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Section 3 Psoriasis and Psoriasiform Dermatoses 59
Psoriatic erythroderma ICD-9: 696.1 ° ICD-10: L40
In this condition psoriasis involves the entire skin. See
Section 8.
Psoriatic Arthritis ICD-9: 696.0 ° ICD-10: L40.5
■ Seronegative. Psoriatic arthritis is included among
the seronegative spondyloarthropathies, which
include ankylosing spondylitis, enteropathic
arthritis, and reactive arthritis.
■ Asymmetric peripheral joint involvement of
upper extremities and especially distal
interphalangeal joints. Dactylitis—sausage fingers
(Fig. 3-15).
■ Axial form involves vertebral column, sacroiliitis.
■ Enthesitis: inflammation of ligament insertion into
bone.
Management of Psoriasis
Factors Influencing Selection of
Treatment
1. Age: childhood, adolescence, young adulthood,
middle age, >60 years.
2. Type of psoriasis: guttate, plaque, palmar
and palmopustular, generalized pustular
psoriasis, erythrodermic psoriasis.
3. Site and extent of involvement: localized
to palms and soles, scalp, anogenital area,
scattered plaques but 30% involvement.
4. Previous treatment: ionizing radiation, systemic
glucocorticoids, photochemotherapy
(PUVA), cyclosporine (CS), and methotrexate
(MTX).
5. Associated medical disorders (e.g., HIV disease).
Management of psoriasis is discussed in the
context of types of psoriasis, sites, and extent
of involvement. Psoriasis has to be managed
by a dermatologist.
Localized Psoriasis (see Fig. 3-3)
• Topical fluorinated glucocorticoid covered with
plastic wrap. Glucocorticoid-impregnated
tape also useful. Beware of glucocosteroid
side effects.
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■ Mutilating with bone erosions, osteolysis, or ankylosis.
Telescoping fingers. Functional impairment.
■ Often associated with psoriasis of nails (Figs. 3-11
and 3-15).
■ Associated with MHC class I antigens, while
rheumatoid arthritis is associated with MHC class
II antigens.
■ Incidence is 5–8%. Rare before age 20.
■ May be present (in 10% of individuals) without any
visible psoriasis; if so, search for a family history.
• Hydrocolloid dressing, left on for 24–48 h, is
effective and prevents scratching.
• For small plaques (≤4 cm), triamcinolone acetonide
aqueous suspension 3 mg/mL diluted
with normal saline injected intradermally into
lesions. Beware of hypopigmentation in skin
of color.
• Topical anthralin also effective but can be
irritant.
• Vitamin D analogues (calcipotriene, ointment
and cream) are good nonsteroidal antipsoriatic
topical agents but less effective than
corticosteroids; they are not associated with
cutaneous atrophy; can be combined with
corticosteroids. Topical tacrolimus, 0.1%,
similarly effective.
• Topical pimecrolimus, 1%, is effective in
inverse psoriasis and seborrheic dermatitislike
psoriasis of the face and ear canals.
• Tazarotene (a topical retinoid, 0.05 and 0.1%
gel) has similar efficacy, best combined with
class II topical glucocorticoids.
• All these topical treatments can be combined
with 311-nm UVB phototherapy or
PUVA.
Scalp. Superficial scaling and lacking thick
plaques: Tar or ketoconazole shampoos followed