and psoriatic arthritis. Methotrexate, retinoids, cyclosporine, and fumarates are possible options. Routine blood, liver functions, and renal functions should be monitored in patients on systemic therapy.

Biologicals are manufactured proteins that interrupt the immune process in psoriasis which are infliximab, adalimumab, etanercept, and interleukin antagonists.

Differential Diagnosis

Differential diagnosis of psoriasis includes

  • Eczema
  • Seborrhoeic dermatitis
  • Pityriasis rosea
  • Mycosis fungoides (a form of cutaneous T-cell lymphoma)
  • Secondary syphilis. 

Prognosis

Psoriasis is a chronic condition which is known to have a negative impact on the quality of life in patients as well as family members. Pustular psoriasis and erythrodermic psoriasis may be life-threatening, while psoriatic arthritis affects the functional prognosis negatively.

Complications

  • Secondary infections
  • Poor cosmesis
  • Psoriatic arthritis
  • Risk of lymphoma
  • Increased risk of adverse cardiac events

Pearls and Other Issues

Summary of Guidelines

  1. Psoriasis is considered extensive when more than 10% BSA is involved
  2. When the condition occurs on the face, nails, scalp, genitals, flexures, and soles- it is also considered severe as this areas are hard to treat and associated with poor cosmesis.
  3. Biological therapy should be considered early if methotrexate is not well tolerated or in patients with active severe psoriasis.
  4. Assess response to treatment by noting a reduction in baseline disease severity and improvement in physical, social and psychological functioning.
  5. Ustekinumab is the first line biological agent of choice. Secukinumab is another alternative
  6. Adalimumab is the first line biological agent of choice in patients with psoriatic arthropathy
  7. Infliximab is reserved for patients with severe disease in whom other biological agents cannot be used
  8. Women of childbearing age who are started on a biological agent should start effective contraception.
  9. Live vaccines are to be avoided on people taking biological agents. All vaccinations must be completed before starting biological agents.
  10. Patients with demyelinating disorders should not be treated with TNF antagonists
  11. Patients with heart failure should not be treated with TNF antagonists

Enhancing Healthcare Team Outcomes

Psoriasis may be a skin disorder but its management is very complex and usually requires a team of professionals dedicated to this disease. Besides the dermatologist, the nephrologist, plastic surgeon, pharmacist, rheumatologist, and an ophthalmologist should manage these patients. The key goal is to improve the quality of life by educating the patient about avoiding the triggers. The pharmacist should educate the patient on the use of moisturizers and managing dry skin. Further compliance with medications is vital; plus the pharmacist should ensure that the patient is on no medications that can cause flare-ups. The nurse should educate the patient on changes in lifestyle by avoiding alcohol, smoking, stress and dry cold weather. While the sun is beneficial, too much should be avoided. The nurse should monitor the patient for self-harm and refer the patient to a mental health counselor. Finally, the patient should be told to eat healthily, exercise regularly and maintain a healthy weight. All patients with psoriasis need lifelong follow up because relapses are common.[15] (level V) 

Outcomes

Even though psoriasis is a benign skin disorder, it is a lifelong illness with no cure. Everyone undergoes remissions and relapses and overall it leads to a poor quality of life. Today there are several reports indicating that psoriasis also increases the risk of adverse cardiac events. Psoriasis also is associated with alcoholism, smoking, depression, a risk of lymphoma, suicide, adverse drug reactions and several types of skin cancers. Evidence continues to mount that psoriasis is associated with hypertension, renal disease, and heart disease. Overall, patients with psoriasis involving the palms and soles tend to have a much poorer quality of life than those who have psoriasis on other parts of the body. [16][17][18](Level V)


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Psoriasis - Questions

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A male presents with scaly skin lesions on the elbow. Scraping the lesions reveals numerous punctuate bleeding spots. What is the most probable diagnosis?



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What is the term for occurrence of psoriasis at sites of trauma?



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A 27-year-old female with generalized aches and joint pain is seen in the clinic. She says she has a skin rash that does not appear to respond to any over-the-counter medication. On examination, you discover she has nail pitting. She may have which of the following conditions?

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Skin involvement is most commonly seen in which of the following arthritic conditions?

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Which of the following is characterized by a skin lesion with pink, silvery scales with underlying inflammation?



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Which of the following clinical history is particularly important in the diagnosis of psoriasis?



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What condition causes erythematous scaly patch over knees and elbows?



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Which of the following is the most appropriate initial management of wide spread and extensive psoriasis?



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A 28-year-old female who is obese presents with extreme itching on her elbows. The itching started 2 weeks ago and has worsened. She denies trauma, recent infection, or prior illness. She smokes one pack of cigarettes and drinks three to four alcoholic beverages daily. She has no allergies. Examination reveals a bilateral, scaly maculopapular rash with raised silvery plaques and excoriation marks around the edges. Her blood work is normal. What lifestyle recommendation would not improve her skin condition?



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Which of the following does not have the characteristics of crusts?



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A patient presents with gradual onset of itching and pain in her fingers and nails for the past 3 months. She claims that she initially had itching only now also feels pain in the fingers. She has applied several types of topical creams but this has not helped. She denies any trauma or recent infection. The exam reveals that her nails have multiple pits and are thickened and yellowish in color. Some of the nails appear to be separated from the distal nailbed. You also note the presence of a salmon-colored macular rash with silvery plaques on her left knee but she denies any symptoms with this lesion. Nail scrapings rule out a fungal infection. What treatment is least likely to be useful for her nail condition?



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Which of the following can safely be used to effectively treat facial psoriasis without causing concern of atrophy?



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A 30-year-old man presents with a chronic pruritic rash of the knees, gluteal cleft, and scalp. He has early morning back pain that improves with movement and dandruff. He is noted to have plaques on his knees and elbows and pitting of his nails. Which of the following should not be used in treatment?



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Which of the following illnesses is the least likely to have oral manifestations?



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Which of the following treatments for psoriasis is effective?



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A female has large, silver-white, sharply defined plaques on the scalp and knees and elbow extensor surfaces. There is also pitting and discoloration of the fingernails. Elevation of a scale on the knee causes punctate areas of hemorrhage. Select the histologic change that would be seen on biopsy.



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Which of following is characteristic of psoriasis?



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Which of the following does not exacerbate psoriasis?



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What is the first-line of treatment for psoriasis?



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What risk is increased with phototherapy treatment for psoriasis?



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A patient develops erythematous, scaling plaques at sites of trauma. Characteristic punctate bleeding points are produced by abrading the scale. What is the most likely diagnosis?



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The Munro microabscesses in psoriasis are located within the:



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Which layer is absent in psoriasis?



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A patient with psoriasis is using a questionnaire to screen for arthritis. Which of the following questionnaire has the highest sensitivity for the disorder?



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Which specific tool is used to assess the involvement of the skin in patients with psoriasis?



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Psoriasis - References

References

Elman SA,Weinblatt M,Merola JF, Targeted therapies for psoriatic arthritis: an update for the dermatologist. Seminars in cutaneous medicine and surgery. 2018 Sep     [PubMed]
Yiu ZZ,Warren RB, Ustekinumab for the treatment of psoriasis: an evidence update. Seminars in cutaneous medicine and surgery. 2018 Sep     [PubMed]
Yang EJ,Beck KM,Sanchez IM,Koo J,Liao W, The impact of genital psoriasis on quality of life: a systematic review. Psoriasis (Auckland, N.Z.). 2018     [PubMed]
Nguyen CT,Bloch Y,Składanowska K,Savvides SN,Adamopoulos IE, Pathophysiology and inhibition of IL-23 signaling in psoriatic arthritis: A molecular insight. Clinical immunology (Orlando, Fla.). 2018 Sep 6     [PubMed]
Gamret AC,Price A,Fertig RM,Lev-Tov H,Nichols AJ, Complementary and Alternative Medicine Therapies for Psoriasis: A Systematic Review. JAMA dermatology. 2018 Sep 5     [PubMed]
Larsabal M,Ly S,Sbidian E,Moyal-Barracco M,Dauendorffer JN,Dupin N,Richard MA,Chosidow O,Beylot-Barry M,     [PubMed]
Eder L,Widdifield J,Rosen CF,Cook R,Lee KA,Alhusayen R,Paterson JM,Cheng SY,Jabbari S,Campbell W,Bernatsky S,Gladman DD,Tu K, Trends in the prevalence and incidence of psoriasis and psoriatic arthritis in Ontario, Canada: A population-based study. Arthritis care     [PubMed]
Khan J,Deverapalli SC,Rosmarin D, JAK-STAT signaling pathway inhibition: a role for treatment of various dermatologic diseases. Seminars in cutaneous medicine and surgery. 2018 Sep     [PubMed]
Caiazzo G,Fabbrocini G,Di Caprio R,Raimondo A,Scala E,Balato N,Balato A, Psoriasis, Cardiovascular Events, and Biologics: Lights and Shadows. Frontiers in immunology. 2018     [PubMed]
Trayes KP,Savage K,Studdiford JS, Annular Lesions: Diagnosis and Treatment. American family physician. 2018 Sep 1     [PubMed]
Vázquez-Herrera NE,Sharma D,Aleid NM,Tosti A, Scalp Itch: A Systematic Review. Skin appendage disorders. 2018 Aug     [PubMed]
Perez-Chada LM,Cohen JM,Gottlieb AB,Duffin KC,Garg A,Latella J,Armstrong AW,Ogdie A,Merola JF, Achieving international consensus on the assessment of psoriatic arthritis in psoriasis clinical trials: an International Dermatology Outcome Measures (IDEOM) initiative. Archives of dermatological research. 2018 Aug 25     [PubMed]
Schadler ED,Ortel B,Mehlis SL, Biologics for the primary care physician: Review and treatment of psoriasis. Disease-a-month : DM. 2018 Jul 20     [PubMed]
Dauden E,Blasco AJ,Bonanad C,Botella R,Carrascosa JM,González-Parra E,Jodar E,Joven B,Lázaro P,Olveira A,Quintero J,Rivera R, Position statement for the management of comorbidities in psoriasis. Journal of the European Academy of Dermatology and Venereology : JEADV. 2018 Jul 10     [PubMed]
Luchetti MM,Benfaremo D,Campanati A,Molinelli E,Ciferri M,Cataldi S,Capeci W,Di Carlo M,Offidani AM,Salaffi F,Gabrielli A, Clinical outcomes and feasibility of the multidisciplinary management of patients with psoriatic arthritis: two-year clinical experience of a dermo-rheumatologic clinic. Clinical rheumatology. 2018 Oct     [PubMed]
Sears AV,Szlumper C,Liu KW,Smith CH,Barker JNWN,Pink AE, Clinical outcomes in patients on secukinumab (Cosentyx{sup}®{/sup} ) within a specialist psoriasis clinic: A single centre, retrospective cohort study. Journal of the European Academy of Dermatology and Venereology : JEADV. 2018 Sep 10     [PubMed]
Murage MJ,Tongbram V,Feldman SR,Malatestinic WN,Larmore CJ,Muram TM,Burge RT,Bay C,Johnson N,Clifford S,Araujo AB, Medication adherence and persistence in patients with rheumatoid arthritis, psoriasis, and psoriatic arthritis: a systematic literature review. Patient preference and adherence. 2018     [PubMed]
Langenbruch A,Radtke MA,Gutknecht M,Augustin M, Does the Dermatology Life Quality Index (DLQI) underestimate the disease-specific burden of psoriasis patients? Journal of the European Academy of Dermatology and Venereology : JEADV. 2018 Aug 30     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of CNS-Adult-Gerontology. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for CNS-Adult-Gerontology, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in CNS-Adult-Gerontology, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of CNS-Adult-Gerontology. When it is time for the CNS-Adult-Gerontology board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study CNS-Adult-Gerontology.