History
Symptoms of psoriasis may include the following:
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Worsening of a long-term erythematous scaly area
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Sudden onset of many small areas of scaly redness
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Recent streptococcal throat infection, viral infection, immunization, use of antimalarial drug, or trauma
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Family history of similar skin condition
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Pain (especially in erythrodermic psoriasis and in some cases of traumatized plaques or in the joints affected by psoriatic arthritis)
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Pruritus (especially in eruptive, guttate psoriasis)
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Afebrile (except in pustular or erythrodermic psoriasis in which the patient may have high fever)
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Dystrophic nails
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Long-term rash with recent presentation of joint pain
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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.
Physical Examination
Findings on physical examination depend on the type of psoriasis present.
The most common skin manifestations are scaling, salmon-colored/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.
Guttate psoriasis erupted in this patient after topical steroid therapy was withdrawn during a pregnancy. Contributed by Randy Park, MD.
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; this is considered the most common nail finding. Oil spots, caused by exocytosis of leukocytes beneath the nail plate, are considered the most specific nail finding in psoriasis. Nails may separate from the nail bed, known as onycholysis, due to the parakeratosis of the distal 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.
A retrospective study from 2014 reports that nail involvement in psoriasis is a significant predictor of the patient also having psoriatic arthritis. [31] The study looked at retrospective data from three German cross-sectional independent national studies on patients with psoriasis and psoriatic arthritis. Data on the patient’s history of psoriasis and psoriatic arthritis, clinical findings, nail involvement, and patient- and practitioner-reported outcomes were collected from standardized questionnaires. In the results, the regression model of 4146 patients indicated one of the strongest predictors of concomitant psoriatic arthritis was nail involvement.
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.
Ocular Manifestations
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. [1]
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. [32]
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. [33, 34]
Complications
Complications of psoriasis may include the following:
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Secondary infections
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Possible increased risk of lymphoma
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Possible increased risk of cardiovascular and ischemic heart disease
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Possibly inflammatory bowel disease [35]
Even after plaques have cleared, there may be a longstanding or permanent dyschromia. Arthritis, if not controlled, may be mutilating and crippling. Arthritic changes cannot be reversed; therefore, initiation of treatment is imperative to slow, or even halt, progression of disease. It is suggested that psoriatic patients have a higher incidence of cancer, especially lymphoma, but how much of this increased risk can be ascribed to the psoriasis and how much to the medications used for psoriasis is less certain. Psoriatic patients have a higher incidence of depression and anxiety, and, while these conditions usually improve with successful treatment, it is not guaranteed. Many other potential complications are directly related to the treatment, such as a higher incidence of skin cancer in patients treated with phototherapy and a higher incidence of infections, mild and serious, in patients on immune-suppressing medications.
Meta-analyses of cohort and case control studies of predominantly white participants reported in 2018 have shown a statistically significant association between psoriasis and inflammatory bowel disease (Crohn disease and ulcerative colitis). [36] However, a 2011 study of an Asian population showed a negative association between psoriasis and Crohn disease. [37]
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Plaque psoriasis is raised, roughened, and covered with white or silver scale with underlying erythema. Contributed by Randy Park, MD.
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Guttate psoriasis erupted in this patient after topical steroid therapy was withdrawn during a pregnancy. Contributed by Randy Park, MD.
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Plaque psoriasis is most common on the extensor surfaces of the knees and elbows. Contributed by Randy Park, MD.
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Nail psoriasis. Pits, distal onycholysis (nail separation), and brownish staining ("oil spots") are classic nail findings
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Inverse psoriasis. Occurring in skin folds, this will often lack the scale seen in other locations.
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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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