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Psoriasis Workup

  • Author: Jeffrey Meffert, MD; Chief Editor: William D James, MD  more...
 
Updated: Mar 25, 2016
 

Approach Considerations

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. Overlap with other arthritic syndromes is possible, however.

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Lab Studies

Laboratory studies and findings for patients with psoriasis may include the following:

  • Test result for rheumatoid factor (RF) is negative.
  • Erythrocyte sedimentation rate (ESR) is usually normal (except in pustular and erythrodermic psoriasis).
  • Uric acid level may be elevated in psoriasis (especially in pustular psoriasis), causing confusion with gout in psoriatic arthritis.
  • Fluid from pustules is sterile with neutrophilic infiltrate.
  • Perform fungal studies. (This is especially important in cases of hand and foot psoriasis that seem to be worsening with the use of topical steroids.)

If starting systemic therapies such as immunological inhibitors, consider obtaining baseline laboratory studies (ie, complete blood count [CBC], blood urea nitrogen [BUN]/creatinine, liver function tests [LFTs], hepatitis panel, tuberculosis [TB] screening).

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Other Tests

Although most cases of psoriasis are diagnosed clinically, some, particularly the pustular forms, can be difficult to recognize. In these cases, dermatologic biopsy can be used to make diagnosis. 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. Biopsy of acral skin may be less useful as chronic eczematous dermatitis may be psoriasiform and psoriasis  of the palms and soles may show spongiosis more often associated with eczema.

Radiographs of affected joints can be helpful in differentiating types of arthritis. Joint x-rays can facilitate the diagnosis of psoriatic arthritis. Bone scans can identify joint involvement early.

Conjunctival impression cytology has demonstrated an increased incidence of squamous metaplasia, neutrophil clumping, and snakelike chromatin.

When the scales are removed, small droplets of blood appear within a few seconds from exposed vessels in the dermal papillae; this is known as the Auspitz sign.

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Contributor Information and Disclosures
Author

Jeffrey Meffert, MD Associate Clinical Professor of Dermatology, University of Texas School of Medicine at San Antonio

Jeffrey Meffert, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Acknowledgements

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.

Richard Gordon Jr, MD Staff Physician, Department of Emergency Medicine, Detroit Receiving Hospital University Health Center

Richard Gordon Jr, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Physicians, American Medical Student Association/Foundation, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Ryan I Huffman, MD Resident Physician, Department of Ophthalmology, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

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.

Randy Park, MD Chair, Associate Professor, Department of Emergency Medicine, Denton Regional Medical Center

Disclosure: Nothing to disclose.

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.

Christopher J Rapuano, MD Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Director of the Cornea Service, Co-Director 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, and International Society of Refractive Surgery

Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; RPS Ownership interest Other; Bausch & Lomb Honoraria Speaking and teaching; Merck Consulting fee Consulting; Bausch & Lomb Consulting; Merck Honoraria Speaking and teaching

Adam J Rosh, MD Assistant Professor, Program Director, Emergency Medicine Residency, Department of Emergency Medicine, Detroit Receiving Hospital, Wayne State University School of Medicine

Adam J Rosh, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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.

Dana A Stearns, MD Assistant Director of Undergraduate Education, Department of Emergency Medicine, Massachusetts General Hospital; Assistant Professor of Surgery, Harvard Medical School

Dana A Stearns, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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Plaque psoriasis is raised, roughened, and covered with white or silver scale with underlying erythema. Contributed by Randy Park, MD.
Guttate psoriasis erupted in this patient after topical steroid therapy was withdrawn during a pregnancy. Contributed by Randy Park, MD.
Plaque psoriasis is most common on the extensor surfaces of the knees and elbows. Contributed by Randy Park, MD.
Nail psoriasis. Pits, distal onycholysis (nail separation), and brownish staining ("oil spots") are classic nail findings
Inverse psoriasis. Occurring in skin folds, this will often lack the scale seen in other locations.
Pustular psoriasis of the soles. This may be confined to the hands and feet (Acrodermatitis Continua of Hallepeau) or may be part of a generalized pustular psoriasis (Von Zumbusch disease)
 
 
 
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