Psoriasis
Basic Dermatology Curriculum
Last updated March 28, 2011
1
Module Instructions
 The following module contains a number
of blue, underlined terms which are
hyperlinked to the dermatology glossary,
an illustrated interactive guide to clinical
dermatology and dermatopathology.
 We encourage the learner to read all the
hyperlinked information.
2
Goals and Objectives
 The purpose of this module is to help medical students
develop a clinical approach to the evaluation and initial
management of patients presenting with psoriasis.
 By completing this module, the learner will be able to:
•
•
•
•
•
Identify and describe the morphology of psoriasis
Describe associated triggers or risk factors for psoriasis
Describe the clinical features of psoriatic arthritis
List the basic principles of treatment for psoriasis
Discuss the emotional and psychosocial impact of psoriasis
on patients
• Determine when to refer a patient with psoriasis to a
dermatologist
3
Psoriasis: The Basics
 Psoriasis is a chronic multisystem disease with
predominantly skin and joint manifestations
 Affects approximately 2% of the U.S. population
 Age of onset occurs in two peaks: ages 20-30 and ages
50-60, but can be seen at any age
 There is a strong genetic component
• About 30% of patients with psoriasis have a first-degree
relative with the disease
 Waxes and wanes during a patient’s lifetime, is often
modified by treatment initiation and cessation and has few
spontaneous remissions
4
Classification of Psoriasis
is based on morphology
 Plaque: scaly, erythematous patches, papules, and
plaques that are sometimes pruritic
 Inverse/Flexural: lesions are located in the skin folds
 Guttate: presents with drop lesions, 1-10mm
salmon-pink papules with a fine scale
 Erythrodermic: generalized erythema covering
nearly the entire body surface area with varying
degrees of scaling
 Pustular: clinically apparent pustules
5
Classification of Psoriasis
is based on morphology (cont.)
 Pustular psoriasis includes:
• Rare, acute generalized variety called “von
Zumbusch variant”
• Palmoplantar – localized involving palms and soles
 Clinical findings in patients frequently overlap in
more than one category
 Different types of psoriasis may require different
treatment
6
What Type of Psoriasis?
A
C
B
D
7
Guttate Psoriasis
 Acute onset of
raindrop-sized lesions
on the trunk and
extremities
 Often preceded by
streptococcal
pharyngitis
8
Another Example of Guttate
Psoriasis
9
Inverse/Flexural Psoriasis
 Erythematous plaques
in the axilla, groin,
inframammary region,
and other skin folds
 May lack scale due to
moistness of area
10
More Examples of
Inverse/Flexural Psoriasis
11
Pustular Psoriasis




Characterized by psoriatic lesions with pustules.
Often triggered by corticosteroid withdrawal.
When generalized, pustular psoriasis can be life-threatening.
These patients should be hospitalized and a dermatologist
consulted.
12
Palmoplantar Psoriasis
 May occur as either plaque type or pustular type.
 Often very functionally disabling for the patient.
 The skin lesions of reactive arthritis typically occur on the
palms and soles and are indistinguishable from this form
of psoriasis.
13
Psoriatic Erythroderma
 Involves almost the entire
skin surface; skin is bright
red
 Associated with fever, chills,
and malaise
 Like pustular psoriasis,
hospitalization is sometimes
required
See the module on Erythroderma
for more information
14
Question
 How would you describe these lesions?
 What type of psoriasis does this patient have?
15
Plaque Psoriasis
 Well-demarcated plaques with overlying silvery
scale and underlying erythema
 Chronic plaque psoriasis is typically symmetric
and bilateral
 Plaques may exhibit:
• Auspitz sign (bleeding
after removal of scale)
• Koebner phenomenon
(lesions induced by
trauma)
16
More Examples of Plaque
Psoriasis
17
Plaque Psoriasis: The Basics
 Plaque psoriasis is the most common form,
affecting 80-90% of patients
 Approximately 80% of patients with plaque
psoriasis have mild to moderate disease –
localized or scattered lesions covering less than
5% of the body surface area (BSA)
 20% have moderate to severe disease affecting
more than 5% of the BSA or affecting crucial
body areas such as the hands, feet, face, or
genitals
18
Psoriasis: Pathogenesis
 Psoriasis is a hyperproliferative state
resulting in thick skin and excess scale
 Skin proliferation is caused by cytokines
released by immune cells
 Systemic treatments of psoriasis target
these cytokines and immune cells
19
Case One
Mr. Ronald Gilson
20
Case One: History
 HPI: Mr. Gilson is a 24-year-old man who
presents with a red lesion around his belly
button that has been present for one
month with occasional itching.
 He has been reading on the internet and
asks: “Do I have psoriasis?”
21
Case One, Question 1
 What elements in the history are important
to ask when considering the diagnosis of
psoriasis?
a.
b.
c.
d.
e.
Family history
Medications
Recent illnesses / Past medical history
Social history
All of the above
22
Case One, Question 1
Answer: e
 What elements in the history are important
to ask when considering the diagnosis of
psoriasis?
a.
b.
c.
d.
e.
Family history
Medications
Recent illnesses / Past medical history
Social history
All of the above
23
Ask About Past Medical History
 Psoriasis can be triggered by infections, especially
streptococcal pharyngitis
 Psoriasis can be more severe in patients with HIV
 Up to 20% of psoriasis patients have psoriatic arthritis,
which can lead to joint destruction
 There is a positive correlation between increased BMI
and both prevalence and severity of psoriasis
 Patients with psoriasis may have an increased risk for
cardiovascular disease and should be encouraged to
address their modifiable cardiovascular risk factors
24
Ask About Medication History
 Psoriasis can be triggered or exacerbated
by a number of medications including:
•
•
•
•
•
Systemic corticosteroid withdrawal
Beta blockers
Lithium
Antimalarials
Interferons
25
Ask About Family History
 There is a strong genetic predisposition to
developing psoriasis
 1/3 of psoriasis patients have a positive family
history
• However, this means up to 2/3 of patients
with psoriasis do not have a family history
of psoriasis, so a negative family history
does not rule it out
26
Ask about Health-Related
Behaviors
 Studies have revealed smoking as a risk
factor for psoriasis
 Alcohol consumption is more prevalent in
patients with psoriasis and it may increase
the severity of psoriasis
 A higher BMI is associated with an
increased prevalence and severity of
psoriasis
27
Back to Case One
Mr. Ronald Gilson
Twenty-one year-old man with red lesion around his
umbilicus
28
Case One: History Continued





PMH: no major illnesses or hospitalizations
Medications: none
Allergies: none
Family history: adopted, unknown
Social history: lives with roommates in an
apartment, graduate student in physics
 Health-related behaviors: no tobacco or drug use,
consumes 3-6 beers on weekends
 ROS: negative
29
Psoriasis: Clinical Evaluation
 Although you should perform a total body
skin exam, plaque psoriasis tends to
appear in characteristic locations
• Key Areas: scalp, ears, elbows and knees
(extensor surfaces), umbilicus, gluteal cleft,
nails, and sites of recent trauma
• Observation of psoriatic lesions in these
locations helps distinguish psoriasis from
other papulosquamous (scaly) skin disorders
30
Back to Case One: Skin Exam
 Erythematous plaque
around and in the
umbilicus
 Erythematous plaque
with overlying silvery
scale is present in the
gluteal cleft (gluteal
pinking)
31
Differential Diagnosis of
Psoriasis
 Mr. Gilson is given a diagnosis of psoriasis based on
the clinical evaluation
 Psoriasis is typically diagnosed on clinical exam
because of its characteristic location and appearance
 Other conditions to be considered in the patient with
chronic plaque psoriasis are:
• Tinea corporis
• Secondary syphilis
• Nummular eczema
• Drug eruption
• Seborrheic dermatitis
32
Case Two
Mr. Bruce Laney
33
Case Two: History
 HPI: Mr. Laney is a 68-year-old man with a history of
psoriasis who presents with increased joint pain and joint
changes. He currently uses a topical steroid to treat his
psoriasis.
 PMH: psoriasis x 40yrs, hypertension x 20 years
 Medications: topical clobetasol for psoriasis,
hydrochlorothiazide for blood pressure
 Allergies: none
 Family history: mother and father both had psoriasis
 Social history: lives with his wife in a house, retired
 ROS: negative
34
Case Two: Skin Exam
 Large erythematous
plaque with
overlying silvery
scale on anterior
scalp
35
Case Two: Skin Exam
 Erythematous plaque with
overlying silvery scale at the
external auditory meatus and
behind the ear
 Also with nail pitting
36
Case Two: Exam Continued
 Erythematous and
edematous foot, with
dactylitis (sausage
digit) of the 2nd digit,
and destruction of the
DIP joints
 Onychodystrophy: nail
pitting and onycholysis
37
Case Two, Question 1
 Mr. Laney has psoriasis complicated by
psoriatic arthritis. What part(s) of his
history/exam are most characteristic of a
patient with psoriatic arthritis?
a.
b.
c.
d.
History of extensive psoriasis
Presence of nail pitting
Use of clobetasol
All of the above
38
Case Two, Question 1
Answer: b
 Mr. Laney has psoriasis complicated by psoriatic
arthritis. What part(s) of his history/exam is most
consistent with this diagnosis?
a. History of extensive psoriasis
b. Presence of nail pitting (up to 90% of patients
with psoriatic arthritis may have nail changes)
c. Use of clobetasol
d. All of the above
39
Psoriatic Onychodystrophy
 Nail psoriasis can occur in all psoriasis subtypes
 Fingernails are involved in ~ 50% of all patients with
psoriasis.
 Toenails in 35%
 Changes include:
• Pitting: punctate depressions of the nail
plate surface
• Onycholysis: separation of the nail plate
from the nail bed
• Subungual hyperkeratosis: abnormal
keratinization of the distal nail bed
• Trachyonychia: rough nails as if scraped
with sandpaper longitudinally
40
Psoriatic Arthritis (PsA)
 Arthritis in the presence of psoriasis
• A member of the seronegative spondyloarthropathies
 Symptoms can range from mild to severe
 Occurs in 10-25 percent of patients with psoriasis
• Can occur at any age, but for most it appears between the ages of
30 and 50 years
• It is NOT related to the severity of psoriasis
 Five clinical patterns of arthritis occur
• Most common is oligoarthritis with swelling and tenosynovitis of one
or a few hand joints
 Flares and remissions usually characterize the course of
psoriatic arthritis
41
Psoriatic Arthritis Continued
 Health care providers are encouraged to actively seek
signs and symptoms of PsA at each visit
 PsA may appear before the diagnosis of psoriasis
 If psoriatic arthritis is diagnosed, treatment should be
initiated to:
• Alleviate signs and symptoms of arthritis
• Inhibit structural damage
• Maximize quality of life
 Diagnosis is based on clinical judgment
• Specific patterns of joint inflammation, absence of rheumatoid
factor, and the presence of skin and nail lesions of psoriasis
aid clinicians in making the diagnosis of PsA
42
More Examples of PsA
Desquamation of the overlying
skin as well as joint swelling and
deformity (arthritis mutilans) of
both feet
Swelling of the PIP joints of
the 2-4th digits, DIP
involvement of the 2nd digit
43
Case Three
Ms. Sonya Hagerty
44
Case Three: History
 HPI: Ms. Hagerty is an 18-year-old healthy woman with a new
diagnosis of psoriasis. She reports lesions localized to her
knees with no other affected areas. She has not tried any
therapy.
 PMH: no major illnesses or hospitalizations
 Medications: occasional multivitamin
 Allergies: none
 Family history: noncontributory
 Social history: lives in the city with her parents and attends
high school
 Health-related behaviors: no tobacco, alcohol, or drug use
 ROS: slight pruritus
45
Case Three: Skin Exam
 Erythematous plaques
with overlying silvery
scale on the extensor
surface of the knee.
46
Case Three, Question 1
 Which of the following would you recommend to
start treatment for Ms. Hagerty’s psoriasis?
a.
b.
c.
d.
e.
Biologic (immunomodulators)
High potency topical steroid
Low potency topical steroid
Systemic steroids
Topical antifungal
47
Case Three, Question 1
Answer: b
 Which of the following would you recommend
to start treatment for Ms. Hagerty’s psoriasis?
a.
b.
c.
d.
e.
Biologic (immunomodulators)
High potency topical steroid
Low potency topical steroid
Systemic steroids
Topical antifungal
48
Psoriasis: Treatment
 Since the psoriasis is localized (less than
5% body surface area), topical treatment
is appropriate
 First line agents: high potency topical
steroid in combination with calcipotriene
(vitamin D analog)
 Other topical options: tazarotene, salicylic
or lactic acid, tar, calcineurin inhibitors
49
Psoriasis: Treatment
 Factors that influence type of treatment:
• Age
• Type of psoriasis:
– plaque, guttate, pustular, erythrodermic
psoriasis
• Site and extent of psoriasis:
– localized = <5% of BSA
– generalized = diffuse or >30% involvement
• Previous treatment
• Other medical conditions
50
Psoriasis: Treatment
 Patients with localized plaque psoriasis
can be managed by a primary care
provider
 Psoriasis of all other types should be
evaluated by a dermatologist
51
Psoriasis: Topical Treatment
Medication
Topical steroids
Uses in Psoriasis
Plaque-type psoriasis
Calcipotriene
Use in combination with topical
(Vitamin D derivative) steroids for added benefit
Side Effects
Skin atrophy,
hypopigmentation, striae
Skin irritation, photosensitivity
(but no contraindication with
UVB phototherapy)
Plaque-type psoriasis. Best
when used with topical
corticosteroids.
Skin irritation, photosensitivity
Salicylic or Lactic
acid
(Keratolytic agents)
Plaque-type psoriasis to reduce
scaling and soften plaques
Systemic absorption can
occur if applied to > 20%
BSA. Decreases efficacy of
UVB phototherapy
Coal tar
Plaque-type psoriasis
Skin irritation, odor, staining of
clothes
Calcineurin inhibitors
Off-label use for facial and
intertriginous psoriasis
Skin burning and itching
Tazarotene
(Topical retinoid)
Clinical Pearl
 Topical medications for psoriasis are more
effective when used with occlusion which
allows for better penetration
 A bandage, saran-wrap, gloves, or socks
placed over the medication can serve this
purpose
53
Case Three, Question 2
 What would be an appropriate
treatment if a patient had
presented with this skin exam?
a. Systemic steroid
b. Topical steroid
c. Topical steroid and systemic
steroid
d. Topical steroid and UV light
therapy
e. All of the above
54
Case Three, Question 2
Answer: d
 What would be an appropriate
treatment if a patient had
presented with this skin exam?
a. Systemic steroid
b. Topical steroid
c. Topical steroid and systemic
steroid
d. Topical steroid and UV light
therapy
e. All of the above
55
Psoriasis: Systemic Treatment
 In patients with moderate to severe disease, systemic
treatment can be considered and should be
supplemented with topical treatment
 Many patients with moderate to severe psoriasis are
only given topical therapy and experience little
treatment success
• Undertreating the patient can lead to a loss of hope
regarding their disease
 Oral steroids should never be used in psoriasis as they
can severely flare psoriasis upon discontinuation
56
Systemic Treatment
 There are 3 choices for systemic treatment:
1. Phototherapy: narrow-band ultraviolet B light
(nbUVB), broad-band ultraviolet B light (bbUVB),
or psoralen plus ultraviolet A light (PUVA)
2. Oral medications: methotrexate, acitretin,
cyclosporine
3. Biologic Agents: T- cell blocker (alefacept), TNF-α
inhibitors (infliximab, etanercept, adalumimab), IL
12/23 blocker (ustekinumab)
57
Systemic Treatment
 The choice of systemic therapy depends on
multiple factors:
•
•
•
•
convenience
side effect risk profile
presence or absence of psoriatic arthritis
co-morbidities
 Systemic treatment for psoriasis should be
given only after consultation with a
dermatologist
58
The Patient’s Experience
 A successful treatment regimen should include patient
education as well as provider awareness of the patient’s
experience
• Find out the patients’ views about their disease
• Ask the patient how psoriasis affects their daily living
• Ask about symptoms such as pain, itching, burning, and
dry skin
• Ask patients about their experience with previous
treatments
• Important to ask patients about their hopes and
expectations for treatment
• Provide time for patients to ask questions
59
Psoriasis and QOL
 Psoriasis is a lifelong disease and can affect all aspects
of a patient’s quality of life (QOL), even in patients with
limited skin involvement
 Remember to address both the physical and
psychosocial aspects of psoriasis
 Many patients with psoriasis:
•
•
•
•
•
Feel socially stigmatized
Have high stress levels
Are physically limited by their disease
Have higher incidences of depression and alcoholism
Struggle with their employment status
60
Take Home Points
 Psoriasis is a chronic multisystem disease with
predominantly skin and joint manifestations
 About 1/3 of patients with psoriasis have a 1st-degree
relative with psoriasis
 Different types of psoriasis are based on morphology:
plaque, guttate, inverse, pustular, and erythrodermic
 Plaque psoriasis is the most common, affecting 80-90% of
patients
 A detailed history should be taken in patients with psoriasis
 Plaque psoriasis is often diagnosed clinically
 Nail disease is common in patients with psoriasis
61
Take Home Points
 Health care providers are encouraged to actively seek signs
and symptoms of psoriatic arthritis at each visit
 Topical treatment alone is used when the psoriasis is localized
 Patients with moderate to severe disease often require
systemic treatment in addition to topical therapy
 Systemic treatment includes phototherapy, oral medications
and biologic agents
 Oral steroids should never be used in psoriasis
 A successful treatment plan should include patient education
as well as provider awareness of the patient’s experience
 Psoriasis is a lifelong disease and can affect all aspects of a
patient’s quality of life
62
Acknowledgements
 This module was developed by the American
Academy of Dermatology Medical Student Core
Curriculum Workgroup from 2008-2012.
 Primary authors: Sarah D. Cipriano, MD, MPH; Eric
Meinhardt, MD; Timothy G. Berger, MD, FAAD;
Wilson Liao, MD, FAAD.
 Peer reviewers: Peter A. Lio, MD, FAAD; Jennifer
Swearingen, MD.
 Revisions and editing: Sarah D. Cipriano, MD, MPH;
John Trinidad. Last revised March 2011.
63
End of the Module
 Abdelaziz A, Burge S. What should undergraduate medical students know about
psoriasis? Involving patients in curriculum development: modified Delphi technique.
BMJ 2005;330:633-6.
 Berger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The Web-Based
Illustrated Clinical Dermatology Glossary. MedEdPORTAL; 2007. Available from:
www.mededportal.org/publication/462.
 Bremmer S et al. Obesity and psoriasis: From the Medical Board of the National
Psoriasis Foundation. J Am Acad Dermatol 2009 article in press.
 Gelfand JM, et al. Risk of Myocardial Infarction in Patients With Psoriasis. JAMA
2006;296:1735-41.
 Gottlieb et al. Guidelines of care for the management of psoriasis and psoriatic
arthritis. Section 2. Psoriatic arthritis: Overview and guidelines of care for treatment
with an emphasis on biologics. J Am Acad Dermatol 2008;58:851-864.
 Gudjonsson Johann E, Elder James T, "Chapter 18. Psoriasis" (Chapter). Wolff K,
Goldsmith LA, Katz SI, Gilchrest B, Paller AS, Leffell DJ: Fitzpatrick's Dermatology in
General Medicine, 7e: http://www.accessmedicine.com/content.aspx?aID=2983780.
64
End of the Module
 James WD, Berger TG, Elston DM, “Chapter 13. Acne” (chapter). Andrews’
Diseases of the Skin Clinical Dermatology. 10th ed. Philadelphia, Pa: Saunders
Elsevier; 2006: 231-239, 245-248.
 Jobling R. A Patient’s Journey. Psoriasis. BMJ 2007;334:953-4.
 Kimball AB et al. The Psychosocial Burden of Psoriasis. Am J Clin Dermatol
2005;6:383-392.
 Luba KM, Stulberg DL. Chronic Plaque Psoriasis. Am Fam Physician
2006;73:636-44.
 Menter A et al. Guidelines of care for the management of psoriasis and psoriatic
arthritis. Section 1. Overview of psoriasis and guideline of acre for the treatment
of psoriasis with biologics. J Am Acad Dermatol 2008;58:826-850.
 Menter A et al. Guidelines of care for the management of psoriasis and psoriatic
arthritis. Section 3. Guidelines of care for the management and treatment of
psoriasis with topical therapies. J Am Acad Dermatol 2009;60:643-659.
 Smith CH. Clinical Review. Psoriasis and its management. BMJ 2006;333:380-4.
65