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__NOTOC__
__NOTOC__
{{Psoriasis}}
{{Psoriasis}}
{{CMG}}
{{CMG}}; {{AE}} {{HK}}
 
==Overview==
Psoriasis can be classified according to clinical appearance, [[Morphology (biology)|morphology]], and localization. According to the International Psoriasis Council, psoriasis may be classified into four subtypes: plaque-type psoriasis, guttate psoriasis, generalized pustular psoriasis (GPP), and [[erythroderma]]. Several further subphenotypes have been named according to distribution (localized vs. widespread), [[anatomical]] localization (flexural or inverse, [[scalp]], [[Palms of the hands|palms]]/[[soles]]/nail), size (large vs. small) and thickness (thick vs. thin) of [[Plaque|plaques]], onset (early vs. late), and disease activity (active vs. stable).


==Classification==
==Classification==
Psoriasis is a chronic relapsing disease of the skin, which may be classified into nonpustular and [[pustule|pustular]] types as follows<ref name="Fitz2">Freedberg, et. al. (2003). ''Fitzpatrick's Dermatology in General Medicine''. (6th ed.). McGraw-Hill. ISBN 0071380760.</ref>:


*Nonpustular psoriasis
=== Classification based on clinical appearance, morphology, and localization ===
**[[Psoriasis vulgaris]] (Chronic stationary psoriasis, Plaque-like psoriasis)
*The International Psoriasis Council classifies psoriasis into four main forms, according to clinical appearance, [[Morphology (biology)|morphology]] and localization:<ref name="pmid2530253">{{cite journal |vauthors=Boyd AS, Menter A |title=Erythrodermic psoriasis. Precipitating factors, course, and prognosis in 50 patients |journal=J. Am. Acad. Dermatol. |volume=21 |issue=5 Pt 1 |pages=985–91 |year=1989 |pmid=2530253 |doi= |url=}}</ref><ref name="pmid12362257">{{cite journal |vauthors=Tauscher AE, Fleischer AB, Phelps KC, Feldman SR |title=Psoriasis and pregnancy |journal=J Cutan Med Surg |volume=6 |issue=6 |pages=561–70 |year=2002 |pmid=12362257 |doi=10.1177/120347540200600608 |url=}}</ref><ref name="pmid2878015">{{cite journal |vauthors=Abel EA, DiCicco LM, Orenberg EK, Fraki JE, Farber EM |title=Drugs in exacerbation of psoriasis |journal=J. Am. Acad. Dermatol. |volume=15 |issue=5 Pt 1 |pages=1007–22 |year=1986 |pmid=2878015 |doi= |url=}}</ref><ref name="pmid23971052">{{cite journal |vauthors=Skroza N, Proietti I, Pampena R, La Viola G, Bernardini N, Nicolucci F, Tolino E, Zuber S, Soccodato V, Potenza C |title=Correlations between psoriasis and inflammatory bowel diseases |journal=Biomed Res Int |volume=2013 |issue= |pages=983902 |year=2013 |pmid=23971052 |pmc=3736484 |doi=10.1155/2013/983902 |url=}}</ref><ref name="pmid22751586">{{cite journal |vauthors=Gelfand JM, Yeung H |title=Metabolic syndrome in patients with psoriatic disease |journal=J Rheumatol Suppl |volume=89 |issue= |pages=24–8 |year=2012 |pmid=22751586 |pmc=3670770 |doi=10.3899/jrheum.120237 |url=}}</ref><ref name="pmid23845151">{{cite journal |vauthors=Pouplard C, Brenaut E, Horreau C, Barnetche T, Misery L, Richard MA, Aractingi S, Aubin F, Cribier B, Joly P, Jullien D, Le Maître M, Ortonne JP, Paul C |title=Risk of cancer in psoriasis: a systematic review and meta-analysis of epidemiological studies |journal=J Eur Acad Dermatol Venereol |volume=27 Suppl 3 |issue= |pages=36–46 |year=2013 |pmid=23845151 |doi=10.1111/jdv.12165 |url=}}</ref> 
**[[Psoriatic erythroderma]] (Erythrodermic psoriasis)
**Plaque-type psoriasis
*Pustular psoriasis
**Guttate psoriasis
**[[Generalized pustular psoriasis]] (Pustular psoriasis of von Zumbusch)
**Generalized Pustular Psoriasis (GPP)
**[[Pustulosis palmaris et plantaris]] (Persistent palmoplantar pustulosis, Pustular psoriasis of the Barber type, Pustular psoriasis of the extremities)
**[[Erythroderma]]
**[[Annular pustular psoriasis]]
 
**[[Acrodermatitis continua]]
{| class="wikitable" font-size: 90%
**[[Impetigo herpetiformis]]
! align="center" style="background: #4479BA; color: #FFFFFF; " |Type of Psoriasis
! align="center" style="background: #4479BA; color: #FFFFFF; " |Typical Lesion
! align="center" style="background: #4479BA; color: #FFFFFF; " |Body Distribution
! align="center" style="background: #4479BA; color: #FFFFFF; " |Associated Conditions
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''Plaque-type psoriasis'''
|
* Oval or irregularly shaped
* [[Erythematous]]
* Sharply demarcated
* Raised [[plaques]] covered by silvery scales
|
* Large plaques  >3cm


Additional types of psoriasis include<ref name="Andrews">James, William; Berger, Timothy; Elston, Dirk (2005). ''Andrews' Diseases of the Skin: Clinical Dermatology''. (10th ed.). Saunders. ISBN 0721629210.</ref>{{rp|191-197}}:
* Small plaques <3cm
*[[Drug-induced psoriasis]]
*[[Inverse psoriasis]]
*[[Napkin psoriasis]]
*[[Seborrheic-like psoriasis]]


===Types of Psoriasis=== 
* [[Dorsal|Extensor]] surface of [[elbows]] and [[knees]]
The symptoms of psoriasis can manifest in a variety of forms. Variants include plaque, pustular, guttate and flexural psoriasis. This section describes each type.<ref>[http://web.ilds.org/icd10_list.php?VIEW=1&START_CODE=L40.0&START_EXT=00 "Application to dermatology of International Classification of Disease (ICD-10) - ICD sorted by code: L40.000 - L41.000"], The International League of Dermatological Societies</ref>
* [[Scalp]]
* [[Lower back]]
|
* [[Psoriatic arthritis]]
* [[Metabolic syndrome]]
* [[Inflammatory bowel disease]]
* [[Skin cancer|Non-melanoma skin cancer]]
Triggers include:
* Drugs including:
** [[Lithium]]
** [[Antimalarial drug|Antimalarials]]
** Withdrawal of [[systemic]] [[steroids]]
** [[Beta blockers]]
** [[Non-steroidal anti-inflammatory drug|Non-steroidal anti-inflammatory drugs]]([[NSAIDS]])
** [[ACE inhibitor|Angiotensin-converting enzyme (ACE) inhibitors]]
** [[Trazodone]]
** [[Terfenadine]]
** [[Gemfibrozil]]
** [[Antibiotics]] ([[tetracycline]], [[Penicillin VK|penicillin]])
** [[Imiquimod]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''Guttate psoriasis'''
|
* Multiple
* Small
* Drop-shaped
* Scaly [[plaques]]
|
* [[Trunk]]
* [[Upper extremities]]
* [[Thighs]]
|
* 2–4 weeks after a [[Bacterial|bacterial infection]] of the upper ways, notably [[streptococcal pharyngitis]] in children and adolescents
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''Generalized pustular psoriasis'''<ref name="pmid4236712">{{cite journal |vauthors=Baker H, Ryan TJ |title=Generalized pustular psoriasis. A clinical and epidemiological study of 104 cases |journal=Br. J. Dermatol. |volume=80 |issue=12 |pages=771–93 |year=1968 |pmid=4236712 |doi= |url= |issn=}}</ref>
|
* Four sub-[[types]]:
** Zumbusch
*** [[Erythema]], sheeted [[Pustular rash|pustulation]] and scarlatiniform peeling
** Annular
*** Gyrate and annular [[Pustular rash|pustular]] [[lesions]]
** Localized
*** Restricted areas of pustular psoriasis in and around ordinary psoriatic [[plaques]]
** Exanthematic
*** Single short-lived episode following [[infection]] or [[drug]] exposure


* [[Plaque]] psoriasis (psoriasis vulgaris) (L40.0) is the most common form of psoriasis. It affects 80 to 90% of people with psoriasis. [[Plaque]] psoriasis typically appears as raised areas of inflamed skin covered with silvery white scaly skin. These areas are called plaques.
* Episodic, widespread [[skin]] and systemic [[inflammation]]
* Sheeted, pinhead-sized, [[sterile]], sub-corneal [[pustules]]
|
* Generalized
|
* High [[fever]]
* [[Fatigue]]
* [[Leukocytosis]]


* Flexural psoriasis (inverse psoriasis) (L40.83-4) appears as smooth inflamed patches of skin. It occurs in [[skin fold]]s, particularly around the genitals (between the thigh and groin), the armpits, under an overweight stomach ([[pannus]]), and under the [[breasts]] ([[inframammary fold]]). It is aggravated by friction and sweat, and is vulnerable to fungal infections.
* Triggers include:
**[[Pregnancy]]
**[[Infection]]
**Exposure to or withdrawal from drugs
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''Erythrodermic psoriasis (most severe)'''
|
* Diffuse [[erythema]]
|
* >70 % of the body surface area
|
* [[Hypothermia]]
* Extremity [[edema]]
* [[Myalgias]]
* [[Fatigue]]
* [[Fever|High grade fever]]
|}


* Guttate psoriasis (L40.4) is characterized by numerous small oval (teardrop-shaped) spots. These numerous spots of psoriasis appear over large areas of the body, such as the trunk, limbs, and [[scalp]]. Guttate psoriasis is associated with [[Strep throat|streptococcal throat]] infection.
=== Classification based on sub-phenotypes ===
Several further sub-phenotypes have been named according to:
* Distribution (localized vs. widespread)
* Anatomical localization (flexural or inverse, scalp, palms/soles/nail)
* Size (large vs. small)
* Thickness (thick vs. thin) of [[Plaque|plaques]]
* Onset (early vs. late)
* Disease activity (active vs. stable)
===Classification based on disease severity===
<figure-inline><figure-inline>[[Image:Psoriasis severity.jpg|500x500px]]</figure-inline></figure-inline>


* Pustular psoriasis (L40.1-3, L40.82) appears as raised bumps that are filled with non-infectious [[pus]] ([[pustules]]). The skin under and surrounding pustules is red and tender. Pustular psoriasis can be localised, commonly to the hands and feet (palmoplantar pustulosis), or generalised with widespread patches occurring randomly on any part of the body.
Psoriasis is usually graded as:
* Mild (affecting less than 3% of the body)  
* Moderate (affecting 3-10% of the body)
* Severe (affecting >10% of the body)


* Nail psoriasis (L40.86) produces a variety of changes in the appearance of finger and toe nails. These changes include discolouring under the nail plate, pitting of the nails, lines going across the nails, thickening of the skin under the nail, and the loosening (onycholysis) and crumbling of the nail.
==== Degree of severity ====
The degree of severity is generally judged based on the following factors:
*The proportion of body surface area affected
*Disease activity (degree of plaque redness, thickness, and scaling)  
*Response to previous therapies
*The impact of the disease on the patient's quality of life
====Psoriasis Area Severity Index (PASI)====
The Psoriasis Area Severity Index (PASI) is the most widely used measurement tool for psoriasis. PASI combines the assessment of the severity of [[lesions]] and the area affected into a single score ranging between 0 (no disease) to 72 (maximal disease).<ref>{{cite web |url=http://www.skinandaging.com/article/5394 |title=Psoriasis Update -Skin & Aging |accessdate=2007-07-28 |format= |work=}}</ref> The PASI can be very difficult to use outside of trials, which has led to attempts to simplify the index for clinical use.<ref name="pmid15530297">{{cite journal |author=Louden BA, Pearce DJ, Lang W, Feldman SR |title=A Simplified Psoriasis Area Severity Index (SPASI) for rating psoriasis severity in clinic patients |journal=Dermatol. Online J. |volume=10 |issue=2 |pages=7 |year=2004 |pmid=15530297 |doi=}}</ref>


* [[Psoriatic arthritis]] (L40.5) involves joint and [[connective tissue]] [[inflammation]]. Psoriatic arthritis can affect any joint but is most common in the joints of the fingers and toes. This can result in a sausage-shaped swelling of the fingers and toes known as [[dactylitis]]. Psoriatic arthritis can also affect the hips, knees and spine ([[spondylitis]]). About 10-15% of people who have psoriasis also have psoriatic arthritis.
=== Other types of psoriasis ===
*'''[[Ventral|Flexural]] psoriasis:'''
**Smooth, [[inflamed]] patches of [[skin]]
**Occurs in [[skin fold]]s, particularly around the [[genitals]] (between the [[thigh]] and [[groin]]), [[axillae]], under an overweight [[stomach]] ([[pannus]]), and under the [[breasts]] ([[inframammary fold]])
**Aggravated by [[friction]] and [[sweat]] and is vulnerable to [[fungal]] [[infections]]
*'''Nail psoriasis:'''
**Changes in the appearance of [[finger]] and [[toe]] nails:
**Discoloration under the nail plate, pitting of the nails, lines going across the nails, thickening of the [[skin]] under the nail, and the loosening ([[onycholysis]]) or crumbling of the nail
*'''Drug-induced psoriasis'''


* Erythrodermic psoriasis (L40.85) involves the widespread inflammation and exfoliation of the skin over most of the body surface. It may be accompanied by severe itching, swelling and pain. It is often the result of an exacerbation of unstable plaque psoriasis, particularly following the abrupt withdrawal of systemic treatment. This form of psoriasis can be fatal, as the extreme inflammation and exfoliation disrupt the body's ability to regulate temperature and for the skin to perform barrier functions.
*'''Napkin psoriasis'''
*'''Seborrheic-like psoriasis'''
*'''Pustular psoriasis'''


<div align="left"><ref>http://picasaweb.google.com/mcmumbi/USMLEIIImages/</ref>
=== Classification of psoriatic arthritis ===
<gallery heights="175" widths="175">
Psoriatic arthritis may be classified based on severity into the following types:<ref name="urlPsoriasis: Recommendations for broadband and narrowband UVB therapy | American Academy of Dermatology">{{cite web |url=https://www.aad.org/practicecenter/quality/clinical-guidelines/psoriasis/phototherapy-and-photochemotherapy/uvb-therapy |title=Psoriasis: Recommendations for broadband and narrowband UVB therapy &#124; American Academy of Dermatology |format= |work= |accessdate=}}</ref>
Image:Psoriasis.jpg|Photograph of an arm covered with plaque psoriasis.
* Mild psoriatic arthritis
Image:Psoriasis nail pitting.jpg|Psoriasis nail pitting
* Moderate psoriatic arthritis
</gallery>
* Severe psoriatic arthritis
</div>
{| class="wikitable" font-size: 90%
! align="center" style="background: #4479BA; color: #FFFFFF; " |Type of psoriatic arthritis
! align="center" style="background: #4479BA; color: #FFFFFF; " |Response to therapy
! align="center" style="background: #4479BA; color: #FFFFFF; " |Quality of life
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''Mild psoriatic arthritis'''
|[[Non-steroidal anti-inflammatory drug|NSAIDs]]
|Minimal
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''Moderate psoriatic arthritis'''
|Requires [[DMARDs|disease modifying anti-rheumatic drugs]] ([[Disease-modifying antirheumatic drug|DMARD]]) '''or''' [[Tumour necrosis factor|tumor necrosis factor]] blockers  ([[Tumor necrosis factors|TNF-blockers]])
|Daily life tasks affected including mental and physical tasks/ No response to [[Non-steroidal anti-inflammatory drug|NSAIDs]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''Severe psoriatic arthritis'''
|Requires [[DMARDs|disease modifying anti-rheumatic drugs]] ([[DMARDs|DMARD]]) '''plus''' [[Tumour necrosis factor|tumor necrosis factor]] blockers ([[TNF inhibitor|TNF-blockers]]) '''or''' biologic agents
|Unable to perform major daily tasks of living without pain or dysfunction; large impact on physical and mental functions
|}


===Severity===
Psoriatic arthritis also, may be classified into different subtypes as below table:  
[[Image:Psoriasis severity.jpg|thumb|150px|left|Pie chart showing the distribution of severity among people with psoriasis.]]
Psoriasis is usually graded as mild (affecting less than 3% of the body), moderate (affecting 3-10% of the body) or severe. Several scales exist for measuring the severity of psoriasis.


The degree of severity is generally based on the following factors: the proportion of body surface area affected; disease activity (degree of plaque redness, thickness and scaling); response to previous therapies; and the impact of the disease on the person.
{| class="wikitable"
! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" + |Subtype
! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" + |Disease pattern<ref name="pmid158990443">{{cite journal |vauthors=Kruithof E, Baeten D, De Rycke L, Vandooren B, Foell D, Roth J, Cañete JD, Boots AM, Veys EM, De Keyser F |title=Synovial histopathology of psoriatic arthritis, both oligo- and polyarticular, resembles spondyloarthropathy more than it does rheumatoid arthritis |journal=Arthritis Res. Ther. |volume=7 |issue=3 |pages=R569–80 |year=2005 |pmid=15899044 |pmc=1174942 |doi=10.1186/ar1698 |url=}}</ref>
! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" + |Percentage of patients affected
! colspan="4" align="center" style="background:#4479BA; color: #FFFFFF;" + |Radiological features<ref name="urlPsoriatic Arthritis Mutilans: Clinical and Radiographic Criteria. A Systematic Review | The Journal of Rheumatology">{{cite web |url=http://www.jrheum.org/content/42/8/1432.long |title=Psoriatic Arthritis Mutilans: Clinical and Radiographic Criteria. A Systematic Review &#124; The Journal of Rheumatology |format= |work= |accessdate=}}</ref>
! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" + |Histopathological features<ref name="pmid15899044">{{cite journal |vauthors=Kruithof E, Baeten D, De Rycke L, Vandooren B, Foell D, Roth J, Cañete JD, Boots AM, Veys EM, De Keyser F |title=Synovial histopathology of psoriatic arthritis, both oligo- and polyarticular, resembles spondyloarthropathy more than it does rheumatoid arthritis |journal=Arthritis Res. Ther. |volume=7 |issue=3 |pages=R569–80 |year=2005 |pmid=15899044 |pmc=1174942 |doi=10.1186/ar1698 |url=}}</ref><ref name="pmid11592363">{{cite journal |vauthors=Fraser A, Fearon U, Reece R, Emery P, Veale DJ |title=Matrix metalloproteinase 9, apoptosis, and vascular morphology in early arthritis |journal=Arthritis Rheum. |volume=44 |issue=9 |pages=2024–8 |year=2001 |pmid=11592363 |doi=10.1002/1529-0131(200109)44:9<2024::AID-ART351>3.0.CO;2-K |url=}}</ref><ref name="pmid12563678">{{cite journal |vauthors=Fearon U, Griosios K, Fraser A, Reece R, Emery P, Jones PF, Veale DJ |title=Angiopoietins, growth factors, and vascular morphology in early arthritis |journal=J. Rheumatol. |volume=30 |issue=2 |pages=260–8 |year=2003 |pmid=12563678 |doi= |url=}}</ref>
|-
! style="background:#4479BA; color: #FFFFFF;" + |X-ray
! style="background:#4479BA; color: #FFFFFF;" + |Ultrasonography
! style="background:#4479BA; color: #FFFFFF;" + |<nowiki>Computed tomography|CT scan</nowiki>
! style="background:#4479BA; color: #FFFFFF;" + |MRI
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''Classical psoriatic arthritis'''
|
* Involvement of the [[distal interphalangeal joints]]
* Involvement of [[Nail (anatomy)|nails]]
|~5 %
| rowspan="5" |
* Bony [[proliferation]]
* Bone erosion
* "Pencil-in-cup" [[deformity]] (distal head of a bone becomes pointed-like a sharpened pencil, and the neighboring surface becomes rounded due to erosion)
| rowspan="5" |
* [[Synovitis]]
* [[Tenosynovitis]]
* Peritendinitis
* [[Retrocalcaneal bursitis|Retrocalcaneal]] or pre-Achilles bursitis
| rowspan="5" |
* Useful in assessing [[spine]] disease
* [[Joint (anatomy)|Joint]] erosions
* [[Synovitis]]
| rowspan="5" |
* [[Synovitis]] (usually secondary to extrasynovial involvement - helps to differentiate PsA from [[rheumatoid arthritis]])
* [[Gadolinium|Gadolinium contrast]] use can more reliably differentiate PsA from [[rheumatoid arthritis]] by relative enhancement and rate of enhancement on [[MRI]]
* [[Enthesitis]]
* [[Osteitis]]
| rowspan="5" |
* [[Neovascularization]]
* [[Inflammatory cells|Inflammatory]] infiltration with predominantly [[mononuclear cells]] ([[T lymphocytes]], [[B lymphocytes]] and [[Plasma cell|plasma cells]], and [[macrophages]])
* [[Synovial]] lining [[hyperplasia]] 
* High expression of [[E-selectin]]
* [[Synovial]] expression of [[S100A12]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" | '''Destructive psoriatic arthritis (arthritis mutilans)'''
|
* Severe [[joint]] destruction


The Psoriasis Area Severity Index (PASI) is the most widely used measurement tool for psoriasis. PASI combines the assessment of the severity of lesions and the area affected into a single score in the range 0 (no disease) to 72 (maximal disease).<ref>{{cite web |url=http://www.skinandaging.com/article/5394 |title=Psoriasis Update -Skin & Aging |accessdate=2007-07-28 |format= |work=}}</ref>
* Involvement of any of the [[Interphalangeal joints|interphalangeal]], [[Metacarpophalangeal joint|metacarpophalangeal]], or [[Metatarsophalangeal joint|metatarsophalangeal]] [[joints]]
* [[Dactylitis]]
* [[Enthesitis]]
* Involvement of [[axial skeleton]]
* Involvement of [[Nail (anatomy)|nails]]
* Digital tapering (opera glass hands)  
* [[Joint]] [[ankylosis]]
|< 5 %
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" | '''Symmetric polyarthritis'''
|
* Involvement of [[joints]] on both sides of the body simultaneously
* Most similar to [[rheumatoid arthritis]] 
|~15 %
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" | '''Asymmetric psoriatic arthritis'''
|
* Involvement of < 3 [[joints]]


Nevertheless, the PASI can be too unwieldy to use outside of trials, which has led to attempts to simplify the index for clinical use.<ref name="pmid15530297">{{cite journal |author=Louden BA, Pearce DJ, Lang W, Feldman SR |title=A Simplified Psoriasis Area Severity Index (SPASI) for rating psoriasis severity in clinic patients |journal=Dermatol. Online J. |volume=10 |issue=2 |pages=7 |year=2004 |pmid=15530297 |doi=}}</ref>
* Does not occur in the same [[joints]] on both sides of the body
|~70 %
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" | '''Ankylosing spondylitis-like psoriatic arthritis'''
|
* Stiffness of the [[spine]] or neck, but can also affect the hands and feet, in a similar fashion to symmetric arthritis
|~ 5 %
|}


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
{{WH}}
{{WS}}


[[Category:Primary care]]
[[Category:Dermatology]]
[[Category:Dermatology]]
[[Category:Needs overview]]
{{WH}}
{{WS}}

Latest revision as of 23:52, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2]

Overview

Psoriasis can be classified according to clinical appearance, morphology, and localization. According to the International Psoriasis Council, psoriasis may be classified into four subtypes: plaque-type psoriasis, guttate psoriasis, generalized pustular psoriasis (GPP), and erythroderma. Several further subphenotypes have been named according to distribution (localized vs. widespread), anatomical localization (flexural or inverse, scalp, palms/soles/nail), size (large vs. small) and thickness (thick vs. thin) of plaques, onset (early vs. late), and disease activity (active vs. stable).

Classification

Classification based on clinical appearance, morphology, and localization

  • The International Psoriasis Council classifies psoriasis into four main forms, according to clinical appearance, morphology and localization:[1][2][3][4][5][6]
    • Plaque-type psoriasis
    • Guttate psoriasis
    • Generalized Pustular Psoriasis (GPP)
    • Erythroderma
Type of Psoriasis Typical Lesion Body Distribution Associated Conditions
Plaque-type psoriasis
  • Oval or irregularly shaped
  • Erythematous
  • Sharply demarcated
  • Raised plaques covered by silvery scales
  • Large plaques >3cm
  • Small plaques <3cm

Triggers include:

Guttate psoriasis
  • Multiple
  • Small
  • Drop-shaped
  • Scaly plaques
Generalized pustular psoriasis[7]
  • Generalized
Erythrodermic psoriasis (most severe)
  • >70 % of the body surface area

Classification based on sub-phenotypes

Several further sub-phenotypes have been named according to:

  • Distribution (localized vs. widespread)
  • Anatomical localization (flexural or inverse, scalp, palms/soles/nail)
  • Size (large vs. small)
  • Thickness (thick vs. thin) of plaques
  • Onset (early vs. late)
  • Disease activity (active vs. stable)

Classification based on disease severity

<figure-inline><figure-inline></figure-inline></figure-inline>

Psoriasis is usually graded as:

  • Mild (affecting less than 3% of the body)
  • Moderate (affecting 3-10% of the body)
  • Severe (affecting >10% of the body)

Degree of severity

The degree of severity is generally judged based on the following factors:

  • The proportion of body surface area affected
  • Disease activity (degree of plaque redness, thickness, and scaling)
  • Response to previous therapies
  • The impact of the disease on the patient's quality of life

Psoriasis Area Severity Index (PASI)

The Psoriasis Area Severity Index (PASI) is the most widely used measurement tool for psoriasis. PASI combines the assessment of the severity of lesions and the area affected into a single score ranging between 0 (no disease) to 72 (maximal disease).[8] The PASI can be very difficult to use outside of trials, which has led to attempts to simplify the index for clinical use.[9]

Other types of psoriasis

  • Napkin psoriasis
  • Seborrheic-like psoriasis
  • Pustular psoriasis

Classification of psoriatic arthritis

Psoriatic arthritis may be classified based on severity into the following types:[10]

  • Mild psoriatic arthritis
  • Moderate psoriatic arthritis
  • Severe psoriatic arthritis
Type of psoriatic arthritis Response to therapy Quality of life
Mild psoriatic arthritis NSAIDs Minimal
Moderate psoriatic arthritis Requires disease modifying anti-rheumatic drugs (DMARD) or tumor necrosis factor blockers (TNF-blockers) Daily life tasks affected including mental and physical tasks/ No response to NSAIDs
Severe psoriatic arthritis Requires disease modifying anti-rheumatic drugs (DMARD) plus tumor necrosis factor blockers (TNF-blockers) or biologic agents Unable to perform major daily tasks of living without pain or dysfunction; large impact on physical and mental functions

Psoriatic arthritis also, may be classified into different subtypes as below table:

Subtype Disease pattern[11] Percentage of patients affected Radiological features[12] Histopathological features[13][14][15]
X-ray Ultrasonography Computed tomography|CT scan MRI
Classical psoriatic arthritis ~5 %
  • Bony proliferation
  • Bone erosion
  • "Pencil-in-cup" deformity (distal head of a bone becomes pointed-like a sharpened pencil, and the neighboring surface becomes rounded due to erosion)
Destructive psoriatic arthritis (arthritis mutilans) < 5 %
Symmetric polyarthritis ~15 %
Asymmetric psoriatic arthritis
  • Does not occur in the same joints on both sides of the body
 ~70 %
Ankylosing spondylitis-like psoriatic arthritis
  • Stiffness of the spine or neck, but can also affect the hands and feet, in a similar fashion to symmetric arthritis
 ~ 5 %

References

  1. ↑ Boyd AS, Menter A (1989). "Erythrodermic psoriasis. Precipitating factors, course, and prognosis in 50 patients". J. Am. Acad. Dermatol. 21 (5 Pt 1): 985–91. PMID 2530253.
  2. ↑ Tauscher AE, Fleischer AB, Phelps KC, Feldman SR (2002). "Psoriasis and pregnancy". J Cutan Med Surg. 6 (6): 561–70. doi:10.1177/120347540200600608. PMID 12362257.
  3. ↑ Abel EA, DiCicco LM, Orenberg EK, Fraki JE, Farber EM (1986). "Drugs in exacerbation of psoriasis". J. Am. Acad. Dermatol. 15 (5 Pt 1): 1007–22. PMID 2878015.
  4. ↑ Skroza N, Proietti I, Pampena R, La Viola G, Bernardini N, Nicolucci F, Tolino E, Zuber S, Soccodato V, Potenza C (2013). "Correlations between psoriasis and inflammatory bowel diseases". Biomed Res Int. 2013: 983902. doi:10.1155/2013/983902. PMC 3736484. PMID 23971052.
  5. ↑ Gelfand JM, Yeung H (2012). "Metabolic syndrome in patients with psoriatic disease". J Rheumatol Suppl. 89: 24–8. doi:10.3899/jrheum.120237. PMC 3670770. PMID 22751586.
  6. ↑ Pouplard C, Brenaut E, Horreau C, Barnetche T, Misery L, Richard MA, Aractingi S, Aubin F, Cribier B, Joly P, Jullien D, Le Maître M, Ortonne JP, Paul C (2013). "Risk of cancer in psoriasis: a systematic review and meta-analysis of epidemiological studies". J Eur Acad Dermatol Venereol. 27 Suppl 3: 36–46. doi:10.1111/jdv.12165. PMID 23845151.
  7. ↑ Baker H, Ryan TJ (1968). "Generalized pustular psoriasis. A clinical and epidemiological study of 104 cases". Br. J. Dermatol. 80 (12): 771–93. PMID 4236712.
  8. ↑ "Psoriasis Update -Skin & Aging". Retrieved 2007-07-28.
  9. ↑ Louden BA, Pearce DJ, Lang W, Feldman SR (2004). "A Simplified Psoriasis Area Severity Index (SPASI) for rating psoriasis severity in clinic patients". Dermatol. Online J. 10 (2): 7. PMID 15530297.
  10. ↑ "Psoriasis: Recommendations for broadband and narrowband UVB therapy | American Academy of Dermatology".
  11. ↑ Kruithof E, Baeten D, De Rycke L, Vandooren B, Foell D, Roth J, Cañete JD, Boots AM, Veys EM, De Keyser F (2005). "Synovial histopathology of psoriatic arthritis, both oligo- and polyarticular, resembles spondyloarthropathy more than it does rheumatoid arthritis". Arthritis Res. Ther. 7 (3): R569–80. doi:10.1186/ar1698. PMC 1174942. PMID 15899044.
  12. ↑ "Psoriatic Arthritis Mutilans: Clinical and Radiographic Criteria. A Systematic Review | The Journal of Rheumatology".
  13. ↑ Kruithof E, Baeten D, De Rycke L, Vandooren B, Foell D, Roth J, Cañete JD, Boots AM, Veys EM, De Keyser F (2005). "Synovial histopathology of psoriatic arthritis, both oligo- and polyarticular, resembles spondyloarthropathy more than it does rheumatoid arthritis". Arthritis Res. Ther. 7 (3): R569–80. doi:10.1186/ar1698. PMC 1174942. PMID 15899044.
  14. ↑ Fraser A, Fearon U, Reece R, Emery P, Veale DJ (2001). "Matrix metalloproteinase 9, apoptosis, and vascular morphology in early arthritis". Arthritis Rheum. 44 (9): 2024–8. doi:10.1002/1529-0131(200109)44:9<2024::AID-ART351>3.0.CO;2-K. PMID 11592363.
  15. ↑ Fearon U, Griosios K, Fraser A, Reece R, Emery P, Jones PF, Veale DJ (2003). "Angiopoietins, growth factors, and vascular morphology in early arthritis". J. Rheumatol. 30 (2): 260–8. PMID 12563678.

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