II. Epidemiology
- Bimodal peaks
- Young adulthood (ages 16 to 22 years old)
- Older age (late 50s)
- Prevalence: 1-2% of general population (U.S.)
- Men and women affected equally
III. Pathophysiology
- Underlying genetic predisposition is common (30% with Psoriasis also have a first degree relative with Psoriasis)
- Pathogenesis is likely a combination between genetic predisposition and exposure to inciting triggers
- Autoimmune
- Viral infection may precipitate process
- T-Cell-mediated autoimmune response
- Cytokines released and stimulate Keratinocytes
-
Keratinocytes proliferate
- Epidermal cells proliferate too fast
- Cells cycle in 4 days instead of normal 3-4 weeks
- Abnormal keratin production
- Dermal inflammation
- Epidermal cells proliferate too fast
IV. Risk Factors: Associated environmental factors
- Suppressed by:
- Sun and humidity
- Provocative
- Injury to skin (Koebner Reaction)
- Streptococcal Pharyngitis
- Emotional upset
- Tobacco Use
- Obesity
- Alcohol Abuse
- HIV Infection (severe exacerbations)
- Medications
- Antimalarials
- Beta Blockers (e.g. Propranolol)
- Lithium
- NSAIDS
V. Symptoms
-
Pruritus is present in >80% of psorisis
- Psora is greek for itching
VI. Signs: Chronic Plaque Psoriasis (90% of cases)
VII. Signs: Associated findings
- Location specific signs
- Nail (Psoriatic Onychodystrophy)
- Lifetime Prevalence in up to 90% of Psoriasis patients (esp. Fingernails)
- Findings secondary to abnormal nail plate growth
- Nail Pitting
- Subungual hyperkeratosis
- Onycholysis
- Separation of distal edge of nail from nail bed
- Accumulation of crumbly subungual debris
- Gluteal cleft
- Eroded pinkness in crease
- Penis (genital involvement in 40% of cases)
- Large joints
- Hyperkeratosis over elbows, knees, and ankles
- Tongue
- Geographic Tongue (rare)
- Nail (Psoriatic Onychodystrophy)
- Uncommon Clinical Variants
- Guttate Psoriasis (drop-like)
- Uncommon, accounting for only 2% of Psoriasis cases
- Typically affects younger patients, under age 30 years
- Trunk lesions are 1-10 mm Papules with fine scale
- Commonly occurs following Streptococcal Pharyngitis or Upper Respiratory Infection
- Inverse Psoriasis (flexural)
- Less scale present than in Plaque form
- Affects flexor surfaces (inframammary, axillary and inguinal folds)
- Affects perineal and intergluteal regions
- Palmoplantar Pustulosis (Pustular Psoriasis)
- Erythrodermic Psoriasis (Erythroderma)
- Broad-spread generalized erythema
- Systemic symptoms are typically present
- Guttate Psoriasis (drop-like)
- Systemic Signs
- Psoriatic Arthritis
- Uveitis (up to 20% of Psoriatic Arthritis cases)
- Severe widespread Psoriasis systemic signs
- Benign Lymphadenopathy
- Fever, chills, and Hyperthermia
- Increased cardiac demand
- High output Heart Failure
- Increased Sedimentation Rate and Uric Acid
- Decreased Serum Albumin
- Iron Deficiency Anemia
VIII. Differential diagnosis
- Lichen Simplex Chronicus
- Nummular Eczema
- Seborrheic Dermatitis
- Tinea Corporis
- Group A Beta Hemolytic Streptococcus
- May present as Guttate Psoriasis in children
- Obtain ASO Titer and Throat Culture
IX. Associated Conditions (related to psoriatic medications)
-
Inflammatory Bowel Disease (Crohns' Disease or Ulcerative Colitis)
- Risk increased 3.8 to 7.5x
- Malignancy
- Squamous Cell Skin Cancer
- Risk increased 14x associated with PUVA in caucasians
- Lymphoma
- Risk increased 1.3 to 3x
- Squamous Cell Skin Cancer
-
Major Depression
- Prevalence: 60% of Psoriasis patients
- Other associated conditions with increased risk
X. Management: Moderate Chronic Plaque Psoriasis
- Trunk and extensor surface involvement
- Initial and exacerbation therapy (<4 weeks only)
- Protocol 1: Steroid and Calcipotriene
- High potency Topical Corticosteroid qAM
- Calcipotriene applied qPM
- Protocol 2: Single agent
- High potency Topical Corticosteroid or
- Calcipotriene or
- Tazorotene (Tazorac)
- Protocol 1: Steroid and Calcipotriene
- Long-term maintenance (beyond 4 weeks)
- Calcipotriene or
- Tazorotene (Tazorac)
- Initial and exacerbation therapy (<4 weeks only)
- Flexor surface involvement
- Moderate Topical Corticosteroids (<4 weeks) or
- Tacrolimus or Pimecrolimus
- Scalp involvement
- Exacerbations
- Topical Corticosteroid (brief use)
- Example: Clobetasol 0.05% Shampoo
- Maintenance
- Exacerbations
- Adjuncts
- Lac-Hydrin or salicylic acid applied daily
XI. Management: Severe Chronic Plaque Psoriasis
- Criteria
- Psoriasis refractory to above therapy
- Chronic Plaque Psoriasis involving >5-20% of body
- Comorbid Psoriatic Arthritis
- Involvement of hands, feet, face or genitalia
- Protocol usually managed by dermatology
- Use above topical agents
- See Ultraviolet light below
- See Systemic Agents below
XII. Management: General Measures
- Soak lesions to ease adherent scale removal
- Apply skin Emollients (e.g. vaseline, aquaphor)
- Apply after soaks
- Apply 20 minutes after Corticosteroid application to boost steroid effect (similar to Occlusion)
- Consider Emollient only periods of steroid holiday
XIII. Management: Topical Preparations
-
Topical Corticosteroids
- Consider limiting potent steroids to 2-4 weeks at a time
- Then rotate to lower potency steroids or Emollient only periods until reexacerbation
- High Potency Topical Steroids (Usually indicated)
- Very high potency: e.g. Clobetasol (Temovate)
- High potency: e.g. Fluocinonide (Lidex)
- Low Potency Topical Steroids
- Face
- Genitals
- Maintenance Therapy
- Consider limiting potent steroids to 2-4 weeks at a time
-
Vitamin D based topicals
- Indicated for moderate Psoriasis involving 5-20% of body surface area
- Used alone or in combination with Phototherapy or Topical Corticosteroids
- Risk of Hypercalcemia in high dose exposure and Renal Insufficiency
- Preparations
- Calcipotriene (Dovonex)
- Calcitriol (Vectical)
- May be less irritating than Calcipotriene (Dovonex)
-
Retinoid based topicals
- Tazarotene (Tazorac)
- More irritating than Calcipotriene
- As effective as Corticosteroids, but with longer disease-free periods
- Do not use in pregnancy (Teratogenic)
- Immunosuppressant based topicals
- Indications
- Effective in facial and intertriginous Psoriasis (due to less skin atrophy than with Corticosteroids)
- Agents
- Tacrolimus 0.1% cream
- Pimecrolimus 0.1% cream
- Efficacy
- Effective in facial and intertriginous Psoriasis
- Lebwohl (2004) J Am Acad Dermatol 51:723-30 [PubMed]
- Adverse effects
- Risk of skin cancer and Lymphoma (especially in combination with UV Light Therapy)
- Indications
- Adjunctive agents in combination with above
- Topical Salicylic Acid (Keratolytic Agent)
- Poorly tolerated topicals (use Calcipotriene instead)
- Historically used with UVB light exposure
- Anthralin (Anthra-Derm)
- Coal Tar (e.g. Zetar)
- Effective and inexpensive
- Consider in patients who can not afford other options
XIV. Management: Ultraviolet Light
- Risk of non-Melanoma skin cancer
- Protocols
- Ultraviolet B exposure alone
- Ultraviolet A exposure with psoralen (PUVA)
- Increased risk of non-Melanoma skin cancer
XV. Management: Systemic agents (most are higher risk) for moderate to severe Psoriasis
- Immunosuppressants
- Methotrexate
- Typically trialed as a first-line systemic agent (unclear efficacy)
- See Methotrexate for monitoring guidelines
- Folic Acid 1-5 mg daily (except for the day Methotrexate is taken) reduces adverse effects
- Cyclosporine
- Used as a rescue agent for flares in refractory cases for up to 12 weeks
- Monitor Blood Pressure and Renal Function (see Cyclosporine for monitoring)
- Etretinate
- Methotrexate
- Systemic Retinoids (oral)
- Acitretin (Soriatane)
- Slow onset over 3-6 months
- Most effective in combination with Phototherapy (and Corticosteroids, Calcipotriene)
- Similar adverse effects to Accutane
- Acitretin (Soriatane)
-
Phosphodiesterase Inhibitor (Type 4)
- Apremilast (Otezla)
- Available as of 2015 in U.S.
- Does not require lab monitoring
- Expensive ($1875/month)
- Adverse effects include Diarrhea, Nausea, as well as weight loss and depression
- Avoid use with Strong Cytochrome P450-3A4 Inducers (e.g. Rifampin, Carbamazepine)
- Apremilast (Otezla)
- Biologic agents (Cost from $10k to >$20k/year)
- Tumor Necrosis Factor (tnf) receptor blockers
- Adalimumab (Humira)
- Preferred TNF agent
- Ustekinumab (Stelara)
- Preferred TNF agent
- Etanercept (Enbrel)
- Less effective than Adalimumab (Humira) and Ustekinumab (Stelara)
- Leonardi (2003) N Engl J Med 349:2014-22 [PubMed]
- Infliximab (Remicade)
- More adverse effects than other TNF agents
- Winterfield (2004) Dermatol Clin 22:437-47 [PubMed]
- Brodalumab (Siliq)
- Increased Suicide Risk
- Guselkumab (Tremfya)
- Adalimumab (Humira)
- Other mechanisms
- Alefacept (Amevive)
- Efalizumab (Raptiva)
- Cosentyx (secukinumab)
- New Interleukin-17a blocker available in U.S. in 2015
- Tumor Necrosis Factor (tnf) receptor blockers
- Experimental
- Thiazolidinedione (Actos)
- Appears effective in Psoriasis even in non-diabetics
- Only small trials support to date
- Ellis (2000) Arch Dermatol 136(5):609-16 [PubMed]
- Thiazolidinedione (Actos)
XVI. References
- (2015) Presc Lett 22(3): 16
- Hsu (2012) Arch Dermatol 148(1): 95-102 [PubMed]
- Luba (2006) Am Fam Physician 73:636-46 [PubMed]
- Mason (2002) Br J Dermatol 146:351-64 [PubMed]
- Menter (2008) J Am Acad Dermatol 58(5): 826-50 [PubMed]
- Teichman (2018) Am Fam Physician 97(2): 102-10 [PubMed]
- Weigle (2013) Am Fam Physician 87(9): 626-33 [PubMed]
Images: Related links to external sites (from Bing)
Related Studies
Definition (MEDLINEPLUS) |
Psoriasis is a skin disease that causes itchy or sore patches of thick, red skin with silvery scales. You usually get the patches on your elbows, knees, scalp, back, face, palms and feet, but they can show up on other parts of your body. Some people who have psoriasis also get a form of arthritis called psoriatic arthritis. 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 be hard to diagnose because it can look like other skin diseases. Your doctor might need to look at a small skin sample under a microscope. Psoriasis can last a long time, even a lifetime. Symptoms come and go. Things that make them worse include
Psoriasis usually occurs in adults. It sometimes runs in families. Treatments include creams, medicines, and light therapy. NIH: National Institute of Arthritis and Musculoskeletal and Skin Diseases |
Definition (NCI) | An autoimmune condition characterized by red, well-delineated plaques with silvery scales that are usually on the extensor surfaces and scalp. They can occasionally present with these manifestations: pustules; erythema and scaling in intertriginous areas, and erythroderma, that are often distributed on extensor surfaces and scalp.(NICHD) |
Definition (NCI_NCI-GLOSS) | A chronic disease of the skin marked by red patches covered with white scales. |
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. |
Concepts | Disease or Syndrome (T047) |
MSH | D011565 |
ICD10 | L40 , L40.9 |
SnomedCT | 156369008, 200978009, 156371008, 267851002, 200961000, 9014002 |
LNC | LA15165-6 |
English | Psoriases, Psoriasis, PSORIASIS, Psoriasis NOS, Psoriasis unspecified, Psoriasis, unspecified, psoriasis (diagnosis), psoriasis, Psoriasis [Disease/Finding], psoriases, psoriasi, Psoriasis NOS (disorder), Psoriasis unspecified (disorder), Psoriasis (disorder), Psoriasis, NOS |
French | PSORIASIS, Psoriasis |
Portuguese | PSORIASE, Psoríase |
Spanish | PSORIASIS, psoriasis no especificada (trastorno), psoriasis, SAI, psoriasis, SAI (trastorno), psoriasis no especificada, psoriasis (trastorno), psoriasis, soriasis, Psoriasis |
German | PSORIASIS, Psoriasis, nicht naeher bezeichnet, Psoriasis, Schuppenflechte |
Japanese | 乾癬, カンセン |
Swedish | Psoriasis |
Czech | lupénka, psoriáza, Psoriáza |
Finnish | Psoriaasi |
Russian | PSORIAZ, LADONNO-PODOSHVENNYI PUSTULEZ, ЛАДОННО-ПОДОШВЕННЫЙ ПУСТУЛЕЗ, ПСОРИАЗ |
Korean | 건선, 상세불명의 건선 |
Croatian | PSORIJAZA |
Polish | Łuszczyca |
Hungarian | Psoriasis |
Norwegian | Psoriasis |
Dutch | Psoriasis, niet gespecificeerd, psoriasis, Psoriasis |
Italian | Psoriasi |
Ontology: Guttate psoriasis (C0343052)
Concepts | Disease or Syndrome (T047) |
ICD10 | L40.4 |
SnomedCT | 156371008, 267851002, 37042000 |
Dutch | gespikkelde psoriasis, guttata; psoriasis, psoriasis; guttata, Psoriasis guttata |
French | Psoriasis en gouttes |
Italian | Psoriasi guttata |
Portuguese | Psoríase em gotas |
Spanish | Psoriasis gutata, 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 guttata, psoriasis guttate, guttate psoriasis (diagnosis), guttate psoriasis, Guttate psoriasis, Psoriasis guttata, Guttate psoriasis (disorder), guttata; psoriasis, psoriasis; guttata |
Hungarian | Psoriasis guttata |
German | Psoriasis guttata |
Ontology: Flexural psoriasis (C0343053)
Concepts | Disease or Syndrome (T047) |
ICD10 | L40.8 |
SnomedCT | 238600001, 25847004 |
Dutch | psoriasis inversa, flexurale psoriasis, gewrichtsplooi; psoriasis, psoriasis; gewrichtsplooi |
French | Psoriasis aux plis de flexion, Psoriasis inversé |
German | Psoriasis inversa, inverse Psoriasis |
Italian | Psoriasi di piega, Psoriasi inversa |
Portuguese | Psoríase das superfícies de flexão, Psoríase inversa |
Spanish | Psoriasis inversa, Psoriasis en superficie flexora, psoriasis de los pliegues (trastorno), psoriasis de los pliegues |
Japanese | 逆型乾癬, 屈側性乾癬, クッソクセイカンセン, ギャクガタカンセン |
Czech | Flexurální psoriáza, Inverzní psoriáza |
English | inverse psoriasis, Inverse psoriasis, Flexural psoriasis, psoriasis inverse, psoriasis inverse (diagnosis), Flexural psoriasis (disorder), flexural; psoriasis, psoriasis; flexural |
Hungarian | Flexuralis psoriasis, Inverz psoriasis |
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 |
Hungarian | Plakk psoriasis |
Japanese | キョクメンガタカンセン, 局面型乾癬 |
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 | 56210000, 200977004 |
English | Exfoliative derm due psoriasis, psoriasis erythrodermic, erythrodermic psoriasis, Erythrodermic psoriasis, Exfoliative dermatitis due to psoriasis, Erythrodermic psoriasis (disorder), Exfoliative psoriasis, Psoriatic erythrodermia |
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), soriasis eritrodérmica, psoriasis eritrodérmica (trastorno) |
Dutch | psoriatische erythrodermie, erytrodermische psoriasis |
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 |