Psoriasis is a chronic, inflammatory skin disease characterized by red, scaly plaques that worsen over time. It is a T-cell mediated disorder that typically requires lifelong therapy to control symptoms, as individuals experience flares and remissions. Treatment involves topical therapy for mild cases, along with phototherapy and systemic or biological agents for more severe psoriasis, with the most effective treatments carrying increased risks of side effects like cancer.

1. Psoriasis: Diagnosis and
Management
By Tatenda Chikwetu

2. Overview
1. Epidemiology and pathophysiology
2. Clinical presentation.
3. Diagnosis
4. Management

3. What Is Psoriasis?
• Inflammatory and
hyperplastic disease of
skin.
• Characterised by
erythema and elevated
scaly plaques.
• Chronic, relapsing
condition.
• Course of disease often
unpredictable.

4. Epidemiology
• Common skin disorder
• Prevalence variable: ~ 0.3–2.5%
• Prevalence equal in males and females
• Estimated incidence: ~ 60 per 100,000 per
year

5. Psoriasis

6. Diagnosis
• Worsening of a long-term erythematous scaly area.
• Sudden onset of many small areas of scaly redness.
• Pain (especially in erythrodermic psoriasis).
• Pruritus (especially in eruptive, guttate psoriasis).
• Afebrile (except in pustular or erythrodermic psoriasis, in which
the patient may have high fever).
• Dystrophic nails, which may resemble onychomycosis.
• Long-term, steroid-responsive rash with recent presentation of
joint pain.
• Joint pain (psoriatic arthritis) without any visible skin findings
• Conjunctivitis or blepharitis.

7. Symptoms

8. Onset
• Mean age: ~ 23–37 years
• Current theory:
• 2 distinct peaks with possible genetic associations
– Early onset (16–22 years)
– More severe and extensive
– More likely to have affected first-degree family
member
• Late onset (57–60 years)
– Milder form
– Affected first-degree family members nearly absent

9. Genetic Influence
• Evidence suggests strong genetic
association
– Studies of monozygotic twins show
concordance for psoriasis (e.g. 64% in a
Danish Study)
– Multiple susceptibility loci have been
identified
• Disease expression
– likely result of genetic and environmental
factors

10. Common Trigger
Factors For Psoriasis
• Infections (e.g. streptococcal, viral)
• Skin trauma (Koebner phenomenon)
• Psychological stress
• Drugs (e.g. lithium, beta blockers)
• Sunburn
• Metabolic factors (e.g. calcium deficiency)
• Hormonal factors (e.g. pregnancy)

11. Impact Of Disease
• Concerns that it will worsen
• Depression
• Feeling embarrassed
• Feeling unattractive

12. Common Sites
Affected By Psoriasis
• Can affect any part of
the body –
– typically scalp,
– elbow, knees and
– sacrum
• Extent of disease varies

13. Types Of Psoriasis
• Chronic plaque
• Guttate
• Flexural
• Erythrodermic
• Pustular
– Localised and
generalised
• Local forms
– Palmoplantar
– Scalp
– Nail (psoriatic
onychodystrophy)

14. Clinical Presentation:
Classic Psoriasis
• Well-defined and sharply demarcated
– Round/oval-shaped lesions
– Usually symmetrical
– Erythematous,
• Raised plaques
– Covered by white, silvery scales

15. Chronic Plaque
Psoriasis
• Most common type – affects
approximately 85%
– Features pink, well-defined
plaques with silvery scale
– Lesions may be single or
numerous
– Plaques may involve large
areas of skin
– Classically affects
elbows,knees, buttocks
and scalp

17. Guttate Psoriasis
• Numerous and small
lesions
– ~ 1 cm diameter
– Pink with less scale than
plaque psoriasis
• Commonly found on trunk
and proximal limbs
• Typically seen in
individuals < 30 years
• Often preceded by an
upper respiratory tract
streptococcal infection

18. Flexural Psoriasis
• Lesions in skin folds
– articularly groin,
– gluteal cleft, axillae and
– submammary regions
• Often minimal or absent
scaling
• May cause diagnostic
difficulty when genital or
perianal region is affected in
isolation

19. Erythrodermic
Psoriasis
• Generalised erythema covering
entire skin surface
– May evolve slowly from
chronic plaque psoriasis or
appear as eruptive
phenomenon
• Patients may become febrile,
hypo/hyperthermic and
dehydrated
• Complications include cardiac
failure, infections, malabsorption
and anaemia
– Relatively uncommon

20. Other Forms
• Pustular Psoriasis
• Palmoplantar Psoriasis
• Scalp Psoriasis
• Nail Psoriasis

21. Psoriatic Arthritis
• Approximately 5–20% have
associated arthritis
• Five major patterns of psoriatic
arthritis:
– Distal interphalangeal
involvement
– Symmetrical polyarthritis
– Psoriatic spondylarthropathy
– Arthritis mutilans
– Oligoarticular, asymmetrical
arthritis
• Clinical expressions often overlap

22. Diagnosing
Psoriasis
• Other dermatological disorders can resemble
psoriasis
• Diagnosed clinically according to appearance,
distribution, history of lesions and family history
• Important to consider non-cutaneous
complications
– Heart problems
– Arthritis

23. Differential Diagnosis

24. • Lacks
symmetrical
lesions
• Presence of
peripheral scale
and central
clearing
Tinea corporis

25. Discoid eczema
• Individualised
patches more
pruritic than
psoriasis
• Lack silvery scale
• Less vivid colour
than psoriasis

26. Tinea Manuum
• Ringworm of hands
• Fine powdery scale,
particularly involving
palms and palmar
creases
• Usually
asymmetrical

27. Managing
Psoriasis
• Before starting treatment.
– Establish relationship of trust with patient.
– Provide patient with information.
• Emphasise benign nature of disease.
• Explain that psoriasis tends to be
chronic and recurrent.

28. Treatment Options
For Psoriasis
• Stepwise approach is advised
• Treatments include:
– General measures and topical therapy
– Phototherapy
– Systemic and biological therapies
– Combination therapies : may reduce toxicity
and improve outcomes

29. Drug Options
• Topical corticosteroids (eg, triamcinolone acetonide
0.025-0.1% cream, betamethasone 0.025-0.1% cream
• Ophthalmic corticosteroids (eg, prednisolone acetate
1% ophthalmic, dexamethasone ophthalmic)
• IM corticosteroids (eg, triamcinolone):
• Intralesional corticosteroids: Useful for resistant
plaques and for the treatment of psoriatic nails
• Coal tar 0.5-33%
• Keratolytic agents (eg, anthralin, urea): Use of these
medications may facilitate more direct steroid contact
with the skin
• Artificial tears

30. Drug Options
• Vitamin D analogs (eg, calcitriol ointment, calcipotriene,
calcipotriene and betamethasone topical ointment)
• Topical retinoids (eg, tazarotene aqueous gel and cream
0.05% and 0.1%)
• Antimetabolites (eg, methotrexate)
• Immunomodulators (eg, tacrolimus topical 0.1%,
cyclosporine, alefacept, ustekinumab)
• TNF inhibitors (eg, infliximab, etanercept, adalimumab)
• Phosphodiesterase-4 inhibitors (eg, apremilast)
• Interleukin inhibitors (eg, ustekinumab, secukinumab,
ixekizumab, brodalumab)

31. Topical Therapies
• Approximately 70% of patients with mild-to-
moderate psoriasis can be managed with
topical therapies alone
• Tailor to needs of patient
• Potency, delivery vehicle and patient
motivation may affect compliance
• Application may be time-consuming for
patients

32. Topical Therapies:
Emollients
• Include aqueous cream, sorbolene
cream, white soft paraffin and wool fats
• When used regularly they can:
– alleviate pruritus
– reduce scale
– enhance penetration of concomitant topical
therapy
– hydrate dry and cracked skin

33. Topical Therapies:
Keratolytics
• Over-the-counter products include:
– Salicylic acid
– Urea
• Help dissolve keratin to soften and lift
psoriasis scales
• May enhance penetration of other actives

34. Topical Therapies:
Coal Tar
• Help reduce inflammation and pruritus
• May induce longer remissions.
• Use limited by distinctive smell and
ability to stain clothing and skin.
• May cause local skin irritation

35. Other Topical
• DITHRANOL - Anti-proliferative
properties
• TAZAROTENE - Topical synthetic
retinoid
• CALCIPOTRIOL - Synthetic vitamin D
analogue
– Reverses abnormal keratinocyte
changes

36. Topical Therapies:
Corticosteroids
• Possess anti-inflammatory,
antiproliferative and
immunomodulatory properties
• Reduce superficial inflammation within
plaques
• Potency choice depends on disease
severity, location and patient
preference.

37. Topical Therapies:
Corticosteroids
• Adverse effects associated with long-term use
include:
– Skin atrophy and telangiectasia
– Hypopigmentation
– Striae
– Rapid relapse or rebound on stopping therapy
– Precipitation of pustular psoriasis
– Pituitary-adrenal axis suppression through
significant systemic absorption (rare)

38. Other Therapies
• Phototherapy
• Systemic therapies
– Methotreaxate
– Cyclospirin
• Biological agent
– Target immune system
– Tumour necrosis factor-alpha inhibitors
• Etanercept
• Adalimumab
• Infliximab
– Interleukin (IL-12 and IL-32) inhibitor
• Ustekinumab

39. Summary
• Psoriasis is a lifelong condition.
• Chronic, inflammatory disease of skin
• T-cell mediated disorder
• Classic presentation characterised by red, scaly
plaques.
• Gets worse over time
• Individuals will often experience flares and remissions
throughout their lives.
• Controlling the signs and symptoms typically requires
lifelong therapy

40. Summary
• Management should address both medical and
psychological aspects
• There is currently no cure but various
treatments can help to control the symptoms.
• Most effective agents for severe psoriasis carry
an increased risk of skin cancers, lymphoma
and liver disease.
• Treatments include topical therapy,
phototherapy, systemic therapy and biological
agents