Page 143 - Journal of Special Operations Medicine - Summer 2015

Family history of the disease is a strong genetic predic- life threatening, presenting with rapid onset of bright
tor for its development. 2 red skin erythema initially and then rapidly progressing
to pinpoint sterile clusters of pustules that coalesce into
2
The pathogenesis of psoriasis involves an immune- “lakes.” Patients are usually febrile with severe malaise
2
mediated inflammatory response initiated by T cells. It and leukocytosis. Nikolsky sign is positive; onycholysis
causes abnormal differentiation and hyperproliferation with subungual pus and tongue desquamation are also
1
of keratinocytes. Other autoimmune diseases have been present. Generalized acute pustular psoriasis can be pre-
associated with psoriasis, including Crohn disease, ul- cipitated by withdrawal of topical and systemic steroids
cerative colitis, and multiple sclerosis. In addition, car- or other topical medications such as tar and anthralin.
diovascular disease, metabolic syndrome, lymphoma, Fortunately, it responds well to acitretin, methotrexate,
and depression are more prevalent in individuals suffer- and cyclosporine. 1
ing from psoriasis than in the general population. 2
Erythrodermic psoriasis presents as generalized ery-
Some of the triggers that have been identified in precipi- thema with significant scaling. As in generalized pus-
tating or exacerbating the symptoms include physical tular psoriasis, it can be precipitated by withdrawal of
trauma that leads to new lesions at the injury site (also systemic steroids, tar, or anthralin. However, some other
known as Koebner phenomenon), streptococcal pharyn- risk factors include excessive topical steroid use, infec-
gitis preceding guttate psoriasis, stress, drugs (lithium, tion, phototherapy adverse effects, and severe stress.
2
β-blockers, antimalarial agents, withdrawal of systemic Bacterial suprainfection is a possible complication of
steroids), and alcohol consumption. 1 the generalized disease—either erythrodermic or pustu-
2
lar psoriasis—due to skin barrier breakdown.
Clinical Manifestation and Course
Inverse psoriasis is characterized by the distribution of
Psoriasis can be disabling and emotionally challenging the plaques in the body folds, where the moist environ-
for patients to deal with because of its appearance. There ment makes the lesions look deep red and fissured with
are a number of variations in psoriasis morphology and no scaling. The most common locations are axillae, glu-
presentation, including chronic plaque psoriasis, guttate teal folds, groin, submammary folds, and penis. 2
psoriasis, pustular psoriasis, and erythrodermic psoriasis.
Nail involvement is noted in 25% of skin psoriasis cases
1,2
The most common variant is plaque psoriasis, which and is characteristic of the disease. Nail abnormali-
presents as irregular, well-demarcated, deep red plaques ties include pitting, subungual hyperkeratosis, yellow-
or papules with silvery white scales. If removed, scales brown spots (oil spots) that resemble fungal infection,
give way to bleeding points, called Auspitz sign. The and onycholysis.
most common areas of distribution are extensor sur-
faces, such as the elbows, knees, scalp, nails, and gluteal Psoriatic arthritis is associated with skin psoriasis as
cleft. Palms and soles can also be involved, as well as well and is present in 5% to 42% of affected people.
2
joints. Facial involvement is uncommon and indicates It is an inflammatory arthropathy most commonly seen
1
a refractory disease. However, psoriatic lesions on the in peripheral joints in asymmetric distribution. Psori-
scalp can have denser scale and may extend onto the atic nail changes are present in more than 80% of the
2
forehead; hair loss is not permanent. 2 individuals suffering from arthritis. Psoriatic arthritis
needs to be recognized and treated early, due to signifi-
1
Guttate psoriasis can follow a streptococcal pharyngitis cant bone destruction associated with this condition.
2
or viral upper respiratory tract infection. It presents as Mild symptoms can be treated with nonsteroidal anti-
numerous salmon-pink papules with or without scales inflammatory drugs or intra-articular steroid injections
and distribution mostly on the trunk and extremities, for pain relief. However, this therapy is not effective for
2
sparing palms and soles. The lesions might resolve preventing bone damage. Methotrexate, anti–tumor ne-
1
spontaneously within weeks or be readily susceptible crosis factor-α (also called biologic agents, and including
1
to the standard therapies. However, it most commonly infliximab, etanercept, and adalimumab), sulfasalazine,
2
transitions into a chronic plaque type. 1 and cyclosporine are effective therapies. 1,2
Pustular psoriasis can be localized to palms and soles or Treatment
generalized with characteristic pustules that appear more
frequently in women than in men (4:1 ratio) aged 50–60 Management of psoriasis could be a lifelong battle and
1
years. Clinical symptoms include recurring pruritic pus- depends on the extent of the disease, its location, and
tules on palms or soles that transition into macules and type. Patient compliance is also a big challenge, given
2
then crust. Generalized acute pustular psoriasis can be the lengthy treatment course for disease management.

Psoriasis 133