Diagnosis and management of psoriasis

Abstract

Objective: To provide primary care clinicians with an up-to-date and practical overview of the diagnosis and management of psoriasis.

Quality of evidence: PubMed, MEDLINE, EMBASE, and Cochrane databases were searched for relevant meta-analyses, randomized controlled trials, systematic reviews, and observational studies about the diagnosis and management of psoriasis.

Main message: Psoriasis is a chronic, multisystem inflammatory disease with predominantly skin and joint involvement. Beyond the physical dimensions of disease, psoriasis has an extensive emotional and psychosocial effect on patients, affecting social functioning and interpersonal relationships. As a disease of systemic inflammation, psoriasis is associated with multiple comorbidities, including cardiovascular disease and malignancy. The diagnosis is primarily clinical and a skin biopsy is seldom required. Depending on the severity of disease, appropriate treatment can be initiated. For mild to moderate disease, first-line treatment involves topical therapies including corticosteroids, vitamin D3 analogues, and combination products. These topical treatments are efficacious and can be safely initiated and prescribed by primary care physicians. Patients with more severe and refractory symptoms might require further evaluation by a dermatologist for systemic therapy.

Conclusion: Many patients with psoriasis seek initial evaluation and treatment from their primary care providers. Recognition of psoriasis, as well as its associated medical and psychiatric comorbidities, would facilitate timely diagnosis and appropriate management with effective and safe topical therapies and other medical and psychological interventions, as needed. More severe and refractory cases might warrant referral to a dermatologist for further evaluation and possible systemic therapy.

Figure 1.

Plaque psoriasis is characterized by well-demarcated and erythematous plaques with silvery scale: A) Plaque psoriasis on the elbow; B) Psoriasis on the trunk, marked by confluent red, well-demarcated, scaly plaques; C) Psoriasis on the dorsal foot and metatarsophalangeal joint with psoriatic nails showing dystrophy; D) Psoriasis in the postauricular area, which is a common site of involvement.

Figure 2.

Patients with psoriasis might have nail involvement, which can present without concomitant plaques: A) Psoriatic nails, consisting of pitting, distal onycholysis, subungual hyperkeratosis, and crumbling; B) Leukonychia and splinter hemorrhages; C) Distal onycholysis and oil drop sign.

Figure 3.

Annular psoriasis on the back: Annular psoriasis is characterized by well-demarcated, erythematous, and scaly plaques with central clearing.

Figure 4.

Pustular psoriasis on the palm

Figure 5.

Guttate psoriasis, which developed 12 d after onset of streptococcal pharyngitis

Figure 6.

Approaching erythrodermic psoriasis

Figure 7.

Treatment algorithm for healthy adult men with chronic plaque psoriasis (> 5% BSA) without psoriatic arthritis BB—broadband, BSA—body surface area, NB—narrowband, PUVA—psoralen plus UVA, UV—ultraviolet.