COMMON DERMATOSES

Psoriasis Key points

Eleanor Higgins C Psoriasis is a clinical diagnosis. It is characterized by red
plaques with scale at typical sites including the extensor sur-
faces of the elbows, knees, scalp, natal cleft and umbilicus.
Abstract Psoriatic arthritis occurs in up to 30% of patients with psori-
Psoriasis is a common, chronic inflammatory skin disease affecting 2 asis. Patients with moderate/severe disease or who fail to
e3% of the UK population. A family history of psoriasis occurs in respond to first-line topical therapy should be referred to a
approximately 30% of patients, and usual age of onset is 20e35 dermatology department for second-line therapy
years. Psoriasis is predominantly an immunological T lymphocyte-
driven disease, involving both the innate and T-cell-mediated immune C Newer biological agents have revolutionized the management
systems. Chronic plaque psoriasis accounts for 85% of cases. of severe psoriasis and psoriatic arthritis
Commonly affected sites include the scalp, extensor surfaces of the
knees and elbows, umbilicus, genitalia, anterior lower legs and nails. C Co-morbidities associated with psoriasis include psoriatic
Psoriasis can significantly impact on a patient’s quality of life. Associ- arthritis, metabolic syndrome, inflammatory bowel disease,
ated co-morbidities include psoriatic arthritis, obesity and the meta- non-alcoholic steatohepatitis and cardiovascular disease
bolic syndrome, cardiovascular disease and fatty liver disease.
Treatment is stratified by disease severity, impact on quality of life, pa- C Psychological distress, anxiety and depression are common in
tient preference, relevant co-morbidities and treatment efficacy. patients with psoriasis. The Hospital Anxiety and Depression
Topical treatment such as emollients, tar, vitamin D analogues and Scale, Patient Health Questionnaire 9 and Generalized Anxiety
corticosteroids are first line for localized/mild disease. In the UK, up Disorder 7-item scale are useful screening tools
to 30% of patients may require specialist referral for phototherapy or
systemic therapy (methotrexate, ciclosporin, acitretin, apremilast).
Recent therapeutic advances with targeted biological therapies have Pathogenesis
revolutionized the management of patients with severe disease.
Despite this, erythrodermic and pustular forms may still present as The pathogenesis of psoriasis is a complex interplay between
life-threatening dermatological emergencies. genetic and environmental factors, adaptive and innate im-
mune responses and key inflammatory and epidermal cells
Keywords Biological therapies; ciclosporin; methotrexate; palmo-
that drive the disease. Epidermal and capillary proliferation
plantar pustulosis; psoriasis; psoriatic arthritis; pustular psoriasis;
appear to be stimulated by the release of cytokines from
treatment; tumour necrosis factor inhibitor
lymphocytes. The mediators involved include interferon-g,
interleukin (IL)-2, tumour necrosis factor (TNF)-a, IL-17, IL-
12, IL-23 and IL-8.

Genetic factors
Epidemiology Affected relatives are found in up to 30% of patients with pso-
riasis. Family and twin studies have indicated an important ge-
In the UK, psoriasis occurs in about approximately 2e3% of the netic component to psoriasis.
population. Male and female patients are equally affected. The Two types of chronic plaque psoriasis have been identified,
age of onset is usually before 25e30 years, but there is a second based on age of onset, disease course and association with
peak with some people developing psoriasis age 50e60. Around human leukocyte antigen (HLA) Cw6:1
75% of cases occur before age 40 years. Most cases are mild and
type 1 e young onset, positive family history, more severe
are managed in primary care with topical therapy. Evidence disease; 80% have HLA-Cw6
suggests that up to 30% of UK patients require second-line
type 2 e older onset, peak age of incidence 50e60 years,
therapy with either phototherapy or systemic therapy. family history less common, tend to have milder disease;
20% have HLA-Cw6.
Socioeconomic burden Weaker associations are seen with HLA B13, B17 and DR7.
Psoriasis represents a significant burden in terms of its effect on Recent key genetic advances include chromosomal localization
quality of life. This has been found to be similar to the impact of of the major psoriasis genetic locus, psoriasis susceptibility 1
ischaemic heart disease, chronic obstructive airways disease and (PSORS1), to 6p21.3. PSORS1 contributes up to 50% of the ge-
diabetes mellitus. netic risk. Several other genes have also been discovered that
point to specific biological pathways involved in epidermal bar-
rier and adaptive and innate immune responses, and may
represent future therapeutic targets.
Eleanor Higgins MB BCh BAO MRCP MSc MEd is a Consultant
Dermatologist at St John’s Institute of Dermatology, London, UK.
Competing interests: Eleanor Higgins has received speaker’s Environmental factors
honoraria from Leo and educational support for conference Infection: upper respiratory tract infections, particularly with
attendance from AbbVie UK. streptococci, are associated with disease flares. In 60% of

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 COMMON DERMATOSES

patients with guttate psoriasis, there is a preceding systemic

infection, usually from the upper respiratory tract. Psoriasis can
be more severe in individuals with untreated HIV.

Medications: psoriasis can be worsened by several drugs

(notably lithium, b-adrenoceptor blockers, antimalarial agents
related to chloroquine), although these drugs are often taken
without any effect on the patient’s psoriasis. Withdrawal of
systemic corticosteroids sometimes results in a flare-up.
Both smoking and alcohol excess are more common in in-
dividuals with psoriasis than the rest of the population. Excess
alcohol is associated with more severe disease, may limit sys-
temic treatment options and can make the psoriasis less stable
and more difficult to treat.

Other factors: many patients say that stress induces flares in

disease activity. Ultraviolet light worsens psoriasis in some pa-
Figure 2 Dusky red plaques with thick scale.
tients. Physical trauma such as surgical trauma, burns and
abrasions can also induce psoriasis.

Clinical features of psoriasis e overview

Plaque psoriasis (Figure 1) is the most common presentation,
accounting for 80e90% of cases. Psoriatic plaques usually
demonstrate three characteristic features of scale, thickening
(induration) and redness (inflammation). Plaques are usually
symmetrical and typical sites include the scalp, extensor surfaces
of the elbows, anterior aspects of the lower legs, umbilicus and
natal cleft.
The colour of plaques varies from a dark, dusky red to a paler
‘salmon pink’ (Figures 2 and 3). The plaque surface is usually
scaly, ranging from a fine silvery scale to a thick, adherent scale.
Psoriatic plaques may vary from small/guttate (<1 cm) to large
plaques. Treated plaques can resolve to leave post-inflammatory
erythema, which can persist for several months. Post-
inflammatory hypo- or hyperpigmentation is common, espe-
cially in darker skinned individuals.
Disease activity fluctuates over a variable timescale of months
or years, and larger or smaller areas may be affected at different
times. Prolonged remission can occur spontaneously or be
brought about by treatment.

Figure 3 Paler thin plaques.

Diagnosis
Psoriasis is a clinical diagnosis. Clues include a history of long-
standing scalp scale/dandruff, scaling in the ears, pruritus in
the genital area or arthralgia. The Koebner phenomenon is the
development of psoriatic lesions at sites of trauma (surgical
wounds, trivial scratches, abrasions, burns). If present, koebne-
rization may be a helpful clue but can also be seen in other in-
flammatory dermatoses such as lichen planus. There is no
specific blood test for psoriasis.
Figure 1 Chronic plaque psoriasis of the elbow. Psoriasis is associated with several other conditions (Table 1).

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 COMMON DERMATOSES

increased risk of non-alcoholic steatohepatitis, which causes

Co-morbidities in psoriasis liver fibrosis.
C Psoriatic arthritis e seronegative inflammatory arthritis
Other co-morbidities
C Metabolic syndrome and cardiovascular risk factors, such as
Cutaneous malignancy is more commonly with severe disease,
hyperlipidaemia, hypertension, diabetes mellitus and history of
and is increased in patients who are given multiple phototherapy
myocardial infarction
treatments (especially psoralen and ultraviolet A (PUVA)) and
C Obesity
subsequent immunosuppression. Excess natural sunlight/sun-
C Depression
seeking behaviour in psoriatic patients may also increase risk
C Non-melanoma skin cancer e sometimes related to previous
of skin cancer. It remains to be seen whether systemic therapy
treatment, i.e. psoralen þ ultraviolet A
and biological therapy increase the risk of cancer with long-term
C Non-alcoholic steatohepatitis
use, and pharmacovigilance registries should further elucidate
C Inflammatory bowel disease (particularly Crohn’s disease)
this.
Table 1
Assessment of a patient with psoriasis
A physician’s assessment and the individual’s self-assessment
Psoriasis and co-morbidities
can both be used (Table 2).3
Psoriatic arthritis The most widely used score in both secondary clinical and
Psoriatic arthritis usually develops several years after disease research settings is the Psoriasis Area and Severity Index (PASI).
onset. It presents as a range of destructive inflammatory ar- This combines assessment of the area of involvement (%),
thropathies. On clinical and radiological evaluation, 30% of pa- severity of scaling, plaque thickness and erythema using a scale
tients have evidence of psoriatic arthritis; many more complain of 1e4.
of mild arthralgia. Early clinical features include enthesitis The PEST is a validated screening tool for psoriatic arthritis. It
(inflammation of the tendons and ligaments attaching to bones) is recommended that patients with psoriasis who do not have a
and dactylitis (swollen, sausage-like digits). diagnosis of psoriatic arthritis complete a PEST questionnaire
Five main patterns of psoriatic arthritis are seen: annually. A score of 3 or more indicates that referral to a rheu-

distal interphalangeal arthropathy matology department should be considered.

symmetrical polyarthritis

asymmetrical oligoarthritis Management

spondyloarthropathy (sacroiliitis)

arthritis mutilans. Psoriasis is a long-term condition that requires a long-term
Untreated psoriatic arthritis can produce severe disability. It is treatment plan. Before a patient embarks on therapy, it is
therefore recommended that patients who do not have psoriatic important that their expectations are managed and they have a
arthritis complete the Psoriasis Epidemiology Screening Tool realistic expectation of the outcome. The aims of treatment
(PEST) annually (see below). include:

achieving long-term disease control
Psychological impact of psoriasis
improving the patient’s quality of life
Psoriasis can have a significant impact on a person’s self-image
minimizing adverse drug effects
and self-confidence. Individuals with psoriasis can develop
tailoring treatment to individual patient factors.
dysfunctional thought processes, pathological worry and fear of Several factors must be considered in relation to treatment:
stigmatization that can result in maladaptive behaviour. Depres-
the patient’s perception of disease severity
sion and anxiety are commonly seen; a recent meta-analysis has
objective measures of severity (PASI, body surface area)
reported depressive symptoms in 28% of patients in tertiary care.2
the pattern, location and extent of disease
It is easy to underestimate the impact of psoriasis on quality of
patient factors (lifestyle, ability to comply with or under-
life: it may have an even greater effect than illnesses such as take topical treatment, patient preference)
diabetes mellitus, arthritis, myocardial infarction and cancer.
previous treatments and responses

coexisting medical problems and drug therapy.
Obesity and metabolic syndrome
Topical treatments e mild to moderate disease
There is an association between severe psoriasis and the ‘meta-
Topical treatments (Table 3) are the mainstay of treatment for
bolic syndrome’. The metabolic syndrome, defined as a
localized psoriasis. Patients with more extensive psoriasis also
constellation of clinical features including truncal obesity,
often use topical therapies for selected body areas, along with
hyperlipidaemia, hypertension and impaired glucose tolerance, is
additional systemic or phototherapy.
a significant risk factor for cardiovascular mortality. The reason
for this association with psoriasis is uncertain. Obesity is more
Corticosteroids of mild to moderate potency (hydrocortisone 1%
common in psoriatic patients, especially with more severe dis-
ointment, clobetasone butyrate ointment (Eumovate)) are the
ease. This association starts at an early age, and obese children
treatment of choice for the face and neck, flexures and genitalia.
have been found to have more psoriasis.
Mild/moderate-potency corticosteroids can be used in unstable,
Patients with metabolic syndrome have a fivefold increased
erythrodermic and generalized pustular psoriasis, but more
risk of developing type 2 diabetes mellitus. They are also at

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 COMMON DERMATOSES

How to assess a patient with psoriasis Topical therapies for chronic plaque psoriasis
Physician’s assessment Agent Efficacy Relapse Adverse Cosmetic
The site and extent of psoriasis are used to determine appropriate rate effects problems
management:
C The amount of body surface area affected can be estimated using Emollients þ þ e þ
the ‘rule of nines’. Dermatology specialist input is required if Keratolytics þ þ þ þ
>10% of body surface area is affected, or if there is more local- Coal tar þþ þ þ þþ
ized disease that has failed to respond to treatment Dithranol þþ þ þ þþ
C The Physician Global Assessment (PGA) score classifies psoriasis Corticosteroids: þþþ þþ þþ þ
as clear, nearly clear, mild, moderate, severe or very severe potent/very potent
Acute erythrodermic psoriasis and generalized pustular psoriasis are Vitamin D3 analogues þþ þ þ þ
medical emergencies and require same-day specialist assessment Corticosteroide vitamin þþþ þ þ þ
and treatment D3 combination
Person’s self-assessment e, little or none; þþþ, very great or frequent.
C The Patient’s Global Assessment. Similar to the PGA score, the Source: Adapted from Greaves M, Weinstein GD, Treatment of psoriasis. N Engl
patient assesses their psoriasis from mild to very severe. J Med 1995 332(9):581e8.
C Useful questions about the impact of the psoriasis on the pa-
Table 3
tient’s daily life include:
 What aspects of your daily living are affected by your
psoriasis? and smell of tar treatments have limited the use of tar-containing
 How are you coping with your skin condition, and what agents. Dithranol, applied under supervision at increasing con-
treatments are you using? centrations (0.05e2 %) on a daily basis, can be useful for
 Is your psoriasis having an impact on your mood? localized, thick plaques. Tar- and dithranol-based treatments can
 Is your psoriasis having any impact on your family or carers? be irritant and are not recommended for acute or unstable forms
C The Dermatology Life Quality Index. This is a validated patient of the disease.
questionnaire with 10 questions that is suitable for use in primary
care. It is free to download http://www.bad.org.uk/shared/get-file. Topical vitamin D analogues (calcipotriol) can be effective in
ashx?itemtype¼document&id¼1653 and is accompanied by psoriasis. Various preparations are available commercially
advice on how to use it and interpret the results (ointment, spray foam), as are calcipotriolecorticosteroid com-
Psoriatic arthritis binations. They can, however, cause local irritation, and exces-
Assess at least annually for the presence of presence of psoriatic sive use can lead to hypercalcaemia in at-risk individuals.
arthritis using self-administered questionnaires such as the Psoriasis
Epidemiology Screening Tool. This validated patient questionnaire is Topical tacrolimus 0.1% ointment (licensed for use in atopic
available on the British Association of Dermatologists’ website: dermatitis) can be very useful for facial and eyelid psoriasis, and
http://www.bad.org.uk/healthcare-professionals/psoriasis is a good alternative to topical corticosteroids for facial disease.
Cardiovascular risk
Assess cardiovascular risk (particularly if there is severe psoriasis). Topical retinoids are also sometimes used in psoriasis.
Other co-morbidities
Assess for the presence of other co-morbidities such as: Second-line treatments: phototherapy and systemic
C Depression therapy
C Inflammatory bowel disease Second-line treatments, including phototherapy and systemic
C Non-melanoma skin cancer agents (Table 4),4,5 should be used for more severe disease, or for
patients with milder disease that has failed to respond to topical
Table 2 therapy.

potent corticosteroids should be avoided in these cases as they Phototherapy: UV radiation in the form of natural sunlight is
can destabilize the disease. Potent topical corticosteroids are known to have beneficial effects in treating psoriasis. Photo-
useful for localized disease on the scalp, palms and soles (often therapy involves exposure to artificial UV radiation. Photo-
in combination with tar or salicylic acid). therapy has been established in the UK for approximately 50
Continuous use of topical corticosteroids should be limited to years as an effective, low-cost outpatient treatment for psoriasis
4 weeks (very potent) and 8 weeks (potent), aiming for a mini- and other inflammatory skin conditions.
mum of 4-week break before restarting. Other topical treatments Natural radiation is subdivided into:
(see below) or specialist dermatology referral should be consid-
UVC (wavelength <280 nm) e this is screened from the
ered for individuals requiring ongoing or frequent courses of earth’s surface by ozone
potent topical corticosteroids.
UVB (wavelength 280e320 nm)

UVA (wavelength 320e400 nm).
Tar has been used in the treatment of psoriasis for many years. Narrow-band UVB (311 nm) is widely used for extensive plaque
However, the shortage of in-patient beds and the messy nature psoriasis and guttate psoriasis. Patients usually attend two or three

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 COMMON DERMATOSES

Phototherapy and systemic therapy

Treatment Efficacy Speed of onset Benefits Disadvantages

Phototherapy þþþ þþþ Rapid onset Not suitable for long-term use owing to risk of
Well tolerated skin cancer with cumulative exposure
Not suitable for photosensitive patients
Variable remission after discontinuation

Methotrexate þþ þþ Effective Nausea (try a switch to subcutaneous)

Low cost Myelosuppression
Suitable for long-term use Teratogenicity
Effective for psoriatic arthritis Hepatotoxicity
Can be co-administered in a Caution in the elderly and with renal
low dose with biological therapy impairment

Ciclosporin þþþ þþþ Effective Not suitable for long-term use

Rapid onset of action Risk of nephrotoxicity and hypertension
Well tolerated in the short term

Acitretin þ þ Well tolerated in the long term Dry skin, dry lips
Hair-thinning/loss
Hypertriglyceridaemia
Teratogenicity

Fumaric acid esters þþ þþ Variable efficacy Flushing, diarrhoea

Fumaderm Lymphopenia
(unlicensed in UK) Risk of progressive multifocal
leucoencephalopathy
Unlicensed
High cost

Table 4

times a week for 8e10 weeks. It can be used for children and in Accurate monitoring and recording of doses, combined with
pregnancy. Treatment is given under close supervision of trained precise calibration of equipment, is essential to minimize risk of
nursing staff. The dosing schedule varies depending on the patient’s burning and maximize efficacy.
skin type and is based on the minimal erythema dose, which is the The British Photobiology Group in association with the British
amount of radiation required to provoke faint but definite erythema. Association of Dermatologists has developed National Institute
UVA is minimally effective in the treatment of psoriasis when for Health and Care Excellence accredited phototherapy service
used alone but is highly effective when combined with photo- guidance and standards for the use and delivery of phototherapy.
sensitizing psoralen (PUVA). Psoralen is usually administered http://www.phototherapysupport.net is an extremely useful
orally as 5- or 8-methoxypsoralen, with the dose based on the phototherapy clinical network.
patient’s weight.
Topical PUVA is useful when limited areas such as palms and Biological therapy
soles are treated. Bath PUVA (a 20-minute soak in a bath of Biological therapies (‘biologics’) are proteins that target specific
psoralen solution before UVA exposure) avoids systemic expo- receptors in the psoriasis pathway. The use of biological therapy
sure to psoralen. PUVA is sometimes used in combination with has revolutionized the management of severe psoriasis and
systemic retinoids. contributed much to our understanding of the underlying disease
The adverse effects and safety considerations include: pathogenesis.

burning and rarely photosensitive eruptions Biological therapy is occasionally indicated in patients who

short-term risks including nausea, itch and phototoxic have difficult localized disease at high-impact sites (face,
reactions hands, genital area, nails). Dosing is usually according to

nausea and vomiting in 10e20% of patients who take 8- licence (Table 5).
methoxypsoralen, but this appears to be less frequent The available agents are also licensed in the UK for use in
with newer forms of psoralen such as 5-methoxypsoralen psoriatic arthritis. Short-term data (up to 1 year) indicate marked

requirement for appropriate eye protection and protection efficacy (Table 3), tolerability and an excellent safety profile in
of the genital areas appropriately selected patients. Real-world safety data, predom-

as with any form of chronic UV exposure, an increased risk inantly from pharmacovigilance registries, indicate that infec-
of certain skin cancers with cumulative treatments. This tion, particularly reactivation of latent tuberculosis, can
appears lower with narrow-band UVB than PUVA. complicate therapy.5 Long-term data are required to fully

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 COMMON DERMATOSES

Receptor-targeted therapies
Drug name Drug type Dosing schedulea Efficacy (% clear
or nearly clear)a,b

Infliximab Chimeric humanemurine monoclonal anti-TNF 5 mg/kg intravenous infusion Week 10

antibody at weeks 0, 2 and 6 and 82%
then 8-weekly
Etanercept Fusion protein composed of an extracellular 50 mg subcutaneous injection Week 12
ligand-binding portion of the TNF receptor once weekly 32e39%
fused to the Fc portion of human IgG1
Adalimumab Fully human IgG1 anti-TNF antibody 80 mg week 0, 40 mg week 1 and Week 16
then 40 mg every 2 weeks 62.2%
Ustekinumab Fully human IgG1 k monoclonal antibody, Weight <100 kg e 45 mg at Week 16
which binds to the shared p40 protein subunit weeks 0, 4 and 12 and then 3-monthly 67.5%
of cytokines IL-12 and IL-23 Weight >100 kg e 90 mg at
weeks 0, 4 and 12 and then 3-monthly
Secukinumab Fully human IgG1 antibody that selectively 300 mg weekly at weeks Week 16
binds and neutralizes IL-17A 0, 1, 2, 3 and 4 and then monthly 82.9% clear
or nearly clear
Targeted systemic therapy
Apremilast Phosphodiesterase 4 (PDE4) inhibitor 30 mg twice daily Week 16
(after an initial titration schedule) 38.7% PASI 75

Ig, immunoglobulin; IL, interleukin; PASI, Psoriasis Area and Severity Index; TNF, tumour necrosis factor.
a
See individual drug Summary of Product Characteristics for further information.
b
Trials not directly comparable.

Table 5

elucidate the overall safety profile, particularly in relation to risk Newer agents for psoriasis
of malignancy. Apremilast is an oral small-molecule inhibitor of phosphodies-
Challenges include immunogenicity and the development of terase 4 (PDE4). It is licensed for the treatment of moderate to
anti-drug antibodies leading to a gradual loss of efficacy, parental severe chronic plaque psoriasis in adult patients who have failed
administration (subcutaneous or, for infliximab, intravenous to respond to, have a contraindication to or are intolerant to
injection) and high cost. other systemic therapy, including ciclosporin, methotrexate and
PUVA.
Licensed indications: TNF antagonists (infliximab, adalimumab,
etanercept) and ustekinumab are licensed in the UK for use in Treatment for special groups
patients with moderate to severe plaque psoriasis who fail to
Psoriasis and pregnancy
respond to, have a contraindication to or are intolerant to sys-

Most systemic treatments have the potential to be terato-
temic therapy, including ciclosporin, methotrexate and PUVA.
genic. Ciclosporin, however, has been used extensively in
Secukinumab (anti-IL-17) is licensed for the treatment of
pregnancy in women who have undergone organ
moderate to severe plaque psoriasis in patients who are candi-
transplantation.
dates for systemic therapy. Ixekizumab, which blocks IL-17A, is

Retinoids are teratogenic and should be avoided in women
expected to be available soon for use in the UK. Agents targeting
of childbearing age. Women should avoid pregnancy for 3
IL-17 are associated with an increased risk of candidiasis
years after taking acitretin.
compared with TNF and IL-12/IL-23 antagonists.

Biological therapies are actively transported across the
Cautions with biological therapy placenta during the second and third trimesters (with

Only dermatologists familiar with the use of biological measurable drug concentrations found in infants) and are
agents and with the management of moderate/severe also secreted in breast milk.
psoriasis should prescribe these drugs.
Psoriasis in the elderly

Serious infection or reactivation of tuberculosis while
Older patients may struggle to apply topical therapy and require
taking biological therapy should prompt immediate
assistance from family or carers. Phototherapy may be a good
cessation of biological therapy and further specialist input.
option if they are able stand in the booth. Methotrexate and

Live attenuated virus vaccines must be avoided because of
ciclosporin need to be used with caution due to the limited renal
the risk of uninhibited viral or bacterial replication.
reserve in elderly patients. Acitretin may be well tolerated in

Moderate/severe cardiac failure (New York Heart Associ-
older patients and effective for palmoplantar psoriasis in this
ation grade III/IV) is a contraindication to TNF inhibitors.
population.

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 COMMON DERMATOSES

Figure 4 Guttate psoriasis.

Clinical variants of psoriasis

Guttate psoriasis: a specific pattern of small (<1 cm) psoriasis
lesions that often presents acutely after an upper respiratory tract
infection in young adults. The lesions are found over the trunk and
often involve the limbs (Figure 4). They are often triggered by a
streptococcal sore throat. The condition may resolve spontane-
ously; if not, topical corticosteroids and UVB are helpful. The dif-
ferential diagnosis includes pityriasis rosea, which usually starts
with an initial (herald) patch and has a more peripheral scale.

Palmoplantar psoriasis: the hands and feet may be affected

concurrently. Hand and foot involvement may be pustular and
localized to these areas (associated with smoking). Non-pustular
plaque psoriasis may present with well-demarcated scale and
inflammation, with significant nail dystrophy (Figure 5). Hand

Figure 6 Plantar psoriasis with thick scale.

and foot disease may cause significant disability. Plantar psori-

asis can produce thick, adherent scale (Figure 6) and pain on
walking.
First-line therapy includes avoidance of exacerbating factors
(irritants e soaps, detergents) and application of potent topical
corticosteroids. Corticosteroidesalicylic acid combinations can
be helpful. More severe disease may require oral or topical
PUVA, or systemic therapy with acitretin or methotrexate.

Pustular psoriasis: this presents in two forms: localized (hands

Figure 5 Hand psoriasis with nail dystrophy. and feet) and generalized.

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Palmoplantar pustular psoriasis e affects the palms and

soles and follows a chronic, relapsing course. Sterile pustules
develop in crops, and change from yellow or white in the acute
phase to brown macules before desquamating (Figure 7). There
is associated severe redness and scale, and it may be very
painful, Palmoplantar pustulosis usually responds poorly to
standard topical and systemic therapy for psoriasis. It tends to
remain localized and does not often evolve into generalized
pustular psoriasis.
Recent studies have identified that the disease pathways are
different in palmoplantar pustular psoriasis and plaque psoriasis,
and involve the IL-1 pathway. A clinical trial examining the use
of anakinra (an IL-1 inhibitor) for patients with palmoplantar Figure 8 Acrodermatitis continua of Hallopeau.
pustulosis of more than 6 months’ duration who have not
responded to topical treatment is currently recruiting in several
urgent dermatological assessment
UK locations.
bed rest in hospital
Acrodermatitis continua of Hallopeau e is a rare, destructive
adequate hydration and close monitoring of body
form of pustular psoriasis that affects the distal digit and nail temperature
(Figure 8). It can be particularly painful and disabling, and be
regular emollients
recalcitrant to treatment with topical and systemic therapy.
topical therapy e mild or moderate-potency topical
Generalized pustular psoriasis e occurs with erythrodermic corticosteroids
psoriasis and is a severe, life-threatening condition. Multiple tiny
systemic treatment, supervised by specialists.
pustules are seen on a background of extensive, inflammatory
erythema (Figure 9). It may be triggered by withdrawal of potent Nail disease: psoriatic nail disease can be disfiguring and a cause
topical or systemic corticosteroids. Sheets of pustules may occur of significant morbidity. Nail changes may take several forms
in waves, followed by desquamation. Patients require hospital including:
admission under specialist supervision for bed rest, supportive
pitting e fine, pinpoint indentations
care and strict fluid balance, temperature control and topical
onycholysis e separation of the nail from the nail bed,
treatment. Systemic therapies such as infliximab, methotrexate with white/yellow discoloration
and biological agents may be used.
subungual hyperkeratosis e white and crusting, with
debris under the nail (Figure 11)
Erythrodermic psoriasis: this form involves widespread (90%
oil drop sign e a circular or well-circumscribed pink/red
body surface area) severe erythema and scaling (Figure 10). colour change seen on the nail that may be adjacent to an
Other causes of erythroderma include severe drug eruptions, area of onycholysis or the free nail margin.
atopic eczema, pityriasis rubra pilaris and Sezary syndrome Nail changes, such as pitting, may also be seen in alopecia areata.
(cutaneous T cell lymphoma), and it may be very difficult to Drug or phototoxic reactions (e.g. during PUVA therapy) can also
distinguish these in the acute phase. cause onycholysis. Dermatophyte infection can produce subungual
Erythrodermic psoriasis is a dermatological emergency as hyperkeratosis and may also cause secondary infection in existing
patients can rapidly become extremely unwell. They are at grave nail psoriasis. Single-nail dystrophy and toenail dystrophy is more
risk of septicaemia, hypothermia and dehydration. Elderly pa- likely to be fungal, whereas multiple/20-nail dystrophy, especially
tients are particularly vulnerable and can deteriorate rapidly. with fingernail involvement, is most likely to be psoriasis.
Management includes: The management of nail disease is difficult. Various therapies
that have been tried with varying degrees of success include
topical corticosteroid lotion, calcipotriol lotion and PUVA.

Figure 7 Palmoplantar pustulosis. Figure 9 Generalized pustular psoriasis.

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 COMMON DERMATOSES

Figure 11 Nail psoriasis e thickening, dystrophic, subungual

Figure 10 Erythrodermic psoriasis. hyperkeratosis.

Flexural and genital psoriasis: this form usually involves the

axillae, groins, umbilicus and genitalia. In contrast to psoriasis
elsewhere, it may not be scaly (Figure 12). The psoriasis plaques
can appear wetter and become macerated. The well-demarcated
nature of genital psoriasis may help to distinguish it from dif-
ferential diagnoses such as allergic contact dermatitis, atopic
eczema, erythrasma and Candida infection.
Management includes:

corticosteroids (mild/moderately potent e flexural sites
are at increased risk of side effects with corticosteroids)

calcipotriol (irritant in some patients)

antifungalecorticosteroid combinations

tacrolimus 0.1% ointment

systemic therapy for localized high-impact disease.

Scalp lesions: these present as usually well-demarcated plaques

Figure 12 Flexural psoriasis.
with adherent scale (Figure 13). The condition can vary from
mild, generalized, seborrhoeic dermatitis-like scale to thick pla-
ques with severe scale (pityriasis amiantacea). It may extend overnight occluded by a shower cap and washed out with
beyond the hair line onto the forehead and nape of neck. tar shampoo in the morning.
Management includes the following:
Corticosteroidecalcipotriol combination lotions and foams

If thick scale is present, the areas should first be descaled are now available.
with a combination tar 12%, salicylic acid and coconut oil
Milder scalp disease can be treated with tar shampoos
preparation (Cocois ointment; Sebco). This is left (leaving the shampoo in contact for at least 5 minutes).

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 COMMON DERMATOSES

2 Dowlatshahi EA, Wakkee M, Arends LR, Nijsten T. The prevalence

and odds of depressive symptoms and clinical depression in
psoriasis patients: a systematic review and meta-analysis.
J Investig Dermatol 2014; 134: 1542e51.
3 National Institute for Health and Care Excellence. Psoriasis:
assessment and management of psoriasis. 2012. Clinical Guideline
no 153, https://www.nice.org.uk/guidance/cg153.
4 Warren RB, Weatherhead SC, Smith CH, et al. British Association
of Dermatologists’ guidelines for the safe and effective prescribing
of methotrexate for skin disease 2016. Br J Dermatol 2016; 175:
23e44.
5 Yiu ZZ, Exton LS, Jabbar-Lopez Z, et al. Risk of serious infections
in patients with psoriasis on biologic therapies: a systematic review
and meta-analysis. J Investig Dermatol 2016; 136: 1584e91.

Figure 13 Scalp psoriasis. FURTHER READING

Burden AD, Kirby B. Psoriasis and related disorders. In: Rook’s text-

Foams and mousse preparations are sometimes preferable
book of dermatology. 9th edn. Oxford: Blackwell, 2016 [Chapter
to alcohol-based lotions because of their ease of use.
35].
Lebwohl MG, van de Kerkhof PCM. Psoriasis. In: Lebwohl MG,
Facial psoriasis: lesions are usually located in the frontal hair-
Heymann WR, Berth-Jones J, Coulson I, eds. Treatment of skin
line, with localized psoriasis in the nasolabial folds and eyebrows
disease: comprehensive therapeutic strategies. 4th edn. Oxford:
(sebopsoriasis). Eyelid psoriasis can be troublesome but can
Elsevier, 2013 [Chapter 203].
respond to topical tacrolimus. The differential diagnosis includes
Menter A, Smith C, Barker J. Fast facts: psoriasis. revised 4th edn. UK:
seborrhoeic dermatitis, contact dermatitis and atopic dermatitis.
Health Press, 2015.
Management involves:
South-East of England Phototherapy Network, www.

mild/moderate topical corticosteroids, that is, clobetasone
phototherapysupport.net.
butyrate (Eumovate) for the face, except for the eyelids

tacrolimus 0.1% ointment

for the eyelids, hydrocortisone 1% ointment or topical
Patient support groups
tacrolimus 0.1% ointment. A British Skin foundation: http://www.britishskinfoundation.org.uk/.
Psoriasis Association: https://www.psoriasis-association.org.uk/.
KEY REFERENCES Psoriasis Help Organisation: http://www.psoriasis-help.co.uk/.
1 Capon F, Munro M, Barker J, Trembath R. Searching for the major Psoriasis and Psoriatic Arthritis Alliance: http://www.papaa.org/.
histocompatibility complex psoriasis susceptibility gene. J Investig
Dermatol 2002; 118: 745e51.

TEST YOURSELF
To test your knowledge based on the article you have just read, please complete the questions below. The answers can be found at the
end of the issue or online here.

Question 1 D. Methotrexate
E. Acitretin
A 28-year-old woman presented with widespread, thin plaque
psoriasis. She was at 24 weeks’ gestation in her first pregnancy.
Question 2
The psoriasis had developed 2 months previously, and had not
responded to topical emollients and mild/moderate-potency A 56-year-old man was brought to the emergency department by
topical corticosteroids. his wife because of ‘red skin all over’. He had a background of 10
On examination, she had generalized pink, thin plaques years of chronic plaque psoriasis affecting his scalp, elbows and
consistent with guttate psoriasis, covering 7% of her body sur- lower legs, as well as arthritis and hypertension. In the past year,
face area. his psoriasis had become extensive and he had been using
increasing quantities of potent topical corticosteroids.
Which treatment is the most appropriate? On examination, there was confluent erythema on the face, trunk
A. Psoralen combined with ultraviolet A (PUVA) and limbs. He was shivering but his skin felt very hot to the
B. Narrow-band ultraviolet B (UVB) phototherapy touch and his temperature was 38 C. His blood pressure was
C. Ciclosporin 100/70 mmHg and heart rate 100 beats/minute.

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 COMMON DERMATOSES

Which is the next appropriate management step, after emer- She had a 5-pack-year smoking history and her father had
gency ABC, while awaiting dermatology specialist review? psoriasis.
A. Obtain intravenous (IV) access and administer IV
hydrocortisone Which is the most appropriate first-line treatment?
B. Administer 1 mg/kg oral prednisolone A. Topical emollient combined with a moderately potent
C. Administer high-dose IV H1 antihistamines topical corticosteroidevitamin D twice daily until the skin
D. Commence broad-spectrum IV antibiotics is smooth
E. Remove the patient’s clothing, apply a greasy emollient all B. Phototherapy with narrow-band ultraviolet B at the local
over him and nurse him on bed rest in a warm environ- skin clinic
ment with careful fluid balance and temperature regulation C. Ciclosporin at a dose of 2.5 mg/kg per day in two divided
doses for 8 weeks
D. Topical tacrolimus twice daily until the affected skin is
Question 3
smooth
A 19-year-old woman presented with new-onset scaly plaques E. Tar-based cream to be applied once daily and left on for 30
on her elbows and knees. She was bothered by her appearance. minutes before washing off

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