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Psoriasis http;//emedicine.medscape.com/article/1943419-overview

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Psoriasis

 Author: Jeffrey Meffert, MD; Cief Editor: Robert E O’Connor,MD, MPH more…

Updated: Sep 23, 2011

Background

Psoriasis is a chronic, noncontagious, multisystem, inflammatory disorder. Patients with
psoriasis have a genetic predisposition for the illness, which most commonly manifests itself on
the skin of the elbows, knees, scalp, lumbosacral areas, intergluteal clefts, and glans penis. The
joints are also affected by psoriasis in up to 30% of patients with the disease. (See
Pathophysiology and Etiology.)

Psoriasis has a tendency to wax and wane with flares related to systemic or environmental
factors, including life stress events and infection. It impacts quality of life and potentially long-
term survival. There should be a higher clinical suspicion for depression in the patient with
psoriasis. (See Prognosis.)

Multiple types of psoriasis are identified, with plaque-type psoriasis, also known as discoid
psoriasis, being the most common type. Plaque psoriasis usually presents with plaques on the
scalp, trunk, and limbs (see the image below). These plaques appear as focal, raised, inflamed,
edematous lesions covered with silvery-white “micaceous” scales. (See Clinical Presentation.)

Psoriasis pictures. Plaque psoriasis is most common on the
extensor surfaces of the knees and elbows. Contributed by Randy Park, MD.

Ocular signs occur in approximately 10% of psoriasis patients, and they are more common in
men than in women. Patients with ocular findings almost always have psoriatic skin disease;
however, it is rare for the eye to become involved before the skin.

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The diagnosis of psoriasis is clinical. (See Workup.) Management of psoriasis may involve topical
or systemic medications, light therapy, stress reduction, climatotherapy, and various adjuncts
such as sunshine, moisturizers, and salicylic acid. (See Treatment and Management.)

For more information, see the following:

 Guttate Psoriasis
 Nail Psoriasis
 Plaque Psoriasis
 Pustular Psoriasis
 Psoriatic Arthritis
 Imaging of Psoriatic Arthritis
 Parapsoriasis

Pathophysiology

Psoriasis is a complex, multifactorial disease that appears to be influenced by genetic and
immune-mediated components. This is supported by the successful treatment of psoriasis with
immune-mediating, biologic medications.

The pathogenesis of this disease is not completely understood. Multiple theories exist
regarding triggers of the disease process including an infectious episode, traumatic insult, and
stressful life event. In many patients, no obvious trigger exists at all. However, once triggered,
there appears to be substantial leukocyte recruitment to the dermis and epidermis resulting in
the characteristic psoriatic plaques.

Specifically, the epidermis is infiltrated by a large number of activated T cells, which appear to
be capable of inducing keratinocyte proliferation. This is supported by histologic examination
and immunohistochemical staining of psoriatic plaques revealing large populations of T cells
within the psoriasis lesions. One report calculated that a patient with 20% body surface area
affected with psoriasis lesions has around 8 billion blood circulating T cells compared with
approximately 20 billion T cells located in the dermis and epidermis of psoriasis plaques.

[4]


Ultimately, a ramped-up, deregulated inflammatory process ensues with a large production of
various cytokines (eg, tumor necrosis factor-α *TNF-α+, interferon-gamma, interleukin-12).
Many of the clinical features of psoriasis are explained by the large production of such
mediators. Interestingly, elevated levels of TNF-α specifically are found to correlate with flares
of psoriasis.

One study adds further support that T-cell hyperactivity and the resulting proinflammatory
mediators (in this case IL-17/23) play a major role in the pathogenesis of psoriasis.

[5]


http://emedicine.medscape.com/article/1107850-overview
http://emedicine.medscape.com/article/1107949-overview
http://emedicine.medscape.com/article/1108072-overview
http://emedicine.medscape.com/article/1108220-overview
http://emedicine.medscape.com/article/331037-overview
http://emedicine.medscape.com/article/394752-overview
http://emedicine.medscape.com/article/1107425-overview
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Many of the therapies for psoriasis manipulate the function of the immune system and expose
the patient to risk of severe infections while blunting the body’s response. In these patients,
findings suggestive of minor infections must be taken seriously, and the risk versus the benefit
of continuing the drug in the face of the infection must be weighed.

Treatment of Ocular Complications

Keratoconjunctivitis sicca can be treated with ocular lubricants and punctal occlusion. Trichiasis
and cicatricial ectropion usually require surgical treatment. Conjunctival, corneal, and anterior
chamber inflammation can be treated with topical corticosteroids. Nonsteroidal anti-
inflammatory agents or oral corticosteroids are occasionally necessary. Whether systemic
immunosuppression is effective for ocular disease is not clear.

Corneal melting, inflammation, and vascularization can be difficult to treat. A bandage contact
lens may retard the melting. Topical corticosteroids can control the infiltration and delay the
vascularization. In some cases, progression can occur in spite of these treatments and can lead
to the need for lamellar or penetrating keratoplasty.

Consultations

Psoriasis is a chronic problem, and consultation for follow-up with a dermatologist or a
rheumatologist is appropriate. Close follow-up is necessary to design an optimal treatment plan
in accordance with the severity of disease.

Severity of psoriasis can be classified as follows:

 Mild - Less than 2% of the body is affected
 Moderate - From 3-10% of the body is affected
 Severe - More than 10% of the body is affected

Of note, the palm of the patient’s hand is equal to 1% body surface area.

Determining the severity of psoriasis requires combining objective measures, such as body
surface area involvement; disease location; symptoms; and presence of psoriatic arthritis with
subjective measures such as the physical, financial, and emotional impact of the disease.

Patients with infectious diseases and psoriasis may be using drugs that modify immunologic
response and render them immunocompromised. Investigation into the type of therapy is
important and, if such an agent is identified, referral and close follow-up is needed.

Medication Summary

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http://reference.medscape.com/medline/abstract/18086997
http://reference.medscape.com/medline/abstract/21472501
http://reference.medscape.com/medline/abstract/10459113
http://reference.medscape.com/medline/abstract/20713823
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2928071/
http://reference.medscape.com/medline/abstract/12894076
http://reference.medscape.com/medline/abstract/16634884
http://reference.medscape.com/medline/abstract/18569794
http://reference.medscape.com/medline/abstract/7785699
http://reference.medscape.com/medline/abstract/15652834
http://reference.medscape.com/medline/abstract/18626741
http://reference.medscape.com/medline/abstract/18423260

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