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Psoriasis: Recognition and Management Strategies

Kathryn K. Garner, MD
Kattie D. S. Hoy, MD
Adriana M. Carpenter, DO

American Family Physician. 2023;108(6):562-573.

Author disclosure: No relevant financial relationships.

Patient information: A related handout on psoriasis is available.

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 infectious 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. Psoriasis 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 conceive.

Psoriasis is an inflammatory skin and systemic disorder that affects 3.2% of the U.S. population, including 1% of children.1 In adults with psoriasis, 90% have plaque psoriasis.2 Up to 30% of adults with plaque psoriasis develop psoriatic arthritis, with a median onset of 10 to 11 years following the development of skin abnormalities.3 However, one prospective study showed that arthritic symptoms preceded skin findings in 19.4% of adults. In children, arthritis may precede skin findings by two to three years with bimodal age presentation at two to three years and 10 to 12 years.4,5

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comments
All patients with psoriasis should be screened for metabolic syndrome and, if positive, treated to decrease the severity of psoriasis.12 C Systematic review and meta-analysis of observational studies
Topical corticosteroids are first-line treatment for all forms of mild to moderate psoriatic skin disease and are often combined with vitamin D analogues. The combination of corticosteroids and vitamin D analogues performed better than either agent alone.44 A Systematic review
Calcipotriene foam and calcipotriene/betamethasone dipropionate gel should be used for four to 12 weeks for the treatment of mild to moderate scalp psoriasis.51–53 A Randomized controlled trials
Systemic agents can generally be considered when the involved body surface area exceeds 5%.38,57,58 C Multiple consensus guidelines
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, switching to another systemic treatment is recommended.59 B Prediction rule developed from a large randomized controlled trial
For procedures with a moderate risk of postoperative infection (e.g., intra-abdominal surgery without bowel resection, intrathoracic surgery without lung resection, gynecologic surgery) or those with a high risk of infection (e.g., joint replacement, oncologic surgery, bowel resection), systemic therapies usually require cessation and should be discussed with the surgical team.38 C Consensus guidelines and narrative review

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

KATHRYN K. GARNER, MD, FAAFP, is an assistant program director in the Family Medicine Residency Program at Mike O’Callaghan Military Medical Center, Nellis Air Force Base, Nev., and an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md.

KATTIE D. S. HOY, MD, FAAFP, is the program director in the Family Medicine Residency Program at Mike O’Callaghan Military Medical Center and an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

ADRIANA M. CARPENTER, DO, is a faculty member in the Family Medicine Residency Program at Mike O’Callaghan Military Medical Center and an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

Address correspondence to Kathryn K. Garner, MD, FAAFP, 4700 N. Las Vegas Blvd., Nellis AFB, NV 89191 (Kathryn.k.garner2.mil@health.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial relationships.

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