Psoriasis

What is psoriasis?

Psoriasis is a chronic inflammatory skin condition characterised by clearly defined, red and scaly plaques. It is classified into a number of types.

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Who gets psoriasis?

Psoriasis affects 2–4% of males and females. It can start at any age including childhood, with peaks of onset at 15–25 years and 50–60 years. It tends to persist lifelong, fluctuating in extent and severity. It is particularly common in Caucasians but may affect people of any race. About one-third of patients with psoriasis have family members with psoriasis.

What causes psoriasis?

Psoriasis is multifactorial. It is classified as an immune-mediated inflammatory disease (IMID).

Genetic factors are important. An individual's genetic profile influences their type of psoriasis and its response to treatment.

Genome-wide association studies report that the histocompatibility complex HLA-C*06:02 (previously known as HLA-Cw6) is associated with early-onset psoriasis and guttate psoriasis. This major histocompatibility complex is not associated with arthritis, nail dystrophy, or late-onset psoriasis.

Theories about the causes of hyperproliferation of the skin in psoriasis need to explain why the skin is red, inflamed, and thickened.

It is clear that immune factors and inflammatory cytokines (messenger proteins) such as IL1β and TNFα are responsible for the clinical features of psoriasis. Current theories are exploring the TH17 pathway and release of the cytokine IL17A.

What are the clinical features of psoriasis?

Psoriasis usually presents with symmetrically distributed, red, scaly plaques with well-defined edges. The scale is typically silvery white, except in skin folds where the plaques often appear shiny with a moist peeling surface. The most common sites are scalp, elbows, and knees, but any part of the skin can be involved. The plaques are usually very persistent without treatment.

Itch is mostly mild but may be severe in some patients, leading to scratching and lichenification characterised by thickened leathery skin and increased skin markings. Painful skin cracks or fissures may occur.

When psoriatic plaques clear up, they may leave brown or pale marks that can be expected to fade over several months.

How is psoriasis classified?

Certain features of psoriasis can be categorised to help determine appropriate investigations and treatment pathways. Overlap may occur.

  • Early age of onset < 35 years (75%) vs late age of onset > 50 years
  • Acute eg guttate psoriasis vs chronic plaque psoriasis
  • Localised eg, scalp, palmoplantar psoriasis vs generalised psoriasis
  • Small plaques < 3 cm vs large plaques > 3 cm
  • Thin plaques vs thick plaques
  • Nail involvement vs no nail involvement

Types of psoriasis

Guttate psoriasis

Post-streptococcal acute guttate psoriasis

  • Widespread small plaques
  • Often resolves after several months

Small plaque psoriasis

  • Often late age of onset
  • Plaques < 3 cm

Chronic plaque psoriasis

  • Persistent and treatment-resistant
  • Plaques > 3 cm
  • Most often affects elbows, knees and lower back
  • Ranges from mild to very extensive