12/9/22, 6:34 PM Psoriasis - StatPearls - NCBI Bookshelf
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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.
Psoriasis
Pragya A. Nair; Talel Badri.
Author Information
Last Update: April 6, 2022.
Continuing Education Activity
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. This activity reviews the pathophysiology, presentation, and diagnosis of
psoriasis and highlights the role of the interprofessional team in its management.
Objectives:
Describe the subtypes of psoriasis.
Recall the presentation of a patient with psoriasis.
List the treatment and management options available for psoriasis.
Discuss interprofessional team strategies for improving care coordination and outcomes in
patients with psoriasis.
Earn FREE continuing education credits (CME/CE) on this topic.
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]
The disorder can also affect the joints and eyes. Psoriasis has no cure and the disease waxes and
wanes with flareups. Many patients with psoriasis develop depression as the quality of life is
poor. There are several subtypes of psoriasis but the plaque type is the most common and
presents on the trunk, extremities, and scalp. Close examination of the plaques usually reveals
white silvery scales.
The eye is involved in about 10% of patients, mostly women. In general, the eye is rarely
involved alone; it is almost always associated with skin features.
Etiology
Psoriasis has a prevalence ranging from 0.2% to 4.8%.[4] 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
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psoriasis while winter aggravates it. Apart from the 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 the 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, and extensors of extremity, particularly over knees, 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-Cw6. Psoriasis 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 the 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 the Koebner phenomenon. It indicates the
activeness of the 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% of patients. On successive removal of psoriatic scales
pinpoint bleeding points are seen. This is called the Auspitz sign which is used to confirm the
diagnosis clinically.
Guttate psoriasis also called 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 the 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.
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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 the skin, disturbance in basal metabolic rate, and 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 flexural psoriasis or intertriginous psoriasis. It appears as smooth,
erythematous, and sharply demarcated patches affecting intertriginous areas like groins, armpits,
intergluteal region, and inframammary region. The skin may be moist, macerated, and may
contain fissures that 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% of 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, and 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, and spongiform
pustules of Kogoj with dilated and tortuous capillaries in the dermal papilla.[10][11]
Laboratory studies
One should order complete CBC, renal, and liver function tests
Rheumatoid factor
ESR may be elevated in erythrodermic and pustular psoriasis
Uric acid levels are high in psoriasis
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If only hand and feet are involved, obtain scrappings for fungal studies
Pregnancy test
Hepatitis serology
PPD
Treatment / Management
Psoriasis Area Severity Index (PASI) is the most widely used measurement tool which assesses
the severity of the condition and allows for the evaluation of 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 the stratum corneum. Topical agents used are coal tar,
dithranol, corticosteroids, vitamin D analog, and retinoids are used initially. [12][13][14]
In patients who do not respond to the above treatments, methotrexate can be effective.
Cyclosporine can be used to induce a clinical response but its use should be intermittent.
When patients fail to respond to methotrexate, switch to biological agents; in some cases
combine with methotrexate
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 effects. It can safely be given to
children, pregnant and lactating females, and even older patients. Guttate psoriasis has been
known to respond best to phototherapy
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. Before starting any biological
agent, the patient should be worked up for tuberculosis and hepatitis. There is a serious risk of
infections in these patients and all precautions should be taken that the patient is not severely
immunocompromised.
Prolonged use of steroids and other immunosuppressives may delay wound healing.
Ocular psoriasis requires aggressive treatment with topical corticosteroids.
Patients with psoriasis should avoid all skin trauma for fear of inducing the Kobner reaction. In
addition, psoriatic patients should avoid the use of beta-blockers, chloroquine, or NSAIDs. They
should also avoid alcohol because of the risk of developing fatty liver.
Differential Diagnosis
Eczema
Seborrhoeic dermatitis
Pityriasis rosea
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Mycosis fungoides (a form of cutaneous T-cell lymphoma)
Secondary syphilis
Prognosis
Psoriasis is a chronic condition that is known to have a negative impact on the quality of life in
patients as well as a family members. Psoriasis is a lifelong illness marked by relapses and
remissions. About 10% of patients develop severe deforming arthritis. Remissions are
experienced in 10-60% of patients. Over the course of the disease, psoriasis has been associated
with depression, suicide, alcoholism, smoking, substance abuse, metabolic syndrome, and a
variety of skin cancers. In addition, patients with psoriasis tend to have major medical
comorbidities like kidney disease, heart disease, and joint problems. Several studies have noted a
link between psoriasis and adverse cardiac events.
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
Deterrence and Patient Education
There is no specific diet for psoriasis but patients should eat a healthy diet. Patients should be
educated on reducing the risk factors for heart disease. Exposure to sunlight is beneficial and
patients should be encouraged to spend time outdoors. In addition, the patient should maintain a
healthy body weight.
In the clinic, the patient should be screened for type 2 diabetes, hypertension, and dyslipidemia.
Finally, a consult with a psychiatrist is recommended as many patients develop severe
depression.
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 these 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.
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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 in 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 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] An interprofessional team approach to management will yield improved
outcomes.[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 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 alcohol use, smoking, depression, 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 5]
Review Questions
Access free multiple choice questions on this topic.
Access free CME on this topic.
Comment on this article.
Figure
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Nail Psoriasis. Contributed by DermNetNZ
Figure
Plaque Psoriasis. Contributed by DermNetNZ
Figure
Psoriatic plaques. Image courtesy S Bhimji MD
Figure
Psoriasis, on bilaterally on lower leg. Contributed by Dr.
Shyam Verma, MBBS, DVD, FRCP, FAAD, Vadodara, India
Figure
Scalp Psoriasis. Contributed by Dr. Shyam Verma, MBBS,
DVD, FRCP, FAAD, Vadodara, India
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