Department of Dermatology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
Abstract
Psoriasis is a chronic inflammatory skin disease. Associated comorbidities or risks may include psoriatic
arthritis, obesity, depression, smoking, diabetes, hyperlipidemia, an increased risk of cardiovascular
disease with myocardial infarction, or an increased risk of lymphoma. The clinical presentation
of psoriasis can range from the more common red scaling elevated plaques on the elbows, knees, or
scalp to the less common superficial pustules scattered on the palms or soles, or in rare cases widespread
pustules on the body. More specifically, the clinical spectrum of psoriasis includes the plaque,
guttate, small plaque, inverse, erythrodermic, and pustular variants. The determinants of the clinical
severity of psoriasis, the risk of comorbidities, and the quality of life of a psoriatic patient are influenced
by multiple factors. At the minimum, these include variations in the quality and type of psoriasis,
the quantity of skin involved, and the distribution of skin lesions (including special areas such
as the scalp, nails, face, intertriginous regions, and palmoplantar surfaces). Objective measures used
to quantify the severity of psoriasis, including the body surface area involved, Physician’s Global
Assessment, Psoriasis Area and Severity Index, and quality of life measures, are all assessments that
can be useful in guiding approaches to management and therapeutics. In this paper, we review the
clinical spectrum of psoriasis, the differential diagnoses, measures and determinants of severity, and
the recommendations on when to refer a patient to a specialist in psoriasis. We also briefly review
the comorbidities, and note the importance of referring the psoriatic patient to the internist/general
practitioner for evaluation and management for these comorbidities.
Copyright © 2009 S. Karger AG, Basel
Psoriasis is a chronic inflammatory disorder of the skin that can affect a person at any
age. It can present in various patterns and forms. The most common morphologic
presentation of psoriasis is that of the plaque type, with the second form being the
pustular type. Its course is variable and unpredictable. It may be episodic with short
or long periods of reported complete clearance, or be unrelenting and persistent with
waxing and waning of activity influenced by identifiable or unidentifiable triggers
and alleviators. Initially it may be indolent and virtually unrecognizable as ‘psoriasis’ by the patient or physician, only to present itself in a more classic presentation during
times of emotional, physical, or medical stress.
Throughout history, psoriasis has been understood and misunderstood as a disease
solely of the skin. Its consequences on the social, psychological, physical, and spiritual
fabric of the individual and those close to him/her have been increasingly recognized.
However, by the end of the 20th century, the psoriasis model had evolved to become
a disorder of the skin and joints. Accepted as the consequence of an immune system
gone awry, psoriasis has become a model of a skin disease with ‘systemic inflammation’.
Much work is now being done to understand the association of comorbidities
with psoriasis and their impact on the patient and society.
With the advances in technology and medical research, the current pathogenetic
model for psoriatic disease includes a combination of genetic predisposition, immunologic
dysfunction, and keratinocyte factors that lead to the formation of psoriasis.
Along with these, the roles of the peripheral and central nervous systems, vascular
system, adaptive and innate immune systems, environmental factors, and infectious
agents contribute to the formation of psoriasis. In this paper, we will review the clinical
spectrum, the differential diagnosis, and the severity of psoriasis as they relate to
quality of life, therapeutic options, and signs that indicate when further evaluation by
a dermatologist or a specialist in psoriatic disease is warranted.
Psoriasis Study Part II continues here.
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