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Emergency And Acute Medicine – Psoriasis
Psoriasis is a chronic, noncontagious, inflammatory skin disorder characterized by hyperproliferation of keratinocytes and immune dysregulation. It is now considered an autoimmune-mediated disease. Clinically, it presents with well-demarcated erythematous plaques covered by silvery scale, most commonly affecting the extensor surfaces of the elbows and knees, scalp, lumbar region, gluteal cleft, and glans penis. The course is unpredictable, with periods of remission and exacerbation. Up to one-third of patients develop psoriatic arthritis, and approximately 10% have ocular involvement. Psoriasis is associated with metabolic syndrome and occurs more commonly in Caucasians. There are two incidence peaks, between ages 20–30 and 50–60, and it affects about 2.2% of the U.S. population. Although rarely fatal, severe disease and treatment-related complications account for a small number of deaths annually.
Several clinical variants exist. Plaque psoriasis (psoriasis vulgaris) is the most common form and presents with raised, erythematous plaques with silvery scale. Guttate psoriasis presents abruptly with small, salmon-colored, drop-like papules, often following streptococcal pharyngitis and frequently resolving spontaneously. Pustular psoriasis may be localized to palms and soles or generalized, with sheets of sterile pustules, systemic symptoms, and potentially life-threatening complications requiring inpatient management. Erythrodermic psoriasis presents with generalized erythema, fine scaling, pruritus, and increased risk of infection and dehydration. Nail involvement, including pitting and onycholysis, occurs in up to 50% of patients. Inverse psoriasis affects flexural areas without prominent scaling. HIV-associated psoriasis may be severe and can be an early manifestation of AIDS. A strong genetic predisposition exists, with 40% of patients reporting a first-degree relative with the disease.
Pathophysiology involves epidermal stem cell proliferation, shortened keratinocyte cell cycles, inflammatory infiltrates, and vascular changes. Common triggers include medications such as lithium, beta-blockers, antimalarials, NSAIDs, and steroid withdrawal; infections such as streptococcal pharyngitis and HIV; skin trauma (Koebner phenomenon); emotional stress; winter weather; smoking; and elevated body mass index.
Diagnosis is clinical. Patients often report long-standing scaly erythematous lesions, mild pruritus, family history, and improvement with sun exposure. The classic lesion is a sharply demarcated red plaque with overlying silvery scale on extensor surfaces. The Auspitz sign—pinpoint bleeding after scale removal—may be present. Lesions may appear gray in darker skin tones. Scalp lesions extending beyond the hairline suggest psoriasis rather than seborrheic dermatitis. Nail pitting and onycholysis are common. Psoriatic arthritis frequently involves the distal interphalangeal joints and may present with asymmetric oligoarthritis or dactylitis (“sausage digits”). Biopsy is rarely necessary.
Laboratory studies are not required to confirm diagnosis but may assist in evaluating severe disease. Erythrodermic and pustular forms may show elevated inflammatory markers. Guttate psoriasis may be associated with positive streptococcal titers. Psoriatic arthritis is typically rheumatoid factor negative. Imaging may demonstrate erosive changes, sacroiliitis, or features of ankylosing spondylitis.
Emergency management focuses on stabilization in severe cases and patient education. Acute erythrodermic and generalized pustular psoriasis require admission for fluid and electrolyte management, infection surveillance, and systemic therapy in consultation with dermatology. Systemic corticosteroids are generally avoided due to risk of rebound and severe flare. In less severe cases, treatment in the emergency setting typically involves topical therapy. Emollients are beneficial for limited plaque disease. Topical corticosteroids are first-line therapy for mild to moderate psoriasis and may be used alone or in combination with other agents. Vitamin D analogs such as calcipotriene, topical retinoids such as tazarotene (contraindicated in pregnancy), coal tar preparations, salicylic acid, and topical calcineurin inhibitors for inverse or facial psoriasis are additional options.
Moderate to severe disease may require phototherapy or systemic agents such as methotrexate, retinoids, cyclosporine, or biologic therapies; these should not be initiated without dermatology consultation. Phototherapy is effective but not an emergency department modality.
Patients should be counseled that psoriasis is chronic and not contagious. They should avoid known triggers, including certain medications and skin trauma. Many treatments are contraindicated in pregnancy, and pediatric cases may have significant psychosocial impact. Referral to dermatology is appropriate for most patients, particularly those with extensive disease, arthritis, or refractory symptoms.
Severe pustular psoriasis carries risk of systemic infection, and erythrodermic psoriasis can result in dehydration and metabolic disturbances similar to extensive burns. Improvement with treatment occurs over weeks rather than days, and setting appropriate expectations is essential.
Psoriasis is a chronic, noncontagious, inflammatory skin disorder characterized by hyperproliferation of keratinocytes and immune dysregulation. It is now considered an autoimmune-mediated disease. Clinically, it presents with well-demarcated erythematous plaques covered by silvery scale, most commonly affecting the extensor surfaces of the elbows and knees, scalp, lumbar region, gluteal cleft, and glans penis. The course is unpredictable, with periods of remission and exacerbation. Up to one-third of patients develop psoriatic arthritis, and approximately 10% have ocular involvement. Psoriasis is associated with metabolic syndrome and occurs more commonly in Caucasians. There are two incidence peaks, between ages 20–30 and 50–60, and it affects about 2.2% of the U.S. population. Although rarely fatal, severe disease and treatment-related complications account for a small number of deaths annually.
Several clinical variants exist. Plaque psoriasis (psoriasis vulgaris) is the most common form and presents with raised, erythematous plaques with silvery scale. Guttate psoriasis presents abruptly with small, salmon-colored, drop-like papules, often following streptococcal pharyngitis and frequently resolving spontaneously. Pustular psoriasis may be localized to palms and soles or generalized, with sheets of sterile pustules, systemic symptoms, and potentially life-threatening complications requiring inpatient management. Erythrodermic psoriasis presents with generalized erythema, fine scaling, pruritus, and increased risk of infection and dehydration. Nail involvement, including pitting and onycholysis, occurs in up to 50% of patients. Inverse psoriasis affects flexural areas without prominent scaling. HIV-associated psoriasis may be severe and can be an early manifestation of AIDS. A strong genetic predisposition exists, with 40% of patients reporting a first-degree relative with the disease.
Pathophysiology involves epidermal stem cell proliferation, shortened keratinocyte cell cycles, inflammatory infiltrates, and vascular changes. Common triggers include medications such as lithium, beta-blockers, antimalarials, NSAIDs, and steroid withdrawal; infections such as streptococcal pharyngitis and HIV; skin trauma (Koebner phenomenon); emotional stress; winter weather; smoking; and elevated body mass index.
Diagnosis is clinical. Patients often report long-standing scaly erythematous lesions, mild pruritus, family history, and improvement with sun exposure. The classic lesion is a sharply demarcated red plaque with overlying silvery scale on extensor surfaces. The Auspitz sign—pinpoint bleeding after scale removal—may be present. Lesions may appear gray in darker skin tones. Scalp lesions extending beyond the hairline suggest psoriasis rather than seborrheic dermatitis. Nail pitting and onycholysis are common. Psoriatic arthritis frequently involves the distal interphalangeal joints and may present with asymmetric oligoarthritis or dactylitis (“sausage digits”). Biopsy is rarely necessary.
Laboratory studies are not required to confirm diagnosis but may assist in evaluating severe disease. Erythrodermic and pustular forms may show elevated inflammatory markers. Guttate psoriasis may be associated with positive streptococcal titers. Psoriatic arthritis is typically rheumatoid factor negative. Imaging may demonstrate erosive changes, sacroiliitis, or features of ankylosing spondylitis.
Emergency management focuses on stabilization in severe cases and patient education. Acute erythrodermic and generalized pustular psoriasis require admission for fluid and electrolyte management, infection surveillance, and systemic therapy in consultation with dermatology. Systemic corticosteroids are generally avoided due to risk of rebound and severe flare. In less severe cases, treatment in the emergency setting typically involves topical therapy. Emollients are beneficial for limited plaque disease. Topical corticosteroids are first-line therapy for mild to moderate psoriasis and may be used alone or in combination with other agents. Vitamin D analogs such as calcipotriene, topical retinoids such as tazarotene (contraindicated in pregnancy), coal tar preparations, salicylic acid, and topical calcineurin inhibitors for inverse or facial psoriasis are additional options.
Moderate to severe disease may require phototherapy or systemic agents such as methotrexate, retinoids, cyclosporine, or biologic therapies; these should not be initiated without dermatology consultation. Phototherapy is effective but not an emergency department modality.
Patients should be counseled that psoriasis is chronic and not contagious. They should avoid known triggers, including certain medications and skin trauma. Many treatments are contraindicated in pregnancy, and pediatric cases may have significant psychosocial impact. Referral to dermatology is appropriate for most patients, particularly those with extensive disease, arthritis, or refractory symptoms.
Severe pustular psoriasis carries risk of systemic infection, and erythrodermic psoriasis can result in dehydration and metabolic disturbances similar to extensive burns. Improvement with treatment occurs over weeks rather than days, and setting appropriate expectations is essential.
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