Review ArticlePractice

Diagnosis and management of psoriasis

Whan B. Kim, Dana Jerome and Jensen Yeung
Canadian Family Physician April 2017; 63 (4) 278-285;

Article Figures & Data

Figures

  • Figure 1.
    Figure 1.

    Plaque psoriasis is characterized by well-demarcated and erythematous plaques with silvery scale:

    A) Plaque psoriasis on the elbow; B) Psoriasis on the trunk, marked by confluent red, well-demarcated, scaly plaques; C) Psoriasis on the dorsal foot and metatarsophalangeal joint with psoriatic nails showing dystrophy; D) Psoriasis in the postauricular area, which is a common site of involvement.

  • Figure 2.
    Figure 2.

    Patients with psoriasis might have nail involvement, which can present without concomitant plaques:

    A) Psoriatic nails, consisting of pitting, distal onycholysis, subungual hyperkeratosis, and crumbling; B) Leukonychia and splinter hemorrhages; C) Distal onycholysis and oil drop sign.

  • Figure 3.
    Figure 3.

    Annular psoriasis on the back: Annular psoriasis is characterized by well-demarcated, erythematous, and scaly plaques with central clearing.

  • Figure 4.
    Figure 4.

    Pustular psoriasis on the palm

  • Figure 5.
    Figure 5.

    Guttate psoriasis, which developed 12 d after onset of streptococcal pharyngitis

  • Figure 6.
    Figure 6.

    Approaching erythrodermic psoriasis

  • Figure 7.
    Figure 7.

    Treatment algorithm for healthy adult men with chronic plaque psoriasis (> 5% BSA) without psoriatic arthritis

    BB—broadband, BSA—body surface area, NB—narrowband, PUVA—psoralen plus UVA, UV—ultraviolet.

Tables

  • Table 1.

    Clinical manifestations of psoriasis

    CLINICAL MANIFESTATIONCLINICAL FINDINGS
    Plaque psoriasis

    • Well circumscribed, erythematous, scaly plaques > 0.5 cm in diameter, either as single lesions or as generalized disease

    • Classified further according to anatomic sites

      • Flexural

    • Also known as intertriginous or inverse psoriasis

    • Well circumscribed, minimally scaly, thin plaques localized to the skin folds (inframammary, axillary, groin, genital, natal cleft regions)

      • Nail

    • Can present without concomitant skin plaques

    • Pitting, distal onycholysis, subungual hyperkeratosis, oil drop sign, splinter hemorrhages, leukonychia, crumbling, red lunula

    • Nail involvement is a predictor of psoriatic arthritis

      • Scalp

    • One of the most common sites of psoriasis

    • Often difficult to treat

      • Palmoplantar

    • Localized to the hands and soles of feet

    • Confluent redness and scaling without obvious plaques to poorly defined scaly or fissured areas to large plaques covering the palm or sole

    Other variants
      • Guttate

    • Acute eruption of “dew-drop,” salmon-pink, fine-scaled, small papules on the trunk or limbs

    • Can follow history of group A streptococcal pharyngitis or perianal group A streptococcus dermatitis

      • Pustular

    • Sheets of monomorphic pustules on painful, inflamed skin

    • Most commonly localized to the palms or soles

      • Erythroderma

    • Acute or subacute onset of generalized erythema covering 90% or more of the patient’s entire body with little scaling

    • Might be associated with hypothermia, hypoalbuminemia, electrolyte imbalances, and high-output cardiac failure

    • Life-threatening emergency

      • Annular

    • Well demarcated erythematous scaly plaques with central clearing

    • Data from the Canadian Psoriasis Guidelines Committee.1

  • Table 2.

    Measures of disease severity

    SEVERITYMEASURES*
    Mild

    • < 3% BSA†

    • Disease with a minimal effect on the patient’s QoL; patient can achieve an acceptable level of symptomatic control by routine skin care measures and topical therapy

    Moderate

    • 3% to 10% BSA†

    • Disease that cannot be, or would not be expected to be, controlled to an acceptable degree by routine skin care measures or disease that substantially affects the patient’s QoL, either because of the extent of the disease, physical discomfort (pain or pruritus), or location (eg, the face, hands, feet, or genitals)

    Severe

    • > 10% BSA†

    • Disease that cannot be, or would not be expected to be, satisfactorily controlled by topical therapy and that causes severe degradation of the patient’s QoL

    • BSA—body surface area, QoL—quality of life.

    • ↵* These are definitions for clinical practice, as applied in the Canadian guideline. The Psoriasis Area and Severity Index is another measure of disease severity, based on BSA, erythema, induration, and scaling.

    • ↵† The size of a single hand is estimated to be 1% BSA.

    • Data from the Canadian Psoriasis Guidelines Committee.1

  • Table 3.

    Differential diagnoses and distinguishing clinical features

    DIFFERENTIAL DIAGNOSESDISTINGUISHING CLINICAL FEATURES
    Atopic dermatitis• Predominant symptom of pruritus and typical morphology and distribution (flexural lichenification in adults and older children; facial and extensor papules and vesicles in infancy)
    Contact dermatitis• Patches or plaques with angular corners, geometric outlines, and sharp margins dependent on the nature of the exposure to the irritant or allergen
    Lichen planus• Violaceous lesions and frequent mucosal involvement
    Secondary syphilis• Copper-coloured lesions and frequent involvement of palms and soles
    Mycosis fungoides• Irregularly shaped lesions with asymmetric distribution, peculiar colour, and wrinkling due to epidermal atrophy
    Tinea corporis• Fewer lesions with annular configuration
    Pityriasis rosea• Tannish-pink, oval papules and patches with “Christmas tree” configuration on trunk with sparing of the face and distal extremities
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Diagnosis and management of psoriasis
Whan B. Kim, Dana Jerome, Jensen Yeung
Canadian Family Physician Apr 2017, 63 (4) 278-285;
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