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Psoriasis is a chronic inflammatory disease that affects primarily the skin and joints.
Psoriasis is a chronic inflammatory disease that affects primarily the skin and joints.1The condition is triggered and worsened by some medications, infections, skin trauma, obesity, and stress, and those suffering from psoriasis are at higher risk for both cardiovascular disease and depression.1Below is a review and update on the assessment, diagnosis, and treatment of psoriasis.
There are 5 types of psoriasis, and patients may present with more than 1 type.1Those are plaque psoriasis, intertriginous psoriasis, erythrodermic psoriasis, pustular psoriasis, and guttate psoriasis.
Psoriasis typically presents before age 40 and affects males and females equally.2About 2% of the US population is afflicted, with an incidence in adults of about 14 per 10,000.3Without a family history of psoriasis, the risk of developing it is about 4%. However, the risk increases to 28% and 65%if 1 or both parents, respectively, are affected.4
Risk factors for developing psoriasis include taking medications, weight gain, smoking, and infection. In addition, alcohol abuse, cold weather, stress, HIV, and postpartum hormonal changes can trigger or exacerbate psoriasis.1,5Medications that most commonly induce or worsen psoriasis include beta-blockers, lithium, indomethacin, tetracyclines, and synthetic anti-malarials.6Other medications that have some evidence suggesting that they may induce or worsen psoriasis include doxycycline, amoxicillin, ampicillin, penicillin, amiodarone, clonidine, digoxin, quinidine, fluoxetine, olanzapine, and benzodiazepine.6
Other conditions associated with psoriasis include psoriatic arthritis, which occurs in 25% of patients with psoriasis and typically affects the hands and feet.2Furthermore, psoriasis increases a patient’s risk for a variety of mental health conditions including depression, anxiety, and suicidal ideation.2Research suggests that nearly 60% of patients with psoriasis also suffer from depression.1Psoriasis also increases a patient’s risk for metabolic syndrome, Crohn’s disease, ulcerative colitis, lymphoma, diabetes, cardiovascular disease, kidney disease, and chronic obstructive pulmonary disease.2
HISTORY AND PHYSICAL PRESENTATIONS
Patients typically have skin lesions that are erythematous, scaly patches, papules, or plaques on the extensor surfaces of their hands, feet, scalp, trunk, and/or buttocks.1These skin lesions may or may not be itchy and painful.
The presentation for psoriasis is typically chronic, though it may have a waxing and waning course.2Sometimes lesions can occur after trauma, which is called the Koebner phenomenon.2The clinician should ask about recent medication use as well as recent group A streptococcal upper respiratory infection, which often proceeds guttate psoriasis.1In addition, assess for alcohol and tobacco use as well as a family history of psoriasis.2
During the physical assessment, focus on the skin and head, eyes, ears, nose, and throat (HEENT). The general physical should look for toxic signs such as fever, hypothermia, and/or dehydration.2The HEENT assessment should look for facial lesions, though these are uncommon, except on the scalp and forehead.2Oral symptoms might be found on the tongue.2
The skin assessment should focus on the extensor surfaces of the elbows and knees, buttocks, trunk, and scalp.1Other sites that may have lesions include the genitals, the palms and soles, and skin folds.1Also look for sebopsoriasis, greasy scales found on the nasolabial folds and eyebrows as well as Woronoff ring, a circle of pale skin surrounding a psoriatic plaque.1The common physical findings for each type of psoriasis are as follows1:
Diagnosis is made based on the clinical appearance (table 1).1,2Typically, the severity of psoriasis is measured by the amount of body surface area affected. Mild-to-moderate psoriasis affects less than 5% of the patient’s body surface area and does not affect their hands, feet, face, and genitals. Moderate-to-severe psoriasis affects greater than 5% of the patient’s body surface area or affects their hands, feet, face, and genitals. A biopsy is rarely needed for confir- mation of the diagnosis.7
For plaque psoriasis, the differential diagnosis should include atopic dermatitis (history of hay fever or asthma), contact dermatitis (no silvery scale), lichen planus (involves the wrist and ankles with less scale), seborrheic dermatitis (greasy scale), onychomycosis, tinea corporis (thinner scale with positive potassium hydroxide preparation), pityriasis rosea, and mycosis fungoide (less distinct lesion borders).2,7For guttate psoriasis, the differential diagnosis should include sec- ondary syphilis, which presents with red-brown lesions on the palms of the patient’s hands and the soles of the patient’s feet.2For erythrodermic psoriasis, the differential diagnosis should include drug rash with eosinophilia and systemic symptoms and Stevens-Johnson syndrome.2,7Finally, with pregnant women, evaluate for impetigo herpetiformis, also called pustular psoriasis of pregnancy.7
Patient preferences and the ability to adhere to treatment (table 2) are important when choosing therapy. Psoriasis treatment for pregnant women includes topical steroids, followed by phototherapy if necessary. Specific treatment options for each type of psoriasis are listed below.2,8-10
As mentioned above, depression is often comorbid with psoriasis. It is important to both recognize and treat the depression, as well, because this can lead to poor adherence to treatment regimens and a lower overall quality of life. Consider referring these patients to mental health counseling in addition to treating their psoriasis.
Melissa DeCapua, DNP, PMHNP-BC
, is a psychiatric nurse practitioner with a clinical background in psychosomatic medicine. She now works as a design researcher in
the technology industry, guiding product development by combining her clinical expertise and creative thinking. She is a strong advocate for empowering nurses, and she fiercely believes that nurses should play a pivotal role in shaping modern health care. For more about Dr. DeCapua, visit her website at melissadecapua.com and follow her on Twitter @melissadecapua.