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Psoriasis and Psoriatic Spectrum Disease: A Primer for the Primary Care Physician

Erythematous plaques with thick, micaceous scale on the extensor lower leg of a man with plaque psoriasis.

Psoriasis is a chronic, immune-mediated disorder with cutaneous, articular, and systemic manifestations that are associated with significant morbidity.1 The burden of disease is directly related to its prevalence, which ranges from 0.5%-11.4% in adults and 0%-1.4% in children worldwide.2 In the United States alone, approximately 7.4 million individuals have psoriasis,3 and both the incidence and prevalence of psoriasis are increasing, commensurate with the increase of obesity.4 Importantly, a growing body of evidence supports that psoriasis independently confers an increased risk of cardiovascular disease, metabolic syndrome, chronic kidney disease, certain inflammatory conditions (eg, inflammatory bowel disease), malignancy, and depression.5

As the burden of disease increases, appropriate management strategies with the goal of mitigating disease-related morbidity and economic cost are becoming increasingly relevant. Both primary care physicians and specialists play specific roles in this effort. For primary care physicians, such efforts entail accurately diagnosing psoriasis, screening for and managing associated comorbidities, treating patients with mild to moderate disease, and triaging/referring those with more severe disease for specialty care. What follows is a practical review of psoriasis and psoriatic spectrum disease specifically for the primary care physician, with the intent of providing a basic framework on disease fundamentals that may be used to inform routine clinical management.

Clinical Features of Psoriasis

Psoriasis is a heterogeneous disease. The skin is the most commonly affected organ, but joints, nails, eyes, and the cardiovascular system may also be involved.6 The phenotype and severity of disease depends on several innate (eg, certain human leukocyte antigen haplotypes) and exogenous (eg, medication exposure, Streptococcalinfection, etc) factors.

Cutaneous Features

The most common form of cutaneous psoriasis—chronic plaque-type—typically presents with thick erythematous, sharply marginated plaques with characteristic micaceous, silvery scale (Figure 1). Lesions tend to occur on the scalp, extensor limbs, such as the elbows (Figure 2) and knees (Figure 3), trunk (Figure 4), umbilicus (Figure 5), and gluteal cleft. In general, psoriasis is asymptomatic, but in some cases, lesions may be pruritic or tender. In individuals with darker skin, psoriasis plaques may appear violaceous or hyperpigmented (Figure 6). Apart from chronic plaque disease, several other forms of psoriasis exist and include guttate (rain drop-like morphology), pustular (Figure 7), erythrodermic (Figure 8), palmoplantar (Figure 9), and inverse or flexural disease.7

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-Jawad Bilal, MD, Saad Ullah Malik, MD, Irbaz Bin Riaz, MBBS, MM, Drew J.B. Kurtzman, MD

This article originally appeared in the October issue of The American Journal of Medicine.

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