Psoriasis Risks and Variants: Educating Patients to Optimize Outcomes

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Welcome to DermConsult on ReachMD. On this episode, we’ll hear from Dr. Jenny Murase, who’s the Director of Medical Consultative Dermatology at the Palo Alto Foundation Medical Group and Associate Clinical Professor of Dermatology at the University of California, San Francisco. She’ll be discussing how to talk to patients about psoriasis. Here’s Dr. Murase now.

Dr. Murase: 
I think that during every psoriasis office visit when a patient is following up on a biologic agent, or some kind of other oral systemic treatment, or phototherapy, it’s really important for the clinicians to mention two points to their patients. The first is that the risk of developing psoriatic arthritis—so inflammation of the joints—would occur at any point. It’s not like the risk stabilizes over time, so with every single visit, it’s important to ask about the onset of new joint pain so that they can be connected to a rheumatologist if needs be. Usually, psoriasis precedes the psoriatic arthritis. The average is about 10 years. And there can be permanent damage to joints if the joint pain goes unchecked and the inflammation goes unchecked, so that’s important to ask about. And then the second is that patients with chronic plaque psoriasis do have an increased risk of cardiovascular disease, so it’s very important for clinicians to make sure that their patients have had a lipid panel and understand that it’s more important for their triglycerides and cholesterol levels to be normal than the average patient. 

I think that psoriasis in general is oftentimes thought of as these thick silver plaques on the elbows and knees, and maybe the back of the scalp. Those are common areas to be involved, but there are other variants of psoriasis that can look very different. So, for example, inverse psoriasis can present where there’s involvement in the armpits or in the groin area. You can get erythrodermic psoriasis, where the whole body is covered in a red rash, and you can also get patterns like palmoplantar psoriasis that has almost a pustular variant, where you get little white pustules filled with pus. And it can also affect the nails, only sometimes. When it does affect the nails, there’s an increased risk of arthritis, so it’s even more important to ask about symptoms of joint pain in patients with nail involvement. 

And so it can have a variety of different manifestations and sometimes be misinterpreted as infection. And that’s particularly true for the palmoplantar variant, where, if there’s pustules on the hands, patients will think that they have a bacterial infection for example. If it involves the tip of a finger, we have a special name for that: acrodermatitis of Hallopeau. And when it affects the tip of the finger, it can have a lot of pustules and almost look like what we call paronychia, which is inflammation of the distal portion of the finger. And in addition, it can be mistaken for onychomycosis, which is a fungal infection of the toenails or the fingernails. 

And so I think that going into a dermatologist is helpful because the dermatologists have tests and also a visual exam that can help distinguish a chronic inflammation from psoriasis from an infectious process. 

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That was Dr. Jenny Murase talking about counseling psoriasis patients to optimize care. To access this and other episodes in our series, visit DermConsult on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!