History Taking for Psoriasis Vulgaris

Essential Clinical History Components

Document the distribution pattern: Ask specifically about involvement of the scalp, elbows, knees, presacral region, palms, soles, nails, and genitalia, as these are classic locations for psoriatic plaques 1.
Assess body surface area (BSA) involvement: Quantify the percentage of skin affected, as <3% BSA indicates mild disease, 3-10% moderate disease, and ≥10% severe disease 1, 2.
Identify morphologic features: Inquire about well-demarcated red plaques with silvery scale, which are pathognomonic for psoriasis vulgaris 2.
Determine psoriasis subtype: Ask about the pattern of lesions to distinguish between plaque (vulgaris), guttate, palmoplantar, inverse, pustular, or erythrodermic forms 1.

Quantify pruritus severity: Use a visual analog scale (VAS) or numeric rating scale (NRS) to measure itch intensity, as significant pruritus may warrant more aggressive management 2.
Assess pain levels: Document any associated pain, particularly in palmoplantar or inverse psoriasis 1.

Evaluate psychosocial impact: Ask directly about social withdrawal, avoidance of activities, shame, bullying, or impact on relationships, as these factors define disease severity independent of BSA 1.
Document occupational impact: Inquire about work limitations or clothing restrictions that affect daily functioning 1.
Screen for depression and anxiety: Psoriasis is associated with significant mental health comorbidities that require identification 1, 2.

Ask about joint pain, swelling, and morning stiffness: Up to 25-30% of psoriasis patients develop psoriatic arthritis, making routine screening essential 2.
Inquire about enthesitis: Ask about pain at tendon insertion sites (Achilles tendon, plantar fascia) 1.
Document dactylitis: Ask about "sausage digits" or diffuse finger/toe swelling 1.

Identify infectious triggers: Ask about recent streptococcal pharyngitis, perianal infections, or upper respiratory infections, particularly in guttate psoriasis 1.
Document medication history: Specifically ask about beta-blockers, lithium, antimalarials (chloroquine, mepacrine), NSAIDs, and tetracyclines, as these can precipitate or worsen psoriasis 1.
Assess alcohol consumption: Alcohol excess is associated with disease worsening and may contraindicate certain systemic therapies like methotrexate 1.
Inquire about trauma history: Document any Koebner phenomenon (lesions appearing at sites of skin injury) 1.
Ask about stress: Both physiologic and emotional stressors can trigger flares 1.
Evaluate for recent corticosteroid withdrawal: Abrupt cessation of systemic corticosteroids can precipitate severe flares 1.

Document all previous therapies: Record specific topical agents (corticosteroids, vitamin D analogues, tar, dithranol), phototherapy (UVB, PUVA), and systemic medications with their efficacy and reasons for discontinuation 1.
Assess adherence barriers: Ask about patient preferences regarding formulations (creams, ointments, foams, solutions) and treatment burden 3.
Identify treatment failures: Document inadequate responses to guide future therapy selection 1.

Screen for metabolic syndrome components: Ask about diabetes, hypertension, dyslipidemia, and obesity, as these are strongly associated with psoriasis 1, 2.
Assess cardiovascular risk: Document history of coronary artery disease, myocardial infarction, or stroke 1, 2.
Inquire about inflammatory bowel disease: Ask about abdominal pain, diarrhea, or bloody stools 1, 2.
Screen for uveitis: In patients with psoriatic arthritis, ask about eye pain, redness, or vision changes 1.
Document smoking history and secondhand smoke exposure: These are risk factors, particularly in pediatric patients 1.

Obtain family history of psoriasis: Genetic predisposition is significant 1.
Assess pregnancy plans: This is critical for women of childbearing age, as many systemic therapies (acitretin, methotrexate) are teratogenic and require specific contraception requirements 1, 3.
Document current contraception: Essential before initiating systemic therapy 1.

For pediatric patients: Ask about BMI, secondhand smoke exposure, recent infections (especially streptococcal), and impact on school performance and social development 1.
For pregnant/breastfeeding patients: Document trimester and breastfeeding status to guide safe therapy selection 3.

Calculate BSA involvement: Use the palm method (patient's palm = 1% BSA) or body mapping 1.
Assess plaque characteristics: Document erythema intensity, scale thickness, and induration 1.
Examine special sites: Carefully inspect scalp (using a comb to part hair), nails (pitting, onycholysis, oil spots), genitals, and intertriginous areas, as involvement of these sites may warrant systemic therapy even with low BSA 1.
Look for inverse psoriasis: Check axillae, groin, inframammary folds, and intergluteal cleft for erythematous plaques with minimal scale 1.

Palpate joints: Assess for swelling, warmth, and tenderness in peripheral joints 1.
Examine entheses: Palpate Achilles tendons and plantar fascia insertion sites for tenderness 1.
Assess spinal mobility: In suspected axial involvement, perform modified Schober's test, chest expansion, and occiput-to-wall measurements 4.

Consider PASI scoring: While rarely used outside clinical trials, the Psoriasis Area Severity Index (0-72 scale) provides standardized severity assessment 1.
Use CDLQI in children: The Children's Dermatology Life Quality Index is a validated 10-question survey for pediatric patients 1.