eMedicine Specialties > Ophthalmology > Dermatologic Disorders
Psoriasis
Updated: May 15, 2009
Introduction
Background
Psoriasis is a common skin disease. Ocular signs occur in approximately 10% of patients, and they are more common in men than in women. Patients with ocular findings almost always have psoriatic skin disease; however, it is rare for the eye to become involved before the skin.1,2,3
Pathophysiology
Psoriasis involves hyperproliferation of the keratinocytes in the epidermis. The cause of the loss of control of keratinocyte turnover is unknown. However, environmental, genetic, and immunologic factors appear to play a role. Psoriasis is associated with certain human leukocyte antigen (HLA) alleles, particularly human leukocyte antigen Cw6 (HLA-Cw6). In some families, psoriasis is an autosomal dominant trait.
Disease exacerbations can be triggered by trauma, stress, alcohol, medications, and infection (eg, staphylococcal, streptococcal, human immunodeficiency virus). The epidermis is infiltrated by a large number of activated T cells, which appear to be capable of inducing keratinocyte proliferation. Conjunctival impression cytology demonstrated a higher incidence of squamous metaplasia, neutrophil clumping, and nuclear chromatin changes in patients with psoriasis.4,5
Frequency
United States
This condition affects 1-2% of the population. Approximately 6.4 million Americans have psoriasis.
International
Internationally, the incidence of psoriasis varies dramatically. A study of 26,000 South American Indians did not reveal a single case of psoriasis. In the Faeroe Islands, an incidence of 2.8% was observed.
Sex
Psoriasis appears to be slightly more prevalent among women than among men; however, men are thought to be more likely to experience the ocular disease.
Age
- Psoriasis can begin at any age. The median age of onset is 28 years.
- About 10-15% patients have onset of psoriasis before age 10 years.
Clinical
History
- The skin almost always is affected before the eyes. Ocular findings occur in approximately 10% of patients.
- The nonocular symptoms are related to rash and psoriatic arthritis.
- The rash can be uncomfortable or even painful.
- Psoriatic arthritis can cause stiffness, pain, throbbing, swelling, or tenderness of the joints. The distal joints, such as the fingers, toes, wrists, knees, and ankles, are most often affected.
- The most common ocular symptoms are redness and tearing due to conjunctivitis or blepharitis.
Physical
- Ocular manifestations6,7
- Eyelid: Blepharitis is the most common ocular finding in psoriasis. Erythema, edema, and psoriatic plaques may develop, and they can result in madarosis, cicatricial ectropion, trichiasis, and even loss of the lid tissue.
- Conjunctiva
- A chronic nonspecific conjunctivitis is fairly common. It usually occurs in association with eyelid margin involvement. Psoriatic plaques can extend from the lid onto the conjunctiva.
- Chronic conjunctivitis can lead to symblepharon, keratoconjunctivitis sicca, and trichiasis.
- Nodular episcleritis and limbal lesions resembling phlyctenules also can be seen.
- Corneal involvement
- Corneal disease is relatively rare. Most often, it is secondary to lid or conjunctival complications, such as dryness, trichiasis, or exposure.
- The most common finding is punctate keratitis. Filaments, epithelial thickening, recurrent erosions, vascularization, ulceration, and scarring can occur. The vascularization tends to be superficial, peripheral, and interpalpebral or inferior.
- Rarely, peripheral infiltration and melting can occur in the absence of trichiasis and exposure.8
- Lacrimal sac: In one case, recurrent nasolacrimal duct occlusion was observed, presumably caused by washing of the scales into the lacrimal sac.
- Uvea: Usually, anterior uveitis can be seen in association with psoriatic arthritis. Acute psoriatic uveitis tends to be bilateral, prolonged, and more severe than nonpsoriatic cases.9,10
- Complications of psoriasis treatment
- Retinoids have been reported to cause dry eye, blepharitis, corneal opacities, cataracts, and decreased night vision.11,12
- Psoralen-ultraviolet A (PUVA) treatment results in conjunctival hyperemia and dry eye, particularly if sun protection is not used. There does not appear to be a risk of cataract.
- The most common skin manifestations are scaling erythematous macules, papules, and plaques. Typically, the macules are seen first, and these progress to maculopapules and ultimately well-demarcated, noncoherent, silvery plaques overlying a glossy homogeneous erythema. The area of skin involvement varies with the form of psoriasis.
- The most common type of psoriasis is chronic stationary psoriasis (psoriasis vulgaris). This involves the scalp, extensor surfaces, genitals, umbilicus, and lumbosacral and retroauricular regions.
- Psoriasis inversa: It involves flexural surfaces and intertriginous areas, and it is not associated with scaling.
- Eruptive psoriasis: It involves the upper trunk and upper extremities. Most often, it is seen in younger patients.
- Other forms: Psoriatic erythroderma is a generalized form. Various pustular forms also exist.
Causes
- The pathogenesis of psoriasis is poorly understood. A genetic tendency seems to exist.
- Many factors have been observed to trigger exacerbations, including cold, trauma, infections (eg, streptococcal, human immunodeficiency virus), stress, alcohol, and drugs (eg, iodides, steroid withdrawal, aspirin, lithium, beta-blockers, botulinum A, antimalarials).
- Hot weather, sunlight, and pregnancy may be beneficial.
Differential Diagnoses
Blepharitis, Adult
Dry Eye Syndrome
Keratoconjunctivitis, Atopic
Keratoconjunctivitis, Sicca
Workup
Laboratory Studies
- The diagnosis of psoriasis is clinical. The differentiation of psoriatic arthritis from rheumatoid arthritis and gout can be facilitated by the absence of the typical laboratory findings of those conditions.
Imaging Studies
- Joint x-rays can facilitate the diagnosis of psoriatic arthritis.
Procedures
- When the scales are removed, small droplets of blood appear within a few seconds; this is known as the Auspitz sign.
- Köbner phenomenon is the appearance of psoriatic lesions in previously uninvolved areas after irritation or trauma.
Histologic Findings
Biopsy of the skin lesion may reveal basal cell hyperplasia, proliferation of subepidermal vasculature, absence of normal cell maturation, and keratinization. A large number of activated T cells are present in the epidermis.
Conjunctival impression cytology has demonstrated an increased incidence of squamous metaplasia, neutrophil clumping, and snakelike chromatin.
Treatment
Medical Care
- Management of the skin disease
- The simplest treatment of psoriasis is daily sun exposure, sea bathing, topical moisturizers, and relaxation.
- Topical therapy
- Moisturizers, such as petrolatum jelly, are helpful.
- Anthralin, coal or wood tar, corticosteroids, salicylic acid, phenolic compounds, and calcipotriene (a vitamin D analog) also may be effective.
- Various ultraviolet light treatments are used; most commonly, PUVA therapy is used. Psoralen is a photosensitizer that is ingested prior to light exposure.
- Systemic therapy
- In severe cases, retinoids, methotrexate, cyclosporine, infliximab, and hydroxyurea may be used.
- Systemic corticosteroids are generally ineffective, and they can exacerbate the disease.
- Management of the ocular complications
- Ocular lubricants and punctal occlusion can be used to treat keratoconjunctivitis sicca.
- Trichiasis and cicatricial ectropion usually require surgical treatment.
- Topical corticosteroids are useful in treating the conjunctival, corneal, and anterior chamber inflammation. Nonsteroidal anti-inflammatory agents or oral corticosteroids are occasionally necessary.
- Whether systemic immunosuppression is effective for ocular disease is not clear.
- Corneal complications include the following:
- Corneal melting, inflammation, and vascularization can be difficult to treat.
- A bandage contact lens may retard the melting.
- Topical corticosteroids can control the infiltration and delay the vascularization.
- In some cases, progression can occur in spite of these treatments and can lead to the need for lamellar or penetrating keratoplasty.
Medication
Artificial tears and topical corticosteroids may be helpful.Topical corticosteroids
Have anti-inflammatory properties and cause profound and varied metabolic effects. Modify the body's immune response to diverse stimuli. Used to treat conjunctivitis, corneal infiltration, melting, or vascularization, and iritis.
Prednisolone acetate 1% (Pred Forte)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
In cases of bacterial infections, concomitant use of anti-infective agents is mandatory; if signs and symptoms do not improve after 2 days, reevaluate patient. Dosing may be reduced, but advise patients not to discontinue therapy prematurely.
Dosing
Adult
1 gtt qid; frequency is determined by severity of disease
Pediatric
Not established
Interactions
None reported
Contraindications
Documented hypersensitivity; viral, fungal, or tubercular infections
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hypertension; known to cause cataract formation with chronic use; fungal invasion should be suspected in any persistent corneal ulceration where a corticosteroid has been used or is in use (fungal cultures should be taken when appropriate)
Dexamethasone 0.1% (Ocu-Dex, AK-Dex, Alba-Dex)
For various allergic and inflammatory diseases. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.
Dosing
Adult
1 gtt qid; frequency is determined by severity of the disease
Pediatric
Not established
Interactions
None reported
Contraindications
Documented hypersensitivity; active bacterial, viral, or fungal infection
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Prolonged use may increase hazard of secondary ocular infection; fungal invasion should be suspected in any persistent corneal ulceration where a corticosteroid has been used or is in use (fungal cultures should be taken when appropriate)
Artificial tears
Used to treat dry eye irritation. Many types of artificial tears are available over the counter. In mild cases, preserved tears can be used. In severe cases, only nonpreserved tears should be used. Preserved tears include GenTeal, Refresh Tears, and Tears Naturale II. Nonpreserved tears include Refresh, Refresh Plus, OcuCoat, Bion, and Hypo Tears PF.
Artificial tears
Contains equivalent of 0.9% NaCl and are used to maintain ocular tonicity. Acts to stabilize and thicken precorneal tear film and prolong tear film breakup time, which occurs with dry eye states.
Dosing
Adult
Starting dose: 1 gtt q2h; adjust dose prn by the symptoms and punctate keratopathy
Pediatric
Not established
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Hyperemia, photophobia, stickiness of eyelashes, ocular discomfort or irritation may occur
Follow-up
Further Outpatient Care
- Patients should receive follow-up care as needed.
Inpatient & Outpatient Medications
- See Medication.
Deterrence/Prevention
- Hot weather, sunlight, and pregnancy help in the prevention of psoriasis.
- Patients should try to avoid trauma, stress, alcohol, medications, and infection.
Complications
- Psoriasis can affect the lid, conjunctiva, and cornea. Ectropion and trichiasis can occur on the lid. Conjunctivitis and conjunctival hyperemia can occur. Corneal dryness with punctate keratitis and corneal melt can occur.
Prognosis
- Psoriasis is a lifelong illness with remissions and exacerbations. About 17-55% of patients experience remissions.
Patient Education
- Dry eye and its manifestations may be present. Avoiding drying conditions and using lubricants can be effective. Patient recognition of these symptoms is vital for effective early treatment of this disease.
- For excellent patient education resources, visit eMedicine's Psoriasis Center. Also, see eMedicine's patient education articles Psoriasis, What Is Psoriasis?, Types of Psoriasis, and Understanding Psoriasis Medications.
Miscellaneous
Medicolegal Pitfalls
- Early recognition of this disorder will allow prompt treatment.
References
Christophers E, Sterry W. Psoriasis. In: Fitzpatrick TB, Eisen AZ, Wolff K, eds. Dermatology in General Medicine. New York: McGraw Hill; 1993:489-511.
Farber EM, Cox AJ, eds. Psoriasis: Proceedings of the Third International Symposium Yorke Medical, New York. 1981.
Gulliver W. Long-term prognosis in patients with psoriasis. Br J Dermatol. Aug 2008;159 Suppl 2:2-9. [Medline].
Karabulut AA, Yalvac IS, Vahaboglu H, et al. Conjunctival impression cytology and tear-film changes in patients with psoriasis. Cornea. Sep 1999;18(5):544-8. [Medline].
Pietrzak AT, Zalewska A, Chodorowska G, et al. Cytokines and anticytokines in psoriasis. Clin Chim Acta. Aug 2008;394(1-2):7-21. [Medline].
Catsarou-Catsari A, Katambus A, Theodorpoylos P. Ophthalmological manifestations in patients with psoriasis. Acta Derm Venereol (Stock). 1984;64:557-559.
Huynh N, Cervantes-Castaneda RA, Bhat P, et al. Biologic response modifier therapy for psoriatic ocular inflammatory disease. Ocul Immunol Inflamm. May-Jun 2008;16(3):89-93. [Medline].
Moadel K, Perry HD, Donnenfeld ED, et al. Psoriatic corneal abscess. Am J Ophthalmol. Jun 1995;119(6):800-1. [Medline].
Durrani K, Foster CS. Psoriatic Uveitis: A Distinct Clinical Entity?. Am J Ophthalmol. 2005;139:106-11. [Medline].
Takahashi H, Sugita S, Shimizu N, et al. A high viral load of Epstein-Barr virus DNA in ocular fluids in an HLA-B27-negative acute anterior uveitis patient with psoriasis. Jpn J Ophthalmol. Mar-Apr 2008;52(2):136-8. [Medline].
Lerman S. Ocular side effects of accutane therapy. Lens Eye Toxic Res. 1992;9(3-4):429-38. [Medline].
Brelsford M, Beute TC. Preventing and managing the side effects of isotretinoin. Semin Cutan Med Surg. Sep 2008;27(3):197-206. [Medline].
Keywords
psoriasis, psoriatic skin disease, conjunctivitis, blepharitis, psoriatic arthritis, anterior uveitis
Contributor Information and Disclosures
Author
Robert Arffa, MD, Clinical Assistant Professor, University of Pittsburgh School of Medicine
Robert Arffa, MD is a member of the following medical societies: American Academy of Ophthalmology
Disclosure: Nothing to disclose.
Medical Editor
Brian A Phillpotts, MD, Former Vitreo-Retinal Service Director, Former Program Director, Clinical Assistant Professor, Department of Ophthalmology, Howard University College of Medicine
Brian A Phillpotts, MD is a member of the following medical societies: American Academy of Ophthalmology, American Diabetes Association, American Medical Association, and National Medical Association
Disclosure: Nothing to disclose.
Pharmacy Editor
Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.
Managing Editor
Christopher J Rapuano, MD, Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Co-Chairman of the Cornea Service, Co-Chairman of Refractive Surgery Department, Wills Eye Institute
Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Cornea Society, Eye Bank Association of America, International Society of Refractive Surgery, and Pan-American Association of Ophthalmology
Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other; Vistakon Honoraria Speaking and teaching
CME Editor
Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.
Chief Editor
Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.