Psoriasis in Adult
See also in: Anogenital,Hair and Scalp,Nail and Distal DigitAlerts and Notices
Synopsis
Psoriasis is a polygenic disease. (Several psoriasis susceptibility genes have been identified over recent years.) Certain individuals with genetic susceptibility develop a psoriatic phenotype after exposure to environmental triggers such as infection, medications, and medical comorbidities, among others. Aberrant T-cell function and keratinocyte responses are believed to be major culprits in the pathogenesis of psoriasis.
There are several variants of the disease, and variants can coexist in the same individual.
Chronic plaque psoriasis is most common, and disease burden can range from 1%-2% (mild disease) to greater than 90% (erythrodermic psoriasis) of the total body surface area (BSA). Typical findings include well-demarcated circular, oval, or polycyclic erythematous plaques with micaceous scale that are often symmetric in distribution. The scalp, elbows, and knees are commonly involved. Lesions are often pruritic and resolve with postinflammatory hyper- or hypopigmentation. Scarring is not a feature of resolution. During exacerbations, erythematous papules usually surround existing plaques, and a ring of intense erythema surrounds the plaques. During resolution, plaques will often have a decreased amount of scale and central clearing, creating annular psoriatic lesions. Lesions can last from months to years in the same location.
Inverse psoriasis occurs in intertriginous areas of the body, such as the axillae, groin, genitals, and submammary area.
When psoriasis involves areas of the face other than the hairline, eyebrows, and beard, it is usually an indication of more severe disease. Seborrheic dermatitis can coexist with psoriasis on the face and scalp (sometimes referred to as "sebopsoriasis").
Other variants include:
- Psoriatic arthritis – Up to 50% of psoriatic individuals may have erosive psoriatic arthritis. Psoriatic arthritis is more common among individuals with nail and scalp psoriasis. Rarely, psoriatic arthritis has been reported to develop prior to the cutaneous findings of psoriasis.
- Guttate psoriasis – An acute generalized eruption of small, discrete, raindrop-like papules with fine scale. This may occur 2-3 weeks after an upper respiratory infection and is most common in children.
- Erythrodermic psoriasis – An uncommon but potentially life-threatening acute complication of psoriasis wherein large red patches with desquamation cover most of the body surface.
- Pustular psoriasis – An uncommon, sometimes severe, variant characterized by widespread erythematous, sterile pustules.
- Acrodermatitis continua of Hallopeau – An uncommon variant of pustular psoriasis affecting the hands and feet.
- Inverse psoriasis – Psoriasis that involves the intertriginous areas including the axillae, inframammary areas, and inguinal folds. The plaques of inverse psoriasis are erythematous and well-demarcated but often lack the classic scale as these body sites are generally moist.
- Nail psoriasis – The nails of individuals with psoriasis can show several features. The most common are pitting, distal onycholysis, and splinter hemorrhages. Individuals with nail psoriasis are at an increased risk of developing psoriatic arthritis.
- Approximately 50% of women report improvement of disease burden during pregnancy.
- Pustular psoriasis developing in hypocalcemic women during pregnancy is known as impetigo herpetiformis.
- HIV infection may precipitate or exacerbate psoriasis.
Codes
ICD10CM:L40.0 – Psoriasis vulgaris
SNOMEDCT:
9014002 – Psoriasis
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Diagnostic Pearls
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Differential Diagnosis & Pitfalls
- Chronic atopic dermatitis – Atopic history, commonly starts in childhood. Mild-to-moderate spongiosis seen on histology. Lichenified plaques on the flexural surfaces and neck. More pruritic than psoriasis.
- Contact dermatitis (allergic, irritant)
- Nummular dermatitis – Intensely pruritic coin-shaped lesions, almost exclusively on the extremities.
- Lichen simplex chronicus – Common around the ankles.
- Seborrheic dermatitis – Sebaceous distribution.
- Lichen planus – Very pruritic, often associated with hepatitis C. Biopsy will differentiate psoriasis from lichen planus.
- Tinea corporis – Scale at leading edge of erythema with central clearing. Check potassium hydroxide (KOH) preparation.
- Drug eruption – Drug eruptions often present with urticarial, exanthematous, or vesicular / bullous lesions. In addition, systemic symptoms are more pronounced than seen with classic psoriasis, including fever, lymphadenopathy, and facial edema. Eosinophilia on CBC and histology are often seen (but not an invariable finding). NSAIDs, sulfonamides, and penicillin are frequently implicated.
- Subacute cutaneous lupus erythematosus (SCLE) – Antinuclear antibody (ANA) will be positive in most lupus patients. SCLE is characterized by annular plaques with raised borders and central clearing or papulosquamous lesions that are restricted to sun-exposed skin.
- Pityriasis lichenoides chronica – Usually smaller papules. Biopsy will assist in differentiating from psoriasis, predominantly CD8+ T-cell infiltrate.
- Lymphomatoid papulosis – Crusted papules and smaller papules. Biopsy will assist in differentiating from psoriasis, predominantly CD30+ T-cell infiltrate.
- Pityriasis rubra pilaris (PRP) – Orange-red, wax-like keratoderma of the palms and soles. Islands of normal skin within larger plaques are characteristically seen in PRP. PRP and psoriasis are histologically different, and a biopsy will aid in the diagnosis. Family history of psoriasis is common in psoriatic patients.
- Mycosis fungoides – Early mycosis fungoides is often misdiagnosed as psoriasis. With time, generalized lymphadenopathy, circulating malignant lymphocytes, leonine facies, and a CD4/CD8 ratio greater than 10.
- Secondary syphilis – Rapid plasma reagin (RPR) test, history of primary chancre, and systemic symptoms.
- Erythema annulare centrifugum
- Extramammary Paget disease
- Pityriasis rosea – Herald patch, collarette of scale, and orientation of lesions ("fir tree" pattern in skin tension lines). Does not follow an intermittently relapsing course.
- Crusted scabies – Most common in elderly, immunocompromised, or institutionalized patients.
- Sarcoidosis
- Reactive arthritis (Reiter syndrome)
- Acrokeratosis paraneoplastica (Bazex syndrome)
- Caspase recruitment domain family member 14 gene (CARD14)-associated papulosquamous eruption refers to a distinctive phenotype with overlapping features of psoriasis and PRP. Patients typically present early in life and report a family history of psoriasis or PRP. The cheeks, chin, and ears are typically affected. This disease is difficult to treat using conventional therapies, while treatment with ustekinumab appears to be effective.
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Therapy
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Drug Reaction Data
Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.Subscription Required
References
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Last Reviewed:08/06/2022
Last Updated:08/07/2022
Last Updated:08/07/2022
Patient Information for Psoriasis in Adult
Overview
Psoriasis is a common, noncontagious condition that can present in a variety of ways in the skin. The subtypes of this condition include plaque, inverse (or skin fold), guttate, erythrodermic, and pustular psoriasis. Plaque psoriasis, which represents approximately 85% of psoriasis cases, is a lifelong skin condition that affects about 2%-3% of the population worldwide. Plaque psoriasis skin lesions are typically red and raised with overlying scale. There may be papules (small, raised bumps) or plaques (larger, raised skin lesions that are bigger than a thumbnail), or both. People with plaque psoriasis typically have thickened, white scaly patches on their skin.While the exact cause of psoriasis is unknown, this condition is the result of an overactive immune system that attacks the skin and other organs of the body. Psoriasis is very common in some families, suggesting a likely genetic component contributing to this disease, but it can also occur in individuals with no family history of psoriasis. Psoriasis can be triggered by certain environmental causes, such as emotional stress, pregnancy, injury to the skin, bacterial skin infections such as a streptococcal infection ("strep"), smoking or alcohol consumption, and ingesting certain medications.
Who’s At Risk
Plaque psoriasis can develop at any age, but it is usually diagnosed in the teenage or early adult years. Psoriasis may also occur for the first time in elderly patients between the ages of 50 and 70. Thirty percent of people with plaque psoriasis have a family member with plaque psoriasis. The condition affects men and women equally.Certain medications can trigger flares of plaque psoriasis. These medications include beta blockers often used for high blood pressure, NSAIDs (eg, ibuprofen [Advil, Motrin], naproxen [Aleve]), lithium, antimalarial drugs, and oral steroids like prednisone. While TNF-alpha inhibitor medications (eg, etanercept [Enbrel], adalimumab [Humira], certolizumab [Cimzia], infliximab [Remicade, Renflexis]) are a known treatment for plaque psoriasis, these medications can sometimes cause plaque psoriasis in people taking these medications for other conditions, such as rheumatoid arthritis or Crohn disease.
Approximately one-third of people with plaque psoriasis also develop psoriatic arthritis, an inflammatory joint condition that causes painful, swollen joints and can lead to irreversible joint destruction. Importantly, individuals with psoriasis are also at increased risk for other health conditions, such as heart disease, stroke, high blood pressure, diabetes, obesity, sleep problems, anxiety / depression, social stigma, cancer, and even death.
Signs & Symptoms
The typical lesions of plaque psoriasis are raised patches of irritated skin that are often covered with a thick, white scale. In lighter skin colors, the patches are most often pink or red. In darker skin colors, the redness may be harder to see or may appear purple, grayish, or dark brown.Psoriasis plaques are most frequently seen on the elbows, knees, trunk, buttocks, belly button, palms / soles, and scalp. The skin lesions are usually found on both sides of the body (symmetrically). Skin areas of physical trauma or friction may develop psoriasis plaques, which is why the hands / feet, scalp, knees, and elbows are commonly affected. Body folds such as the genitals or underarms may also be affected but tend to lack the classic thick, white scale often seen in other body locations. Most individuals experience itching or skin / joint pain, but some may not.
Plaque psoriasis is commonly categorized by disease severity in the following way:
- Mild psoriasis – Few, scattered, limited areas of involvement that account for less than 10% of the body. To generally estimate body percentage involvement, the surface of a person's palm print represents approximately 1% of their body surface area (ie, 3 palm prints of psoriasis lesions on the body is equal to approximately 3% of their body surface area). Topical or ultraviolet-based therapies are commonly used to treat mild psoriasis.
- Moderate-to-severe psoriasis – More widespread disease affecting larger areas of the body and account for at least 10% of the body. Individuals with these more severe forms of psoriasis often require more aggressive medical treatments in addition to or in lieu of topical therapies.
- Special considerations – Categorizing psoriasis solely on the percentage of affected skin has important limitations. Individuals with psoriasis who have pain in the joints and/or involvement of certain skin sites (hands / feet, scalp, genitals, or face), even if the overall percentage is less than 10%, may require more aggressive treatment beyond topical medications due to the impact psoriasis can have when involving these special sites of the body.
Importantly, plaque psoriasis if often confused with other skin conditions that can look similar, such as fungal infections of the skin, eczema (atopic dermatitis), allergic reactions, or irritation of skin exposed to specific environmental materials or products. Your medical professional may be helpful in determining the cause of your skin rash if the diagnosis is unclear.
Self-Care Guidelines
Because plaque psoriasis is a lifelong, chronic condition that currently has no cure, the goal of treatment is to decrease the number of skin lesions and reduce symptoms such as itching and pain. Most beneficial treatments for plaque psoriasis work in part due to their ability to alleviate the body's abnormal immune attack of the skin and help prevent the excessive buildup of skin cells or flakes.- Bathe daily to help soften scales and moisten the skin. Avoid harsh soaps and scrubbing the skin as these may worsen psoriasis. Moisturizing soaps and soap substitutes, such as unscented Dove Sensitive Skin Beauty Bar, Vanicream Cleansing Bar, and CeraVe Psoriasis Cleanser, are milder products for the skin.
- The application of moisturizers after water exposure or bathing may be helpful. Heavier oil-based moisturizers help to retain water in the skin better than water-based moisturizers. Thicker moisturizers such as petroleum jelly (Vaseline), Aquaphor Healing Ointment, Eucerin Original Healing Cream, Vanicream, Aveeno Moisturizing Cream, CeraVe Healing Ointment, or CeraVe Moisturizing Cream can be applied to damp skin daily after bathing. Use cream and ointments rather than lotions because lotions can dry out the skin.
- Apply over-the-counter hydrocortisone cream or ointment (0.5% or 1%) twice daily for 2-3 weeks at a time to help reduce itch and irritation. Stronger topical steroids are typically required for thicker psoriasis plaques. Long-term use of topical steroids should include periodic times of no treatment each month to avoid thinning of the skin.
- Use of products with salicylic acid (shampoos, cleansers, and ointments), such as Neutrogena T/Sal, can help soften and remove thick psoriasis scale in the scalp.
- Small doses of natural sunlight may be helpful, such as 10-15 minutes approximately 2 or 3 times per week. Avoid too much sun; however, and protect your healthy skin from excessive sun exposure to help prevent premature aging of the skin and skin cancers.
- Follow a healthy diet to maintain an ideal weight. (Being overweight may make plaque psoriasis worse.)
The National Psoriasis Foundation (https://www.psoriasis.org/) is a useful resource for patients and health professionals that has additional information regarding psoriasis and the various available treatments. The National Psoriasis Foundation website includes access to psoriasis-related articles, psoriasis research, a directory of health care professionals with an expertise in psoriasis, and opportunities for patients to volunteer or get involved in upcoming events.
When to Seek Medical Care
Individuals with psoriasis should see a medical professional such as a dermatologist or rheumatologist if self-care measures are not helpful, if the psoriasis is widespread, or if there is joint or bone pain in the setting of psoriasis.Individuals with psoriasis are also at increased risk for other health conditions such as heart disease, stroke, high blood pressure, diabetes, obesity, sleep problems, anxiety / depression, social stigma, and cancer. See a medical professional to help screen for these conditions if you have psoriasis.
Treatments
There are many prescription-strength topical, oral, and injectable treatments that are helpful at controlling plaque psoriasis. For localized or mild psoriasis:- The most common therapy for plaque psoriasis is topical steroids, either in cream or ointment form. Low- or mid-potency steroids, such as hydrocortisone 2.5% or triamcinolone, may be useful for thinner areas of skin (face or eyelids) or more sensitive body sites (armpits or genitals). Higher-potency topical steroids, such as clobetasol, halobetasol, or betamethasone, are used for the scalp, trunk, and extremities. Steroid solutions, foams, or liquids are very helpful for the treatment of scalp psoriasis. Use should be limited to twice-daily application for 2-3 weeks at a time followed by a 1-week break due to the possible development of stretch marks (striae) or thinning (atrophy) of the skin with long-term topical steroid use.
- Calcipotriene (Dovonex) is a nonsteroid vitamin D derivative cream that may help treat psoriasis plaques and is even more effective when combined with topical steroids.
- Tazarotene (Tazorac) is a vitamin A–based cream that may be prescribed to help reduce the inflammation, thickening, and scaling of the skin. Individuals of childbearing potential should avoid use in pregnancy as this class of medication may cause birth defects.
- Roflumilast (Zoryve) 0.3% cream is a nonsteroid cream approved for once-daily use in individuals aged 12 years and older and can be used safely on the face and skinfolds as well as other areas of the body.
- Tapinarof (Vtama) 1% cream is another nonsteroid cream approved for once daily use, but it is only approved for adults with plaque psoriasis.
- Coal tar–based therapies and anthralin (Drithocreme) creams are sometimes used, but they are used less frequently than other treatments because they have a foul odor, cause skin irritation, and can stain clothing, and because neither is any more effective than calcipotriene.
- If a large percentage of your skin is affected, ultraviolet (UV) light therapies may be considered. These include UVB phototherapy and PUVA (psoralen [a photosensitizer] and UVA therapy). PUVA may increase your risk for nonmelanoma skin cancers and may be less effective in darker skin colors.
- Injected (subcutaneous) or intravenous biologic therapies are one of the most common medications used for plaque psoriasis. These are proteins that treat plaque psoriasis by blocking certain abnormal immune signals of the immune system that cause psoriasis. This class of medications is highly effective at treating psoriasis but may be costly if not covered by insurance. The number of injections each month and the side effects differ for each medication and should be discussed with your medical professional. Such medications include:
- TNF-alpha inhibitors (eg, etanercept [Enbrel], adalimumab [Humira], certolizumab [Cimzia], infliximab [Remicade, Renflexis])
- IL-12/23 inhibitor (eg, ustekinumab [Stelara])
- IL-23 inhibitors (eg, guselkumab [Tremfya], risankizumab [Skyrizi], tildrakizumab [Ilumya])
- IL-17 inhibitors (eg, secukinumab [Cosentyx], ixekizumab [Taltz], brodalumab [Siliq]).
- Deucravacitinib (Sotyktu) is a once-daily oral pill approved for the treatment of moderate-to-severe plaque psoriasis.
- Apremilast (Otezla) is an oral medication that is taken once to twice daily and is approved for the treatment of plaque psoriasis and psoriatic arthritis.
- Older oral medications may be used for the treatment of moderate-to-severe psoriasis, including acitretin (Soriatane), which is made from vitamin A, methotrexate, and cyclosporine (Gengraf, Neoral). If you are prescribed any of these medicines, you will need to see your medical professional regularly to monitor for possible side effects (such as liver and kidney damage) that may result from use of these medications.
Psoriasis in Adult
See also in: Anogenital,Hair and Scalp,Nail and Distal Digit