Psoriasis Psoriasis is a common chronic inflammatory skin disease that may exhibit a variety of clinical manifestations. Chronic plaque psoriasis, the most common subtype of psoriasis, is characterized by well-demarcated, erythematous plaques with an overlying, coarse scale. Other major subtypes of psoriasis include guttate psoriasis, which typically presents as the acute onset of numerous small, inflammatory plaques; pustular psoriasis, which may present as an acute, subacute, or chronic pustular eruption; and erythrodermic psoriasis, which exhibits cutaneous erythema and scale involving most or all of the body surface area. Psoriasis has also been identified as a multisystem chronic inflammatory disorder associated with multiple comorbidities. Psoriatic arthritis is a common comorbidity that should be screened for in all patients. Examples of other comorbidities that are more common in individuals with psoriasis and may warrant intervention include obesity, metabolic syndrome, hypertension, diabetes, and atherosclerotic disease (Feldman, 2022). Patients with chronic plaque-type psoriasis usually present with symmetrically distributed, cutaneous plaques. The scalp, extensor elbows, knees, and gluteal cleft are common sites for involvement. The extent of involvement can range from limited, localized disease to involvement of the majority of the body’s surface area. Involvement of intertriginous areas (inverse psoriasis), the ear canal, umbilicus, palms of the hands, soles of the feet, or nails may also be present. Psoriasis plaques are erythematous with sharply defined margins. In patients with highly pigmented skin, postinflammatory hyperpigmentation may be prominent and may obscure erythema. The plaques can range from less than 1 to more than 10 cm in diameter. A thick, silvery scale is usually present, although bathing may remove the scale, and applications of emollients may make the scale temporarily invisible. The plaques may be asymptomatic, but pruritus is common. Palm or sole involvement can include painful fissures (Feldman, 2022). A diagnosis of psoriasis can be made by a physical examination in the vast majority of patients. Occasionally, a skin biopsy is needed to rule out other conditions. Urticaria Urticaria, sometimes called hives, is a common disorder, with a prevalence of approximately 20% in the general population (Asero, 2022). Typical descriptions might include complaints of welts or wheals. A typical urticarial lesion is an intensely pruritic, erythematous plaque. Urticaria is sometimes accompanied by angioedema, which is swelling deeper in the skin. A presumptive trigger, such as a drug, food ingestion, insect sting, or infection, may be identifiable in patients with new-onset urticaria, although no specific cause is found in many cases, particularly when the condition persists for weeks or months. Urticarial lesions are circumscribed, raised, erythematous plaques, often with central pallor. Lesions may be round, oval, or serpiginous in shape and vary from less than 1 centimeter to several centimeters in diameter. They are intensely itchy. Pruritus may disrupt work, school, and/or sleep. Symptoms often seem most severe at night. Individual lesions are transient, usually appearing and enlarging over minutes to hours and disappearing within 24 hours. Lesions may coalesce as they enlarge. Patients might see improvement with OTC diphenhydramine. Urticarial lesions are not normally painful and resolve without leaving residual ecchymotic marks on the skin unless there is trauma from scratching. If lesions are long-lasting, are painful, or leave residual bruising, the diagnosis of urticarial vasculitis should be considered. Any area of the body may be affected, although areas in which clothing compresses the skin (e.g., under waistbands) or skin rubs together (e.g., axillae) are sometimes affected more dramatically. Compressed areas become more severely affected once the restricting clothing is removed (Asero, 2022).
Figure 13. Psoriasis
From Fallah, A. (2013). Psoriasis in elbowhttps://commons.wikimedia. org/wiki/File:Psoriasis_in_elbow.jpg. CC BY-SA 3.0 Numerous topical and systemic therapies are available to treat the cutaneous manifestations of psoriasis. Treatment modalities are chosen based on disease severity, relevant comorbidities, patient preference (including cost and convenience), efficacy, and evaluation of individual patient response. Although medication safety plays an important role in treatment selection, this must be balanced by the risk of undertreatment of psoriasis, leading to inadequate clinical improvement and patient dissatisfaction. The desired treatment outcome differs for individual patients and depends upon factors such as patient preferences regarding the preferred amount of disease control and tolerance of specific treatments (Feldman, 2023). A reasonable goal for patients who desire maximum resolution of skin disease is minimal to no skin involvement achieved with a well-tolerated treatment regimen.
Figure 14. Urticaria
From Enochlau. (2006). Rash. https://www.wikidata.org/wiki/Q187440. CC BY-SA 2.5 Note : Angioedema, when associated with urticaria, usually affects the face and lips, extremities, and/or genitals. Angioedema without urticaria should prompt consideration of other angioedema disorders, such as drug-induced angioedema (e.g., angiotensin-converting enzyme [ACE] inhibitors), idiopathic angioedema, and hereditary and acquired C1 inhibitor deficiency. Patients with angioedema of the face should be
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