Presentation | Features | Additional Features | Location | Treatment(s) |
---|---|---|---|---|
Plaque (psoriasis vulgaris is most common) | Well-demarcated papule or plaque with silvery scale and punctuate bleeding when peeled (Auspitz's sign) | Koebner's phenomenon, which is the development of psoriasis in areas of trauma16 | Knees, elbows, trunk (extensor surfaces), nape of neck, postauricular, lumbosacral area, scalp, feet, hands, penis16 | Topical and/or systemic, depending on severity and recalcitrance Intralesional steroids for local recalcitrant disease |
Nail | Proximal nail matrix produces defects in keratinization that are translated as the nail grows out from the cuticle in the form of pits <1 mm in diameter Psoriasis of the nail bed results in oil spots. Patients also get splinter hemorrhages.17 | Subungual hyperkeratosis (onchyolysis) starts as the free nail separates from the nail bed and can be demarcated by a yellow band; this allows for material from the nail bed to accumulate under the nail.16,17 Consider possible future development of PsA. | Fingernails and/or toenails | Intralesional steroids, CsA18 |
Inverse (uncommon) | Painful, well-demarcated, symmetric, erythematous papules and plaques that may become macerated, often eroded, or secondarily infected because of location19 | Intertriginous regions of the body: inframammary, neck, axillary, inguinal crease, and intergluteal | Topical | |
Erythrodermic | >90% Involvement of BSA Acute: develops over days, can be severe and even life threatening because of greater stress on the heart and other metabolic resources of the body Chronic: develops more slowly over months to years | Acute form can result in hospitalization and can be life threatening if severe because of loss of fluids (electrolytes, water, proteins) and unstable body temperature20 | Widespread | Systemic (acetretin,18 MTX, CsA18) |
Pustular (generalized type; rare; 4 types) | Erythema and sterile pustules sometimes in preexisting plaques or in annular lesions | Some can have metabolic disturbances.19 Causes include pregnancy, rapid steroid taper, infections, hypocalcemia, or topical local irritants19 | Widespread in flexures | Systemic (acitretin18) or biological |
Palmar/plantar pustular | Vesicles lead to pain and/or significant itch in involved areas. | Typically recalcitrant because of the thickness of the skin of the palms and soles, limiting penetration of topical treatments and trauma to hands and feet, causing the Koebner phenomenon | Hands/feet | UV light (PUVA/UVB), acitretin,18 CsA18 |
Guttate | Abrupt eruption of psoriasis that is characterized by 2- to 5-mm teardrop-shaped papules. | Preceded by a streptococcal infection or drug-induced (carbamazepine, α-interferon, antimalarials, abrupt cessation of systemic corticosteroids, lithium, β-blockers)2 | Trunk and extremities | With UV light and withdrawal of offending drugs or resolution of streptococcal disease, some patients have resolution. Some patients will go on to have psoriasis later in life, with most developing plaque-type psoriasis. |
↵* Psoriasis is a disease that is diagnosed clinically, but if the condition fails to respond to therapy or lesions do not appear classic, a biopsy or dermatology referral may be warranted.
CsA, cyclosporin A; MTX, methotrexate; PsA, psoriatic arthritis; UV, ultraviolet; PUVA/UVB, psoralen + ultraviolet A/ultraviolet B; BSA, body surface area.