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Clinical Presentation
General
Psoriasis generally begins
as red, scaling papules that coalesce to form round-to-oval plaques. The rashes
are often pruritic and may be painful.
Plaque Psoriasis
Plaque
psoriasis, also known as psoriasis vulgaris, is the most common form of
psoriasis approximately affecting 80-90% of patients.
It presents as scaling,
erythematous, well-demarcated, and silvery plaques with various sizes ranging
from 1 cm to several centimeters. The plaques are irregular, round to oval in
shape, and tend to be symmetrically distributed. It typically affects areas such
as the elbows, knees, scalp, trunk, intergluteal cleft, buttocks, soles, and
palms. Occasionally, the genitalia may also be affected. Painful fissuring
within plaques can occur when lesions are present over joint lines, palms, and
soles.
Guttate Psoriasis
Guttate psoriasis is common
in persons <30 years old and affects <2% of patients with psoriasis. It
usually occurs after an upper respiratory infection with group A beta-hemolytic
streptococci. It presents as teardrop-shaped, salmon-pink papules usually
within a fine scale measuring 1 to 10 mm. It is usually found on the trunk and
proximal extremities and may be the first manifestation of psoriasis in a
healthy individual or an acute exacerbation of a long-standing plaque.
Pustular Psoriasis
The
generalized type of pustular psoriasis is also called von Zumbusch psoriasis.
It is characterized by sterile pustules on an erythematous base that cover
large portions of the trunk and extremities. The pustules may coalesce and form
large pools of pus in severe cases. The skin’s protective functions are lost,
and the patient is susceptible to infection and loss of fluids and nutrients.
It is also considered an uncommon, severe form of psoriasis associated with
systemic symptoms (eg fever, malaise) and can be life-threatening.
The localized type of
pustular psoriasis presents as pustules that are localized to the palms and
soles of the feet, although they may also localize on top of the plaque. It is
not life-threatening, but it may be debilitating because of difficulty in using
the hands or feet.
Erythrodermic Psoriasis
Erythrodermic psoriasis is a
severe, generalized erythema affecting up to 100% of the body surface area
(BSA) with various degrees of scaling. The skin’s protective functions are
lost, and the patient is susceptible to infection, uncontrollable body
temperature, and loss of fluids and nutrients. It is often associated with
systemic symptoms (eg fever and malaise) and can be life-threatening.
Inverse Psoriasis
In inverse psoriasis, the
lesions consist of erythematous plaques with minimal scales and are located in
the skin folds (eg axillary, genital, perineal, intergluteal, inframammary
areas).
History
Psoriasis
has a bimodal age of onset at 16 to 22 years and 57 to 60 years old. Obtaining
information on the patient’s history of the environmental or pharmacological
impact on lesions is essential. Infections particularly streptococcal can
precipitate or exacerbate the disease, and drugs (eg Lithium, antimalarials,
alcohol, nonsteroidal anti-inflammatory drugs [NSAIDs], beta-blockers) may
aggravate the disease.
Past medical (eg heart
failure, demyelinating disease, inflammatory bowel disease, malignancy) and
surgical history are likewise important. The family, social, and symptomatology
history should be reviewed.
Physical Examination
Diagnosis can usually be made from the clinical appearance of the skin lesions. It is important to inspect all areas of the body especially the extensor surfaces, trunk, perineum, scalp, nails, and joints.