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Psoriasis

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General Information

Description

  • chronic inflammatory multisystem disease, predominantly affecting skin and/or joints1

Also called

  • psoriasis vulgaris
  • plaque psoriasis
  • chronic plaque psoriasis

Definitions

  • Fitzpatrick skin typing based on history and physical
    • I - always burn, never tan
    • II - always burn, then slight tan
    • III - sometimes burn, always tan
    • IV - never burn, always tan
    • V - lightly pigmented (such as persons from Indian subcontinent and Mediterranean region)
    • VI - darkly pigmented (such as black persons)
    • Reference - 320992Br J Dermatol 1977 Jan;96(1):1OpenInNew
  • Psoriasis Area and Severity Index (PASI)1
    • measure of overall psoriasis severity and coverage
    • includes
      • body surface area (BSA)
      • erythema
      • induration
      • scaling
    • PASI composite score ranges from 0 (normal) to 72 (maximal disease) (12848110J Drugs Dermatol 2003 Jun;2(3):260OpenInNewfull-textOpenInNew)
    • 75% improvement in PASI (PASI-75) commonly used in clinical trials to measure efficacy but rarely used in clinical practice

Types

  • patients may have clinical findings from > 1 type1
  • plaque psoriasis1
    • well-defined sharply demarcated erythematous plaques
    • affects 80%-90% of patients with psoriasis
      • 80% of patients have mild-to-moderate disease
      • 20% have moderate-to-severe disease involving > 5% of body or affecting crucial body regions including hands, feet, face, or genitals
  • intertriginous psoriasis1
    • also known as inverse psoriasis or flexural psoriasis
    • erythematous plaques with minimal scale
    • lesions located in skin folds
  • erythrodermic psoriasis
    • generalized erythema covering nearly entire body surface area1
    • can be associated with5,6
      • hypothermia
      • hypoalbuminemia
      • electrolyte imbalances
      • high-output cardiac failure
    • considered a life-threatening emergency5
  • pustular psoriasis5
    • monomorphic sterile pustules on painful inflamed skin
    • localized pustular variant involving soles and palms occurring with or without plaque-type disease (palmoplantar psoriasis)
    • acute generalized disease also called von Zumbusch variant
      • consists of widespread pustules on erythematous background
      • uncommon severe form of psoriasis associated with fever and toxicity
  • guttate psoriasis1,5
    • dew-drop-like salmon pink papules with fine scale
    • guttate psoriasis occurs in < 2% of patients with psoriasis
    • often follows Group A streptococcal pharyngitis infection
    • appears more common in children and adolescents

References

General references used

  1. Menter A, Gottlieb A, Feldman SR, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 1. Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics. J Am Acad Dermatol. 2008 May;58(5):826-50OpenInNew
  2. Menter A, Korman NJ, Elmets CA, et al; American Academy of Dermatology. Guidelines of care for the management of psoriasis and psoriatic arthritis. Section 3. Guidelines of care for the management and treatment of psoriasis with topical therapies. J Am Acad Dermatol. 2009 Apr;60(4):643-59OpenInNew
  3. Menter A, Korman NJ, Elmets CA, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 4. Guidelines of care for the management and treatment of psoriasis with traditional systemic agents. J Am Acad Dermatol. 2009 Sep;61(3):451-85OpenInNew
  4. Menter A, Korman NJ, Elmets CA, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 5. Guidelines of care for the treatment of psoriasis with phototherapy and photochemotherapy. J Am Acad Dermatol. 2010 Jan;62(1):114-35OpenInNew
  5. Boehncke WH, Schön MP. Psoriasis. Lancet. 2015 Sep 5;386(9997):983-94OpenInNew
  6. Kupetsky EA, Keller M. Psoriasis vulgaris: an evidence-based guide for primary care. J Am Board Fam Med. 2013 Nov-Dec;26(6):787-801OpenInNewfull-textOpenInNew
  7. Canadian Psoriasis Guidelines Committee. Canadian guidelines for management of plaque psoriasis CDA 2009 June PDFPictureAsPdf
  8. Canadian Psoriasis Guidelines Addendum Committee. 2016 Addendum to the Canadian guidelines for the management of plaque psoriasis 2009. J Cutan Med Surg. 2016 Sep;20(5):375-431OpenInNewfull-textOpenInNew

Recommendation grading systems used

  • Canadian Dermatology Association (CDA) uses modified Scottish Intercollegiate Guidelines Network (SIGN) grading system
    • grades of recommendation
      • Grade A
        • at least 1 meta-analysis, systematic review, or randomized controlled trials (RCT) rated as 1++, and directly applicable to target population
        • systematic review of RCTs or body of evidence consisting principally of studies rated as 1+, directly applicable to target population, and demonstrating overall consistency of results
      • Grade B
        • body of evidence including studies rated as 2++, directly applicable to target population, and demonstrating overall consistency of results
        • extrapolated evidence from studies rated as 1++ or 1+
      • Grade C
        • body of evidence including studies rated as 1, 2, or 2+, directly applicable to target population and demonstrating overall consistency of results
        • extrapolated evidence from studies rated as 2++
      • Grade D
        • evidence level 3 or 4
        • extrapolated evidence from studies rated as 2+
    • levels of evidence
      • Level 1++ - high-quality meta-analyses, systematic reviews of RCTs or RCTs with a very low risk of bias
      • Level 1+ - well-conducted meta-analyses, systematic reviews of RCTs or RCTs with a low risk of bias
      • Level 1 - meta-analyses, systematic reviews of RCTs, or RCTs with high risk of bias
      • Level 2++
        • high-quality systematic reviews of case-control or cohort studies
        • high-quality case-control or cohort studies with very low risk of confounding, bias, or chance, and high probability that relationship causal
      • Level 2+
        • well-conducted case-control or cohort studies with low risk of confounding, bias, or chance, and moderate probability that relationship causal
      • Level 2
        • case-control or cohort studies with high risk of confounding bias and significant risk that relationship not causal
      • Level 3 - non-analytic studies (such as, case series or case reports)
      • Level 4 - expert opinion
    • Reference - CDA guidelines for management of plaque psoriasis (CDA 2009 June PDFPictureAsPdf)
  • National Psoriasis Foundation (NPF) levels of evidence
    • Level IA - includes evidence from meta-analysis of randomized controlled trials
    • Level IB - includes evidence from at least 1 randomized controlled trial
    • Level IIA - includes evidence from at least 1 controlled study without randomization
    • Level IIB - includes evidence from at least 1 other type of quasi-experimental study
    • Level III - includes evidence from nonexperimental descriptive studies such as comparative studies, correlation studies, and case-control studies
    • Level IV - includes evidence from expert committee reports or opinions or clinical experience of respected authorities or both
    • Reference - NPF guideline on treatment of pustular psoriasis (22609220J Am Acad Dermatol 2012 Aug;67(2):279OpenInNew)

Synthesized Recommendation Grading System for DynaMed

  • DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based MethodologyOpenInNew).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed (DM), we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE)OpenInNew to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed (DM) synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

Special acknowledgements

  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of DynaMed Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors are employees of DynaMed and oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T116742, Psoriasis; [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T116742. Registration and login required.
  • KeyboardArrowRight

    Overview and Recommendations

    • Background

    • Evaluation

    • Management

  • Related Summaries

  • KeyboardArrowRight

    General Information

    • Description

    • Also called

    • Definitions

    • Types

  • KeyboardArrowRight

    Epidemiology

    • Who is most affected

    • Incidence/Prevalence

    • Likely risk factors

    • Possible risk factors

    • Associated conditions

  • KeyboardArrowRight

    Etiology and Pathogenesis

    • Causes

    • Pathogenesis

  • KeyboardArrowRight

    History and Physical

    • KeyboardArrowRight

      History

      • Chief concern (CC)

      • History of present illness (HPI)

      • Medication history

      • Past medical history (PMH)

      • Family history (FH)

      • Social history (SH)

    • KeyboardArrowRight

      Physical

      • General physical

      • Skin

      • HEENT

      • Extremities

  • KeyboardArrowRight

    Diagnosis

    • Making the diagnosis

    • Differential diagnosis

    • Testing overview

    • Biopsy and pathology

  • KeyboardArrowRight

    Management

    • Management overview

    • KeyboardArrowRight

      Plaque psoriasis

      • Management overview

      • Skin care

      • KeyboardArrowRight

        Topical medications

        • Topical corticosteroids

        • Vitamin D analogs

        • Tazarotene

        • Topical tacrolimus and pimecrolimus

        • Coal tar

        • Anthralin

        • Salicylic acid

        • Combinations of topical therapies

        • Other topical therapies

      • KeyboardArrowRight

        Systemic medications (nonbiologic)

        • Acitretin

        • Apremilast

        • Cyclosporine

        • Fumaric acid esters

        • Methotrexate

        • Other nonbiologic systemic medications

      • KeyboardArrowRight

        Biologic agents

        • Tumor necrosis factor (TNF) inhibitors

        • Anti-interleukin monoclonal antibodies

        • Janus kinase inhibitor

        • Comparative efficacy

        • Combination therapy

        • Medications under development

      • KeyboardArrowRight

        Phototherapy

        • Ultraviolet B (UVB) radiation

        • Topical targeted phototherapy (laser therapy)

        • Systemic psoralen plus ultraviolet A (PUVA)

        • Topical psoralen plus ultraviolet A (topical PUVA)

        • Comparisons of phototherapy

      • Dietary and lifestyle interventions

      • Tonsillectomy

    • Scalp psoriasis

    • Nail psoriasis

    • Intertriginous psoriasis

    • Erythrodermic psoriasis

    • Guttate psoriasis

    • Pustular psoriasis

    • HIV-associated psoriasis

    • Psoriasis in pregnancy

    • Follow-up

    • Drug-induced psoriasis

  • KeyboardArrowRight

    Complications and Prognosis

    • Complications

    • Prognosis

  • Prevention and Screening

  • KeyboardArrowRight

    Quality Improvement

    • Physician Quality Reporting System Quality Measures

  • KeyboardArrowRight

    Guidelines and Resources

    • KeyboardArrowRight

      Guidelines

      • United States guidelines

      • United Kingdom guidelines

      • Canadian guidelines

      • European guidelines

      • African guidelines

    • Review articles

    • MEDLINE search

  • Patient Information

  • KeyboardArrowRight

    ICD Codes

    • ICD-10 codes

  • KeyboardArrowRight

    References

    • General references used

    • Recommendation grading systems used

    • Synthesized Recommendation Grading System for DynaMed

    • DynaMed Editorial Process

    • Special acknowledgements

    • How to cite

Topic Editor
Katy I. Burris MD
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Affiliations

Assistant Professor of Dermatology, Columbia University Medical Center, Columbia University College of Physicians and Surgeons; New York, United States

Conflicts of Interest

Dr. Burris declares no relevant financial conflicts of interest.

Recommendations Editor
Zbys Fedorowicz MSc, DPH, BDS, LDSRCS
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Affiliations

Director of Bahrain Branch of the United Kingdom Cochrane Center, The Cochrane Collaboration; Awali, Bahrain

Conflicts of Interest

Dr. Fedorowicz declares no relevant financial conflicts of interest.

Deputy Editor
Alan Ehrlich MD, FAAFP
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Affiliations

Executive Editor, DynaMed; Associate Professor of Family Medicine, University of Massachusetts Medical School; Massachusetts, United States

Conflicts of Interest

Dr. Ehrlich declares no relevant financial conflicts of interest.

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Chronic plaque psoriasis

Chronic plaque psoriasis

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