Psoriasis Multimedia

Station Instructions: Assess this patient presenting with a chronic rash and joint pains.

1. Key History‑Taking Points

History of Presenting Complaint:

Skin Lesions:

• Onset & course: Age of onset? Relapsing-remitting course?

• Progression: Stable, worsening, or episodic?

• Distribution: Scalp, elbows, knees, trunk, nails, flexures, genitals?

• Symptoms: Itch, pain, bleeding, fissuring, or discomfort?

• Triggers: Recent infection (e.g., sore throat), stress, trauma (Koebner phenomenon), medications (β-blockers, lithium, NSAIDs), alcohol, smoking, cold weather.

• Remissions: Seasonal variation or improvement with sunlight?

Nail Changes:

• Pitting, onycholysis, subungual hyperkeratosis, nail deformity

Joint Symptoms (Psoriatic Arthritis):

• Morning stiffness, joint pain/swelling, reduced range of movement

• Dactylitis (sausage digits), enthesitis (heel pain), or back stiffness (axial disease)

Impact & Function:

• Effect on self-esteem, sleep, daily function, and relationships

• Clothing avoidance, psychological distress, anxiety or depression

Past Medical & Family History:

• Family history of psoriasis, IBD, metabolic syndrome, or arthritis

• History of cardiovascular disease, obesity, diabetes

• Previous psoriasis treatments and response (topicals, phototherapy, systemics, biologics)

Medication & Social History:

• Current medications (β-blockers, ACE inhibitors, lithium, antimalarials, NSAIDs)

• Alcohol intake and smoking

• Pregnancy or planning pregnancy (treatment implications)

2. Key Examination Findings

• General Inspection:

  • Symmetrical, well-demarcated, erythematous plaques with silvery scale (extensor surfaces typical)

  • Distribution: scalp, elbows, knees, umbilicus, lumbosacral area, nails

  • Auspitz sign (pinpoint bleeding when scale removed), Koebner phenomenon (psoriatic plaques at trauma sites)

  Types of Psoriasis:

  • Chronic plaque (most common)

  • Guttate (post-streptococcal, drop-like lesions)

  • Erythrodermic (generalized erythema >90% BSA, systemic symptoms)

  • Pustular (localized to palms/soles or generalized)

  • Flexural/inverse (erythematous, non-scaly lesions in skin folds)

  Nail Findings:

  • Pitting, onycholysis, subungual hyperkeratosis, “oil drop” discolouration

  Musculoskeletal:

  • Examine joints (DIPs, PIPs, knees, ankles) for swelling or tenderness

  • Dactylitis, enthesitis, restricted spinal movement (modified Schober’s test)

  Systemic:

  • Check for metabolic features: obesity, hypertension, central adiposity

  Psychological:

  • Mention DLQI score (impact on quality of life)

3. Specific Investigations

Clinical Diagnosis (usually based on appearance and distribution)

Laboratory Tests:

• FBC, U&E, LFTs (baseline for systemic therapy)

• CRP/ESR (for psoriatic arthritis or systemic inflammation)

• Lipid profile, glucose (metabolic syndrome association)

• Throat swab if guttate psoriasis (Streptococcal infections)

• HIV screening (in atypical or treatment-resistant cases)

Imaging:

• X-rays of affected joints (for psoriatic arthritis — arthritis mutilans – “pencil-in-cup” deformity)

• Ultrasound/MRI if early or axial disease suspected

Special Scores:

• PASI (Psoriasis Area and Severity Index) — objective severity

• DLQI (Dermatology Life Quality Index) — quality of life impact

• PGA (Physician Global Assessment) — overall clinical impression

• Joint Involvement: Rheumatoid Arthritis, Nodal Osteoarthritis, Inflammatory Arthropathis (Reactive Arthritis, Enteropathic Arthropathy, Ankylosing Spondylitis) 
• Dermatological Differentials: Seborrheic Dermatitis, Tinea Corporis, Pityriasis Rosea, Discoid Dermatitis

5. Management

Multidisciplinary Approach:
Dermatology, Rheumatology, Psychology, and Primary Care

Stepwise Management (NICE Guidelines):

Topical Therapy (first-line):

• Emollients: Soften scale, reduce irritation

• Vitamin D analogues (calcipotriol, calcitriol) ± corticosteroids (Dovobet)

• Coal tar, dithranol (not commonly used)

• Topical steroids: For short-term use on thick plaques or scalp

Phototherapy:

• Narrowband UVB for widespread or refractory disease

Systemic Non-biologic Therapy:

• Methotrexate: 1st line for moderate-severe psoriasis or psoriatic arthritis (monitor FBC, LFTs, contraceptive advice)

• Ciclosporin: Short-term for rapid control or erythrodermic psoriasis

• Acitretin: For pustular psoriasis (teratogenic — avoid in pregnancy)

Biologic Therapy:

Indicated for severe disease (PASI ≥10 and DLQI ≥10) following failure of more than one systemic.

• TNF-α inhibitors: Adalimumab, Etanercept, Infliximab

• IL-17 inhibitors: Secukinumab, Ixekizumab

• IL-12/23 inhibitors: Ustekinumab

• IL-23 inhibitors: Guselkumab, Risankizumab

Supportive Measures:

• Smoking cessation, alcohol reduction, weight management

• Psychological support and patient education

• Screening for depression and metabolic syndrome

Psoriatic Arthritis Management:

• • Early rheumatology referral

  • NSAIDs for pain, DMARDs (methotrexate, sulfasalazine), biologics if resistant

 Psoriasis Cheat Sheet