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10/25/2015

PsoriasisClinicalPresentation:History,PhysicalExamination,OcularManifestations

PsoriasisClinicalPresentation
Author:JeffreyMeffert,MDChiefEditor:WilliamDJames,MDmore...
Updated:Jan22,2015

History
Symptomsofpsoriasismayincludethefollowing:
Worseningofalongtermerythematousscalyarea
Suddenonsetofmanysmallareasofscalyredness
Recentstreptococcalthroatinfection,viralinfection,immunization,useof
antimalarialdrug,ortrauma
Familyhistoryofsimilarskincondition
Pain(especiallyinerythrodermicpsoriasisandinsomecasesoftraumatized
plaquesorinthejointsaffectedbypsoriaticarthritis)
Pruritus(especiallyineruptive,guttatepsoriasis)
Afebrile(exceptinpustularorerythrodermicpsoriasisinwhichthepatient
mayhavehighfever)
Dystrophicnails
Longtermrashwithrecentpresentationofjointpain
Jointpainwithoutanyvisibleskinfindings
Theskinalmostalwaysisaffectedbeforetheeyes.Ocularfindingsoccurin
approximately10%ofpatients.Themostcommonocularsymptomsareredness
andtearingduetoconjunctivitisorblepharitis.
Thenonocularsymptomsarerelatedtorashandpsoriaticarthritis.Therashcanbe
uncomfortableorevenpainful.Psoriaticarthritiscancausestiffness,pain,
throbbing,swelling,ortendernessofthejoints.Thedistaljoints,suchasthe
fingers,toes,wrists,knees,andankles,aremostoftenaffected.

PhysicalExamination
Findingsonphysicalexaminationdependonthetypeofpsoriasispresent.
Themostcommonskinmanifestationsarescalingerythematousmacules,papules,
andplaques.Typically,themaculesareseenfirst,andtheseprogressto
maculopapulesandultimatelywelldemarcated,noncoherent,silveryplaques
overlyingaglossyhomogeneouserythema.Theareaofskininvolvementvarieswith
theformofpsoriasis.
Chronicstationarypsoriasis(psoriasisvulgaris)isthemostcommontypeof
psoriasis.Thisinvolvesthescalp,extensorsurfaces,genitals,umbilicus,and
lumbosacralandretroauricularregions.
Plaquepsoriasisischaracterizedbyraised,inflamedlesionscoveredwithasilvery
whitescale.Thescalemaybescrapedawaytorevealinflamedskinbeneath.This
ismostcommonontheextensorsurfacesoftheknees,elbows,scalp,andtrunk.
Guttatepsoriasispresentsassmallsalmonpinkpapules,110mmindiameter,
predominatelyonthetrunkthelesionsmaybescaly(seetheimagebelow).It
frequentlyappearssuddenly,23weeksafteranupperrespiratoryinfection(URI)
withgroupAbetahemolyticstreptococci.

Guttatepsoriasiseruptedinthispatientaftertopicalsteroidtherapywaswithdrawnduringa
pregnancy.ContributedbyRandyPark,MD.

Inversepsoriasisoccursontheflexuralsurfaces,armpit,groin,underthebreast,
andintheskinfolds.Itischaracterizedbysmooth,inflamedlesionswithoutscaling

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PsoriasisClinicalPresentation:History,PhysicalExamination,OcularManifestations

duetothemoistnatureoftheareawherethistypeofpsoriasisislocated.
Pustularpsoriasispresentsassterilepustulesappearingonthepalmsandsolesor
diffuselyoverthebody.Pustularpsoriasismaycyclethrougherythema,pustules,
thenscaling.ThediffusevariantistermedvonZumbuschvariant,whichis
accompaniedbyfeverandintenseillfeelinginadditiontothewidespreadpustules.
AcrodermatitiscontinuaofHallopeauisconsideredaformofpustularpsoriasisthat
affectsthehandsandfeet.Itmayproveresistanttotopicalandothertherapies.
Erythrodermicpsoriasispresentsasgeneralizederythema,pain,itching,andfine
scalingvariouspustularformsalsoexist.Ittypicallyencompassesnearlytheentire
bodysurfacearea.Itmaybeaccompaniedbyfever,chills,hypothermia,and
dehydrationsecondarytothelargebodysurfaceareainvolvement.Patientswith
severepustularorerythrodermicpsoriasismayrequirehospitaladmissionfor
metabolicandpainmanagement.Olderpatientswitherythrodermicpsoriasismay
experiencecardiacinstabilityandhypotensionduetomassivevascularshuntingin
theskin.
Scalppsoriasisaffectsapproximately50%ofpatients.Itpresentsaserythematous
raisedplaqueswithsilverywhitescalesonthescalp.
Nailpsoriasismaycausepitsonthenails,whichoftenbecomethickenedand
yellowishincolor.Nailsmayseparatefromthenailbed.Psoriaticnailsmaybe
indistinguishablefromfungalnailsand,atthesametime,maybemoreproneto
developingonychomycosisbecauseofthenailseparationandsubungualdebris.
Aretrospectivestudyfrom2014reportsthatnailinvolvementinpsoriasisisa
significantpredictorofthepatientalsohavingpsoriaticarthritis. [30]Thestudylooked
atretrospectivedatafromthreeGermancrosssectionalindependentnational
studiesonpatientswithpsoriasisandpsoriaticarthritis.Dataonthepatientshistory
ofpsoriasisandpsoriaticarthritis,clinicalfindings,nailinvolvement,andpatient
andpractitionerreportedoutcomeswerecollectedfromstandardized
questionnaires.Intheresults,theregressionmodelof4146patientsindicatedone
ofthestrongestpredictorsofconcomitantpsoriaticarthritiswasnailinvolvement.
Psoriaticarthritisaffectsapproximately1030%ofthosewithskinsymptoms.The
arthritisisusuallyinthehandsandfeetand,occasionally,thelargejoints.It
producesstiffness,pain,andprogressivejointdamage.
Oralpsoriasismaypresentwithwhitishlesionsontheoralmucosa,whichmay
appeartochangeinseveritydaily.Itmayalsopresentasseverecheilosiswith
extensionontothesurroundingskin,crossingthevermillionborder.Geographic
tongueisconsideredbymanytobeanoralformofpsoriasis.
Eruptivepsoriasisinvolvestheuppertrunkandupperextremities.Mostoften,itis
seeninyoungerpatients.

OcularManifestations
Inadditiontoskinmanifestations,psoriasismayalsoaffectthelid,conjunctiva,or
corneaandgiverisetoocularmanifestations,includingectropionandtrichiasis,
conjunctivitisandconjunctivalhyperemia,andcornealdrynesswithpunctate
keratitisandcornealmelt. [3,4]
Blepharitisisthemostcommonocularfindinginpsoriasis.Erythema,edema,and
psoriaticplaquesmaydevelop,andtheycanresultinmadarosis,cicatricial
ectropion,trichiasis,andevenlossofthelidtissue.
Achronicnonspecificconjunctivitisisfairlycommon.Itusuallyoccursinassociation
witheyelidmargininvolvement.Psoriaticplaquescanextendfromthelidontothe
conjunctiva.Chronicconjunctivitiscanleadtosymblepharon,keratoconjunctivitis
sicca,andtrichiasis.Nodularepiscleritisandlimballesionsresemblingphlyctenules
alsocanbeseen.
Cornealdiseaseisrelativelyrare.Mostoften,itissecondarytolidorconjunctival
complications,suchasdryness,trichiasis,orexposure.Themostcommonfindingis
punctatekeratitis.Filaments,epithelialthickening,recurrenterosions,
vascularization,ulceration,andscarringcanoccur.Thevascularizationtendstobe
superficial,peripheral,andinterpalpebralorinferior.Rarely,peripheralinfiltration
andmeltingcanoccurintheabsenceoftrichiasisandexposure. [31]
Inonecase,recurrentnasolacrimalductocclusionwasobserved,presumably
causedbywashingofthescalesintothelacrimalsac.
Usually,anterioruveitiscanbeseeninassociationwithpsoriaticarthritis.Acute
psoriaticuveitistendstobebilateral,prolonged,andmoreseverethannonpsoriatic
cases. [32,33]

Complications
Complicationsofpsoriasismayincludethefollowing:
Secondaryinfections
Possibleincreasedriskoflymphoma
Possibleincreasedriskofcardiovascularandischemicheartdisease
Psoriaticarthritis
Mitralvalveprolapse

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DifferentialDiagnoses

ContributorInformationandDisclosures
Author
JeffreyMeffert,MDAssociateClinicalProfessorofDermatology,UniversityofTexasSchoolofMedicineatSan
Antonio
JeffreyMeffert,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofDermatology,
AmericanMedicalAssociation,AssociationofMilitaryDermatologists,TexasDermatologicalSociety
Disclosure:Nothingtodisclose.
ChiefEditor
WilliamDJames,MDPaulRGrossProfessorofDermatology,ViceChairman,ResidencyProgramDirector,
DepartmentofDermatology,UniversityofPennsylvaniaSchoolofMedicine
WilliamDJames,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofDermatology,
SocietyforInvestigativeDermatology
Disclosure:Nothingtodisclose.
Acknowledgements
RobertArffa,MDClinicalAssistantProfessor,UniversityofPittsburghSchoolofMedicine
RobertArffa,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofOphthalmology
Disclosure:Nothingtodisclose.
RichardGordonJr,MDStaffPhysician,DepartmentofEmergencyMedicine,DetroitReceivingHospital
UniversityHealthCenter
RichardGordonJr,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergency
Physicians,AmericanCollegeofPhysicians,AmericanMedicalStudentAssociation/Foundation,Emergency
MedicineResidentsAssociation,andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
RyanIHuffman,MDResidentPhysician,DepartmentofOphthalmology,YaleNewHavenHospital
Disclosure:Nothingtodisclose.
SimonKLaw,MD,PharmDClinicalProfessorofHealthSciences,DepartmentofOphthalmology,JulesStein
EyeInstitute,UniversityofCalifornia,LosAngeles,DavidGeffenSchoolofMedicine
SimonKLaw,MD,PharmDisamemberofthefollowingmedicalsocieties:AmericanAcademyof
Ophthalmology,AmericanGlaucomaSociety,andAssociationforResearchinVisionandOphthalmology
Disclosure:Nothingtodisclose.
RandyPark,MDChair,AssociateProfessor,DepartmentofEmergencyMedicine,DentonRegionalMedical
Center
Disclosure:Nothingtodisclose.
BrianAPhillpotts,MDFormerVitreoRetinalServiceDirector,FormerProgramDirector,ClinicalAssistant
Professor,DepartmentofOphthalmology,HowardUniversityCollegeofMedicine
BrianAPhillpotts,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofOphthalmology,
AmericanDiabetesAssociation,AmericanMedicalAssociation,andNationalMedicalAssociation
Disclosure:Nothingtodisclose.
ChristopherJRapuano,MDProfessor,DepartmentofOphthalmology,JeffersonMedicalCollegeofThomas
JeffersonUniversityDirectoroftheCorneaService,CoDirectorofRefractiveSurgeryDepartment,WillsEye
Institute
ChristopherJRapuano,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyof
Ophthalmology,AmericanSocietyofCataractandRefractiveSurgery,ContactLensAssociationof
Ophthalmologists,CorneaSociety,EyeBankAssociationofAmerica,andInternationalSocietyofRefractive
Surgery
Disclosure:AllerganHonorariaSpeakingandteachingAllerganConsultingfeeConsultingAlconHonoraria
SpeakingandteachingRPSOwnershipinterestOtherBausch&LombHonorariaSpeakingandteaching
MerckConsultingfeeConsultingBausch&LombConsultingMerckHonorariaSpeakingandteaching
AdamJRosh,MDAssistantProfessor,ProgramDirector,EmergencyMedicineResidency,Departmentof
EmergencyMedicine,DetroitReceivingHospital,WayneStateUniversitySchoolofMedicine
AdamJRosh,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergencyMedicine,
AmericanCollegeofEmergencyPhysicians,andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
HamptonRoySr,MDAssociateClinicalProfessor,DepartmentofOphthalmology,UniversityofArkansasfor
MedicalSciences
HamptonRoySr,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofOphthalmology,
AmericanCollegeofSurgeons,andPanAmericanAssociationofOphthalmology
Disclosure:Nothingtodisclose.

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DanaAStearns,MDAssistantDirectorofUndergraduateEducation,DepartmentofEmergencyMedicine,
MassachusettsGeneralHospitalAssistantProfessorofSurgery,HarvardMedicalSchool
DanaAStearns,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergencyPhysicians
Disclosure:Nothingtodisclose.
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment

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