Psoriasis Clinical Presentation

Symptoms of psoriasis may include the following:

• Worsening of a long-term erythematous scaly area
• Sudden onset of many small areas of scaly redness
• Recent streptococcal throat infection, viral infection, immunization, use of antimalarial drug, or trauma
• Family history of similar skin condition
• Pain (especially in erythrodermic psoriasis and in some cases of traumatized plaques or in the joints affected by psoriatic arthritis)
• Pruritus (especially in eruptive, guttate psoriasis)
• Afebrile (except in pustular or erythrodermic psoriasis in which the patient may have high fever)
• Dystrophic nails
• Long-term rash with recent presentation of joint pain
• Joint pain without any visible skin findings

The skin almost always is affected before the eyes. Ocular findings occur in approximately 10% of patients. The most common ocular symptoms are redness and tearing due to conjunctivitis or blepharitis.

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.

Findings on physical examination depend on the type of psoriasis present.

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.

Chronic stationary psoriasis (psoriasis vulgaris) is the most common type of psoriasis. This involves the scalp, extensor surfaces, genitals, umbilicus, and lumbosacral and retroauricular regions.

Plaque psoriasis is characterized by raised, inflamed lesions covered with a silvery white scale. The scale may be scraped away to reveal inflamed skin beneath. This is most common on the extensor surfaces of the knees, elbows, scalp, and trunk.

Guttate psoriasis presents as small salmon-pink papules, 1-10 mm in diameter, predominately on the trunk; the lesions may be scaly (see the image below). It frequently appears suddenly, 2-3 weeks after an upper respiratory infection (URI) with group A beta-hemolytic streptococci.

Inverse psoriasis occurs on the flexural surfaces, armpit, groin, under the breast, and in the skin folds. It is characterized by smooth, inflamed lesions without scaling due to the moist nature of the area where this type of psoriasis is located.

Pustular psoriasis presents as sterile pustules appearing on the palms and soles or diffusely over the body. Pustular psoriasis may cycle through erythema, pustules, then scaling. The diffuse variant is termed von Zumbusch variant, which is accompanied by fever and intense ill feeling in addition to the widespread pustules. Acrodermatitis continua of Hallopeau is considered a form of pustular psoriasis that affects the hands and feet. It may prove resistant to topical and other therapies.

Erythrodermic psoriasis presents as generalized erythema, pain, itching, and fine scaling; various pustular forms also exist. It typically encompasses nearly the entire body surface area. It may be accompanied by fever, chills, hypothermia, and dehydration secondary to the large body surface area involvement. Patients with severe pustular or erythrodermic psoriasis may require hospital admission for metabolic and pain management. Older patients with erythrodermic psoriasis may experience cardiac instability and hypotension due to massive vascular shunting in the skin.

Scalp psoriasis affects approximately 50% of patients. It presents as erythematous raised plaques with silvery white scales on the scalp.

Nail psoriasis may cause pits on the nails, which often become thickened and yellowish in color. Nails may separate from the nail bed. Psoriatic nails may be indistinguishable from fungal nails and, at the same time, may be more prone to developing onychomycosis because of the nail separation and subungual debris.

Psoriatic arthritis affects approximately 10-30% of those with skin symptoms. The arthritis is usually in the hands and feet and, occasionally, the large joints. It produces stiffness, pain, and progressive joint damage.

Oral psoriasis may present with whitish lesions on the oral mucosa, which may appear to change in severity daily. It may also present as severe cheilosis with extension onto the surrounding skin, crossing the vermillion border. Geographic tongue is considered by many to be an oral form of psoriasis.

Eruptive psoriasis involves the upper trunk and upper extremities. Most often, it is seen in younger patients.

In addition to skin manifestations, psoriasis may also affect the lid, conjunctiva, or cornea and give rise to ocular manifestations, including ectropion and trichiasis, conjunctivitis and conjunctival hyperemia, and corneal dryness with punctate keratitis and corneal melt.^{[17, 18]}

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.

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 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.^[19]

In one case, recurrent nasolacrimal duct occlusion was observed, presumably caused by washing of the scales into the lacrimal sac.

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.^{[20, 21]}

Complications of psoriasis may include the following:

• Secondary infections
• Possible increased risk of lymphoma
• Possible increased risk of cardiovascular and ischemic heart disease
• Psoriatic arthritis
• Mitral valve prolapse