Psoriasis is a common chronic inflammatory disease of the skin that is increasingly being recognized as a systemic inflammatory disorder. According to current studies, more than 8 million Americans have psoriasis. Men and women develop psoriasis at equal rates. You can develop psoriasis at any age. A rapidly expanding body of literature supports additional associations between psoriasis and cardiometabolic diseases, gastrointestinal diseases, kidney disease, malignancy, infection, and mood disorders. Given the variety of manifestations of this condition, education of healthcare providers, including PAs, is essential to ensuring comprehensive medical care for patients with psoriasis.
Psoriasis has a variety of clinical presentations.
Classic plaque psoriasis is itchy, symmetric papules and plaques with white silvery scale. Inverse psoriasis appears in body folds, axillae, inframammary, inguinal and gluteal creases. Psoriasis can also appear on the palms and soles causing pain and difficulties with performing activities of daily living. Guttate psoriasis is small less scaly spots (papules) on the chest and back that can appear after a strep infection (Figure 1). Sebopsoriasis is when dandruff or seborrheic dermatitis is so bad that the plaques in the scaly are thickened with pinpoint bleeding, Auspitz sign, when peeled off. Plaque psoriasis is treated with steroids can transform into pustular psoriasis where tens to hundreds of tiny pustules can stud the psoriasis plaques and coalesce into lakes of pus.
Psoriasis of any type can affect the nails causing nail changes that can be mistaken for fungal infection. Nail pits that appear as punctate depressions in the nail plate that look as if they have been caused by a toothpick or ice pick pressed into the nail are the most common finding of nail psoriasis. Oil spots that are yellow brownish discoloration are the most specific finding for nail psoriasis. Trachonychia is the clinical description for nails that look rough as if scraped with sandpaper. Onycholysis is separation of the nail plate (the part of the nail that you pain or clip) from the nail bed. Nail changes are classically associated with Psoriatic Arthritis. A patient can have nail changes and have other cutaneous manifestations of psoriasis.
About 30% of people with cutaneous psoriasis will develop psoriatic arthritis. This is a seronegative inflammation of many joints. This commonly manifests as asymmetric oligoarthritis (mainly hands and feet). Psoriatic Arthritis is characterized by enthesitis –inflammation involving periarticular structures i.e. tendons ligaments at their insertion points.
Things that can exacerbate or trigger a flare of psoriasis :
- Skin injury (Koebner phenomenon)
- Streptococcal infections
- Hypocalcemia can trigger generalized pustular psoriasis
- Medications: Lithium, B-blockers, antimalarials, interferon, ACE-Inhibitors, gemfibrozil, NSAIDS, imiquimod, Rituximab , rapid taper of corticosteroids
- Lifestyle factors: alcohol, smoking and obesity
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