“ This is a wonderful grouping of 39 clinical photographs, mirroring my earlier comments about the tremendous variation in phenotypic expression of this disease we call psoriasis. My great friend, the late Jim Gilliam from Dallas, in the 1970’s with his discovery of subacute cutaneous lupus erythematosus, showed dermatologists and rheumatologists the full spectrum of lupus from mild skin involvement to devastating multi-organ involvement. I do believe psoriasis also has a similar spectrum with an even more protean clinical manifestation than lupus, from a few minor patches or even purely skin involvement to devastating joint disease with or without other systemic immune-mediated diseases such as Crohn’s, diabetes, multiple sclerosis, etc plus aspects of the Metabolic Syndrome. A most important aspect coming out of this wonderful array of clinical photographs is, I believe, the need for all dermatologists to do a total body evaluation of the patient at each visit, as too often a cursory examination is done, or patients because of their natural shyness to expose the surface of their skin to the public frequently will not disclose to the dermatologist areas of concern, such as flexural psoriasis, genital and perianal involvement, etc. In addition, are the various different manifestations of
nail psoriasis important as a marker for psoriatic
arthritis as discussed in Chapter 6?
Alan Menter
Alan Menter
The clinical manifestations of psoriasis are varied. The elementary lesions are the result of all possible combinations of: epidermal proliferation and parakeratosis leading to the exaggerated formation of squamae, epidermal and dermal inflammation responsible for infiltration of the lesions but also for erythema and the formation of micropustules, and sometimes even clinically visible pustules. Consequently, the psoriasis plaques can take highly varied appearances, from simple erythema covered with light desquamation, to the characteristic erythematosquamous plaque, or even to the emergence of a carpet of pustules. Erythema and desquamation are thus the only anomalies to be constantly observed (photos 2 and 3).
Photo 2. Plaque psoriasis, so-called
“vulgar(is)”.
Photo 3. Highly inflammatory plaque psoriasis.
The typical elementary lesion of psoriasis combines all these components and presents a papular, erythematosquamous rounded lesion that is well circumscribed and covered with micaceous, silvery-white scales (photo 4). Scratching these scales with a curette causes one last glossy squama to appear. If tugged at, a characteristic bloody dew connected to the abrasion of the turgescent dermal papillae starts to well up. Sometimes, one can observe a lighter halo, as described by Woronoff, surrounding the plaque. It is not known whether this is a sign of the plaque’s progression or, conversely, of an anti-inflammatory response by restricting the spread (vasoconstriction?).
“ Regarding the Woronoff ring, I
have only seen this sign in healing psoriatic plaques, close to their final
disappearance. I regard it as being caused by different propensity to be
stained to topical antipsoriatic drugs such as
anthralin.
Wolfram Sterry
Wolfram Sterry
Photo 4. A typical psoriasis plaque.
The body areas most often affected and often most resistant to treatment are the elbows (photo 5), the knees (photos 6 and 7), the scalp (photo 9) and the lumbar region (photos 8, 10 and 11).
Photo 5. The refractory areas: the elbows.
Photo 6. The refractory areas: the knees.
Photo 7. The refractory areas: the knees.
Photo 8. The refractory areas: the lower back.
Photo 9. The refractory areas: the scalp. Psoriasis can cause
topicalized alopaecia.
Photo 10. The refractory areas: the buttocks.
Photo 11. The refractory areas: the buttocks.
But all body areas may be affected, even the mucosa. Each of the
possible sites may be associated with other sites, making its diagnosis
easier, or may be isolated, often making diagnosis more difficult
(photos 12 and 13).
Photo 13. An attack worthy of comment: the navel.
Hence the descriptions: psoriasis of the scalp, psoriasis of the face (photo 14), psoriasis of the eyelids (photo 15), psoriasis of the external auditory canals (photo 16), psoriasis of the skin folds (photos 17 and 18)—also called inverse or flexural psoriasis, wherein the squamae are not observed due to maceration, psoriasis of the mucous membranes: lingual mucosae, with geographic tongue (photo 19), genital mucosae (photos 20 and 21), psoriasis of the nails (photos 26, 27, 28, 29 and 30) and palmoplantar psoriasis. Each site poses different differential diagnosis problems, has specific repercussions on the quality of life and raises particular therapeutic problems, which will be detailed.
Photo 14. A limited but incapacitating facial
attack.
Photo 15. Psoriasis on the eyelids, especially in children.
Photo 16. Frequent bouts:
the ear and the external auditory
canal (often affected in
seborrhoeic dermatitis too).
Photo 17. Psoriasis of the
armpits: this is neither eczema
nor mycosis!
Photo 18. Psoriasis of the folds. Not to be
confused with candidosis!
Photo 19. Attack on the tongue during
pustular psoriasis (photo: C. Beylot).
Photo 20. The glans penis may be affected.
Photo 21. Genital attacks are frequent in children.
Pruritus maintains the lesions.
Photo 22. Attacks on the nails are frequent.
Photo 23. Separation of the distal part of the
nail.
Photo 24. Ungual psoriasis, showing “thimble” pitting of
the nails (photo: C. Beylot).
Photo 25. Inflammatory attack of the nail and the
distal interphalangeal: so-called “radish fingers”.
Photo 26. Dry pulpitis.
Photo 27. Incapacitating attack on the hands.
Photo 28. The effect on the hands is disabling.
Photo 29. The effect on the feet is highly painful and
prevents walking.
Photo 30. The effect on the hands is disabling.
Depending on the surface of the plaques
“ In my view this
distinction is made on the size of the lesion rather than on its surface.
Wolfram Sterry
Wolfram Sterry
, we distinguish
guttate psoriasis (photo 31) (guttate psoriasis), nummular psoriasis, generalized psoriasis – so-called universalis (photo 34) – in which a few sites of healthy skin persist, and finally
erythrodermic psoriasis, affecting the entire skin area (photo 32). The shape of the plaques can also vary, some being annular with central clearing, with the rings potentially joining up to form circinate psoriasis (photos 33 and 35).
Photo 32. Erythrodermic
psoriasis.
Photo 33. Circinate psoriasis.
Photo 34. Generalized psoriasis.
Photo 35. Circinate psoriasis (photo: C. Beylot).
The extent of neutrophils migration in epidermis may lead to the formation of clinically visible pustules characteristic of pustular psoriasis (photo 36). The latter may be generalized, with pustules appearing on the plaques of classic psoriasis, as sometimes observed after stopping general corticotherapy, or generalized pustulosis, as described by von Zumbusch (photo 37). Pustular psoriasis may be localized: palmoplantar pustulosis (photo 38) and acrodermatitis continua of Hallopeau.
Photo 37. Generalized von Zumbusch-type pustular psoriasis
in a small girl (photo: C. Beylot).
Photo 38. Palmoplantar pustulosis: is it really
a form of psoriasis?
Depending on people’s age, psoriasis poses particular therapeutic problems. There can be psoriasis in the child (photo 39), psoriasis in the fertile woman and the pregnant woman (with this exceptional generalized pustular form, called impetigo herpetiformis) and psoriasis in the elderly. Comorbidities play, of course, an important role in the choice of therapeutic strategy. Their impact will be discussed when we come to look at different ways of organizing therapeutic strategies.
Photo 39. Spirula-like psoriases are more frequent in children
(photo: C. Beylot).
“ Is that really true?? 30%?
Olle Larkö
Olle Larkö
Two quite disparate situations need to be distinguished:
- generalized pruritus leading to look for an associated atopic diathesis, contact eczema, scabies… , responsible for psoriasis eruption (Köebner’s phenomenon), or an epidermotropic psoriasiform lymphoma;
- localized pruritus, often producing a habit of repetitive scratching and ending not only in a permanent Köebner’s phenomenon but also in an associated neurodermatitis that will need to be treated in its own.
Consensus and controversies forum
