I. See Also

II. Epidemiology

  1. Onset in young adulthood between ages 15 to 40 years
  2. Prevalence: 1-2% of general population
  3. Men and women affected equally

III. Pathophysiology

  1. Underlying genetic predisposition is common (30% with Psoriasis also have a first degree relative with Psoriasis)
    1. Pathogenesis is likely a combination between genetic predisposition and exposure to inciting triggers
  2. Autoimmune
    1. Viral infection may precipitate process
    2. T-Cell-mediated autoimmune response
      1. Cytokines released and stimulate Keratinocytes
  3. Keratinocytes proliferate
    1. Epidermal cells proliferate too fast
      1. Cells cycle in 4 days instead of normal 3-4 weeks
    2. Abnormal keratin production
    3. Dermal inflammation

IV. Risk Factors: Associated environmental factors

  1. Suppressed by:
    1. Sun and humidity
  2. Provocative
    1. Injury to skin (Koebner Reaction)
    2. Streptococcal Pharyngitis
    3. Emotional upset
    4. Tobacco Use
    5. Obesity
    6. Alcohol use
    7. HIV Infection (severe exacerbations)
    8. Medications
      1. Antimalarials
      2. Beta Blockers
      3. Lithium
      4. NSAIDS

V. Symptoms

  1. Pruritus is present in >80% of psorisis
    1. Psora is greek for itching

VI. Signs: Chronic Plaque Psoriasis (90% of cases)

  1. Description
    1. Widespread
    2. Sharply demarcated
    3. Bright pink Plaques
    4. Overlying loose, silvery scale
  2. Location: Symmetrical
    1. Over joints and extensor surfaces of extremities
    2. On trunk, especially lower back and buttocks
    3. Palms and soles
    4. Scalp
    5. Umbilicus
  3. Signs suggestive of Psoriasis
    1. Auspitz Sign
    2. Koebner Phenomenon

VII. Signs: Associated findings

  1. Location specific signs
    1. Nail (Psoriatic Onychodystrophy)
      1. Lifetime Prevalence in up to 90% of Psoriasis patients (esp. Fingernails)
      2. Findings secondary to abnormal nail plate growth
        1. Nail Pitting
        2. Subungual hyperkeratosis
        3. Onycholysis
          1. Separation of distal edge of nail from nail bed
          2. Accumulation of crumbly subungual debris
    2. Gluteal cleft
      1. Eroded pinkness in crease
    3. Penis
      1. Pink Macules or Plaques on penis
    4. Large joints
      1. Hyperkeratosis over elbows, knees, and ankles
    5. Tongue
      1. Geographic Tongue (rare)
  2. Uncommon Clinical Variants
    1. Guttate Psoriasis (drop-like)
      1. Uncommon, accounting for only 2% of Psoriasis cases
      2. Typically affects younger patients, under age 30 years
      3. Trunk lesions are 1-10 mm Papules with fine scale
      4. Commonly occurs following Streptococcal Pharyngitis or Upper Respiratory Infection
    2. Inverse Psoriasis (flexural)
      1. Less scale present than in Plaque form
      2. Affects flexor surfaces (inframammary, axillary and inguinal folds)
      3. Affects perineal and intergluteal regions
    3. Pustular Psoriasis
      1. Pustules on palms and soles without Plaques
      2. von Zumbusch variant causes severe, acute, life-threatening sub-type
    4. Erythrodermic Psoriasis (Erythroderma)
      1. Broad-spread generalized erythema
      2. Systemic symptoms are typically present
  3. Systemic Signs
    1. Psoriatic Arthritis
    2. Uveitis (up to 20% of Psoriatic Arthritis cases)
  4. Severe widespread Psoriasis systemic signs
    1. Benign Lymphadenopathy
    2. Fever, chills, and Hyperthermia
    3. Increased cardiac demand
    4. High output Heart Failure
    5. Increased Sedimentation Rate and Uric Acid
    6. Decreased Serum Albumin
    7. Iron Deficiency Anemia

VIII. Differential diagnosis

  1. Lichen Simplex Chronicus
  2. Nummular Eczema
  3. Seborrheic Dermatitis
  4. Tinea Corporis
  5. Group A Beta Hemolytic Streptococcus
    1. May present as Guttate Psoriasis in children
    2. Obtain ASO Titer and Throat Culture

IX. Associated Conditions (related to psoriatic medications)

  1. Inflammatory Bowel Disease (Crohns' Disease or Ulcerative Colitis)
    1. Risk increased 3.8 to 7.5x
  2. Malignancy
    1. Squamous Cell Skin Cancer
      1. Risk increased 14x associated with PUVA in caucasians
    2. Lymphoma
      1. Risk increased 1.3 to 3x
  3. Major Depression
    1. Prevalence: 60% of Psoriasis patients
  4. Other associated conditions with increased risk
    1. Myocardial Infarction

X. Approach: Moderate Chronic Plaque Psoriasis

  1. Trunk and extensor surface involvement
    1. Initial and exacerbation therapy (<4 weeks only)
      1. Protocol 1: Steroid and Calcipotriene
        1. High potency Topical Corticosteroid qAM
        2. Calcipotriene applied qPM
      2. Protocol 2: Single agent
        1. High potency Topical Corticosteroid or
        2. Calcipotriene or
        3. Tazorotene (Tazorac)
    2. Long-term maintenance (beyond 4 weeks)
      1. Calcipotriene or
      2. Tazorotene (Tazorac)
  2. Flexor surface involvement
    1. Moderate Topical Corticosteroids (<4 weeks) or
    2. Tacrolimus or Pimecrolimus
  3. Scalp involvement
    1. Exacerbations
      1. Topical Corticosteroid (brief use)
      2. Example: Clobetasol 0.05% Shampoo
    2. Maintenance
      1. Anti-DandruffShampoo
      2. Examples: T-gel or selsun
  4. Adjuncts
    1. Lac-Hydrin or salicylic acid applied daily

XI. Approach: Severe Chronic Plaque Psoriasis

  1. Criteria
    1. Psoriasis refractory to above therapy
    2. Chronic Plaque Psoriasis involving >5-20% of body
    3. Comorbid Psoriatic Arthritis
    4. Involvement of hands, feet, face or genitalia
  2. Protocol usually managed by dermatology
    1. Use above topical agents
    2. See Ultraviolet light below
    3. See Systemic Agents below

XII. Management: General Measures

  1. Soak lesions to ease adherent scale removal
  2. Apply skin Emollients (e.g. vaseline, aquaphor)
    1. Apply after soaks
    2. Apply 20 minutes after Corticosteroid application to boost steroid effect (similar to Occlusion)
  3. Consider Emollient only periods of steroid holiday

XIII. Management: Topical Preparations

  1. Topical Corticosteroids
    1. Consider limiting potent steroids to 2-4 weeks at a time
      1. Then rotate to lower potency steroids or Emollient only periods until reexacerbation
    2. High Potency Topical Steroids (Usually indicated)
      1. Very high potency: e.g. Clobetasol (Temovate)
      2. High potency: e.g. Fluocinonide (Lidex)
    3. Low Potency Topical Steroids
      1. Face
      2. Genitals
      3. Maintenance Therapy
  2. Vitamin D based topicals
    1. Indicated for moderate Psoriasis involving 5-20% of body surface area
    2. Used alone or in combination with Phototherapy or Topical Corticosteroids
    3. Risk of Hypercalcemia in high dose exposure and renal insufficiency
    4. Preparations
      1. Calcipotriene (Dovonex)
      2. Calcitriol (Vectical)
        1. May be less irritating than Calcipotriene (Dovonex)
  3. Retinoid based topicals
    1. Tazarotene (Tazorac)
    2. More irritating than Calcipotriene
    3. As effective as Corticosteroids, but with longer disease-free periods
    4. Do not use in pregnancy (Teratogenic)
  4. Immunosuppressant based topicals
    1. Indications
      1. Effective in facial and intertriginous Psoriasis (due to less skin atrophy than with Corticosteroids)
    2. Agents
      1. Tacrolimus 0.1% cream
      2. Pimecrolimus 0.1% cream
    3. Efficacy
      1. Effective in facial and intertriginous Psoriasis
      2. Lebwohl (2004) J Am Acad Dermatol 51:723-30
    4. Adverse effects
      1. Risk of skin cancer and Lymphoma (especially in combination with UV Light Therapy)
  5. Adjunctive agents in combination with above
    1. Topical Salicylic Acid (Keratolytic Agent)
  6. Poorly tolerated topicals (use Calcipotriene instead)
    1. Historically used with UVB light exposure
    2. Anthralin (Anthra-Derm)
    3. Coal Tar (e.g. Zetar)
      1. Effective and inexpensive
      2. Consider in patients who can not afford other options

XIV. Management: Ultraviolet Light

  1. Risk of non-Melanoma skin cancer
  2. Protocols
    1. Ultraviolet B exposure alone
    2. Ultraviolet A exposure with psoralen (PUVA)
      1. Increased risk of non-Melanoma skin cancer

XV. Management: Systemic agents (most are higher risk)

  1. Immunosuppressants
    1. Etretinate
    2. Cyclosporine
    3. Methotrexate (unclear efficacy)
  2. Systemic retinoids (oral)
    1. Acitretin (Soriatane)
      1. Slow onset over 3-6 months
      2. Most effective in combination with Phototherapy
      3. Similar adverse effects to Accutane
        1. Highly Teratogenic (do not use in pregnancy)
  3. Biologic agents (Cost from $10k to >$20k/year)
    1. Tumor necrosis factor (tnf) receptor blockers
      1. Adalimumab (Humira)
      2. Ustekinumab (Stelara)
      3. Etanercept (Enbrel)
        1. Leonardi (2003) N Engl J Med 349:2014-22
      4. Infliximab (Remicade)
        1. Winterfield (2004) Dermatol Clin 22:437-47
    2. Other mechanisms
      1. Alefacept (Amevive)
      2. Efalizumab (Raptiva)
        1. Lebwohl (2003) N Engl J Med 349:2004-13
  4. Thiazolidinedione (Actos) - experimental
    1. Appears effective in Psoriasis even in non-diabetics
    2. Only small trials support to date
    3. Ellis (2000) Arch Dermatol 136(5):609-16

Images: Related links to external sites (from Google)

Ontology: Psoriasis (C0033860)

Definition (NCI) A common genetically determined, chronic, inflammatory skin disease characterized by rounded erythematous, dry, scaling patches. Psoriatic lesions have a predilection for nails, scalp, genitalia, extensor surfaces, and the lumbosacral region; the pathology involves an accelerated epidermopoiesis. Psoriasis is associated with increased risk for melanoma, squamous cell carcinoma, and basal cell carcinoma.
Definition (MEDLINEPLUS)

Psoriasis is a skin disease that causes itchy or sore patches of thick, red skin with silvery scales. You usually get them on your elbows, knees, scalp, back, face, palms and feet, but they can show up on other parts of your body. A problem with your immune system causes psoriasis. In a process called cell turnover, skin cells that grow deep in your skin rise to the surface. Normally, this takes a month. In psoriasis, it happens in just days because your cells rise too fast.

Psoriasis can last a long time, even a lifetime. Symptoms come and go. Things that make them worse include

  • Infections
  • Stress
  • Dry skin
  • Certain medicines

Psoriasis usually occurs in adults. It sometimes runs in families. Treatments include creams, medications and light therapy.

NIH: National Institute of Arthritis and Musculoskeletal and Skin Diseases

Definition (MSH) A common genetically determined, chronic, inflammatory skin disease characterized by rounded erythematous, dry, scaling patches. The lesions have a predilection for nails, scalp, genitalia, extensor surfaces, and the lumbosacral region. Accelerated epidermopoiesis is considered to be the fundamental pathologic feature in psoriasis.
Definition (CSP) common polygenetically determined, chronic, squamous dermatosis characterized by rounded erythematous, dry, scaling patches.
Definition (NCI) A chronic disease of the skin marked by red patches covered with white scales.
Concepts Disease or Syndrome (T047)
MSH D011565
ICD10 L40 , L40.9
SnomedCT 156369008, 200978009, 200961000, 9014002, 156371008, 267851002
English Psoriases, Psoriasis, PSORIASIS, Psoriasis, NOS, Psoriasis NOS, Psoriasis unspecified, Psoriasis, unspecified, psoriasis (diagnosis), psoriasis, Psoriasis unspecified (disorder), Psoriasis NOS (disorder), Psoriasis [Disease/Finding], psoriases, psoriasi, psoriasys, psoriase, Psoriasis (disorder)
French PSORIASIS, Psoriasis
Portuguese PSORIASE, Psoriase, Psoríase
Spanish PSORIASIS, Psoriasis NOS, Psoriasis, psoriasis (trastorno), psoriasis no especificada (trastorno), psoriasis no especificada, psoriasis, SAI (trastorno), psoriasis, SAI, psoriasis, soriasis
German PSORIASIS, Psoriasis, nicht naeher bezeichnet, Psoriasis, Schuppenflechte
Japanese 乾癬, カンセン
Swedish Psoriasis, PSORIASIS
Czech lupénka, psoriáza, Psoriáza
Finnish Psoriaasi, PSORIASIS
Russian PSORIAZ, LADONNO-PODOSHVENNYI PUSTULEZ, ЛАДОННО-ПОДОШВЕННЫЙ ПУСТУЛЕЗ, ПСОРИАЗ
Norwegian PSORIASIS MED/UTEN ARTROPATI
Danish Psoriasis
Hungarian psoriasis, Psoriasis
Korean 건선, 상세불명의 건선
Croatian PSORIJAZA
Basque ARTROPATIADUN EDO GABEKO SORIASIA
Hebrew psoriazis
Polish Łuszczyca
Dutch Psoriasis, niet gespecificeerd, psoriasis, Psoriasis
Italian Psoriasi

Ontology: Pustular psoriasis (C0152081)

Concepts Disease or Syndrome (T047)
SnomedCT 200901002, 200973000
English PSEUDOPSORIASIS, PUSTULAR, PSORIASIS, PUSTULAR, Pustular psoriasis, PSORIASIS PUSTULAR, psoriasis pustular, pustular psoriasis, Pustular psoriasis (disorder), psoriasis; pustular, pustular; psoriasis, Psoriasis pustular
Dutch pustulaire psoriasis, psoriasis pustulair, psoriasis; pustulosa, pustulosa; psoriasis
French Psoriasis pustulaire, PSORIASIS PUSTULEUX
Italian Psoriasi pustolosa
Portuguese Psoríase pustulosa, PSORIASE PUSTULOSA
Spanish Psoriasis pustular, Pustular psoriasis, psoriasis pustulosa (trastorno), psoriasis pustulosa
Japanese 膿疱性乾癬, ノウホウセイカンセン
German PSORIASIS PUSTULAER, Psoriasis pustulosa
Czech Pustulózní psoriáza
Hungarian Pustulosus psoriasis, psoriasis pustulosa

Ontology: Guttate psoriasis (C0343052)

Concepts Disease or Syndrome (T047)
ICD10 L40.4
SnomedCT 37042000, 156371008, 267851002
Dutch gespikkelde psoriasis, guttata; psoriasis, psoriasis; guttata, Psoriasis guttata
French Psoriasis en gouttes
Italian Psoriasi guttata
Portuguese Psoríase em gotas
Spanish Psoriasis gutata, Guttate psoriasis, psoriasis en gotas (trastorno), psoriasis en gotas, psoriasis guttata, soriasis en gotas, soriasis guttata
Japanese 滴状乾癬, テキジョウカンセン
Czech Psoriasis guttata
Korean 물방울 건선
English psoriasis guttate, psoriasis guttata, Guttate psoriasis, Psoriasis guttata, Guttate psoriasis (disorder), guttata; psoriasis, psoriasis; guttata, guttate psoriasis
Hungarian Psoriasis guttata
German Psoriasis guttata

Ontology: Flexural psoriasis (C0343053)

Concepts Disease or Syndrome (T047)
ICD10 L40.8
SnomedCT 238600001
Dutch flexurale psoriasis, gewrichtsplooi; psoriasis, psoriasis; gewrichtsplooi
French Psoriasis aux plis de flexion
German Psoriasis inversa
Italian Psoriasi di piega
Portuguese Psoríase das superfícies de flexão
Spanish Psoriasis en superficie flexora, psoriasis de los pliegues (trastorno), psoriasis de los pliegues
Japanese 屈側性乾癬, クッソクセイカンセン
Czech Flexurální psoriáza
Hungarian Flexuralis psoriasis
English Flexural psoriasis, Flexural psoriasis (disorder), flexural; psoriasis, psoriasis; flexural

Ontology: Chronic small plaque psoriasis (C0406317)

Concepts Disease or Syndrome (T047)
ICD10 L40.0
SnomedCT 200965009, 402308005
English plaque psoriasis, Discoid psoriasis, Nummular psoriasis, Plaque psoriasis, Chronic small plaque psoriasis (disorder), Chronic small plaque psoriasis, Plaque psoriasis (disorder), en plaques; psoriasis, nummular; psoriasis, psoriasis; nummular, psoriasis; plaque
Spanish Psoriasis en placas, placa de psoriasis (trastorno), placa de psoriasis, placa de soriasis, psoriasis crónica en pequeñas placas (trastorno), psoriasis crónica en pequeñas placas, psoriasis discoide, psoriasis numular, soriasis discoide, soriasis numular
Portuguese Psoríase em placas
Italian Psoriasi a placche
German Plaque-Psoriasis
French Psoriasis en plaques
Dutch plaque psoriasis, en plaques; psoriasis, nummularis; psoriasis, psoriasis; en plaques, psoriasis; nummularis
Czech Ložisková lupénka
Japanese 乾癬性局面, カンセンセイキョクメン
Hungarian Plakk psoriasis

Ontology: Psoriatic nail pitting (C0406324)

Concepts Disease or Syndrome (T047)
SnomedCT 238606007
English Psoriatic nail pitting, Psoriatic nail pitting (disorder)
Spanish punteado ungueal psoriásico (trastorno), punteado ungueal psoriásico

Ontology: Psoriatic onycholysis (C0406325)

Concepts Disease or Syndrome (T047)
SnomedCT 238607003
English Psoriatic onycholysis, Psoriatic onycholysis (disorder)
Spanish onicólisis psoriática (trastorno), onicólisis psoriática

Ontology: Erythrodermic psoriasis (C0748052)

Concepts Disease or Syndrome (T047)
SnomedCT 200977004, 56210000
English Exfoliative derm due psoriasis, PSORIASIS EXFOLIATIVE, psoriasis erythrodermic, erythrodermic psoriasis, Erythrodermic psoriasis, Exfoliative dermatitis due to psoriasis, Erythrodermic psoriasis (disorder), Exfoliative psoriasis, Psoriatic erythrodermia
Dutch erythrodermische psoriasis, psoriatische erythrodermie
French Psoriasis érythrodermique, Erythrodermie psoriasique
Italian Psoriasi eritrodermica, Eritrodermia psoriasica
Portuguese Psoríase eritrodérmica, Eritrodermia psoriática
Spanish Psoriasis eritrodérmica, Eritrodermia psoriásica, psoriasis eritrodérmica, soriasis eritrodérmica (trastorno), psoriasis eritrodérmica (trastorno), soriasis eritrodérmica
Japanese 乾癬性紅皮症, カンセンセイコウヒショウ
Czech Psoriatická erytrodermie, Erytrodermní psoriáza
Hungarian Psoriasisos erythrodermia, Erythrodermiás psoriasis
German Psoriasis erythrodermica