• Clinical science

Psoriasis

Abstract

Psoriasis is a common chronic inflammatory skin disorder affecting individuals with an underlying genetic predisposition. The disease manifests following exposure to various triggers (e.g., infection, medication). The typical lesions are sharply demarcated, erythematous, scaly, pruritic plaques, which occur most often on the extensor surfaces of the knees and elbows, but may also affect the scalp and back. Other common clinical findings include involvement of the nails (e.g., pitting or discoloration) or joints, which generally manifests with arthritis of the fingers and lower spine. As psoriasis presents with several subtypes, the size, location, and severity of the lesions vary. The diagnosis is based primarily on clinical findings, but may also be confirmed with tests (e.g., Auspitz sign) or biopsy. Mild psoriasis is treated with topical agents such as steroids, whereas moderate to severe disease requires systemic therapy (e.g., PUVA, biologics).

Epidemiology

  • Prevalence: ∼ 2% of the white population
  • Age of onset: 20–40 years

References:[1][2][3][4]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

References:[3][5][6]

Classification

Psoriasis type I Psoriasis type II
Onset Early onset Late onset
Prevalence 60–70% of cases 30–40% of cases
Genetic predisposition Relatives often affected Relatives rarely affected
Correlation with HLA Strong association with HLA (HLA-Cw6, HLA-B17 and HLA-B57) Rarely correlated with HLA
Clinical presentation Often severe disease Usually mild disease

References:[7][8]

Pathophysiology

References:[3][9]

Clinical features

  • Course: relapsing, with symptom-free intervals
  • Well-demarcated, erythematous lesions and silvery-white scaling plaques
    • Initially, a few single lesions typically appear, which then often become confluent.
    • Mainly on scalp, back, elbows, and knees (extensor surfaces), but any other site may be involved
    • Pruritus in ∼ 80% of cases (typically mild, but may also be severe)
  • Involvement of nails (in ∼ 50% of cases)

References:[2][3][10][5][11]

Subtypes and variants

Psoriatic arthritis

If first-degree relatives of patients with psoriasis have joint problems, psoriatic arthritis should be considered!

Cutaneous variants

References:[1][12][5][13][14][15][16][17]

Diagnostics


References:[5]

Differential diagnoses

Differential diagnosis of scaling
Lesion Distribution
Psoriasis
  • Scalp
  • Extensor surfaces of joints (knees, elbows)
  • Back
Atopic dermatitis
  • Poorly demarcated, eczema, white scales, severe xerosis and pruritus
  • Extensor surfaces of extremities (e.g., shins)
  • Flexural creases (antecubital, popliteal)
Seborrheic dermatitis
  • Clearly demarcated, erythematous plaques, greasy-looking yellow scales
  • Cradle cap in infants
  • Facial involvement (hairline, periocular, nasolabial folds)
  • Trunk
Pityriasis rubra pilaris
  • Typically palms and soles
  • Islands of unaffected skin (sparing)
  • Follicular keratosis
Erythroderma
  • Erythema, scaling 2–6 days following onset, lesions of underlying disease, pruritus
  • Generalized erythema
  • Scaling initially in flexural creases

References:[5][18]

The differential diagnoses listed here are not exhaustive.

Treatment

Medical therapy

Mild to moderate psoriasis Moderate to severe psoriasis Severe psoriasis

Systemic treatment is always required for psoriatic arthritis (immunosuppressants and NSAIDs)!

Topical treatment Adverse effects
Topical steroids
  • Skin atrophy with chronic use
  • Risk: disease flare-up upon discontinuation
Vitamin D derivatives
  • High doses may cause systemic effects due to the absorption by the skin!
Tar preparations
  • Dramatic reddening, burning, and skin discoloration possible
Retinoids (vitamin A derivatives)
  • May cause irritation
Systemic treatment Examples Adverse effects
PUVA

PUVA: psoralen + UVA

  • Long term use
    • Increased risk of skin cancer
    • Premature aging of the skin
Folate antagonists Methotrexate
Retinoids (vitamin A derivatives) Acitretin
  • Teratogenic
Immunosuppressant (suppress T cells) Cyclosporine
  • Nephrotoxic
Biologicals (TNF-α antagonists) Etanercept, adalimumab, infliximab
  • High costs

Phototherapy

Ultraviolet light is effective in treating dermatological conditions, as it has antiproliferative effects (slowing keratinization) and anti-inflammatory effects (inducing apoptosis of pathogenic T cells) on the skin.

References:[1][2][12][3][19]

Complications

References:[3]

We list the most important complications. The selection is not exhaustive.

Prognosis

  • Lifelong disease, usually benign
  • Patients may experience remissions of varying lengths; acute episodes of exacerbation possible.
  • Psoriasis is associated with depression and a decreased quality of life.

References:[3]

Prevention

  • Avoidance of nicotine and alcohol
  • Regular physical activity
  • 1. James WD, Berger T, Elston D. Andrews' Diseases of the Skin: Clinical Dermatology. Philadelphia, PA: Elsevier Health Sciences; 2015.
  • 2. Marks JG Jr, Miller JJ . Lookingbill and Marks' Principles of Dermatology. Saunders Elsevier; 2013.
  • 3. Habashy J. Psoriasis. In: James WD. Psoriasis. New York, NY: WebMD. http://emedicine.medscape.com/article/1943419. Updated April 6, 2017. Accessed May 16, 2017.
  • 4. Parisi R, Symmons DP, Griffiths CE, Ashcroft DM. Global epidemiology of psoriasis: a systematic review of incidence and prevalence. J Invest Dermatol. 2013; 133(2): pp. 377–385. doi: 10.1038/jid.2012.339.
  • 5. Feldman SR. Epidemiology, Clinical Manifestations, and Diagnosis of Psoriasis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/epidemiology-clinical-manifestations-and-diagnosis-of-psoriasis. Last updated December 9, 2015. Accessed May 16, 2017.
  • 6. Hüffmeier U, Lascorz J, Becker T et al. Characterisation of psoriasis susceptibility locus 6 (PSORS6) in patients with early onset psoriasis and evidence for interaction with PSORS1. J Med Genet. 2009; 46(11): pp. 736–744. doi: 10.1136/jmg.2008.065029.
  • 7. Inamadar AC, Palit A, Ragunatha S. Textbook of Pediatric Dermatology. JP Medical Ltd; 2014.
  • 8. Hertl M. Autoimmune Diseases of the Skin: Pathogenesis, Diagnosis, Management. Springer Science & Business Media; 2011.
  • 9. Lowes MA, Suárez-Fariñas M, Krueger JG. Immunology of psoriasis. Annu Rev Immunol. 2014; 32: pp. 227–255. doi: 10.1146/annurev-immunol-032713-120225.
  • 10. Roblin D, Wickramasinghe R, Yosipovitch G. Pruritus severity in patients with psoriasis is not correlated with psoriasis disease severity. http://www.jaad.org/article/S0190-9622(13)01012-8/abstract. Updated February 1, 2014. Accessed May 16, 2017.
  • 11. Rosso Schons KR, Faccin Knob C, Murussi N, Costa Beber AA, Neumaier W, Monticielo OA. Nail psoriasis: a review of the literature. An Bras Dermatol. 2014; 89(2): pp. 312–317. doi: 10.1590/abd1806-4841.20142633.
  • 12. Bolognia J, Jorizzo J, Schaffer J. Dermatology: 2-Volume Set. Elsevier; 2012.
  • 13. Amherd-Hoekstra A, Näher H, Lorenz HM, Enk AH. Psoriatic arthritis: a review. J Dtsch Dermatol Ges. 2010; 8(5): pp. 332–339. doi: 10.1111/j.1610-0387.2009.07334.x.
  • 14. Gladman DD, Ritchlin C. Clinical manifestations and diagnosis of psoriatic arthritis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-psoriatic-arthritis. Last updated February 12, 2016. Accessed May 16, 2017.
  • 15. Lui H. Plaque Psoriasis. In: Elston DM. Plaque Psoriasis. New York, NY: WebMD. http://emedicine.medscape.com/article/1108072. Updated April 6, 2017. Accessed May 16, 2017.
  • 16. Mehlis S. Guttate Psoriasis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/guttate-psoriasis. Last updated November 22, 2016. Accessed September 1, 2017.
  • 17. Hawkes JE, Callis Duffin K. Erythrodermic Psoriasis in Adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/erythrodermic-psoriasis-in-adults. Last updated February 27, 2017. Accessed September 1, 2017.
  • 18. Davis MDP. Erythroderma in Adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/erythroderma-in-adults. Last updated September 21, 2016. Accessed September 2, 2017.
  • 19. Feldman SR. Treatment of Psoriasis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/treatment-of-psoriasis. Last updated March 11, 2017. Accessed May 16, 2017.
last updated 12/12/2018
{{uncollapseSections(['j0b_fH', 'k0bmTH', 'O0bITH', 'l0bvTH', 'N0b-TH', 'm0bVgH', '50bigH', 'n0b7gH', 'o0b0SH', 'K0bUSH', '60bjSH', 'p0bLSH', 'J0bsSH'])}}