Psoriasis: A Primary Care Primer

April 30, 2018

Veronica Hackethal, MD

Most patients seen in primary care have mild to moderate plaque psoriasis, which is usually treatable with topical therapies.

References1. Tucker R. Assessment and management of psoriasis in adults in primary care. The Pharmaceutical Journal. March 2018. Accessed April 26, 2018.2. Weigle N, McBane S. Psoriasis. Am Fam Physician. 2013;87:626-633. Accessed April 26, 2018.3. Menter A, Korman NJ, Elmets CA, et al, for the American Academy of Dermatology. Guidelines of care for the management of psoriasis and psoriatic arthritis. Section 3. Guidelines of care for the management and treatment of psoriasis with topical therapies. J Am Acad Dermatol. 2009;60:643-659. doi: 10.1016/j.jaad.2008.12.032.4. Wilson F, Icen M, Crowson C, et al. Incidence and clinical predictors of psoriatic arthritis in patients with psoriasis: a population-based study. Arthritis Rheum. 2009;61:233-239.5. Lakshmy S, Balasundaram S, Sarkar S, et al. A cross-sectional study of prevalence and implications of depression and anxiety in psoriasis. Indian J Psychol Med. 2015;37:434-440. doi: 10.4103/0253-7176.1685876. National Psoriasis Foundation. About psoriasis. Accessed April 26, 2018.

A patient comes into your office with a red, scaly, itchy rash on his elbows. Closer examination reveals nail pitting as well. Like most patients with plaque psoriasis, he has mild to moderate disease that can usually be treated with topical therapies in primary care.

Click through the slides for a quick overview of psoriasis, including classic symptoms, common comorbidities, assessment of affected body surface area, and treatment options.

(Photo credit: ©Hriana/Shutterstock.com)

Psoriasis affects about 2% of the US population, and the prevalence among men and women is approximately equal.¹ This skin condition usually presents between the ages of 15 and 25 years. Smoking, alcohol, high BMI, and stress all increase risk; however, lifestyle modification may improve symptoms.

Plaque psoriasis is the most common type (about 90% of cases), and 80% of patients have mild to moderate disease, which is treatable with topical therapies.^2,3 Other types of psoriasis are guttate, pustular, inverse/flexural, palmoplantar pustular, and erythrodermic.

Plaque psoriasis is characterized by well-defined, erythematous, silvery-white hyperkeratotic scaling plaques on the extensor surfaces and/or scalp. Nail changes include pitting, keratin buildup under the nail, and separation of the nail from its bed. In children, scaling is less prominent and facial lesions are common. Plaque psoriasis has a relapsing, remitting course.

Comorbidities of psoriasis include psoriatic arthritis, depression and anxiety, and cardiovascular disease (CVD).

^a Surface area of the palm and five fingers is about 1% of total BSA.

Psoriasis is evaluated by the percent of total body surface area (BSA) affected and the Psoriasis Area Severity Index (PASI), which assesses severity in four body regions. A PASI calculator is available at http://www.pasitraining.com/calculator/step_1.php.

Among the topical agents used to treat psoriasis are corticosteroids, vitamin D analogues, anthralin, coal tar, and tazarotene.

DMARD, disease-modifying antirheumatic drug; OTC, over the counter.

In addition to topical agents, treatment of psoriasis in the primary care setting can include adjunctive emollients, shampoos, diet, and sunlight exposure. Specialist referral is recommended for patients with severe disease.