Clinical Patterns

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Several clinical patterns in psoriasis are recognized. The most common is chronic plaque psoriasis in which there are erythematous plaques of psoriasis with an overlying silvery scale usually affecting the elbows, knees, and at times, the scalp and lower back (Fig. 1). Guttate psoriasis, which may be precipitated by a streptococcal infection of the throat, is characterized by numerous small, scaling erythematous plaques on the trunk and limbs. Psoriasis may also affect the flexures and may cause a glazed erythematous appearance similar to that seen in seborrheic eczema.

Erythrodermic psoriasis is characterized by severe erythema affecting the whole of the patient's skin. This may develop following deterioration of the patient's psoriasis or be precipitated by use of potent topical or systemic steroids. There may be associated systemic symptoms, and the patient is at risk from hypothermia owing to excessive heat loss, dehydration, and cardiac failure.

Figure 1 A large plaque of psoriasis on the trunk: There is erythema with overlying silvery scale.

Generalized pustular psoriasis is another rare, but extremely serious, type of psoriasis in which the patient has widespread areas of erythema with overlying sheets of sterile pustules. Localized pustular psoriasis may also affect the palms and soles.

The nails may be involved in psoriasis, and patients may develop pitting or lifting of the nail plate from the nail bed (onycholysis). Patients may also present with gross thickening of the nails owing to subungual hyperkeratosis.

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