Psoriasis natural history, complications and prognosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2]
Overview
If left untreated, patients with psoriasis may progress to develop psoriatic arthritis, joint erosions, and conjunctivitis. Common complications of psoriasis include depression, psoriatic arthritis, chronic inflammatory bowel disease, non-alcoholic fatty liver disease, celiac disease, sensorineural hearing loss, osteopenia, and osteoarthritis. Psoriasis is a life-long disease that involves multiple relapses and remissions, though symptoms can be controlled with proper medication.
Natural History
The natural history of psoriasis differs according to the clinical sub-type. The symptoms of psoriasis usually develop in the second decade of life, beginning with such symptoms as skin lesions characterized by erythema and scales covering the lesions. The chronicity of psoriasis may cause significant distress for the affected patient, which can lead to a decrease in the patient's quality of life.[1]
Plaque-Type Psoriasis
- Plaque-type psoriasis is a chronic condition involving multiple relapses and remissions along the course of the disease.
- Extracutaneous involvement is common and the most commonly affected sites include joints and eyes.
- Typical presentation is that of plaques which persist on the same site for months to years, along with an asymmetric oligoarthritis with involvement of the distal (DIPs) and proximal (PIPs) interphalangeal joints of the hands and feet. Erosive joint disease usually develops years after joint involvement.
Guttate Psoriasis
- Guttate psoriasis presents with spontaneous remissions occurring over the course of weeks to months. In adults, the lesions of guttate psoriasis may become chronic and progress to plaque-type psoriasis.
- It may be aggravated by extrinsic factors such as smoking, excessive alcohol use, pregnancy, HIV infection, and stress.
Pustular Psoriasis
- Generalized pustular psoriasis is a severe form of psoriasis that can be triggered by:[2]
- Pregnancy
- Rapid withdrawal of corticosteroids
- Infections
- Hypocalcemia
Psoriatic arthritis
Psoriatic arthritis goes through the following stages of progression during its course, defined by the change in clinical damage:[3]
- Stage 1:
- Reflects no damaged joints
- Stage 2:
- One to four damaged joints
- Stage 3:
- Five to nine damaged joints
- Stage 4:
- More than 10 joints
Complications
Individuals with psoriasis may develop the following complications:[4]
- High-output cardiac failure in erythroderma[5]
- Psoriatic arthritis
- Infections
- Cachexy
- Amyloidosis
- Anti-TNF medications given during the management of psoriasis may lead to:
Prognosis
- Psoriasis is a lifelong condition.[6] There is currently no cure but various treatments can help to control the symptoms.
- Many of the most effective agents used to treat severe psoriasis carry an increased risk of significant morbidity including skin cancers, lymphoma, and liver disease. However, the majority of people's experience of psoriasis is that of minor localized patches, particularly on the elbows and knees, which can be treated with topical medication.
- Psoriasis does get worse over time but it is not possible to predict who will go on to develop extensive psoriasis or those in whom the disease may appear to vanish. Individuals will often experience flares and remissions throughout their lives.
- Controlling the signs and symptoms typically requires lifelong therapy.
- Psoriasis is linked to 2.5-fold increased risk for non-melanoma skin cancer in men and women, with no preponderance of any specific histologic subtype of cancer.[7]
Indications for referral to secondary or intermediary care for psoriasis
The Primary Care Dermatology Society and the British Association of Dermatologists suggests that the following groups of patients may require secondary care:[8]
- Diagnostic uncertainty
- Request for further counseling or education, including demonstration of topical treatment
- Failure to respond to appropriately used topical therapy for three months
- Psoriasis at sites that are difficult to treat (scalp, face, palms, soles, genitals) if unresponsive to initial therapy
- Adverse reactions to topical therapies
- Need for systemic therapy and phototherapy
- Disability preventing work or excessive time off work
- Acute unstable psoriasis
- Erythrodermic or generalized pustular psoriasis (emergency referral indicated)
References
- ↑ Rehal B, Modjtahedi BS, Morse LS, Schwab IR, Maibach HI (2011). "Ocular psoriasis". J. Am. Acad. Dermatol. 65 (6): 1202–12. doi:10.1016/j.jaad.2010.10.032. PMID 21550135.
- ↑ Hazarika D (2009). "Generalized pustular psoriasis of pregnancy successfully treated with cyclosporine". Indian J Dermatol Venereol Leprol. 75 (6): 638. doi:10.4103/0378-6323.57743. PMID 19915261.
- ↑ Gladman DD, Antoni C, Mease P, Clegg DO, Nash P (2005). "Psoriatic arthritis: epidemiology, clinical features, course, and outcome". Ann. Rheum. Dis. 64 Suppl 2: ii14–7. doi:10.1136/ard.2004.032482. PMC 1766874. PMID 15708927.
- ↑ Roth PE, Grosshans E, Bergoend H (1991). "[Psoriasis: development and fatal complications]". Ann Dermatol Venereol (in French). 118 (2): 97–105. PMID 2048897.
- ↑ FOX RH, SHUSTER S, WILLIAMS R, MARKS J, GOLDSMITH R, CONDON RE (1965). "CARDIOVASCULAR, METABOLIC, AND THERMOREGULATORY DISTURBANCES IN PATIENTS WITH ERYTHRODERMIC SKIN DISEASES". Br Med J. 1 (5435): 619–22. PMC 2165960. PMID 14245176.
- ↑ Jobling R (2007). "A patient's journey:Psoriasis". Br Med J. 334: 953&ndash, 4. doi:10.1136/bmj.39184.615150.802.
- ↑ Olsen JH, Frentz G, Møller H (1993). "[Psoriasis and cancer]". Ugeskr. Laeg. (in Danish). 155 (35): 2687–91. PMID 8212383.
- ↑ Smith CH, Barker JN (2006). "Psoriasis and its management". BMJ. 333 (7564): 380–4. doi:10.1136/bmj.333.7564.380. PMC 1550454. PMID 16916825.