Psoriasis:​Recognition and

Management Strategies
Kathryn K. Garner, MD;​Kattie D. S. Hoy, MD;​and Adriana M. Carpenter, DO
Mike O’Callaghan Military Medical Center Family Medicine Residency Program, Nellis Air Force Base,
Nevada;​Uniformed Services University of the Health Sciences, Bethesda, Maryland

Psoriasis is an inflammatory skin and systemic disorder that affects 3.2% of the U.S. population, including 1% of children. It
is an immune-mediated process triggered by an interplay of genetic, environmental, physical (e.g., skin trauma), and infec-
tious factors. Associated comorbidities include cardiovascular disease, obesity, metabolic syndrome, diabetes mellitus, and
inflammatory bowel disease. Psoriasis presents in various forms, including plaque, guttate, erythrodermic, pustular, inverse,
nail, and psoriatic arthritis. The most common form is plaque psoriasis, which affects 90% of adults with psoriasis. Psori-
asis is diagnosed clinically based on the presence of characteristic erythematous, scaly skin plaques in typical locations,
with associated history and systemic symptoms. Treatment strategies are similar for most forms of psoriasis and based on
body surface area involved. Topical corticosteroids, vitamin D analogues, and tazarotene are used to treat mild to moderate
disease. Systemic treatment with nonbiologic and biologic agents and ultraviolet B phototherapy are used for moderate
to severe disease, with the exception of apremilast, a systemic agent approved for mild psoriasis. Disease management is
improved with maintaining ideal body weight, avoiding tobacco products, limiting alcohol, and practicing stress reduction
techniques. The Psoriasis Area and Severity Index is a tool to assess severity and monitor treatment effectiveness over time.
Special consideration is needed for treatment of children and patients who are pregnant, breastfeeding, or trying to con-
ceive. (Am Fam Physician. 2023;​108(6):​562-573. Copyright © 2023 American Academy of Family Physicians.)

Psoriasis is an inflammatory skin and systemic disorder activating cytokines and growth factors that produce signals
that affects 3.2% of the U.S. population, including 1% of to leukocytes. This causes proliferation of keratinocytes that
children.1 In adults with psoriasis, 90% have plaque pso- create plaques.6
riasis.2 Up to 30% of adults with plaque psoriasis develop
psoriatic arthritis, with a median onset of 10 to 11 years Risk Factors
following the development of skin abnormalities.3 However, Individuals whose parents both have psoriasis have a 50%
one prospective study showed that arthritic symptoms pre- chance of developing the disease;​this decreases to 16%
ceded skin findings in 19.4% of adults. In children, arthri- if only one parent is affected.7 People with type 2 diabetes
tis may precede skin findings by two to three years with mellitus also have an increased risk of psoriasis based on a
bimodal age presentation at two to three years and 10 to shared genetic loci.8 Inflammatory bowel disease is another
12 years.4,5 risk factor.9
Modifiable risk factors for psoriasis include maintaining
Pathophysiology a healthy body weight, preventing metabolic syndrome, and
Psoriasis is a systemic immune-mediated disorder that avoiding tobacco and alcohol use.10-13 Lithium, beta blockers,
involves an interplay between genetic predisposition and angiotensin-converting enzyme inhibitors, and nonsteroi-
environmental stressors, including physical skin trauma and dal anti-inflammatory drugs are associated with the devel-
infectious factors. T cells create an inflammatory reaction by opment of psoriasis. Plaque development may occur 10 to 20
days after skin trauma, including tattoos, an effect known as
the Koebner phenomenon.14
Additional content is available with the online version of this
article. Although streptococcal infection is a trigger for the devel-
CME This clinical content conforms to AAFP criteria for CME.
opment of guttate and plaque psoriasis, a Cochrane review
See CME Quiz on page 539. demonstrated insufficient evidence that antibiotic treatment
Author disclosure:​ No relevant financial relationships. of streptococcal infections shortens the duration of guttate
Patient information:​A handout on this topic is available
psoriasis or prevents progression to plaque psoriasis.15
with the online version of this article. A key risk factor for psoriatic arthritis is obesity;​as
body mass index increases, the risk of psoriatic arthritis

562 American
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 PSORIASIS
SORT:​KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating Comments
also increases. Other risks factors
11,16
All patients with psoriasis should be screened C Systematic review
include psoriatic nail lesions, severe for metabolic syndrome and, if positive, and meta-analysis
skin disease, uveitis, and low educa- treated to decrease the severity of psoriasis.12 of observational
studies
tion level.17,18
Topical corticosteroids are first-line treatment A Systematic review
Clinical Presentation for all forms of mild to moderate psoriatic
and Differential Diagnosis skin disease and are often combined with
vitamin D analogues. The combination of
Psoriasis is diagnosed clinically based corticosteroids and vitamin D analogues per-
on the presence of characteristic ery- formed better than either agent alone.44
thematous, scaly skin plaques in typ-
ical locations, with associated history Calcipotriene foam and calcipotriene/beta- A Randomized con-
methasone dipropionate gel should be used trolled trials
and systemic symptoms. Subtypes for four to 12 weeks for the treatment of mild
of psoriasis include plaque, guttate, to moderate scalp psoriasis.51-53
erythrodermic, pustular, and inverse.
Patients may also develop nail psoriasis Systemic agents can generally be considered C Multiple consen-
when the involved body surface area exceeds sus guidelines
and psoriatic arthritis. 5%. 38,57,58

PLAQUE PSORIASIS If methotrexate is used as initial systemic B Prediction rule

Plaque psoriasis can have a variety of treatment and the patient does not have a 25% developed from a
reduction in Psoriasis Area and Severity Index large randomized
appearances depending on an indi- score after four weeks, switching to another controlled trial
vidual’s skin type (Figure 1). A silvery systemic treatment is recommended. 59
white appearance can occur in all skin
types. In those with Fitzpatrick skin For procedures with a moderate risk of C Consensus
postoperative infection (e.g., intra-abdominal guidelines and
types 1 through 3 (always, usually, or surgery without bowel resection, intrathoracic narrative review
sometimes sunburns), plaque psori- surgery without lung resection, gynecologic
asis can be erythematous or salmon surgery) or those with a high risk of infection
pink, and in those with types 4 (e.g., joint replacement, oncologic surgery,
through 6 (rarely sunburns, brown or bowel resection), systemic therapies usually
require cessation and should be discussed
black skin) it can be violaceous, red, with the surgical team. 38
or bluish. Plaques can also appear
19

on the scalp.2 A = consistent, good-quality patient-oriented evidence;​ B = inconsistent or limited-quality

patient-oriented evidence;​ C = consensus, disease-oriented evidence, usual practice, expert
Several conditions can mimic plaque opinion, or case series. For information about the SORT evidence rating system, go to
psoriasis. The most common is eczema, https://​w ww.aafp.org/afpsort.
which lacks the silvery appearance and
affects flexor, rather than extensor, sur-
faces. Tinea infections are distinguished from psoriasis by a ERYTHRODERMIC PSORIASIS
central clearing. Squamous cell carcinoma tends to appear Erythrodermic psoriasis presents with superficial desqua-
in sun-exposed skin, whereas psoriatic plaques tend to be on mation and erythema (Figure 3), with or without exfoliation,
less sun-exposed skin. and involves more than 75% of body surface area (BSA).
Diagnosis is made clinically but can be verified histologi-
GUTTATE PSORIASIS cally. Type 1 has a gradual progression over years, whereas
Guttate psoriasis presents as diffuse, small, erythematous, type 2 develops abruptly and is a medical emergency.21 Com-
scaly papules and plaques20 (Figure 2). Pityriasis rosea can be mon triggers include sunburn, alcohol use, HIV, lithium,
distinguished from guttate psoriasis by the smaller lesions and withdrawal of topical or oral corticosteroids.21
that form along skin cleavage lines on the trunk. Lesions Although sometimes difficult to differentiate, patients
from pityriasis rosea occur one to two weeks after a viral with type 2 erythroderma are clinically unstable with dif-
infection and resolve spontaneously. The differential diag- fuse erythema and no plaques. Patients may have hyper- or
nosis of guttate psoriasis includes the rash of secondary hypothermia, dehydration due to fluid loss, hypoalbumin-
syphilis. This includes the presence of erythematous pso- emia, or sepsis because lesions often become superin-
riasiform papules on palms and soles, which are spared in fected with bacteria.21,22 The typical age of onset is 40 to 50
guttate psoriasis. years. 22 Differential diagnosis includes atopic dermatitis,

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 PSORIASIS
FIGURE 1

B C D E

Plaque psoriasis. (A) Silvery white annular plaques on the back, an appearance that can occur in patients with any
skin type. (B) Localized plaque psoriasis affecting the elbow. Commonly seen in patients with Fitzpatrick skin types
1 through 3. (C) Violaceous, erythematous plaques on extensor surface of bilateral lower legs. Commonly seen in
patients with Fitzpatrick skin types 4 through 6. (D) Plaque psoriasis appearing as bluish, annular plaques on extensor
surface of bilateral lower legs. Commonly seen in patients with Fitzpatrick skin types 4 through 6. (E) Scaly plaque
psoriasis affecting the scalp.

FIGURE 2

A B C

Guttate psoriasis of the (A) back and trunk, (B) lower back, and (C) elbow.

fixed drug eruption, cutaneous sarcoidosis, and pityriasis infections of dermatitis, severe candidiasis, dermatitis her-
rubra pilaris. petiformis, and diffuse impetigo.27

PUSTULAR PSORIASIS INVERSE PSORIASIS

Pustular psoriasis presents with multiple pin-sized, ster- Inverse psoriasis presents with well-demarcated erythem-
ile pustules on an erythematous base that can be general- atous lesions with minimal scale and is located within skin
ized or only on the palms or soles23 (Figure 4). If a patient folds (Figure 5). Differential diagnosis includes fungal or
presents with generalized pustules, a biopsy of an intact bacterial infections of skin folds.
pustule should be considered to rule out acute generalized
exanthematous pustulosis, a disorder that develops rapidly NAIL PSORIASIS
(less than two weeks).24,25 In most cases (86%), pustular pso- Nail psoriasis presents with pitting, distal onycholysis, oil-
riasis is associated with starting or restarting an offending drop discoloration of the nail plate, and subungual hyper-
drug, most commonly penicillins, macrolides, quinolones, keratosis28 (Figure 6). Patients with nail psoriasis have a
sulfonamides, terbinafine, or diltiazem.24,26 Other condi- higher risk of developing psoriatic arthritis. 29 Periodic
tions included in the differential diagnosis are secondary acid–Schiff stain, fungal cultures, or a potassium hydroxide

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 PSORIASIS
FIGURE 3

preparation can help dis-

tinguish nail psoriasis from
onychomycosis.

PSORIATIC ARTHRITIS
Patients with psoriatic
arthritis experience swol-
len, stiff, and painful joints
(Figure 7), with or without
skin findings. The Classifi-
cation for Psoriatic Arthri-
tis criteria can be useful
to distinguish psoriatic
from rheumatoid arthri-
A B C
tis, gout, and other reactive
arthritides.30 Erythrodermic psoriasis with (A) widespread, confluent scaly plaques, (B) wide-
spread scaly plaques on legs, and (C) severe erythroderma.
Comorbidities Figure 3A:​Image used with permission from VisualDx.
Patients with psoriasis have
an increased prevalence
of metabolic syndrome and obesity, and a propensity to Figure 8 summarizes the overall approach to treat-
develop diabetes, hypertension, myocardial infarction, and ment.1,3,5,37-41 Table 1 provides links to tools that are used to
inflammatory bowel disease.12,31-33 All patients with psoriasis guide treatments.1,5,30,40,42,43
should be screened for metabolic syndrome and, if positive,
treated to decrease the severity of psoriasis.12 Severe psori- TOPICAL TREATMENTS
asis is an independent risk factor for atrial fibrillation and Topical therapies are the mainstay of treatment for mild to
thrombosis.34 moderate psoriasis (Table 2).1,44-50
Psoriasis is also associated with gastrointestinal disorders. Topical corticosteroids are first-line treatment for all types
In particular, there is a 16% increased risk of colorectal can- of psoriatic skin disease and are often combined with vita-
cer, although guidelines do not recommend earlier or more min D analogues or topical retinoids to limit the frequency
intensive screening for colorectal cancer in patients with and potency of corticosteroid therapy needed to control dis-
psoriasis.35 Between 4% and 14% of patients with psoriasis ease. In a Cochrane review of 177 randomized controlled
will have celiac disease, but removing gluten from their diet trials with 34,808 participants, the combination of a corti-
does not appear to reduce psoriasis severity.1,36 costeroid and vitamin D analogue performed better than
Depression, suicidal ideation, and anxiety are associated either agent alone.44 Patients can combine vitamin D and
with psoriasis. These conditions can negatively affect quality corticosteroids in a 1:​1 mixture daily or apply vitamin D
of life and increase psoriatic severity that may warrant stron- during the week and a higher potency corticosteroid on
ger treatment.32 weekends. Calcipotriene foam and calcipotriene/betameth-
asone dipropionate gel should be used for four to 12 weeks
Treatment for the treatment of mild to moderate scalp psoriasis.51-53
Except for erythrodermic psoriasis, which requires prompt Calcineurin inhibitors may be used instead of corticoste-
initiation of systemic drug therapy and inpatient manage- roids in areas of thinner skin as maintenance therapy. If
ment of fluids and electrolytes, all other types of psoriasis are plaques improve after four weeks of daily treatment, patients
treated similarly. Treatment requires regular and consistent can decrease to twice-weekly treatments to reduce the fre-
use of topical agents, systemic therapy, or phototherapy pro- quency of flare-ups.54
tocols. Maintaining an ideal body weight, avoiding tobacco Creams and ointments are preferred for skin without hair.
products, limiting alcohol intake, and practicing stress Ointments tend to be more potent than creams of equal
reduction techniques are important self-care measures but strength. Solutions, shampoos, foams, oils, gels, or sprays
are not sufficient alone to improve psoriatic severity. Min- are recommended in regions of skin with hair, and selec-
imizing environmental triggers, such as cold weather, sun tion is based on patient preference.1 Use of emollients may
exposure, and low humidity, may also be helpful. reduce pruritus or burning from topical therapeutic agents

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 PSORIASIS

and improves outcomes when applied before narrowband living material and are more selective in how they disrupt
ultraviolet B (UVB) phototherapy treatments.5 the immune system to prevent immune-mediated disorders.
Topical treatments can be used for nail lesions, but only Although systemic treatments are generally reserved for
when no more than two nails are involved. A topical solu- moderate to severe psoriasis, one systemic nonbiologic med-
tion of calcipotriene/betamethasone dipropionate and taza- ication (apremilast [Otezla]) has been approved by the U.S.
rotene results in modest improvement.37 Systemic treatment Food and Drug Administration for mild disease.56
is more appropriate when multiple nails are affected. Although individual guidelines vary in their definitions
of psoriasis severity, systemic agents can generally be con-
PHOTOTHERAPY sidered when the involved BSA exceeds 5%. 38,57,58 BSA can
Narrowband UVB phototherapy is effective for plaques be estimated using the surface of the hand (from the wrist
and diffuse guttate psoriasis that do not improve with top- to the fingers and thumb closed together), representing
ical treatments. However, phototherapy typically involves 1% BSA.1 Dosages, contraindications, and adverse effects
multiple visits per week. Insurance often covers in-office of various systemic agents are outlined in eTable A. Rec-
treatments, and one six-year study showed that patients spent ommendations for monitoring during therapy are listed
40% less in drug costs due to a decreased need for prescrip- in eTable B.
tion topical medications 12 months after phototherapy.55 If there is no contraindication to systemic treatment, the
choice of specific agent is individualized based on patient
SYSTEMIC TREATMENTS and physician preference and insurance authorization.
Nonbiologic medications cause global immune suppres- Adalimumab and infliximab are more effective than meth-
sion and are synthetic in origin. Biologics are derived from otrexate for cutaneous psoriasis;​however, most insurance
requires failure of methotrexate before approving these
medications.57
FIGURE 4 If methotrexate is used as initial systemic treatment and
the patient does not have a 25% reduction in Psoriasis Area
and Severity Index score after four weeks of treatment,
switching to another systemic treatment is recommended.59
An alternative to methotrexate alone is combining biologic
treatments with methotrexate to decrease formation of anti-
drug antibodies and improve effectiveness over time.

FIGURE 5

(A) Pustular psoriasis localized on the hand. (B) Pal- Erythematous plaque in an inverse pattern in the
moplantar psoriasis. axilla.
Figure 4A:​Image used with permission from VisualDx. Image used with permission from VisualDx.

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 PSORIASIS

Patients using systemic agents must remain current on For procedures with a low risk of postoperative infection
routine vaccinations and cancer screenings. Consulta- (e.g., hernia repair, endoscopy, or arthroscopy), all biolog-
tion with allergy and immunology is recommended before ics may be continued. For procedures with a moderate risk
administration of any live vaccines. Live vaccines should not of postoperative infection (e.g., intra-abdominal surgery
be given to patients taking biologic therapies;​however, bio- without bowel resection, intrathoracic surgery without lung
logic therapy can be restarted one to two weeks following resection, gynecologic surgery) or high risk of infection (e.g.,
a live vaccine.38 Patients taking tumor necrosis factor-alpha joint replacement, oncologic surgery, bowel resection), sys-
inhibitors require annual skin examinations to assess for temic therapies usually require cessation and should be dis-
nonmelanoma skin cancers.38 cussed with the surgical team.38 If biologic agents should be
discontinued, therapy should be stopped three to four half-
Temporary Discontinuation of Therapy lives before surgery.38 Infliximab can be restarted three to
Primary care physicians should be aware of situations in four weeks after surgery, etanercept 12 days after surgery,
which systemic treatments should be temporarily dis- and adalimumab 56 days after moderate- to high-risk elec-
continued. For example, ustekinumab (Stelara) should be tive surgeries if the wound is fully healed and there are no
temporarily discontinued for febrile illnesses requiring postoperative complications.60
antibiotic treatment. It can be restarted after full resolution
of symptoms and completion of antibiotics. Tumor necrosis Special Considerations for Psoriasis
factor-alpha inhibitors (i.e., etanercept or infliximab) do not in Children and Adolescents
need to be stopped for uncomplicated infections requiring Plaque psoriasis in children usually presents in adolescents;​
antibiotics. however, 28% of children with guttate psoriasis develop the
condition before adolescence. In children who develop gut-
tate psoriasis after a positive streptococcal test, 60% will have
FIGURE 6 complete remission within months. Children with no active
streptococcal infection at the time of guttate psoriasis diag-
nosis have an increased risk of progressing to chronic plaque
psoriasis.61

FIGURE 7

Nail psoriasis. (A) Hyperkeratosis, onychorrhexis,

and leukonychia of the nail in advanced psoriasis.
(B) Pitting of the nails. Dactylitis associated with psoriatic arthritis.

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 PSORIASIS
FIGURE 8

Determine disease severity:

Assess BSA involvement or PASI score
Consider impact of disease on physical, psychosocial, and social
well-being with the DLQI or, if younger than 16 years, the CDLQI
Evaluate for psoriatic arthritis; if present, the disease is considered severe

Severity of disease

Mild Moderate Severe

< 3% BSA involvement or a score 3% to 10% BSA involvement or a score > 10% BSA involvement or a score of
of < 5 on the PASI and a score of 5 to 10 on the PASI and/or a score > 10 on the PASI or a score of > 10 on
of < 5 on the DLQI or CDLQI of 6 to 10 on the DLQI or CDLQI the DLQI or CDLQI or psoriatic arthritis

Topical therapy only Topicals with or without phototherapy* Phototherapy with or

Narrowband ultraviolet B phototherapy without systemic treatment
Could consider systemic ther-
apy if BSA involvement is > 5%
Intermittent Maintenance
Nonbiologic: methotrexate,§ Biologic: tumor necrosis
apremilast (Otezla),|| cyc- factor–alpha inhibitors,
Corticosteroids: Corticosteroid losporine,¶ acitretin,** and interleukin-12/23 inhibitors,
use low potency sparing: vitamin D deucravacitinib (Sotyktu) interleukin-17 inhibitors
on face, genitalia, analogues,‡ calci-
skin folds; use high neurin inhibitors,
potency on palms, topical retinoids, Indications for specialty care from the National Institute for
soles, nails, scalp† emollients Health and Care Excellence 2019 psoriasis overview guidelines:
Psoriasis not responsive to topical agents or diagnosis is uncertain
Severe psoriasis (consider rheumatology for psoriatic arthritis)
Guttate psoriasis requiring phototherapy
Nail disease that has a functional or cosmetic impact
Generalized pustular or erythroderma psoriasis requires
same day evaluation and often hospitalization

BSA = body surface area; CDLQI = Children’s Dermatology Life Quality Index; DLQI = Dermatology Life Quality Index; FDA = U.S. Food and Drug
Administration; PASI = Psoriasis Area and Severity Index.
*— Phototherapy is ideal if there is > 10% BSA involvement.
†—Use a solution, shampoo, foam, oil, gel, or spray for scalp; a solution for nails; or, otherwise, a cream or ointment depending on patient
preference.
‡—Topical vitamin D analogues should be limited to 75 g per week in those with < 30% BSA involvement and no more than 50 g per week in children
six to 12 year of age.
§—Use of methotrexate is usually required first by most insurance companies before approval of other nonbiologic or biologic agents.
||—Approved by the FDA for mild disease, but only authorized for moderate to severe disease by most insurance companies.
¶—Often used only as short-term treatment of flare-ups.
**—Requires a three-year washout period for people who want to conceive.

Treatment algorithm for psoriasis.

Information from references 1, 3, 5, and 37-41.

Only 0.7% to 1.2% of children will develop psoriatic enthesitis (inflammation of the insertion sites of tendons and
arthritis, although it represents 6% to 8% of childhood ligaments) and axial joint involvement are more common in
inflammatory arthritis cases.5,61 Oligoarticular symptoms, older children and teenagers with psoriatic arthritis.5
dactylitis, and a family history of psoriasis in younger chil- Treatment is based on BSA and disease impact. All cor-
dren increase the likelihood of psoriatic arthritis, whereas ticosteroid potencies can be used and applied once or twice

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 PSORIASIS
TABLE 1

Tools for Assessing Psoriatic Disease

Tool Link Indications Limitations
Psoriasis severity assessment
Body surface https://​w ww.health.state.mn.us/ Used to calculate severity and Can be overestimated
area communities/ep/surge/burn/tbsa.html assess response to treatment;​
good interrater reliability1

Nail Psoriasis https://​w ww.sciencedirect.com/science/ Scores each nail for nail bed and Weak consensus for
Severity Index article/pii/S01​909​622​030​091​01?​via​%3​ nail matrix psoriasis to assess use43
Dihub severity42

Physician https://​jamanetwork.com/journals/ Erythema, induration, and scaling Does not consider body
Global jamadermatology/fullarticle/2039085 used to measure severity and surface area
Assessment response to treatment;​simple to
use1

Psoriasis Area https://​w ww.mdcalc.com/calc/10182/ Erythema, induration, scaling, Used in research trials
and Severity psoriasis-area-severity-index-pasi and affected body surface area and less often in the clin-
Index used to determine severity and ical setting;​not accurate
response to treatment1 for mild psoriasis

Psoriasis https://​w ww.tandfonline.com/doi/full/​ Patient-reported inventory that Relies on patient will-

Symptom 10.​3109/​0954​6634.​2012.​742​950 measures severity based on itch, ingness and ability to
Inventory redness, scaling, burning, sting- complete
ing, cracking, flaking, and pain1

Quality-of-life assessment
Children’s Der- https://​w ww.cardiff.ac.uk/medicine/ Derived from the adult index and May be difficult to assess
matology Life resources/quality-​of-​life-​questionnaires/ available in written and cartoon pruritus
Quality Index childrens-dermatology-​life-​quality-index versions5

Dermatology https://​w ww.cardiff.ac.uk/medicine/ Self-reported assessment based Relies on patient will-

Life Quality resources/quality-of-life-questionnaires/ on 10 questions measuring ingness and ability to
Index dermatology-life-quality-index impact of disease on quality complete
of life;​assesses severity and
response to treatment1

Psoriatic arthritis assessment

Classification https://​w ww.mdcalc.com/calc/10039/ Classifies patients with inflam- Used in patients with
for Psoriatic caspar-criteria-psoriatic-arthritis matory musculoskeletal disease known inflammatory
Arthritis Criteria as having psoriatic arthritis based arthritis
on a scoring system, and includes
skin findings, nail lesions, dactyli-
tis, negative rheumatoid factor,
and juxta-articular bone forma-
tion on radiography30

Psoriasis Epi- https://​w ww.psoriasis.org/ Self-administered to detect psori- Not validated in children;​
demiological psoriatic-arthritis-screening-test/ atic arthritis does not detect axial
Screening Tool arthritis or inflammatory
back pain40

Information from references 1, 5, 30, 40, 42, and 43.

daily for up to 14 days, but low- to moderate-potency corti- involvement, and no more than 50 g per week in children
costeroids are preferred for children younger than six years. six to 12 years of age.
Calcipotriene/betamethasone dipropionate ointment Narrowband UVB phototherapy is safe and effective for
that is applied daily for up to four weeks is safe and effec- children with 10% to 25% BSA involvement of any form of
tive for children older than 12 years, and treatment can cutaneous psoriasis.61 In a retrospective study, after 12 days
be extended up to eight weeks on the scalp. 5 To limit the of coal tar use before narrowband UVB phototherapy, 64%
risk of hypercalcemia, vitamin D analogues should be had clearance of lesions and 43% had sustained remission
limited to 75 g per week in those with less than 30% BSA for one year.5

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 PSORIASIS
TABLE 2

Topical Therapies for Mild to Moderate Psoriasis

Class Dosage Treatment considerations
Topical 2 to 4 times per day, depending on potency High-potency corticosteroids should be limited to 1
corticosteroids Moderate- to high-potency agents have the best agent and used no more than 2 times per day for up to
evidence (number needed to treat = 3 for 50% 4 weeks to reduce risk of adverse effects (acceptable to
improvement in 4 weeks) use for a longer duration on palms and soles)

Use lower-potency agents for face, forearms, and Rebound exacerbation with abrupt withdrawal;​recom-
intertriginous areas mend tapering over 2 weeks (every other day for 1 week,
then 2 times per week, then stop)
Use higher-potency agents for thick, chronic
plaques

Intralesional Triamcinolone acetonide injection, 2.5 to 20 mg Localized, thick lesions on glabrous skin, scalp, nails,
corticosteroids per mL every 3 to 4 weeks palms, and soles that do not improve with treatment
Noted effectiveness when symptoms have not
improved with topical corticosteroids

Vitamin D For body lesions:​apply cream or ointment 1 or 2 When used with topical corticosteroids, it is superior to
analogues times per day either topical alone
(e.g., calcipo- For mild to moderate scalp lesions:​calcipotriene Long onset of action;​may not see benefit for 6 to 8 weeks
triene, topical foam or calcipotriene/betamethasone dipropio- When used with methotrexate, it can lead to lower
calcitriol) nate gel applied 2 times per day for 4 to 12 weeks cumulative doses of methotrexate and increased time to
relapse after stopping
Apply after sun exposure or phototherapy to prevent
inactivation of drug

Calcineurin Apply 2 times per day to affected areas Commonly used as maintenance therapy
inhibitors (e.g., Use is off label for psoriasis but randomized con- Regular application minimizes corticosteroid use on
tacrolimus, trolled trials show superiority vs. placebo thinner skin (e.g., face, intertriginous areas, forearms)
pimecrolimus)
Considered first line for facial and flexural psoriasis Do not use with occlusive dressing
Pimecrolimus is ineffective for intertriginous
psoriasis48

Topical ret- Cream or gel used nightly on affected areas When used with topical corticosteroids, it increases
inoids (e.g., Good agent for palmar-plantar and nail psoriasis duration of treatment effect and remission time
tazarotene) Successful with phototherapy

Salicylic acid Concentrations of 2% to 6% used 1 time per day, Effectiveness is increased when used with topical corti-
or 2 times per day for thick plaques before topical costeroids or calcineurin inhibitors
corticosteroids or calcineurin inhibitors Reduces effectiveness of phototherapy
For children 5 years and younger:​only use in small Inactivates vitamin D analogues if used in combination
patches and concentrations of 0.5% or less

Note:​Drugs are listed in order of most to least commonly prescribed.

Information from references 1 and 44-50.

Nonbiologic systemic agents should be used only in Physicians should have a high index of suspicion for child-
children with moderate to severe psoriasis that does not hood and adolescent depression and substance use due to
improve with topical therapy or narrowband UVB photo- bullying and shaming.
therapy.5 Methotrexate is the most widely used agent due
to long-term effectiveness and safety data, followed by Fertility, Pregnancy, and Lactation
biologics, such as etanercept in those four years and older, Considerations
and ustekinumab, ixekizumab (Taltz), and secukinumab During pregnancy, about two-thirds of women with psoriasis
(Cosentyx) in children older than six years. Adalimumab will have improvement, and fewer than one-third will have
is not approved by the U.S. Food and Drug Administration increased severity.39 Topicals may be used by patients trying
for use in children. to conceive and during pregnancy because of their minimal

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 PSORIASIS

Contraindications Adverse effects

For nail disease, do not use topical corticosteroids for > 12 Most common:​folliculitis, purpura, skin atrophy, striae,
weeks due to isolated reports of bone atrophy telangiectasia
May use < 60 g per week in pregnancy per expert consensus;​ May worsen acne, folliculitis, perioral dermatitis, and rosacea
do not apply to breast or nipple lesions while breastfeeding Low risk of hypothalamic-pituitary-adrenal axis suppression
due to reports of neonatal hypertension with topical corticosteroids
Greatest chance of adverse effects with ultra high- and
high-potency corticosteroids applied to > 20% body surface
area of skin or under occlusion > 4 weeks

For nail disease, do not use topical corticosteroids for > 12 Most common:​skin atrophy
weeks due to isolated reports of bone atrophy
May use < 60 g per week in pregnancy per expert consensus;​
do not apply to breast or nipple lesions while breastfeeding
due to reports of neonatal hypertension

Avoid concurrent use with oral vitamin D to decrease the risk Most common:​erythema, local burning, peeling, and pruritus
of hypercalcemia Rare:​hypercalcemia/parathyroid hormone suppression (only
Avoid use on the face noted if > 30% body surface area application and > 100 g used
Use with caution in patients with chronic kidney disease or per week)
history of kidney stones No reports of tachyphylaxis with prolonged use
Studies with up to 52 weeks of daily use showed medication
well tolerated by patients

Limited risk during pregnancy Most common:​burning and pruritus immediately following
Avoid application to breasts and nipples while breastfeeding application (resolves with continued use);​avoid applying to
moist skin to prevent burning
U.S. Food and Drug Administration boxed warning:​theoretical
increased risk of lymphoma, but no evidence with topical use Less common:​flushing in areas of application after ethanol
of either agent consumption

Avoid in pregnancy or patients trying to conceive (negative Most common:​burning, local erythema, and pruritus (with
pregnancy test two weeks before use) higher concentrations)
No human data to recommend for or against use in Decreased adverse effects:​cream formulation or combined
breastfeeding use with a moisturizer or topical corticosteroid every other day

Avoid use in patients with kidney or liver impairment or if Most common:​burning, irritation, peeling, pruritus, and
treatment area is > 20% body surface area to prevent salicylate stinging
toxicity Rare:​systemic toxicity (frontal headache, metabolic acidosis,
Inadequate data to evaluate use in pregnancy or breastfeeding nausea, oral mucosa burning, respiratory alkalosis, tinnitus,
Avoid use on face and genitals vomiting)

systemic absorption. However, calcineurin inhibitors should patients. However, there is a dose-dependent reduction in
be used only on less than 1% BSA, and retinoids should not serum folate during narrowband UVB phototherapy. All
be used. Topical corticosteroids should be limited to less than women of childbearing age should take at least 0.8 mg of
60 g per week during pregnancy, although a recent Cochrane folate daily to ensure adequate supplementation.62
review found no causal association between maternal use of Methotrexate requires a three-month washout period
any potency topical corticosteroid and congenital abnormal- before trying to conceive, and it should be avoided in
ity.1 While breastfeeding, topicals must not be applied to the patients who are pregnant or breastfeeding. Although there
breast or skin that comes in contact with the infant. are no human studies, apremilast was associated with tera-
Narrowband UVB phototherapy is safe in men and women togenicity and pregnancy loss in animals. eTable C summa-
who are trying to conceive and pregnant and breastfeeding rizes the safety of nonbiologic and biologic medications in

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 PSORIASIS

patients with psoriasis who are pregnant, breastfeeding, or 5. Menter A, Cordoro KM, Davis DMR, et al. Joint American Academy of
trying to conceive. Dermatology-National Psoriasis Foundation guidelines of care for the
management and treatment of psoriasis in pediatric patients [published
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Data Sources:​A PubMed search was performed in the Clinical
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Queries function using the key terms psoriasis, plaque psoriasis,
Curr Dermatol Rep. 2014;​3(1):​61-78.
guttate psoriasis, and pustular psoriasis. The search was limited
8. Patrick MT, Stuart PE, Zhang H, et al. Causal relationship and shared
to publications from 2012 or later. Meta-analyses, systematic
genetic loci between psoriasis and type 2 diabetes through trans-disease
reviews, randomized controlled trials, clinical trials, NICE guide- meta-analysis. J Invest Dermatol. 2021;​141(6):​1493-1502.
lines, Essential Evidence Plus, and Choosing Wisely recommen-
9. Li Y, Guo J, Cao Z, et al. Causal association between inflammatory
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2022, March through April 2023, and September 16, 2023. domization study. Front Immunol. 2022;​1 3:​916645.
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and do not necessarily represent the official views of the U.S. Air 633-639.
Force, U.S. military at large, U.S. Department of Defense, or U.S.
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The Authors
with psoriasis:​a population-based cohort study. JAMA Dermatol. 2017;​
KATHRYN K. GARNER, MD, FAAFP, is an assistant program 153(12):​1 256-1262.
director in the Family Medicine Residency Program at Mike 14. Ahad T, Agius E. The Koebner phenomenon. Br J Hosp Med (Lond).
O’Callaghan Military Medical Center, Nellis Air Force Base, 2015;​76(11):​C170-C172.
Nev., and an assistant professor in the Department of Family 15. Dupire G, Droitcourt C, Hughes C, et al. Antistreptococcal interventions
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Sciences, Bethesda, Md. 2019;​(3):​CD011571.
16. Green A, Shaddick G, Charlton R, et al.;​PROMPT study group. Modi-
KATTIE D. S. HOY, MD, FAAFP, is the program director in the fiable risk factors and the development of psoriatic arthritis in people
Family Medicine Residency Program at Mike O’Callaghan Mil- with psoriasis. Br J Dermatol. 2020;​182(3):​714-720.
itary Medical Center and an assistant professor in the Depart- 17. Eder L, Haddad A, Rosen CF, et al. The incidence and risk factors for
ment of Family Medicine at the Uniformed Services University psoriatic arthritis in patients with psoriasis:​a prospective cohort study.
Arthritis Rheumatol. 2016;​68(4):​915-923.
of the Health Sciences.
18. Karreman MC, Weel AEAM, van der Ven M, et al. Prevalence of psori-
ADRIANA M. CARPENTER, DO, is a faculty member in the atic arthritis in primary care patients with psoriasis. Arthritis Rheumatol.
2016;​68(4):​924-931.
Family Medicine Residency Program at Mike O’Callaghan Mil-
itary Medical Center and an assistant professor in the Depart- 19. Gupta V, Sharma VK. Skin typing:​Fitzpatrick grading and others. Clin
Dermatol. 2019;​37(5):​430-436.
ment of Family Medicine at the Uniformed Services University
of the Health Sciences. 20. Maruani A, Samimi M, Stembridge N, et al. Non-antistreptococcal inter-
ventions for acute guttate psoriasis or an acute guttate flare of chronic
psoriasis. Cochrane Database Syst Rev. 2019;​(4):​CD011541.
Address correspondence to Kathryn K. Garner, MD, FAAFP, 4700
N. Las Vegas Blvd., Nellis AFB, NV 89191 (Kathryn.k.​garner2.​mil@​ 21. Singh RK, Lee KM, Ucmak D, et al. Erythrodermic psoriasis:​pathophysiol-
ogy and current treatment perspectives. Psoriasis (Auckl). 2016;​6:​93-104.
health.​mil). Reprints are not available from the authors.
22. Carrasquillo OY, Pabón-Cartagena G, Falto-Aizpurua LA, et al. Treat-
ment of erythrodermic psoriasis with biologics:​a systematic review.
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