What are the characteristic signs and treatment options for psoriasis?

Characteristic Signs and Treatment Options for Psoriasis

Psoriasis is characterized by well-demarcated, red plaques with silvery scale, commonly involving the scalp, elbows, knees, and presacral region, though any area of skin might be involved, including palms, soles, nails, and genitalia. 1

Clinical Presentations of Psoriasis

• Plaque psoriasis (vulgaris): The most common form, presenting with well-demarcated, red plaques with silvery scale 1
• Guttate psoriasis: Characterized by dew-drop-like, 1-10mm, salmon-pink papules with fine scale, primarily on the trunk and proximal extremities, common in individuals younger than 30 years 1
• Inverse psoriasis: Affects flexural surfaces such as the antecubital fossae, intertriginous areas, and inframammary regions 1
• Erythrodermic psoriasis: Presents with generalized erythema covering nearly the entire body surface area with varying degrees of scaling, often accompanied by fever, malaise, chills, and potential dehydration 1
• Pustular psoriasis: Characterized by large collections of neutrophils that are clinically apparent as pustules on an erythematous background, may be generalized (von Zumbusch variant) or localized to palms and soles 1, 2
• Nail psoriasis: Occurs in approximately 50% of patients with psoriasis, presenting with pitting, onycholysis, subungual hyperkeratosis, and oil-drop sign 1

Diagnosis

• Diagnosis is primarily clinical and usually does not require complementary examinations 3
• The Auspitz sign (small bleeding points after removal of scale) is not sensitive or specific for psoriasis 4
• Koebner phenomenon (development of psoriasis at sites of traumatized skin) may be present in some patients 5, 6

Treatment Options

Topical Therapy (First-Line for Mild-Moderate Disease)

• Topical corticosteroids: First-line treatment for mild to moderate psoriasis 3

  • Use moderate to high potency (classes 2-5) for plaques not affecting intertriginous areas for a maximum of 4 weeks 3
  • Use lower potency corticosteroids on the face, intertriginous areas, and sensitive areas to avoid skin atrophy 3
  • For scalp psoriasis, topical corticosteroids of class 1-7 for at least 4 weeks 3

• Vitamin D analogs: Calcipotriol alone or in combination with corticosteroids for a synergistic effect 3

  • Combined products with calcipotriol and corticosteroids are particularly effective 3, 7

• Other topical options:

  • Coal tar preparations starting with concentrations of 0.5-1.0% and gradually increasing up to 10% 3
  • Tazarotene (topical retinoid) in combination with moderate to high potency topical corticosteroids 3
  • Emollients as adjunctive therapy to reduce itching, scaling, and help maintain skin barrier function 3

Phototherapy

• PUVA (psoralens plus ultraviolet A) and narrowband UVB are effective options for moderate-to-severe psoriasis 2, 8

Systemic Therapy for Moderate-Severe Disease

• Conventional systemic agents:

  • Methotrexate, cyclosporine, and acitretin 8
  • Cyclosporine (3-5 mg/kg/day) is particularly effective for erythrodermic psoriasis due to its rapid onset of action 1

• Biologic agents:

  • TNF inhibitors (e.g., etanercept) - effective for moderate to severe plaque psoriasis 9, 8
  • IL-17 and IL-23 inhibitors 8
  • Spesolimab (anti-IL-36 receptor monoclonal antibody) as first-line therapy for generalized pustular psoriasis 2

• Small molecule inhibitors:

  • Dimethyl fumarate and apremilast 8

Important Considerations and Precautions

• Psoriasis is a chronic multisystem inflammatory disorder with associated comorbidities including psoriatic arthritis, cardiovascular disease, and autoimmune diseases 1
• Regular clinical follow-up is essential when using topical corticosteroids to monitor for adverse effects 3
• Avoid systemic corticosteroids as they can precipitate or worsen psoriasis flare-ups, especially when discontinued 3
• Certain medications can worsen psoriasis, including lithium, chloroquine, beta-blockers, and NSAIDs 3, 2
• Treatment is suppressive, aiming to induce remission or make psoriasis tolerable for the patient, with relapses being difficult to predict 3
• Patients with severe psoriasis requiring systemic agents should be followed by a dermatologist due to potential toxicity of these medications 3

Treatment Algorithm

1. For mild-moderate psoriasis (< 3% BSA):

   • Start with topical corticosteroids of appropriate potency based on location 3
   • Consider combination with vitamin D analogs for enhanced efficacy 3
   • Rotate treatments to avoid tachyphylaxis and side effects 3

2. For moderate psoriasis (3-10% BSA):

   • Consider phototherapy (NB-UVB or PUVA) 8
   • Consider topical therapy for resistant plaques 1

3. For severe psoriasis (≥ 10% BSA or severe impact on quality of life):

   • Systemic conventional agents (methotrexate, cyclosporine, acitretin) 8
   • Biologic agents for those who fail conventional therapy 9, 8
   • For erythrodermic psoriasis, consider cyclosporine for rapid control 1
   • For generalized pustular psoriasis, consider spesolimab 2