Psoriasis

Specialties > Dermatology

Background knowledge 🧠

Definition

Psoriasis is a chronic inflammatory skin condition characterized by erythematous plaques with silvery scales.
It is an autoimmune disorder involving hyperproliferation of keratinocytes.
Primarily affects the skin, but can also involve the nails and joints.

Epidemiology

Affects 2-3% of the UK population.
Equal prevalence in men and women.
Most commonly presents between ages 15-35.
Genetic predisposition with polygenic inheritance pattern.

Aetiology and Pathophysiology

Exact cause unknown; involves genetic, immunological, and environmental factors.
T-cell mediated immune response causing keratinocyte hyperproliferation.
Triggers include infections, stress, skin trauma, and medications.
Increased levels of inflammatory cytokines like TNF-alpha and IL-17.

Types

Plaque psoriasis: Most common type, characterized by well-demarcated plaques.
Guttate psoriasis: Small, drop-shaped lesions, often triggered by streptococcal infection.
Pustular psoriasis: Characterized by pustules, can be localized or generalized.
Erythrodermic psoriasis: Severe form involving widespread erythema and scaling.
Inverse psoriasis: Affects skin folds with smooth, red lesions.
Nail psoriasis: Involves pitting, onycholysis, and subungual hyperkeratosis.

Clinical Features 🌡️

Symptoms

Itching and discomfort in affected areas.
Pain, particularly in cases with joint involvement (psoriatic arthritis).
Psychological impact, including anxiety and depression.
Fatigue, especially in more severe cases.

Signs

Erythematous plaques with silvery scales, commonly on extensor surfaces.
Auspitz sign: Removal of scale leads to pinpoint bleeding.
Koebner phenomenon: Lesions appearing at sites of trauma.
Nail changes: Pitting, onycholysis, and subungual hyperkeratosis.
Arthritis: Swelling and tenderness of joints in psoriatic arthritis.

Investigations 🧪

Tests

Clinical diagnosis primarily based on history and examination.
Skin biopsy: May be used to confirm diagnosis in atypical cases.
Blood tests: ESR, CRP may be elevated, especially in psoriatic arthritis.
Imaging: X-rays or MRI in cases of suspected psoriatic arthritis.
PASI (Psoriasis Area and Severity Index) to assess severity.

Management 🥼

Management

Topical treatments: Emollients, corticosteroids, vitamin D analogues.
Phototherapy: Narrowband UVB is most commonly used.
Systemic treatments: Methotrexate, ciclosporin, biologics (e.g., TNF inhibitors).
Lifestyle modifications: Smoking cessation, weight management.
Multidisciplinary approach: Dermatologists, rheumatologists, and psychologists.
Patient education: Importance of adherence to treatment and understanding of triggers.

Complications

Psoriatic arthritis: Occurs in up to 30% of patients.
Cardiovascular disease: Increased risk due to systemic inflammation.
Metabolic syndrome: Higher prevalence in patients with psoriasis.
Psychosocial impact: Depression, anxiety, and social stigma.
Infection risk: Due to immunosuppressive treatments.

Prognosis

Chronic condition with relapsing-remitting course.
Severity varies widely; some patients have mild, localized disease, others severe, widespread involvement.
Early treatment and adherence can improve outcomes.
Complications like psoriatic arthritis may impact long-term prognosis.

Key Points

Psoriasis is a common, chronic inflammatory skin condition with systemic implications.
Multifactorial aetiology involving genetic and environmental factors.
Management requires a combination of topical, systemic, and lifestyle interventions.
Early recognition and treatment of complications, especially psoriatic arthritis, are crucial.

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