Psoriasis Case 1: Limited disease

A 25-year-old woman with a several-year history of psoriasis presents for evaluation. Recently she has noted significant worsening with the onset of colder weather. Previous treatments include coal tar and 2.5% hydrocortisone cream with limited response. She believes that her psoriasis is “ruling her life” because she goes to great lengths to avoid clothing that exposes her psoriasis. She also has started to avoid athletic activities she previously enjoyed, such as tennis, because of concerns of exposing her psoriasis to others and what their reactions may be. Her psoriasis now involves multiple areas of her body including the trunk and all 4 limbs. 

The patient is married, with no children to date. She is anxious to control her psoriasis so that she can regain her feeling of self-confidence and then consider conception within 1 year. She is currently using oral contraceptive pills, does not smoke, and drinks one to two glasses of red wine daily. There are no joint symptoms. The patient works as an exercise instructor, wearing long sleeves, leotards, and sports bras, which on occasion irritate her skin and exacerbate her psoriasis.

Cutaneous examination shows multiple erythematous, well-demarcated plaques with overlying silvery scale involving the elbows, knees, periumbilical area, and back. In addition, there are erythematous, minimally indurated, and nonscaling plaques in the right and left inframammary region, the vulva, and the supragluteal area. No satellite papules or pustules are present. BSA involved with psoriasis is 4%. The scalp, nails, and mucosal surfaces are uninvolved. There is no evident joint swelling, tenderness, or enthesitis (inflammation in the enthesis, the location where tendon, ligament, or joint capsule fibers insert into the bone).

Discussion

Psoriasis has many clinical phenotypes with traditional plaques being by far the commonest presentation. Inverse psoriasis affects intertriginous areas such as the breasts, groin, axillae, and intergluteal clefts.52 Patients frequently present with more than one subtype of psoriasis, as in this case. Secondary candidiasis needs to be considered when psoriasis presents in body folds where moisture is trapped and may complicate the diagnosis and treatment. In this case, the lack of satellite pustules associated with the patient’s intertriginous plaques makes secondary candidal infection unlikely.

The majority of patients with psoriasis have limited involvement, typically defined as less than 5% BSA55; these patients can be effectively treated with topical agents, which have the advantage of being targeted directly to the skin lesions and are generally effective, safe, and well tolerated. Disadvantages of topical therapy include the time required for application, the need for long-term maintenance treatment, and incomplete clearance of lesions, all making adherence to topical regimens a challenge. To encourage the safe and effective use of topical treatments on a long-term basis, it is imperative that patients have individually tailored medical regimens with appropriate education such as verbal and written instructions.

Topical corticosteroids of varying strengths are a first-line treatment for limited psoriasis.52 They are generally used either as monotherapy or in conjunction with nonsteroidal topical agents. Potency can be enhanced with different vehicles, and as needed by occlusion. Caution must be exercised when using occlusive methods, however, as this may result in a significant increase in potency - for example, 0.1% flurandrenolide functions as a class 5 topical corticosteroid when used as a cream but as a class 1 topical corticosteroid when used as a tape52,56 Limitations of topical corticosteroids include the potential for inducing skin atrophy and systemic absorption, especially with the use of higher potency corticosteroids over larger BSA. Although successful treatment of psoriasis often requires the use of more potent topical corticosteroid preparations, care must be taken to balance this need with the risk of these side effects. In many cases, as in this patient, the use of a low-potency topical corticosteroid for standard plaque psoriasis offers little benefit. Efforts to maintain long-term efficacy and to minimize the risks of topical corticosteroids frequently require innovative rotational and combination strategies.

Navigate section 6 of the psoriasis guideline: Case-based review

Citation note

Menter A, Korman NJ, Elmets CA,Feldman SR, Gelfand JM, Gordon KB, Guidelines of care for the management of psoriasis and psoriatic arthritis: section 6. Guidelines of care for the treatment of psoriasis and psoriatic arthritis: case-based presentations and evidence-based conclusions. J Am Acad Dermatol. 2011 Jul;65(1):137-74. 



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