Edit concept Question Editor Create issue ticket

Psoriasis

Psoriases

Psoriasis is a chronic, multifactorial, inflammatory disease, characterized by circumscribed, scaling, erythematous macules, papules and plaques. They frequently occur on the skin of the elbows and knees, but can affect any area. Exacerbations and remissions are typical and often related to systemic or environmental factors, including stress and infection. Common types of psoriasis include psoriasis vulgaris, plaque psoriasis, guttate psoriasis, inverse psoriasis, pustular psoriasi and psoriatic arthritis. Diagnosis is based on evaluation of characteristic lesions.


Presentation

Signs and symptoms of psoriasis may include the following [7]:

  • Family history of similar skin condition
  • Pruritus (mostly seen in eruptive, guttate psoriasis)
  • Cutaneous erythematous plaques, pustules or small papules
  • Erythema and scaling
  • Joint pain
  • Pain (mostly seen in erythrodermic psoriasis and in some instances of traumatized plaques or in the joints affected by psoriatic arthritis)
  • Dystrophic nails
  • Recent streptococcal throat infection, immunization, viral infection, use of antimalarial drug, or trauma
  • Eye related findings are seen in around 10% of patients and conjunctivitis or blepharitis are the most common ocular symptoms.
Pain
  • Owing to its location and manifestations, palmoplantar psoriasis is associated with greater pain, functional limitations, and significant impairment of health-related quality of life.[ncbi.nlm.nih.gov]
  • Signs and symptoms of psoriasis may include the following: Family history of similar skin condition Pruritus (mostly seen in eruptive, guttate psoriasis) Cutaneous erythematous plaques, pustules or small papules Erythema and scaling Joint pain Pain (mostly[symptoma.com]
  • Additional skin cells form thick scales and red fixes which are awfully itchy and sometimes painful. Although there are many therapeutic systems available to get symptomatic relief, unfortunately replete cure for psoriasis is not yet reported.[ncbi.nlm.nih.gov]
  • Abstract A 44-year-old woman with cutaneous psoriasis and no history of joint involvement recently treated with adalimumab was admitted to the inpatient Internal Medicine service for uncontrolled, severe joint pain so debilitating that it limited her[ncbi.nlm.nih.gov]
  • Both topical and intralesional therapies are safe and effective treatment modalities for nail disease, but are limited by poor adherence and pain, respectively.[ncbi.nlm.nih.gov]
Fever
  • During the start of these cycles, von Zumbusch psoriasis can cause fever, chills, weight loss and fatigue. Palmoplantar pustulosis This causes pustules to appear on the palms of your hands and the soles of your feet.[nhs.uk]
  • Tell your provider if you have joint pain or fever with your psoriasis attacks. If you have symptoms of arthritis, talk to your dermatologist or rheumatologist.[nlm.nih.gov]
Nail Abnormality
  • Fawcett RS, Linford S, Stulberg DL (2004) Nail abnormalities: clues to systemic disease. Am Fam Physician 69(6):1417–1424 PubMed Google Scholar 7.[oadoi.org]
  • See 15 Fingernail Abnormalities: Nail the Diagnosis, a Critical Images slideshow, to help identify conditions associated with various nail abnormalities.[emedicine.com]
Blepharitis
  • An elderly male with palmoplantar psoriasis developed periocular psoriasis in the form of blepharitis and conjunctivitis following an external dacryocystorhinostomy as a manifestation of Koebner phenomenon.[ncbi.nlm.nih.gov]
  • Patients with psoriasis had statistically higher incidences of dry eye (16.28%), likely dry eye (32.56%), and blepharitis (16.28%).[ncbi.nlm.nih.gov]
  • […] or in the joints affected by psoriatic arthritis) Dystrophic nails Recent streptococcal throat infection, immunization, viral infection, use of antimalarial drug, or trauma Eye related findings are seen in around 10% of patients and conjunctivitis or blepharitis[symptoma.com]
  • Certain eye disorders — such as conjunctivitis, blepharitis and uveitis — are more common in people with psoriasis. Obesity. People with psoriasis, especially those with more severe disease, are more likely to be obese.[mayoclinic.org]
Arthritis
  • Merola and Sara Davin, The psychosocial burden of psoriatic arthritis, Seminars in Arthritis and Rheumatism, 47, 3, (351), (2017).[doi.org]
  • Up to 30% of patients with psoriasis also develop psoriatic arthritis, a chronic inflammatory and progressive arthritis.[ncbi.nlm.nih.gov]
  • Psoriatic arthritis. Semin Arthritis Rheum. 1973;3:55-78. [ Links ] Hukuda S, Minami M, Saito T, Mitsui H, Matsui N, Komatsubara Y, et al.[scielo.br]
  • Abstract The 2017 Annual Meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) was held in Amsterdam, the Netherlands, and was attended by rheumatologists, dermatologists, representatives of biopharmaceutical companies[ncbi.nlm.nih.gov]
Arthralgia
  • In this case, the skin tightening was successfully improved and ustekinumab was more effective, even though oral prednisolone (9-12 mg/day) had some effect on skin tightening and arthralgia.[ncbi.nlm.nih.gov]
  • Patients may have a preceding history of psoriasis, although this is not a requirement. [11] Constitutional signs and symptoms include headache, fever, chills, arthralgia, malaise, anorexia, and nausea.[emedicine.com]
Joint Deformity
  • Some of those who suffer from the disease develop chronic, inflammatory arthritis (psoriatic arthritis) that leads to joint deformations and disability.[who.int]
Eczema
  • Skin conditions such as psoriasis and eczema negatively impact the patient's quality of life; the primary goal of topical treatments is to minimize the disease-specific symptoms.[ncbi.nlm.nih.gov]
  • . — Jessica Cruel, SELF, "Dandruff Scraping Videos Are the New Pimple Popping Videos," 19 July 2018 In some cases, chronic skin conditions like eczema or psoriasis are to blame, Dr.[merriam-webster.com]
  • Eczema Eczema (also known as atopic dermatitis) can develop at any age, even during infancy. It usually begins before age 5. About 40 percent of children "grow out" of their eczema, but others experience flare-ups throughout their lives.[verywell.com]
  • View as slideshow Conditions Although separate conditions, eczema and psoriasis share the symptoms of painfully dry, tight, and itchy skin.[rd.com]
  • Eczema and psoriasis, pityriasis, impetigo, and porrigo decalvans are forms of skin eruption seen. In psoriasis it is a fairly good remedy, but inferior to crysarobin in P. inveterata.[thesaurus.com]
Erythema
  • HP/TAZ lotion was also superior in maintaining reductions in psoriasis signs of erythema, plaque elevation, and scaling at the target lesion.[ncbi.nlm.nih.gov]
  • The patient presented with tender swelling and erythema of both auricles, and the antibody to type II collagen was detected. The biopsy specimen revealed a dense mixed cell infiltration over the auricular cartilage.[ncbi.nlm.nih.gov]
  • Abstract Psoriasis is a dermatosis with the major clinical symptoms of scale, erythema and itching, and it has a long disease course. In addition, it is easily recurrent and refractory, greatly affecting the physical and mental health of patients.[ncbi.nlm.nih.gov]
  • This enhanced efficacy was more apparent in decreasing scaling and thickness as compared to decrease in erythema. Secondly, combination therapy showed faster clearance of target plaques, with reduction in mean number of treatment sessions.[ncbi.nlm.nih.gov]
  • Psoriasis response was determined by clinical resolution of psoriatic plaques in terms of erythema, induration, scaling and stoma bag adherence. RESULTS: Of 1665 patients, 78 (4.7%) had psoriasis affecting their abdominal stoma.[ncbi.nlm.nih.gov]
Dry Skin
  • They are a valuable first-line treatment, as dry skin is common and adds to the irritability of the diseased skin.[ncbi.nlm.nih.gov]
  • That therapy produced only 1 adverse effect (dry skin near the lesions on the patient's arms and legs) and was relatively inexpensive.[ncbi.nlm.nih.gov]
Koebner Phenomenon
  • Abstract Koebner phenomenon is the development of isomorphic pathologic lesions on a wound of a patient with preexisting cutaneous disease, most commonly psoriasis.[ncbi.nlm.nih.gov]
  • Psoriasis treatment should include skin hydration (regular use of moisturizers and emollients), careful, gentle skin cleansing, and identification and avoidance of Koebner phenomenon triggers (excoriation, maceration) and infectious foci (Streptococcus[ncbi.nlm.nih.gov]
  • Psoriasis treatment should include skin hydration (regular use of moisturizers and emollients), careful, gentle skin cleansing, and identification and avoidance of Koebner phenomenon triggers (excoriation, maceration) and infectious foci ( Streptococcus[doi.org]
Pruritus
  • BACKGROUND: Psoriasis is a chronic and prevalent disease, and the associated pruritus is a common, difficult-to-control symptom. The mediators involved in psoriatic pruritus have not been fully established.[ncbi.nlm.nih.gov]
  • These result in erythema and in some cases, pruritus. If left untreated, acute erythrodermic psoriasis and generalised psoriasis may become life threatening.[symptoma.com]
  • Antihistamines and topical steroids may be used to treat pruritus, and systemic corticosteroids may be used for extreme pruritus. 18 The rash typically resolves one to two weeks after delivery.[aafp.org]
  • Reich A, Hrehorow E, Szepietowski JC (2010) Pruritus is an important factor negatively influencing the well-being of psoriatic patients. Acta Derm Venereol 90:257–263 PubMed Google Scholar 44.[doi.org]

Workup

The diagnosis of psoriasis is mostly clinical. Laboratory findings are useful in differentiating between psoriatic arthritis and rheumatoid arthritis and a typical laboratory finding showing psoriasis will produce the following results: [8].

  • Negative test result for rheumatoid factor (RF) 
  • Normal Erythrocyte sedimentation rate (ESR) (except in pustular and erythrodermic psoriasis)
  • Elevated Uric acid level may be in psoriasis (especially in pustular psoriasis)
  • Fluid from pustules is sterile with neutrophilic infiltrate

In cases of hands and foot psoriasis where the use of topical steroids appear to be worsening the situation, fungal studies should also be performed.

HLA-Cw6
  • Luszczek W, Kubicka W, Cislo M et al (2003) Strong association of HLA-Cw6 allele with juvenile psoriasis in Polish patients. Immunol Lett 85:59–64 PubMed CrossRef Google Scholar 32.[doi.org]
  • Gudjonsson, Andrew Johnston and Helgi Valdimarsson, HLA-Cw6 homozygosity in plaque psoriasis is associated with streptococcal throat infections and pronounced improvement after tonsillectomy: A prospective case series, Journal of the American Academy[doi.org]
  • This illness is closely linked with some human leukocyte antigen alleles (HLA alleles) especially the human leukocyte antigen Cw6 (HLA-Cw6). Psoriasis is an autosomal dominant trait in some families.[symptoma.com]
  • Polygenic disorder with strong HLA-association, mainly with HLA-Cw6. With both parents affected, risk for offspring is 65%; if in addition a sibling is affected, the risk rises to 83%.[clinicaladvisor.com]

Treatment

Management of psoriasis may involve drugs, light therapy, stress reduction, climatotherapy, and various adjuncts such as sunshine, moisturizers, and salicylic acid [9].

Expert dermatologists from across the globe released a consensus report on treatment optimization and transitioning for moderate-to-severe plaque psoriasis. The recommendations are covered below:

  • Methotrexate may be used for as long as it remains effective and well-tolerated.
  • Cyclosporine is generally used intermittently for inducing a clinical response with one or several courses over a 3–6 month period.
  • Transition from conventional systemic therapy to a biological agent may be done directly or with an overlap if transitioning is needed because of lack of efficacy, or with a treatment-free interval if transitioning is needed for safety reasons.
  • Combination therapy may be helpful.
  • Continuous therapy for patients receiving biologicals is recommended.

Prognosis

Psoriasis is generally not life threatening in most cases but it causes some inconvenience [6]. It is a however, a chronic disease and may reoccur is some cases. The peeling, splitting of skins can bring about pain and self-esteem issues. Therefore, psoriasis affects a patient’s quality of life as the individual will have to deal with embarrassment about appearance and self-consciousness. This is not forgetting the cost of remedy.

Etiology

The major causes of keratinocyte turnover remain unknown till date. However, it has been proven that environmental, immunologic and genetic factors all seem to play different roles in the development of the condition [2].

Environmental factors

Stress has been postulated as a major cause but apart from this, other factors have equally been known to trigger the exacerbation of the condition. The factors include trauma, infections, alcohol and drug use. Evidence also exists towards the increased incidence of psoriasis in patients that have been diagnosed with chronic gingivitis. With treatment of the gingivitis came improved control of the psoriasis, however, the long term incidence was not affected. This gives further proof to the fact that there is a multifactorial and genetic influence as far as the disease etiology is concerned.

Genetic factors

The gene locus has been determined therefore, patients with psoriasis definitely have a genetic predisposition for the condition. It is not yet clear what the triggering event maybe for most cases but there is a high possibility that the event is immunologic. The first lesion arising from the condition is seen often after an upper respiratory infection.

This illness is closely linked with some human leukocyte antigen alleles (HLA alleles) especially the human leukocyte antigen Cw6 (HLA-Cw6). Psoriasis is an autosomal dominant trait in some families [3].

According to evidence, there is a high level of dermal and circulating TNF-α suggesting that Psoriasis is an autoimmune condition. This may be why treatment with TNF-α inhibitors has proven successful in some cases. The psoriatic lesions are linked with increased T-cell activity beneath the underlying skin area.

Another important factor to keep in mind is the fact that 2.5% of people with HIV see worsening cases of psoriasis as CD4 continues to decrease.

Epidemiology

There are 970-2300 cases of psoriasis for every 100,000 people around the world, an incidence of 1% to 3%.

Psoriasis can be seen at any age but it is most common in adults aged 20-30 years [4]. There is no sexual predilection and the condition is rarely seen in people of African descent. One out of 3 patients has a positive family history suggesting familial clustering. Risk of getting affected with the condition increases with a first degree relative being affected but the risk increases to 60% when both parents are either affected now or where affected in the past.

Sex distribution
Age distribution

Pathophysiology

As pointed out earlier, psoriasis is multifactorial and complex and it appears to be influenced by immune mediated as well as genetic components. This is of course supported by the fact that psoriasis has been treated successfully in the past with biologic medications and immune mediating medications.

The pathogenesis of the disease is still open to debates till date. There are varying theories as to what causes the disease and thus far, traumatic insult, stressful life events and infection have been mooted. In many patients however, no obvious triggers exist. As soon as the condition is triggered, there is substantial leukocyte recruitment to the dermis and epidermis and this is what causes the rather characteristic psoriatic plaques.

Keratinocyte proliferation arises when the epidermis gets infiltrated by an increased number of activated T-cells [5]. This fact is supported by histologic examination and immunohistochemical staining of psoriatic plaques which have shown large T cell populations within psoriatic lesions.

Finally, a hyper-inflated deregulated inflammatory sequence begins, followed by a strong production of different kinds of cytokines.

Prevention

There is no way to prevent psoriasis.

Summary

Psoriasis is a chronic disorder that is relatively common. It is characterised by excessive proliferation of keratinocytes which lead to the forming of thickened skin, inflammation and scaly plaques [1]. These result in erythema and in some cases, pruritus.

If left untreated, acute erythrodermic psoriasis and generalised psoriasis may become life threatening. Affected patients often need examination by a dermatologist and may be admitted to the hospital in some cases. Due to the sporadic course of the disease, it is often difficult to treat.

Patient Information

Psoriasis is skin disorder that is relatively common. It is a condition that changes the life cycles of skin cells. In doing so, it makes the cells to build up faster than normal on the skin's surface. The extra skin cells formed produce thick scales that are itchy and dry. The red patches that form may be  painful in some cases.  

This disease is chronic (long lasting) and the symptoms fluctuate in appearance. The symptoms may get better at certain times and at other times it may worsen. 

In treating the condition, the focus of the treatment is to stop the cells of the skin from growing rapidly. Although there is no cure for this condition treatment often offers significant relief. 

Exposure to small amounts of sunlight and the use of cortisone and other nonprescription creams can also help in the improvement of symptoms. 

References

Article

  1. Catsarou-Catsari A, Katambus A, Theodorpoylos P. Ophthalmological manifestations in patients with psoriasis. In: Acta Derm Venereol (Stock). 64. 1984:557-559.
  2. Huynh N, Cervantes-Castaneda RA, Bhat P, Gallagher MJ, Foster CS. Biologic response modifier therapy for psoriatic ocular inflammatory disease. Ocul Immunol Inflamm. May-Jun 2008;16(3):89-93.
  3. Menter A, Korman NJ, Elmets CA, Feldman SR, Gelfand JM, Gordon KB, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: section 4. Guidelines of care for the management and treatment of psoriasis with traditional systemic agents. J Am Acad Dermatol. Sep 2009;61(3):451-85.
  4. Mrowietz U, de Jong EM, Kragballe K, Langley R, Nast A, Puig L, et al. A consensus report on appropriate treatment optimization and transitioning in the management of moderate-to-severe plaque psoriasis. J Eur Acad Dermatol Venereol. Feb 26 2013.
  5. Christophers E, Sterry W. Psoriasis. In: Fitzpatrick TB, Eisen AZ, Wolff K, eds. Dermatology in General Medicine. New York: McGraw Hill; 1993:489-511.
  6. Parisi R, Symmons DP, Griffiths CE, et al. Global epidemiology of psoriasis: a systematic review of incidence and prevalence. J Invest Dermatol 2013; 133:377.
  7. Rachakonda TD, Schupp CW, Armstrong AW. Psoriasis prevalence among adults in the United States. J Am Acad Dermatol 2014; 70:512.
  8. Icen M, Crowson CS, McEvoy MT, et al. Trends in incidence of adult-onset psoriasis over three decades: a population-based study. J Am Acad Dermatol 2009; 60:394.
  9. Tollefson MM, Crowson CS, McEvoy MT, Maradit Kremers H. Incidence of psoriasis in children: a population-based study. J Am Acad Dermatol 2010; 62:979.
  10. Armstrong AW, Harskamp CT, Dhillon JS, Armstrong EJ. Psoriasis and smoking: a systematic review and meta-analysis. Br J Dermatol 2014; 170:304.

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2017-08-09 17:56