PSORIASIS: CLINICAL FEATURES

DR. NAZNEEN ARSIWALA

Provisional working classification
Clinical forms Morphological
forms
• Plaque psoriasis
(psoriasis vulgaris) • Linear and
• Acute guttate segmental
psoriasis psoriasis
• Unstable psoriasis • Gyrata
• Erythrodermic • Rupoid
psoriasis • Discoid
• Pustular psoriasis • Ostraceous
• Atypical forms of • Elephantine
psoriasis
Specific sites
• Scalp psoriasis
• Follicular psoriasis
• Seborrhoeic psoriasis
(sebopsoriasis)
• Flexural psoriasis (inverse
psoriasis)
• Genital psoriasis
• Palmoplantar psoriasis
• Nail psoriasis
• Mucosal lesions
• Ocular lesions
Based on age of onset and familial
inheritance
• Type 1
• Type 2
Other specified forms
•Psoriasis in childhood and
old age
•Photo aggrevated psoriasis
•Drug induced or
exacerbated psoriasis
•HIV- induced or exacerbated
psoriasis
 Clinical features
• CLASSICAL LESIONS  Chronic,
symmetrical, well defined,
erythematous (salmon red)
papules and plaques with silvery
white loosely adherent scaling.

• White appearance  trapping of

air between layers of scales.

• Pruritus , burning sensation

• On grattage, scratched wax candle sign (sign de le tache
de bougie)

• When scales are completely removed moist red

membrane ( Duncan Bulkeley membrane)  dilated
capillaries as red dots.

• Removal  multiple pin point bleeding (AUSPITZ sign)

• Occasionally  surrounding clear peripheral halo

Wornoffs ring  after treatment with topical steroids.

• Linear lesions Koebnerization more during active

disease
Auspitz sign

Woronoff’s ring

Koebnerization
CLINICAL FORMS
 Psoriasis Vulgaris
• Commonest type
• Coin to palm sized
• Extensors, stable
• Papules  discoid plaques
 large plaques with
polycyclic borders
• Annular lesions, central
clearing zone.
• Gyrata fusion of many
incomplete annular lesions
 Acute guttate psoriasis
• Sudden onset of a shower of
small lesions, little scaling
• Children and young adults, may
be first presentation of
psoriasis
• Follows several weeks after
group A streptococci pharyngitis
• 2 or 3 mm to 1 cm in diameter
• Trunk and proximal part of
limbs, face, ears and scalp
• Lesions on face are often sparse
and disappear quickly
 Erythrodermic psoriasis
• 90% BSA with erythema, induration
and scaling with severe itching

• 1st form chronic lesions evolve into

extended plaques with exfoliation,
lesser systemic involvement better
prognosis

• 2nd form  spectrum of unstable

psoriasis, sudden, intolerance to local
applications, UV therapy severe
systemic involvement poor
prognosis
• Systemically – fever, hypoproteinemia, malabsorption,
dehydration, hypothermia, high output cardiac failure.
• Infections, alcohol, antimalarials, withdrawal of steroids
 Unstable psoriasis
• Enlargement of plaques intense erythema many new
smaller plaques
• More pain or pruritus within plaques
• Koebner phenomenon frequent

• Outcome is unpredictable
– may return to inactive state
– progress to localized pustular or erythrodermic
psoriasis

• Sudden withdrawal of steroids, irritant topical

application, infections, hypocalcemia, emotional stress
can precipitate the disease
 Atypical forms of psoriasis
• Unusual localizations - digital and
interdigital forms
• Verrucous lesions particularly affect
legs
• Rupioid psoriasis refers to limpet‐like
cone‐shaped lesions
• Elephantine psoriasis  unusual but
very persistent, thick scaling, large
plaques that occur on back, limbs,
hips
• Ostraceous psoriasis  ring‐like
hyperkeratotic lesion with a concave
surface, resembling an oyster shell
 Pustular psoriasis
• Generalized pustular psoriasis
– Clinical Variants
• Von zumbusch (acute generalised) pustular psoriasis
• Subacte Annular and circinate pustular psoriasis
– Other specified forms
• Acute generalised pustular psoriasis of pregnancy
(Impetigo herpetiformis)
• Infantile and juvenile generalised pustular psoriasis
• Localized
– Palmo plantar pustulosis
– Acrodermatitis continua of Hallopeau
 Von zumbusch psoriasis
• Acute and severe form
– From plaque psoriasis due to
provocation
– De novo
• Eruption ushered  sensation of
burning
• Preexisting lesion  fiery (sheets
of pustule)
• CropsPin head sized sterile
pustules lakes of pus
subside by exfoliation
• Fever, chills, polyarthralgia and
malaise
• Annular migrans – buccal
mucosa, tongue
• Proposed Diagnostic criteria:
 Recurrent episodes of fever with general malaise
 Multiple isolated sterile pustules
 Laboratory abnormalities (leukocytosis, elevated ESR or
CRP)
 Supported by Kogoj’s spongiform pustules on
histopathology

• Nails become thickened or separated by subungual lakes of

pus.

• Complications Hypovolaemia, Hypoalbuminaemia,

Hypocalcaemia, Cholestatic jaundice, psoriasis‐associated
aseptic pneumonitis, erythroderma.
 Subacute annular and circinate pustular
psoriasis
• Chronic and subacute pustular psoriasis

• Begin discrete areas of erythema oedematous

• Centrifugal spread  appearance of pustules at the

periphery dessication trailing fringe of scale

• No systemic symptoms
 Impetigo herpetiformis

• Occurs in last trimester of pregnancy persists until

chilbirth and long after

• Symmetrical flexural involvment  centrifugal extension

with central clearing Heals with brownish pigmentation

• Constitutional disturbance high risk of placental

insufficiency  still birth, neonatal death, fetal
abnormalities

• Tends to reccur in subsequent pregnancies

 Infantile and juvenile generalised pustular
psoriasis
• Rare in this age group (1st year of life)

• Infants :No systemic symptoms  spontaneous resolution

 localised to flexural areas

• Severe forms with fever and toxicity active treatment

• Children :All patterns can occur  annular and circinate

more common

• Generalised type disease rapidly progresses to

erythroderma
 Pustular palmoplantar psoriasis
• Females, 40-60 yrs, smoking and septic
foci
• Symmetrical, erythematous, scaly
plaques with sterile tiny yellow
pustules subungual and digital
pustulation
• 25% have psoriasis lesions elsewhere
• Thenar eminence, instep, heel
• Affected area is dusky red and scaly with
fissures removal of scale glazed
surface
• Fresh pustules  yellow; older ones 
yellow‐brown or dark brown
• Subsides with exfoliation
 Acrodermatitis continua of
Hallopeau
• Chronic pustular lesions at tip of
digits, starts with single finger
slow proximal extension

• Trauma  glazed erythema

pustules nail dystrophy
bone

• Digits are painful, may become

wasted and tapered with bony
change (osteolysis)
• Persistent nailfolds and nailbed
• May evolve into GPP in elderly
BY SITE OF INVOLVEMENT
 Scalp psoriasis
• Commonest areas  often
site first affected
– Whole scalp diffusely involved
– multiple discrete plaques of
varying size
• Extending a short distance
beyond hairline and around
the ears (corona psoriatica)
• Hair growth is normal

• Chornic lesionsPityriasis
(tinea) amiantacea asbestos‐
like scaling, firmly adherent
to scalp and associated hair
loss
 Follicular psoriasis

• Hair follicles on trunk and limbs

• May occur as an isolated

phenomenon, or in association
with plaque psoriasis

• Smaller than typical lesions of

guttate psoriasis and may be
either grouped or diffuse
 Seborrhoeic psoriasis
(sebopsoriasis)
• Plaques typical involving
paranasal areas, external ears,
medial eyebrows, hairline, pre-
sternal and inter scapular chest
wall

• It may arises as an isolated

phenomenon

• Should be distinguished from

seborrhoeic dermatitis
 Flexural psoriasis (inverse)
• Inguinal creases, axillae, sub-
mammary folds, gluteal cleft,
umbilicus

• More common in older

adults and is associated with
obesity

• As a primary disorder or as a
Koebner phenomenon

• Plaques are thin, scaling is

greatly reduced or absent
• Plaques are anhidrotic  hyperhidrosis of surrounding
skin maceration and friction  alter appearance of
psoriasis

• Surface has a glazed hue, fissuring at the depth of the

skin fold is common, especially in gluteal cleft

• Involvement of napkin area  first presentation of

psoriasis in infancy
 Genital psoriasis
• More in inverse psoriasis,
than plaque psoriasis and
may be only manifestation of
psoriasis

• Glans penis  Skin of

scrotum and penile shaft

• Plaques lack scales but

colour and well‐defined edge
are usually distinctive
• Vulval involvement  often complain of marked
pruritus

• Most common vulval presentation is a symmetrical,

erythematous, non‐scaly, well‐demarcated thin
plaque affecting labia majora
 Non‐pustular palmoplantar psoriasis
• Typical scaly patches on which a
fine silvery scale can be evoked by
scratching

• Resemble lichen simplex or

hyperkeratotic eczema

 Sharply defined edge at wrist,

forearm or palm
 Absence of vesiculations
 Knuckles frequently show a dull‐red
thickening of skin
 Lesions elsewhere
 Nail psoriasis
• 10 - 50% cases
• Pitting is most common presentation
• Rapid proliferation of cells in proximal matrix  parakeratotic
columns  easily cast off from the surface
• Pits are coarse, irregularly arranged, variable depths

• Changes in middle and distal part of matrix leukonychia

• Subungual hyperkeratosis  parakeratosis of hyponychium

• Splinter haemorrhages  increased fragility of vessels

• Accumulation of parakeratotic material in nail bed brownish

pigmentation olfleck’s phenomenon
 Nail psoriasis

• ss
 Mucosal lesions
• Geographic tongue (benign migratory glossitis) and fissured
tongue are both more frequent among patients with psoriasis
• HLA Cw6

• Confined to the pustular & exfoliative

forms of disease

Ocular lesions
• Chronic non‐specific conjunctivitis, keratitis, xerosis

• Uveitis  immunologically mediated complication associated

with more extensive psoriasis and psoriatic arthritis
• To conclude , psoriasis manifests with various
different presentations.

• Due to their peculiarity , clinical features represent

an irreplaceable tool for diagnosis and therefore,
subsequent management of psoriasis.
Thank you
 References
• Griffiths CEM, Barker JN. Pathogenesis and clinical features
of psoriasis. The lancet 370 (9583). 2007; 263-271

• Langley RGB, Krueger GG, Griffiths CEM. Psoriasis:

epidemiology, clinical features, and quality of life. Annals of
the rheumatic disease 64 (suppl 2). 2005; ii18-ii23

• Myers WA, Gottlieb AB, Mease P. psoriasis and psoriatic

arthritis: clinical features and disease mechanism. Clinics in
dermatology. 2006: 24(5); 438-447
 References
• Lowes MA, Bowcock AM, Krueger JG. Pathogenesis and
therapy of psoriasis. Nature. 2007 Feb 22;445(7130):866-
73.

• Psoriasis and Related Disorders. Burden AD, Kirby B,

editor. Rook’s textbook book of dermatology, 9 th edn.
Blackwell publishing Ltd.; John Wiley and sons; 2016;
36.1.

• Grover C. Psoriasis. Sacchidanand S, editor. IADVL

textbook of dermatology,4th edn. Bhalani publishing
house, Mumbai; 2015;27-69