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Psoriasis - Coggle Diagram
Psoriasis
Differential Diagnosis
Bacterial infection
Eczema
Secondary syphilis
Lichen planus
Norwegian scabies
Lichen simplex chronicus
Candidal intertrigo
Discolour lupus erythematosus
Fungal nail infection
Guttate psoriasis - viral exanthems, pityriasis rosea, drug eruptions
Fungal skin infection
Generalized pustular psoriasis - pyogenic infections, vasculitis, drug eruptions
Seborrhoeic dermatitis
Triggers
Streptococcal infection
Drugs - lithium, antimalarial drugs, beta-blockers, NSAIDs, ACE inhibitors, trazodone, terfenadine, antibiotics.
Ultraviolet light exposure
Trauma eg scratching, piercings, tattoos, burns or surgery
Hormonal changes eg puberty, post partum, menopause
HIV infections and aids
Psychological stress
Smoking
Alcohol
Diagnosis
Flexural psoriasis
The elderly, immobile, and people who are overweight or obese are at increased risk of being affected
Lesions of chronic plaque psoriasis which are well-defined, but there may be little or no scaling, due to friction and occlusion at these sites.
Itchy psoriasis lesions affecting areas such as the groin, genital area, axillae, inframammary folds, abdominal folds, sacral and gluteal cleft.
Lesions are often red and glazed in appearance, and there may be a fissure in the skin crease.
Guttate psoriasis
Small, scattered, round or oval (2 mm to 1 cm in diameter) scaly papules, which may be pink or red.
Multiple lesions which may occur all over the body over a period of 1–7 days, particularly on the trunk and proximal limbs. Lesions may occur on the face, ears, and scalp, but rarely affect the soles of the feet.
A first presentation of psoriasis (classically after acute streptococcal upper respiratory tract infection), or as an acute exacerbation of plaque psoriasis.
Facial psoriasis
Well-demarcated plaques on the face similar to those of chronic plaque psoriasis
Lesions may affect the hairline
Possible mild scaling around the eyebrows and nasolabial folds
Nail psoriasis
Nail pitting (depressions in the nail plate) is the most common finding
Discolouration (for example the 'oil drop sign') — orange-yellow discolouration of the nail bed.
Nail changes can occur with any type of psoriasis, and are particularly common in people with psoriatic arthritis (up to 90% of people are affected). The incidence of nail involvement increases with the duration of psoriasis.
Subungual hyperkeratosis — hyperproliferation of the nail bed, with accumulation of keratinocytes under the nail.
Onycholysis — detachment of the nail from the nail bed, which may allow bacteria and fungi to enter and cause infection.
Complete nail dystrophy.
Scalp psoriasis
Affects 75-90% of people with psoriasis
Whole scalp may be affected, or individual plaques may be visible
Typically presents as chronic plaque psoriasis
May be associated with non-scarring alopecia
Chronic plaque psoriasis
On white skin, the plaques are pink or red; in deeply pigmented skin, plaques usually have a grey colour and may cause marked post-inflammatory hyperpigmentation.
Most lesions are 1 cm to several centimetres in diameter, with an oval or irregular shape.
Lesions which are typically distributed symmetrically and can coalesce to form larger lesions.
Monomorphic, erythematous plaques covered by adherent silvery-white scale, usually on the scalp, behind the ears, trunk, buttocks, periumbilical area, and extensor surfaces (such as forearms, shins, elbows, and knees).
There is usually a clear delineation between normal and affected skin.
Scale is usually present — it is usually silver-white in colour, but less commonly can be a waxy yellow or orange-brown. The thickness of the scale varies, but it can be very thick. If the scale is gently removed, a glossy red membrane with pinpoint bleeding points (Auspitz's sign) is revealed.
Occasionally, a halo-like effect is seen around a plaque, due to vasoconstriction (Woronoff's ring).
Fissures may form if the plaque is over a joint line or on the palm or sole
Erythrodermic psorisis
Diffuse, widespread, affecting > 90% of body.
Can develop gradually from chronic plaque or appear abruptly
May be precipitated by systemic infection, irritants such as coal tar, ciclosporin, phototherapy or sudden withdrawal of corticosteroids
Lesions may feel ward. May be associated with systemic illness.
Pustular psoriasis
Generalized - medical emergency. Rapidly developing widespread erythema, followed by eruption of white, sterile non-follicular pustules leading to large areas of pus. Associated with systemic illness. Usually presents in those with existing or previous chronic plaque psoriasis, but can occur in those with no history.
Localised - lesions on palms and soles, yellow-brown pustules within established psoriasis plaques, or redness, scaling and pustules at the tips of fingers and toes.
Management
Facial/Flexural/Genital psoriasis
Topical treatments - emollient, short-term mild/moderate topical corticosteroid once or twice daily for up to two weeks,
General advise/information/follow up - as above
Scalp Psoriasis
Offer treatment with topical preparations - topical corticosteroids, coal tar shampoo,
General advise/information/follow up - as above
Guttate Psoriasis
Self limiting condition which usually resolves within 3-4 months of onset and is not infectious
Provide sources of information and advise
Assess for stress, distress, anxiety and/or depression and manage appropriately.
If lesions widespread eg > 10% body surface area arrange urgent referral to dermatology for consideration of phototherapy.
Not widespread - options for treatment include: no treatment if person not concerned about appearance or impact or topical treatments.
Topical treatments: Emollient, potent topical corticosteroid plus vitamin D applied once daily but at different times.
Review after four weeks of commencing treatment.
See CKS for further information on treatment failure.
Ongoing treatment failure consider if alternative diagnosis or arrange referral to dermatology.
Trunk and Limbs
General lifestyle advise - smoking cessation, alcohol intake, weight loss if appropriate
Assess for stress, distress, anxiety and/or depression and manage appropriately
Offer advise - not infectious, treatment to control symptoms rather than cure, complete clearance may not be possible, sources of information
Offer treatment with topical preparations - emollient, topical steroids and topical Vitamin D
Review four weeks after commencing treatment
Arrange review at least annually if using multiple intermittent or short courses of potent corticosteroids
Assess cardiovascular risk at least every five years
Give information leaflet on topical treatments for psoriasis
Nail Psoriasis
Provide sources of information and support
Advise person to keep nails short, avoid manicure of cuticle and avoid fake nails
If nail disease mild with no discomfort or distress no treatment needed.
Nail disease severe and having major functional or cosmetic impact - consider alternative diagnosis / arrange referral to dermatologist
Pustular or Erythrodermic Psoriasis
Generalized - medical emergency - arrange immediate same day assessment from specialist dermatologist
Localized - Provide sources of information and referral to dermatology urgency dependent on clinical judgement
Assessment
Ask about
Sites and extent of involvement
Any known trigger factors
Symptoms of systemic illness such as fever, malaise, weight loss, especially if medical emergencies such as generalized pustular psoriasis or erythrodermic psoriasis are suspected
Articular symptoms of unexplained joint stiffness, pain or swelling, or nail changes that may suggest psoriatic arthritis.
Symptoms of skin involvement such as itch, irritation, burning pain, bleeding and scaling.
Associated conditions such as IBD or obesity
Any over the counter treatment used
Assess the person's perceptions of severity of psoriasis - 7-point Patient's Global Assessment
Consider using Dermatology Life Quality Index tool to assess impact of Psorisis
Assess any associated stress, distress, anxiety or depression.
Family history of psoriasis
Assess Cardiovascular risk - QRISK
Examination
Size and shape - plaque psoriasis generally large plaques, guttate smaller droplet lesions. Clear delineation between normal and affected skin.
Number of lesions - varies
Distribution - often occurs on elbows, knees, trunk, flexures, sacral and natal cleft, scalp and behind the ears, and umbilicus
Severity of lesions - 7 point Physician's Global Assessment score
Assess the skin lesions over the whole body to classify the type of psorasis
Surface features - smooth, scaly, pustular
Signs of systemic illness hypothermia, weight loss, dehydration, tachycardia, hypotension
Colour - pink or red, may not be obvious in those with pigmented skin. Scale typically silvery in colour.
Involvement of other areas - eg joints/nails
Assess and document the proportion of total body surface area affected - estimated using Rule of Nines
Psoriasis is a systemic, immune-mediated, inflammatory skin disease which typically has a chronic relapsing-remitting course, and may have nail and joint (psoriatic arthritis) involvement. The skin lesions of psoriasis are characterized by: Epidermal hyperproliferation — cells multiplying too quickly, Abnormal keratinocyte differentiation — cells not maturing normally, Lymphocyte inflammatory infiltrate — the presence of cells which cause inflammation.