Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

Clinical Features and Genetic Polymorphism in Chinese Patients with Erythrodermic Psoriasis in a Single Dermatologic Clinic



Erythrodermic psoriasis (EP) is a rare variant of psoriasis that involves more complications and poorer biologic drug survival than plaque-type psoriasis vulgaris (PV). No prior study has explored human leukocyte antigen (HLA) or other genetic polymorphisms in patients with EP.


Our objective was to describe the clinical features, comorbidities, and HLA polymorphisms among Chinese patients with EP.


We enrolled consecutive patients with EP from our clinic, with EP defined as generalized confluent erythematous thin plaques covering at least 80% body surface area. Patients were categorized as having primary or secondary EP. Aggravating factors, comorbidities including psoriatic arthritis, family history of psoriasis, age of onset, and treatment history were also identified. Genetic studies were performed for HLA-C and HLA-DRB1, and the results were compared with those from a healthy population and patients with PV.


Of the 63 included patients, the male to female ratio was 2.71:1. Five (7.9%) patients had primary EP, and 58 (92.1%) had secondary EP. Genotyping of HLA-C and HLA-DRB1 was available in 61 and 58 subjects, respectively. HLA-C*0102 was the most frequent HLA-C allele (34.4%), followed by HLA-C*0702 (18.0%). The frequency of HLA-C*0602 allele (4.1%) was lower than in patients with plaque-type psoriasis (4.1 vs. 16.3%, corrected p value [Pc] = 0.02) and similar to that in the healthy population in Taiwan. The most frequent HLA-DRB1 allele was HLA-DRB1*0901 (20.7%), followed by HLA-DRB1*0803 (13.8%). An increased prevalence of psoriatic arthritis (61.9%) and higher male predominance were also noted in comparison with PV.


There are HLA differences in Chinese patients with EP compared with patients with PV. The incidence of psoriatic arthritis is also higher. The implications of the above findings await further investigation.

This is a preview of subscription content, log in to check access.


  1. 1.

    Chen L, Tsai TF. HLA-Cw6 and psoriasis. Br J Dermatol. 2018;178:854–62.

  2. 2.

    Henseler T, Koch F, Westphal E. Presence of HLA- DR7 in type I psoriasis. J Invest Dermatol. 1992;98:607.

  3. 3.

    Tsai TF, Hu CY, Tsai WL, Chu CY, Lin SJ, Liaw SH, et al. HLA-Cw6 specificity and polymorphic residues are associated with susceptibility among Chinese psoriatics in Taiwan. Arch Dermatol Res. 2002;294:214–20.

  4. 4.

    Noda S, Suárez-Fariñas M, Ungar B, Kim SJ, de Guzman Strong C, Xu H, et al. The Asian atopic dermatitis phenotype combines features of atopic dermatitis and psoriasis with increased TH17 polarization. J Allergy Clin Immunol. 2015;136:1254–64.

  5. 5.

    Kim J, Oh CH, Jeon J, Baek Y, Ahn J, Kim DJ, et al. Molecular phenotyping small (Asian) versus large (Western) plaque psoriasis shows common activation of IL-17 pathway genes but different regulatory gene sets. J Invest Dermatol. 2016;136:161–72.

  6. 6.

    Mallon E, Bunce M, Savoie H, Rowe A, Newson R, Gotch F, et al. HLA-C and guttate psoriasis. Br J Dermatol. 2000;143:1177–82.

  7. 7.

    Wang TS, Chiu HY, Hong JB, Chan CC, Lin SJ, Tsai TF. Correlation of IL36RN mutation with different clinical features of pustular psoriasis in Chinese patients. Arch Dermatol Res. 2016;308:55–63.

  8. 8.

    Chen K, Wang G, Jin H, Xu J, Zhu X, Zheng M, et al. Clinic characteristics of psoriasis in China: a nationwide survey in over 12,000 patients. Oncotarget. 2017;8:46381–9.

  9. 9.

    Yan D, Afifi L, Jeon C, Cordoro KM, Liao W. A cross-sectional study of the distribution of psoriasis subtypes in different ethno-racial groups. Dermatol Online J. 2018;24:4.

  10. 10.

    Saeki H, Nakagawa H, Nakajo K, Ishii T, Morisaki Y, Aoki T, et al. Efficacy and safety of ixekizumab treatment for Japanese patients with moderate to severe plaque psoriasis, erythrodermic psoriasis and generalized pustular psoriasis: results from a 52-week, open-label, phase 3 study (UNCOVER-J). J Dermatol. 2017;44:355–62.

  11. 11.

    Okubo Y, Mabuchi T, Iwatsuki K, Elmaraghy H, Torisu-Itakura H, Morisaki Y, et al. Long-term efficacy and safety of ixekizumab in Japanese patients with erythrodermic or generalized pustular psoriasis: subgroup analyses of an open-label, phase 3 study (UNCOVER-J). J Eur Acad Dermatol Venereol. 2019;33:325–32.

  12. 12.

    Meier M, Sheth PB. Clinical spectrum and severity of psoriasis. Curr Probl Dermatol. 2009;38:1–20.

  13. 13.

    Raychaudhuri SK, Maverakis E, Raychaudhuri SP. Diagnosis and classification of psoriasis. Autoimmun Rev. 2014;13:490–5.

  14. 14.

    Chen PL, Fann CS, Chu CC, Chang CC, Chang SW, Hsieh HY, et al. Comprehensive genotyping in two homogeneous Graves’ disease samples reveals major and novel HLA association alleles. PLoS One. 2011;6:e16635.

  15. 15.

    Singh RK, Lee KM, Ucmak D, Brodsky M, Atanelov Z, Farahnik B, et al. Erythrodermic psoriasis: pathophysiology and current treatment perspectives. Psoriasis. 2016;6:93–104.

  16. 16.

    Dupont WD, Plummer WD Jr. Power and sample size calculations. A review and computer program. Control Clin Trials. 1990;11:116–28.

  17. 17.

    Gelfand JM, Weinstein R, Porter SB, Neimann AL, Berlin JA, Margolis DJ. Prevalence and treatment of psoriasis in the United Kingdom: a population-based study. Arch Dermatol. 2005;141:1537–41.

  18. 18.

    Parisi R, Symmons DP, Griffiths CE, Ashcroft DM. Global epidemiology of psoriasis: a systematic review of incidence and prevalence. J Invest Dermatol. 2013;133:377–85.

  19. 19.

    Tsai TF, Wang TS, Hung ST, Tsai PI, Schenkel B, Zhang M, et al. Epidemiology and comorbidities of psoriasis patients in a national database in Taiwan. J Dermatol Sci. 2011;63:40–6.

  20. 20.

    Wang TS, Hsieh CF, Tsai TF. Epidemiology of psoriatic disease and current treatment patterns from 2003 to 2013: a nationwide, population-based observational study in Taiwan. J Dermatol Sci. 2016;84:340–5.

  21. 21.

    Mohd Affandi A, Khan I, Ngah Saaya N. Epidemiology and clinical features of adult patients with psoriasis in Malaysia: 10-year review from the Malaysian Psoriasis Registry (2007–2016). Dermatol Res Pract. 2018;2018:4371471.

  22. 22.

    Boyd AS, Menter A. Erythrodermic psoriasis. Precipitating factors, course, and prognosis in 50 patients. J Am Acad Dermatol. 1989;21:985–91.

  23. 23.

    Chen HS, Tseng MP, Tsai TF. An epidemiologic study of Taiwanese psoriatic patients in a single clinic. Dermatol Sinica. 2003;21:216–24.

  24. 24.

    Yeh MH, Tsai TF. Clinical analysis of psoriatic inpatients: a 10-year retrospective study. Dermatol Sinica. 2007;25:103–11.

  25. 25.

    Zhang P, Chen HX, Duan YQ, Wang WZ, Zhang TZ, Li JW, et al. Analysis of Th1/Th2 response pattern for erythrodermic psoriasis. J Huazhong Univ Sci Technol Med Sci. 2014;34:596–601.

  26. 26.

    Moy AP, Murali M, Kroshinsky D, Duncan LM, Nazarian RM. Immunologic overlap of helper T-Cell subtypes 17 and 22 in erythrodermic psoriasis and atopic dermatitis. JAMA Dermatol. 2015;151:753–60.

  27. 27.

    Bressan AL, Picciani BLS, Azulay-Abulafia L, Fausto-Silva AK, Almeida PN, Cunha KSG, et al. Evaluation of ICAM-1 expression and vascular changes in the skin of patients with plaque, pustular, and erythrodermic psoriasis. Int J Dermatol. 2018;57:209–16.

  28. 28.

    Mansur AT, Göktay F, Yaşar SP. Peripheral blood eosinophilia in association with generalized pustular and erythrodermic psoriasis. J Eur Acad Dermatol Venereol. 2008;22:451–5.

  29. 29.

    Li LF, Sujan SA, Yang H, Wang WH. Serum immunoglobulins in psoriatic erythroderma. Clin Exp Dermatol. 2005;30:125–7.

  30. 30.

    Green MS, Prystowsky JH, Cohen SR, Cohen JI, Lebwohl MG. Infectious complications of erythrodermic psoriasis. J Am Acad Dermatol. 1996;34:911–4.

  31. 31.

    Wang TS, Tsai TF. Clinical experience of ustekinumab in the treatment of erythrodermic psoriasis: a case series. J Dermatol. 2011;38:1096–9.

  32. 32.

    Weng HJ, Wang TS, Tsai TF. Clinical experience of secukinumab in the treatment of erythrodermic psoriasis: a case series. Br J Dermatol. 2018;178:1439–40.

  33. 33.

    Lo Y, Tsai TF. Clinical experience of ixekizumab in the treatment of patients with history of chronic erythrodermic psoriasis who failed secukinumab: a case series. Br J Dermatol. 2019.

  34. 34.

    Tsai YC, Tsai TF. Sparing of injection sites in patients with extensive psoriasis treated with various biologics. Dermatol Sinica. 2000.

  35. 35.

    Rosenbach M, Hsu S, Korman NJ, Lebwohl MG, Young M, Bebo BF Jr, et al. Treatment of erythrodermic psoriasis: from the medical board of the National Psoriasis Foundation. J Am Acad Dermatol. 2010;62:655–62.

  36. 36.

    Ejaz A, Raza N, Iftikhar N, Iftikhar A, Farooq M. Presentation of early onset psoriasis in comparison with late onset psoriasis: a clinical study from Pakistan. Indian J Dermatol Venereol Leprol. 2009;75:36–40.

  37. 37.

    Ye F, Gui X, Wu C, Yu X, Jin H. Severity evaluation and prognostic factors in erythrodermic psoriasis. Eur J Dermatol. 2018;28:851–3.

  38. 38.

    Zhang P, Chen HX, Xing JJ, Jin Z, Hu F, Li TL, et al. Clinical analysis of 84 cases of erythrodermic psoriasis and 121 cases of other types of erythroderma from 2010 to 2015. J Huazhong Univ Sci Technol Med Sci. 2017;37:563–7.

  39. 39.

    Christensen TE, Callis KP, Papenfuss J, Hoffman MS, Hansen CB, Wong B, et al. Observations of psoriasis in the absence of therapeutic intervention identifies two unappreciated morphologic variants, thin-plaque and thick-plaque psoriasis, and their associated phenotypes. J Invest Dermatol. 2006;126:2397–403.

  40. 40.

    Gelfand JM, Gladman DD, Mease PJ, Smith N, Margolis DJ, Nijsten T, et al. Epidemiology of psoriatic arthritis in the population of the United States. J Am Acad Dermatol. 2005;53:573.

  41. 41.

    Alamanos Y, Voulgari PV, Drosos AA. Incidence and prevalence of psoriatic arthritis: a systematic review. J Rheumatol. 2008;35:1354–8.

  42. 42.

    Ohara Y, Kishimoto M, Takizawa N, Yoshida K, Okada M, Eto H, et al. Prevalence and clinical characteristics of psoriatic arthritis in Japan. J Rheumatol. 2015;42:1439–42.

  43. 43.

    Shin D, Kim HJ, Kim DS, Kim SM, Park JS, Park YB, et al. Clinical features of psoriatic arthritis in Korean patients with psoriasis: a cross-sectional observational study of 196 patients with psoriasis using psoriatic arthritis screening questionnaires. Rheumatol Int. 2016;36:207–12.

  44. 44.

    Tsai YC, Tsai TF. A review of clinical trials of biologic agents and small molecules for psoriasis in Asian subjects. G Ital Dermatol Venereol. 2016;151:412–31.

  45. 45.

    Pérez-Plaza A, Carretero G, Ferrandiz C, Vanaclocha F, Gómez-García FJ, Herrera-Ceballos E, et al. Comparison of phenotype, comorbidities, therapy and adverse events between psoriatic patients with and without psoriatic arthritis. Biobadaderm registry. J Eur Acad Dermatol Venereol. 2017;31:1021–8.

  46. 46.

    Christophers E, Barker JN, Griffiths CE, Daudén E, Milligan G, Molta C, et al. The risk of psoriatic arthritis remains constant following initial diagnosis of psoriasis among patients seen in European dermatology clinics. J Eur Acad Dermatol Venereol. 2010;24:548–54.

  47. 47.

    Eder L, Haddad A, Rosen CF, Lee KA, Chandran V, Cook R, et al. The incidence and risk factors for psoriatic arthritis in patients with psoriasis: a prospective cohort Study. Arthritis Rheumatol. 2016;68:915–23.

  48. 48.

    Scher JU, Ogdie A, Merola JF, Ritchlin C. Preventing psoriatic arthritis: focusing on patients with psoriasis at increased risk of transition. Nat Rev Rheumatol. 2019;15:153–66.

  49. 49.

    Rouzaud M, Sevrain M, Villani AP, Paul C, Richard MA, Jullien D, et al. Is there a psoriasis skin phenotype associated with psoriatic arthritis? Systematic literature review. J Eur Acad Dermatol Venereol. 2014;28:17–26.

  50. 50.

    Wittkowski KM, Leonardi C, Gottlieb A, Menter A, Krueger GG, Tebbey PW, et al. Clinical symptoms of skin, nails, and joints manifest independently in patients with concomitant psoriasis and psoriatic arthritis. PLoS One. 2011;6:e20279.

  51. 51.

    Ikäheimo I, Tiilikainen A, Karvonen J, Silvennoinen-Kassinen S. HLA risk haplotype Cw6, DR7, DQA1*0201 and HLA-Cw6 with reference to the clinical picture of psoriasis vulgaris. Arch Dermatol Res. 1996;288:363–5.

  52. 52.

    Ikaheimo I, Silvennoinen-Kassinen S, Karvonen J, Jarvinen T, Tiilikainen A. Immunogenetic profile of psoriasis vulgaris: association with haplotypes A2, B13, Cw6, DR7, DQA1*0201 and A1, B17, Cw6, DR7, DQA1*0201. Arch Dermatol Res. 1996;288:63–7.

  53. 53.

    Bojko A, Ostasz R, Białecka M, Klimowicz A, Malinowski D, Budawski R, et al. IL12B, IL23A, IL23R and HLA-C*06 genetic variants in psoriasis susceptibility and response to treatment. Hum Immunol. 2018;79:213–7.

  54. 54.

    Gladman DD, Farewell VT. The role of HLA antigens as indicators of disease progression in psoriatic arthritis. Multivariate relative risk model. Arthritis Rheum. 1995;38:845–50.

  55. 55.

    Gladman DD, Farewell VT, Kopciuk KA, Cook RJ. HLA markers and progression in psoriatic arthritis. J Rheumatol. 1998;25:730–3.

  56. 56.

    Ho PY, Barton A, Worthington J, Plant D, Griffiths CE, Young HS, et al. Investigating the role of the HLA-Cw*06 and HLA-DRB1 genes in susceptibility to psoriatic arthritis: comparison with psoriasis and undifferentiated inflammatory arthritis. Ann Rheum Dis. 2008;67:677–82.

  57. 57.

    Mabuchi T, Ota T, Manabe Y, Ikoma N, Ozawa A, Terui T, et al. HLA-C*12:02 is a susceptibility factor in late-onset type of psoriasis in Japanese. J Dermatol. 2014;41:697–704.

  58. 58.

    Jee SH, Tsai TF, Tsai WL, Liaw SH, Chang CH, Hu CY. HLA-DRB1*0701 and DRB1*1401 are associated with genetic susceptibility to psoriasis vulgaris in a Taiwanese population. Br J Dermatol. 1998;139:978–83.

  59. 59.

    Fan X, Yang S, Sun LD, Liang YH, Gao M, Zhang KY, et al. Comparison of clinical features of HLA-Cw*0602-positive and -negative psoriasis patients in a Han Chinese population. Acta Derm Venereol. 2007;87:335–40.

  60. 60.

    Chiu H, Huang PY, Jee SH, Hu CY, Chou CT, Chang YT, et al. HLA polymorphism among Chinese patients with chronic plaque psoriasis: subgroup analysis. Br J Dermatol. 2012;166:288–97.

  61. 61.

    Stuart PE, Nair RP, Hiremagalore R, Kullavanijaya P, Kullavanijaya P, Tejasvi T, et al. Comparison of MHC class I risk haplotypes in Thai and Caucasian psoriatics shows locus heterogeneity at PSORS1. Tissue Antigens. 2010;76:387–97.

  62. 62.

    Choonhakarn C, Romphruk A, Puapairoj C, Jirarattanapochai K, Romphruk A, Leelayuwat C. Haplotype associations of the major histocompatibility complex with psoriasis in Northeastern Thais. Int J Dermatol. 2002;41:330–4.

  63. 63.

    Kim TG, Lee HJ, Youn JI, Kim TY, Han H. The association of psoriasis with human leukocyte antigens in Korean population and the influence of age of onset and sex. J Invest Dermatol. 2000;114:309–13.

  64. 64.

    Cao K, Song FJ, Li HG, Xu SY, Liu ZH, Su XH, et al. Association between HLA antigens and families with psoriasis vulgaris. Chin Med J (Engl). 1993;106:132–5.

  65. 65.

    Schmitt-Egenolf M, Boehncke WH, Ständer M, Eiermann TH, Sterry W. Oligonucleotide typing reveals association of type I psoriasis with the HLA-DRB1*0701/2, -DQA1*0201, -DQB1*0303 extended haplotype. J Invest Dermatol. 1993;100:749–52.

  66. 66.

    Sin CZ, Wang TS, Chiu HY, Tsai TF. Human leukocyte antigen and demographic characteristics in Chinese patients with active peripheral type psoriatic arthritis who had inadequate response to conventional disease-modifying antirheumatic drugs in a single dermatologic clinic. PLoS One. 2019;14:e0210076.

  67. 67.

    Lin-Chu M, Lin SJ, Chang SL, Tsai SJ, Yang TF. HLA antigens among Chinese in Taiwan: association of Cw1 and Cw3 on the same haplotype. Hum Hered. 1989;39:89–93.

Download references


The authors thank Dr. Pei-Lung Chen for his assistance with collection of data from unrelated healthy controls.

Author information

Correspondence to Tsen-Fang Tsai.

Ethics declarations


No sources of funding were used to conduct this study or prepare this manuscript.

Conflicts of interest

Dr. Tsen‐Fang Tsai has conducted clinical trials for or received honoraria for serving as a consultant for AbbVie, Boehringer Ingelheim, Celgene, Eli Lilly, Galderma, GSK‐Stiefel, Janssen‐Cilag, Leo‐Pharma, Merck, Novartis, Pfizer, and Serono International SA (now Merck Serono International). Dr. Hsien-Yi Chiu has received speaking fees from AbbVie, Novartis Pharmaceuticals Corporation, Eli Lilly, Janssen-Cilag Pharmaceutica, and Pfizer Limited. Dr. Yang Lo has no conflicts of interest that are directly relevant to the content of this article.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOCX 17 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Lo, Y., Chiu, H. & Tsai, T. Clinical Features and Genetic Polymorphism in Chinese Patients with Erythrodermic Psoriasis in a Single Dermatologic Clinic. Mol Diagn Ther 24, 85–93 (2020).

Download citation