Differentiating psoriasis from other diseases

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Differentiating Psoriasis from other Diseases

  • Psoriasis must be differentiated from other diseases causing papulosquamous or erythematosquamous rash especially when the psoriatic lesions are localized in particular sites for example, palms, soles, scalp, body folds, penis and nails.
  • The differentials include:
    • Cutaneous T cell lymphoma/mycosis fungoides
    • Pityriasis rosea
    • Pityriasis rubra pilaris
    • Pityriasis lichenoides chronica
    • Nummular dermatitis
    • Secondary syphilis
    • Bowen’s disease
    • Exanthematous pustulosis
    • Hypertrophic lichen planus
    • Sneddon–Wilkinson disease
    • Small plaque parapsoriasis
    • Intertrigo
    • Langerhans cell histiocytosis
    • Dyshidrotic dermatitis
    • Tinea manuum/pedum/capitis
    • Seborrheic dermatitis
Disease Rash Characteristics Signs and Symptoms Associated Conditions
Cutaneous T cell lymphoma/Mycosis fungoides[1]
    • Premycotic phase: A scaly, red rash in areas of the body that usually are not exposed to the sun. This rash does not cause symptoms and may last for months or years.
    • Patch phase: Thin, reddened, eczema -like rash.
    • Plaque phase: Small raised bumps (papules) or hardened lesions on the skin, which may be reddened.
    • Tumor phase: Tumors form on the skin. These tumors may develop ulcers and the skin may get infected.
  • Generalized itching (pruritus)
  • Pain in the affected area of the skin.
  • Insomnia
  • Red (erythematous) patches scattered over the skin of the trunk and the extremities
  • Tumor-like lobulated outgrowths form on the skin in the latter part of the disease
  • Weight loss
  • Lymphadenopathy
  • Malaise and fatigue
  • Anemia
  • May progress to Sezary syndrome (Skin involvement plus hematogenous dissemination)
  • Sezary syndrome
Pityriasis rosea[2]
  • Pink or salmon in colour, which may be scaly, termed as "herald patch"
  • Oval in shape
  • Long axis oriented along the clevage lines
  • Distributed on the trunk and proximal extremities
  • Squamous marginal collarette and a “fir-tree” or “Christmas tree” distribution on the posterior trunk
  • Develops after viral infection
  • Resolves spontaneously after 6-8 weeks
  • Preceded by a prodrome of:
    • Sore throat
    • Gastrointestinal disturbance
    • Fever
    • Arthralgia
  • Infection by any of the following:[3]
    • HHV-6
    • HHV-7
    • HHV-8
Pityriasis lichenoides chronica
  • Recurrent lesions are usually less evenly scattered than psoriasis
  • Brownish red or orange-brown color
  • Lesions are capped by a single detachable opaque mica-like scale
  • Often leave hypopigmented macules
  • High fever
  • Malaise
  • Myalgias
  • Skin burning
  • Pruritis
  • Infection by any of the following:[4]
    • Epstein-Barr virus (EBV)
    • Toxoplasma gondii
    • Human immunodeficiency virus (HIV)
Nummular dermatitis[5]
  • Multiple coinshaped eczematous lesions
  • Commonly affecting the extremities (lower>upper) and trunk
  • May ooze fluid and become dry and crusty
  • Often appears after a skin injury, such as a burn, abrasion (from friction), or insect bite
  • Lesions commonly relapse after occasional remission or may persist for long periods
  • Pruritis
  • Associated with:
    • Dry skin
    • Emotional stress
    • Allergens(rubber chemicals, formaldehyde, neomycin, chrome, mercury and nickel)
    • Staphylococcus infection
    • Seasonal variation
    • Alcohol
    • Drugs
    • Atopy
Secondary syphilis[6]
  • Round coppery red color lesions on palms and soles
  • Papules with collarette of scales
  • Fever
  • Generalized lymphadenpathy
  • Sore throat
  • Patchy hair loss
  • Headaches
  • Weight loss
  • Myalgia
  • Fatigue
  • Associated with:
    • Condylomata lata
    • Corona verinata
    • Positive VDRL test
Bowen’s disease[7]
  • Erythematous little scaly plaque, which enlarges over time in an erratic manner
  • Scale is usually yellow or white and it is easily detachable without producing any bleeding
  • Well defined margins
  • Pruritis
  • Pain
  • Bleeding lesions
  • Associated with:[8]
    • Erythroplasia of Queyrat (Bowen's disease of the penis)
    • Squamous cell carcinoma
    • Solar radiation and ultraviolet (UV) exposure
    • Radiotherapy
    • Immunosuppression
    • Arsenic exposure
    • Human papilloma virus (HPV) type 16
    • Merkel cell polyomavirus
    • Sjögren’s syndrome
Exanthematous pustulosis[9]
  • Numerous small, primarily non-follicular, sterile pustules, arising within large areas of edematous erythema
  • Fever
  • Leukocytosis
  • Intracorneal, subcorneal, and/or intraepidermal pustules with papillary dermal edema containing neutrophils and eosinophils
  • Associated with:[10]
    • Antibiotics(penicillins, sulfonamides, tetracyclines)
    • Carbamazepine
    • Calcium channel blockers(Diltiazem)
    • Hydroxychloroquine

References

  1. ↑ "Mycosis Fungoides and the Sézary Syndrome Treatment (PDQ®)—Patient Version - National Cancer Institute".
  2. ↑ Mahajan K, Relhan V, Relhan AK, Garg VK (2016). "Pityriasis Rosea: An Update on Etiopathogenesis and Management of Difficult Aspects". Indian J Dermatol. 61 (4): 375–84. doi:10.4103/0019-5154.185699. PMC 4966395. PMID 27512182.
  3. ↑ Prantsidis A, Rigopoulos D, Papatheodorou G, Menounos P, Gregoriou S, Alexiou-Mousatou I, Katsambas A (2009). "Detection of human herpesvirus 8 in the skin of patients with pityriasis rosea". Acta Derm. Venereol. 89 (6): 604–6. doi:10.2340/00015555-0703. PMID 19997691.
  4. ↑ Smith KJ, Nelson A, Skelton H, Yeager J, Wagner KF (1997). "Pityriasis lichenoides et varioliformis acuta in HIV-1+ patients: a marker of early stage disease. The Military Medical Consortium for the Advancement of Retroviral Research (MMCARR)". Int. J. Dermatol. 36 (2): 104–9. PMID 9109005.
  5. ↑ Jiamton S, Tangjaturonrusamee C, Kulthanan K (2013). "Clinical features and aggravating factors in nummular eczema in Thais". Asian Pac. J. Allergy Immunol. 31 (1): 36–42. PMID 23517392.
  6. ↑ "STD Facts - Syphilis".
  7. ↑ Neagu TP, Ţigliş M, Botezatu D, Enache V, Cobilinschi CO, Vâlcea-Precup MS, GrinŢescu IM (2017). "Clinical, histological and therapeutic features of Bowen's disease". Rom J Morphol Embryol. 58 (1): 33–40. PMID 28523295.
  8. ↑ Murao K, Yoshioka R, Kubo Y (2014). "Human papillomavirus infection in Bowen disease: negative p53 expression, not p16(INK4a) overexpression, is correlated with human papillomavirus-associated Bowen disease". J. Dermatol. 41 (10): 878–84. doi:10.1111/1346-8138.12613. PMID 25201325.
  9. ↑ Szatkowski J, Schwartz RA (2015). "Acute generalized exanthematous pustulosis (AGEP): A review and update". J. Am. Acad. Dermatol. 73 (5): 843–8. doi:10.1016/j.jaad.2015.07.017. PMID 26354880.
  10. ↑ Schmid S, Kuechler PC, Britschgi M, Steiner UC, Yawalkar N, Limat A, Baltensperger K, Braathen L, Pichler WJ (2002). "Acute generalized exanthematous pustulosis: role of cytotoxic T cells in pustule formation". Am. J. Pathol. 161 (6): 2079–86. doi:10.1016/S0002-9440(10)64486-0. PMC 1850901. PMID 12466124.

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