The clinical spectrum of psoriasis
Introduction
Psoriasis is a chronic relapsing skin disease. The diagnosis is usually made on clinical grounds by a “visually literate” clinician.1 In view of wide variations in morphology of clinical lesions and course, it is rather surprising that clinicians usually agree on what constitutes psoriasis.2 Limiting psoriasis to a problem on the skin is a rather restrictive approach. Psoriasis deeply affects well-being and has emotional and relational consequences that go far beyond the skin.3 In addition, a link has been repeatedly suggested between the inflammatory process sustaining psoriasis and metabolic derangements.4, 5, 6 A number of diseases have been associated with psoriasis; in particular, arthritic manifestations in so-called psoriatic arthritis.7 A holistic approach, including education and psychologic support, is needed for optimal care of psoriatic patients. The main aim of the treatment is to reduce the burden of the disease over time by controlling symptoms, helping the patient to cope with the chronic nature of the disease, limiting psychologic and relational consequences, and preventing systemic complications and comorbidity. The presentation and clinical course of psoriasis show wide variations, from subtle minimal signs to generalized skin involvement.8 A better knowledge of factors affecting disease severity may allow for the application of a preventive approach. Such an approach has been advocated decades ago by Farber and Nall,9 under the label of “disability prevention.”
This review will summarize clinical features and diagnostic and severity criteria of psoriasis. An evidence-based approach will be tentatively adopted when discussing these issues.
Section snippets
Disease onset
The onset of psoriasis may be abrupt as in guttate psoriasis or may follow a slowly progressive course. Early subtle signs exist, and skin lesions may be reversible. As a consequence, criteria are clearly needed to define onset. The first diagnosis made by a physician and the first appearance of skin lesions as reported by the patient have been taken as markers of onset in epidemiological and clinical studies.10 This is a rather unsatisfactory indicator, but no better alternatives are available.
Latent, minimal, and overt psoriasis
A disease gradation exists among psoriatic patients and in the same individual over time, ranging from apparently healthy to minor signs to overt clinical manifestations. At present, the diagnosis of “latent psoriasis” in individuals without a previous history of the disease remains impossible because no diagnostic test is available to predict future psoriasis development. The diagnosis of “minimal psoriasis,” on the other hand, is prone to large variations in the lack of validated criteria.
Classifying psoriasis: the spectrum of clinical varieties
From a practical point of view, the act of making a clinical diagnosis has been described as “classification for a purpose.” It involves the recognition of the class or group to which the patient's illness belongs so that, based on previous collective experience with that class, the subsequent clinical acts will maximize that patient's health.16 The collective experience is represented by structured clinical and epidemiological research, providing sound data for disease management.
At the actual
Beyond the skin: associated features
There is evidence that the clinical impact of psoriasis is not limited to the skin. Arthritis is an established association of psoriasis. Psoriatic arthritis has been defined as “an inflammatory arthritis occurring during the course of psoriasis and characterized by negative rheumatoid factor.”7, 18 In spite of the fact that psoriatic arthritis represents in clinical series a proportion as high as 25% of all patients, population-based estimates suggest that no more than 4% to 5% of psoriatic
Severity grading
Severity assessment implies an understanding of the many influences of the disease on the patient's life, including the most ominous one, death, and other less extreme consequences such as disease-associated discomfort, level of disability, and social disruption.49 Most of these influences, with the remarkable exception of death, are better expressed as a continuum of severity rather than a yes-or-no phenomenon. Nonetheless, there are practical advantages in trying to translate the continuum
Clinical course and prognosis
Psoriasis is a disorder with a relatively high prevalence in the general population, mainly as a result of its chronicity and the absence of a cure. Because psoriasis is present throughout life, when examining population data, it is expected that point prevalence and lifetime prevalence would increase with age. On the contrary, in many studies, prevalence does not increase with age and even decreases.10 The most obvious deduction from these data is that mortality among psoriatic patients may be
What for the future?
In spite of advancements in understanding pathogenesis and treatment options, psoriasis still remains a rather elusive and even enigmatic disease. Standardized diagnostic criteria should be developed and refined by establishing relations with identifiable risk factors, including genotype-phenotype correlations. There is a need for a better clinimetrics of disease severity taking into account the many influences of the disease on the patient's life. Once developed, measures should be applied in
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