Psoriasis: Overview and Diagnosis

  • Grace W. KimmelEmail author
  • Mark Lebwohl
Part of the Updates in Clinical Dermatology book series (UCD)


Psoriasis is a chronic, common, inflammatory skin disease. The classic skin lesions can be described as sharply demarcated, scaly, erythematous plaques often found on the extensor surfaces. Several variants of psoriasis have also been described, including palmoplantar, pustular, erythrodermic, and guttate forms. Although psoriasis is usually diagnosed clinically, characteristic histologic findings include hyperkeratosis, parakeratosis, and acanthosis of the epidermis with dilated blood vessels and a lymphocytic infiltrate. Psoriasis is an immune-mediated disease, and although the etiology is not fully understood, genetic and environmental factors have been implicated. Importantly, psoriasis is associated with a number of systemic complications and comorbidities that have a high impact on affected patients.


Psoriasis Diagnosis Histopathology Erythrodermic psoriasis Guttate psoriasis Pustular psoriasis 


  1. 1.
    Lebwohl MG, Bachelez H, Barker J, Girolomoni G, Kavanaugh A, Langley RG, Paul CF, Puig L, Reich K, van de Kerkhof PC. Patient perspectives in the management of psoriasis: results from the population-based Multinational Assessment of Psoriasis and Psoriatic Arthritis Survey. J Am Acad Dermatol. 2014;70(5):871–881.e871–830.CrossRefPubMedGoogle Scholar
  2. 2.
    Rachakonda TD, Schupp CW, Armstrong AW. Psoriasis prevalence among adults in the United States. J Am Acad Dermatol. 2014;70(3):512–6.CrossRefPubMedGoogle Scholar
  3. 3.
    Parisi R, Symmons DP, Griffiths CE, Ashcroft DM. Global epidemiology of psoriasis: a systematic review of incidence and prevalence. J Invest Dermatol. 2013;133(2):377–85.CrossRefPubMedGoogle Scholar
  4. 4.
    Henseler T, Christophers E. Psoriasis of early and late onset: characterization of two types of psoriasis vulgaris. J Am Acad Dermatol. 1985;13(3):450–6.CrossRefPubMedGoogle Scholar
  5. 5.
    Andressen C, Henseler T [Inheritance of psoriasis. Analysis of 2035 family histories]. Hautarzt. 1982;33(4):214–7.Google Scholar
  6. 6.
    Menter A, Gottlieb A, Feldman SR, van Voorhees AS, Leonardi CL, Gordon KB, Lebwohl M, Koo JYM, Elmets CA, Korman NJ, 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;58(5):826–50.CrossRefPubMedGoogle Scholar
  7. 7.
    Krueger G, Koo J, Lebwohl M, Menter A, Stern RS, Rolstad T. The impact of psoriasis on quality of life: results of a 1998 National Psoriasis Foundation patient-membership survey. Arch Dermatol. 2001;137(3):280–4.PubMedGoogle Scholar
  8. 8.
    Pariser D, Schenkel B, Carter C, Farahi K, Brown TM, Ellis CN. A multicenter, non-interventional study to evaluate patient-reported experiences of living with psoriasis. J Dermatolog Treat. 2016;27(1):19–26.CrossRefPubMedGoogle Scholar
  9. 9.
    Rapp SR, Feldman SR, Exum ML, Fleischer AB Jr, Reboussin DM. Psoriasis causes as much disability as other major medical diseases. J Am Acad Dermatol. 1999;41(3 Pt 1):401–7.CrossRefPubMedGoogle Scholar
  10. 10.
    Lebwohl MG, Kavanaugh A, Armstrong AW, Van Voorhees AS. US perspectives in the Management of Psoriasis and Psoriatic Arthritis: patient and physician results from the population-based multinational assessment of psoriasis and psoriatic arthritis (MAPP) survey. Am J Clin Dermatol. 2016;17:87–97.CrossRefPubMedGoogle Scholar
  11. 11.
    Gottlieb A, Korman NJ, Gordon KB, Feldman SR, Lebwohl M, Koo JYM, Van Voorhees AS, Elmets CA, Leonardi CL, Beutner KR, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 2. Psoriatic arthritis: overview and guidelines of care for treatment with an emphasis on the biologics. J Am Acad Dermatol. 2008;58(5):851–64.CrossRefPubMedGoogle Scholar
  12. 12.
    Sommer DM, Jenisch S, Suchan M, Christophers E, Weichenthal M. Increased prevalence of the metabolic syndrome in patients with moderate to severe psoriasis. Arch Dermatol Res. 2006;298(7):321–8.CrossRefPubMedGoogle Scholar
  13. 13.
    Herron MD, Hinckley M, Hoffman MS, Papenfuss J, Hansen CB, Callis KP, Krueger GG. Impact of obesity and smoking on psoriasis presentation and management. Arch Dermatol. 2005;141(12):1527–34.CrossRefPubMedGoogle Scholar
  14. 14.
    Higgins. Alcohol, smoking and psoriasis. Clin Exp Dermatol. 2000;25(2):107–10.CrossRefPubMedGoogle Scholar
  15. 15.
    Gelfand JM, Neimann AL, Shin DB, Wang X, Margolis DJ, Troxel AB. RIsk of myocardial infarction in patients with psoriasis. JAMA. 2006;296(14):1735–41.CrossRefPubMedGoogle Scholar
  16. 16.
    Mallbris L, Akre O, Granath F, Yin L, Lindelöf B, Ekbom A, Ståhle-Bäckdahl M. Increased risk for cardiovascular mortality in psoriasis inpatients but not in outpatients. Eur J Epidemiol. 2004;19(3):225–30.CrossRefPubMedGoogle Scholar
  17. 17.
    Griffiths CEM, Barker JNWN. Pathogenesis and clinical features of psoriasis. The Lancet. 2007;370(9583):263–71.CrossRefGoogle Scholar
  18. 18.
    Sheu J-J, Wang K-H, Lin H-C, Huang C-C. Psoriasis is associated with an increased risk of parkinsonism: a population-based 5-year follow-up study. J Am Acad Dermatol. 2013;68(6):992–9.CrossRefPubMedGoogle Scholar
  19. 19.
    Mahil SK, Capon F, Barker JN. Update on psoriasis immunopathogenesis and targeted immunotherapy. Semin Immunopathol. 2016;38(1):11–27.CrossRefPubMedGoogle Scholar
  20. 20.
    Basavaraj KH, Ashok NM, Rashmi R, Praveen TK. The role of drugs in the induction and/or exacerbation of psoriasis. Int J Dermatol. 2010;49(12):1351–61.CrossRefPubMedGoogle Scholar
  21. 21.
    Gilleaudeau P, Vallat VP, Carter DM, Gottlieb AB. Angiotensin-converting enzyme inhibitors as possible exacerbating drugs in psoriasis. J Am Acad Dermatol. 1993;28(3):490–2.CrossRefPubMedGoogle Scholar
  22. 22.
    Marquart-Elbaz C, Grosshans E, Lipsker D, Lipsker D. Sartans, angiotensin II receptor antagonists, can induce psoriasis. Br J Dermatol. 2002;147(3):617–8.CrossRefPubMedGoogle Scholar
  23. 23.
    Brauchli YB, Jick SS, Curtin F, Meier CR. Association between beta-blockers, other antihypertensive drugs and psoriasis: population-based case-control study. Br J Dermatol. 2008;158(6):1299–307.CrossRefPubMedGoogle Scholar
  24. 24.
    Schleicher SM. Psoriasis: pathogenesis, assessment, and therapeutic update. Clin Podiatr Med Surg. 2016;33(3):355–66.CrossRefPubMedGoogle Scholar
  25. 25.
    Asumalahti K, Ameen M, Suomela S, Hagforsen E, Michaëlsson G, Evans J, Munro M, Veal C, Allen M, Leman J, et al. Genetic analysis of PSORS1 distinguishes guttate psoriasis and palmoplantar pustulosis. J Investig Dermatol. 2003;120(4):627–32.CrossRefPubMedGoogle Scholar
  26. 26.
    Nair RP, Stuart PE, Nistor I, Hiremagalore R, Chia NVC, Jenisch S, Weichenthal M, Abecasis GR, Lim HW, Christophers E, et al. Sequence and haplotype analysis supports HLA-C as the psoriasis susceptibility 1 gene. Am J Hum Genet. 2006;78(5):827–51.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Tsoi LC, Stuart PE, Tian C, Gudjonsson JE, Das S, Zawistowski M, et al. Large scale meta-analysis characterizes genetic architecture for common psoriasis associated variants. Nat Commun. 2017;24(8):15392.Google Scholar
  28. 28.
    Elder JT, Bruce AT, Gudjonsson JE, Johnston A, Stuart PE, Tejasvi T, Voorhees JJ, Abecasis GR, Nair RP. Molecular dissection of psoriasis: integrating genetics and biology. J Investig Dermatol. 2010;130(5):1213–26.CrossRefPubMedGoogle Scholar
  29. 29.
    Eberle F, Brück J, Holstein J, Hirahara K, Ghoreschi K. Recent advances in understanding psoriasis [version 1; referees: 2 approved]. F1000 Res. 2016:5.CrossRefGoogle Scholar
  30. 30.
    Kim J, Krueger JG. The immunopathogenesis of psoriasis. Dermatol Clin. 2015;33(1):13–23.CrossRefPubMedGoogle Scholar
  31. 31.
    Fredriksson T, Pettersson U. Severe psoriasis—oral therapy with a new retinoid. Dermatology. 1978;157(4):238–44.CrossRefGoogle Scholar
  32. 32.
    Langley RG, Ellis CN. Evaluating psoriasis with psoriasis area and severity index, psoriasis global assessment, and lattice system physician's global assessment. J Am Acad Dermatol. 2004;51(4):563–9.CrossRefPubMedGoogle Scholar
  33. 33.
    Nestle FO, Kaplan DH, Barker J. Psoriasis. N Engl J Med. 2009;361(5):496–509.CrossRefPubMedGoogle Scholar
  34. 34.
    Raposo I, Torres T. Palmoplantar psoriasis and palmoplantar pustulosis: current treatment and future prospects. Am J Clin Dermatol. 2016;17(4):349–58.CrossRefPubMedGoogle Scholar
  35. 35.
    Lisi P. Differential diagnosis of psoriasis. Reumatismo. 2007;59(Suppl 1):56–60.PubMedGoogle Scholar
  36. 36.
    Martin BA, Chalmers RG, Telfer NR. HOw great is the risk of further psoriasis following a single episode of acute guttate psoriasis? Arch Dermatol. 1996;132(6):717–8.CrossRefPubMedGoogle Scholar
  37. 37.
    Varman KM, Namias N, Schulman CI, Pizano LR. Acute generalized pustular psoriasis, von Zumbusch type, treated in the burn unit. A review of clinical features and new therapeutics. Burns. 2014;40(4):e35–9.CrossRefPubMedGoogle Scholar
  38. 38.
    Matsubara M, Komori M, Koishi K, Yasuno H, Ueda K, Seto Y, Nonomura K. Generalized pustular psoriasis and bacteremia. J Dermatol. 1983;10(6):525–9.CrossRefPubMedGoogle Scholar
  39. 39.
    Augey F, Renaudier P, Nicolas JF. Generalized pustular psoriasis (Zumbusch): a French epidemiological survey. Eur J Dermatol. 2006;16(6):669–73.PubMedGoogle Scholar
  40. 40.
    Sharkey MP, Muir JB. Staphylococcal scalded skin syndrome complicating acute generalized pustular psoriasis. Australas J Dermatol. 2002;43(3):199–201.CrossRefPubMedGoogle Scholar
  41. 41.
    Pettey AA, Balkrishnan R, Rapp SR, Fleischer AB, Feldman SR. Patients with palmoplantar psoriasis have more physical disability and discomfort than patients with other forms of psoriasis: implications for clinical practice. J Am Acad Dermatol. 2003;49(2):271–5.CrossRefPubMedGoogle Scholar
  42. 42.
    Sampogna F, Tabolli S, Söderfeldt B, Axtelius B, Aparo U, Abeni D, investigators IDIMPRoVE. Measuring quality of life of patients with different clinical types of psoriasis using the SF-36. Br J Dermatol. 2006;154(5):844–9.CrossRefPubMedGoogle Scholar
  43. 43.
    Yamamoto T. Extra-palmoplantar lesions associated with palmoplantar pustulosis. J Eur Acad Dermatol Venereol. 2009;23(11):1227–32.CrossRefPubMedGoogle Scholar
  44. 44.
    Goeckerman WH, O'Leary PA. Erythroderma psoriaticum: a review of twenty-two cases. J Am Med Assoc. 1932;99(25):2102–5.CrossRefGoogle Scholar
  45. 45.
    Murphy M, Kerr P, Grant-Kels JM. The histopathologic spectrum of psoriasis. Clin Dermatol. 2007;25(6):524–8.CrossRefPubMedGoogle Scholar
  46. 46.
    Green MS, Prystowsky JH, Cohen SR, Cohen JI, Lebwohl MG. Infectious complications of erythrodermic psoriasis. J Am Acad Dermatol. 1996;34(5:911–4.CrossRefGoogle Scholar
  47. 47.
    Syed ZU, Khachemoune A. Inverse psoriasis. Am J Clin Dermatol. 2011;12(2):143–6.CrossRefPubMedGoogle Scholar
  48. 48.
    Fransson J, Storgards K, Hammar H. Palmoplantar lesions in psoriatic patients and their relation to inverse psoriasis, tinea infection and contact allergy. Acta Derm Venereol. 1985;65(3):218–23.PubMedGoogle Scholar
  49. 49.
    Jiaravuthisan MM, Sasseville D, Vender RB, Murphy F, Muhn CY. Psoriasis of the nail: anatomy, pathology, clinical presentation, and a review of the literature on therapy. J Am Acad Dermatol. 2007;57(1):1–27.CrossRefPubMedGoogle Scholar
  50. 50.
    Aydin O, Engin B, Oğuz O, İlvan Ş, Demirkesen C. Non-pustular palmoplantar psoriasis: is histologic differentiation from eczematous dermatitis possible? J Cutan Pathol. 2008;35(2):169–73.PubMedGoogle Scholar
  51. 51.
    Raychaudhuri SK, Maverakis E, Raychaudhuri SP. Diagnosis and classification of psoriasis. Autoimmun Rev. 2014;13(4–5):490–5.CrossRefPubMedGoogle Scholar
  52. 52.
    Lowes MA, Bowcock AM, Krueger JG. Pathogenesis and therapy of psoriasis. Nature. 2007;445(7130):866–73.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of DermatologyIcahn School of Medicine at Mount SinaiNew YorkUSA

Personalised recommendations