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Psoriasis is an ongoing (chronic) skin disease that appears in many different forms and can affect any part of the body. In psoriasis, new skin cells are produced about 10 times faster than normal, but the rate at which old cells are shed remains unchanged. As a result, the live cells stack up, forming thickened patches covered by dead, flaking skin.
The most common type of psoriasis is called plaque psoriasis and is characterized by raised, thickened patches of red skin, covered with silvery-white scales. These patches (plaques) generally begin as little red bumps that gradually grow larger and eventually develop scales, becoming itchy and irritated. Any part of the body can be affected, but the elbows, knees, groin, genitals, arms, legs, scalp, and nails are the most common sites. If the nails are affected, they will generally be pitted or thickened. Usually, the same place on both sides of the body will be affected. Other types of psoriasis are pustular psoriasis, erythrodermic psoriasis, guttate psoriasis, and inverse psoriasis (see Physical Exam).
Although the exact cause of psoriasis is unknown, heredity is a factor. About 30% of the individuals with psoriasis have a close family member who is also affected. Other risk factors include local injury or irritation, infection, hormonal changes, physical or emotional stress, sudden withdrawal of certain medications (steroids), use of certain medications (e.g., antimalarials, some antibiotics, drugs used to control blood pressure or pain), alcohol use, smoking, climate changes, and obesity.
Risk: Psoriasis may develop at any age and occurs in both children and adults. Most commonly, it is diagnosed between the ages of 15 and 35. Whites are more commonly affected than other races. Men and women are affected equally. Incidence and Prevalence: Psoriasis affects 2% to 2.6% of population in US, with over 150,000 new cases diagnosed each year ("Questions"). Psoriasis affects 1% to 3% of the world's population (Thornton 89). |
Source: Medical Disability Advisor
| History: The signs and symptoms of psoriasis will come and go, with varying degrees of severity. Most individuals have stable, slowly growing patches (plaques) of scaly, thickened skin. The patches may be itchy or sore. Attempts to remove the scales may cause pinpoint bleeding (Auspitz sign). Seven to ten percent of individuals will complain of joint stiffness (psoriatic arthritis). Some will report a history of skin injury 1 to 2 weeks prior to the development of the skin lesions. Some individuals will report a sore throat (generally associated with guttate psoriasis). In patients with erythrodermic psoriasis, chills and malaise may be present. Physical exam: Findings will vary depending on the form of psoriasis. Plaque psoriasis is the most common form, occurring in 90% of individuals, and is characterized by red, raised, thickened patches of skin, covered with silvery-white scales. Any part of the body may be affected, but the elbows, knees, groin, genitals, arms, legs, scalp, and nails are the most common sites. If nails are affected, they may be pitted or thickened and may also be only loosely attached to the nail bed. Hair loss in the affected area may be noted.
Pustular psoriasis will appear as pus-like blisters, which may be localized to the palms or soles.
Guttate psoriasis, usually in children and young adults, is characterized by small, drop-like, scaly spots. These spots occur all over the body but are most concentrated on the trunk.
Erythrodermic psoriasis is characterized by intense redness and swelling of large areas of the body. It is one of the most severe forms of psoriasis, and in many cases, patients will also present with chills, fever, and malaise.
Inverse psoriasis, seen mostly in older adults, involves smooth, red lesions in the folds of the skin, particularly beneath the breasts, on the groin, genitals, or buttocks, and in the armpits. Tests: The diagnosis is made based on the clinical presentation. If a certain diagnosis cannot be made from the history and physical exam, further testing would include a skin scraping examined under a microscope to check for other causes of the rash. If necessary, a skin biopsy will show the characteristic changes of psoriasis. Since 10% to 20% of the cases are associated with arthritis, blood tests for other diseases that can cause arthritis are usually done. |
Source: Medical Disability Advisor
| Currently, there is no cure for psoriasis. Treatment is directed at elimination of disease triggers when possible (e.g., stress reduction or removal, discontinuation of certain medications that are associated with either exacerbation or development of psoriasis) and control of symptoms. Treatment will vary depending on the individual's age, lifestyle, health, symptoms, and severity of disease. Frequent visits to the dermatologist's office may be necessary.
Patients with somewhat limited psoriasis (when disease is limited to <20% of the body) may be helped by exposure to sunlight or an ultraviolet lamp (actinotherapy). Patients may also benefit from daily baths (in warm water) and the use of emollient moisturizing creams and lotions afterwards to loosen scales and help control itching. In milder cases, medications to be applied to the skin also may be prescribed. Such medications include topical steroids, vitamin A derivatives, vitamin D analogs, coal tar, or keratolytics (e.g., salicylic acid, anthralin). In more involved cases, intralesional steroids, occlusive dressings or tape, and combination treatments of coal tar preparations with ultraviolet light, such as UVB (a treatment called the Goeckerman regimen) might be used.
In generalized psoriasis (>20% of the body is affected), topical therapy alone may not be enough. These patients would benefit from either phototherapy (UVB or PUVA) or systemic treatments (either oral or injectable medications). Treatment with PUVA can either be oral or topical. In oral PUVA treatment, patients take medications that sensitize the skin to the effects of sunlight (photosensitizers) by mouth before strong ultraviolet light (UVA) is directed at the lesions. When repeated 2 to 3 times a week, the psoriasis clears in 90% of the individuals within 2 months. In topical PUVA treatment, photosensitizers are applied as a topical preparation (e.g., cream, lotion) before a low dose of UVA is given.
In severe cases, oral psoriasis medication, prescription oral vitamin A-related drugs, or oral/injectable immunosuppressive agents may be prescribed.
Arthritis symptoms can be alleviated with medications that reduce inflammation (nonsteroidal anti-inflammatory medications) in milder cases and with a disease-modifying antirheumatic agent (etanercept) in more severe cases. |
Source: Medical Disability Advisor
| Psoriasis is considered a chronic condition, with no permanent cure. However, individual episodes can be relieved with appropriate treatment. While the signs and symptoms of psoriasis can be terribly bothersome and cosmetically unappealing, most cases of psoriasis do not represent serious medical conditions. The Goeckerman regimen, when used daily over a period of a month, can produce remissions of 1 year or longer. When oral PUVA treatment is repeated 2-3 times a week, the psoriasis clears in 90% of the individuals within 2 months. Out of all types of psoriasis, erythrodermic psoriasis, which is one of the more severe forms of this condition, can lead to a variety of complications involving the entire body and can be life-threatening, requiring hospitalization in some cases. |
Source: Medical Disability Advisor
| Psoriasis can be accompanied by painful swelling and stiffness of the joints (psoriatic arthritis), which occurs in 10% to 20% of patients with psoriasis (Thornton 89). |
Source: Medical Disability Advisor
| Work restrictions and accommodations will depend on the location and extent of the condition, the severity of symptoms, and the nature of the job. Lesions on limbs, knees, elbows, palms, or soles may prohibit certain types of work or limit an individual's ability to perform certain duties.
Individuals with psoriatic arthritis may have difficulty with tasks requiring flexibility and/or dexterity. If the job requires these types of tasks (such as professional musicians, typists, cashiers, bank tellers, etc.), a change in jobs may be required.
In mild cases, no long-term disability is expected, and patients usually self-administer treatment. In moderate-to-severe forms of psoriasis, when patients are treated with phototherapy, patients may not be able to work full-time, as they would need to go to their doctor's office 2 to 3 times a week to have the treatment administered. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Does individual have any risk factors (such as a family history of psoriasis, local injury or inflammation, stress, hormonal changes, alcohol use, smoking, use of medications associated with psoriasis exacerbation or development, or steroid use)?
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Did individual present with symptoms such as intermittent outbreaks of the red, scaly, thickened skin, particularly on the elbows, knees, groin, arms, legs, scalp, nails?
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Did the physical exam reveal red, scaly, or pustular lesions on the breasts, elbows, knees, groin, genitals, arms, legs, scalp, buttocks, or armpits?
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Was the diagnosis confirmed with a skin biopsy?
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Does the patient have limited (less than 20% of body affected) or generalized (greater than 20% of body affected) psoriasis?
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Did the diagnostic workup include blood tests to detect the associated finding of arthritis?
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If the diagnosis was uncertain, were other conditions with similar symptoms considered in the differential diagnosis?
Regarding treatment:
- Was the treatment selected appropriate for patient's severity of disease?
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If the disease was mild to moderate or limited, was the treatment with moisturizers and topical medications tried? If yes, and they have failed, was phototherapy tried? If yes, and phototherapy failed, were oral or injectable medications considered and tried?
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If the disease was moderate to severe, was treatment with phototherapy tried? If yes, and phototherapy failed, was treatment with oral antipsoriatics, vitamin A-related drugs, anti-cancer drugs, transplant medications, or immunosuppressive agents tried?
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Were symptoms of arthritic pain managed with NSAIDs?
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If psoriatic arthritis was severe, was the disease-modifying antirheumatic agent prescribed and administered?
Regarding prognosis:
- Have necessary work accommodations been made so individual can return to work safely?
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Has individual been compliant with treatment recommendations? If not, are physical restrictions impairing the ability to apply topical treatments?
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Does individual have any underlying conditions or associated complications that may affect recovery and prognosis?
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Does patient have any comorbid conditions that may hamper recovery?
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Did patient experience severe adverse effects from phototherapy or oral or injectable drug treatment?
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Source: Medical Disability Advisor
| "Questions and Answers About Psoriasis." National Institute of Arthritis and Musculoskeletal and Skin Diseases. National Institutes of Health (NIH). 1 Nov. 2004 <http://www.niams.nih.gov/hi/topics/psoriasis/psoriafs.htm#3>.Thornton, Angela. "Understanding Treatment Options for Psoriasis." U.S. Pharmacist 29 (2004): 89-98. |
Source: Medical Disability Advisor
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