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Types of Psoriasis & Physical findings: Findings on physical examination depend on the type of psoriasis.

Plaque [plak] psoriasis is the most common type of the disease (80 %) and is characterized by raised, thickened patches of red skin covered with silvery-white scales. Plaque psoriasis is characterized by raised inflamed lesions covered with a silvery white scale. The scale may be scraped away to reveal inflamed skin beneath. This is most common on the extensor surfaces of the knees, elbows, scalp, and trunk, although it can occur on any area of the skin. Its scientific name is psoriasis vulgaris(vulgaris means common). It may first appear as small red spots. They may enlarge gradually into well-defined patches of red, raised skin called either "plaques" or "lesions." They are covered by a flaky, silvery white buildup called "scale," which is composed of dead skin cells. This scale comes loose and sheds constantly from the plaques. Skin affected with psoriasis is generally very dry, and other possible symptoms include skin pain, itching and cracking.

Guttate [GUH-tate] psoriasis (guttate means drop-like) It is characterized by small, drop-like lesions on the trunk, limbs, and scalp. Guttate psoriasis is most often triggered by bacterial infections (for example, Streptococcus). That usually appear on the trunk, arms, and legs; the lesions may have some scale. It frequently appears suddenly after an upper respiratory infection (URI). Guttate psoriasis is a form of psoriasis that often starts in childhood or young adulthood. The word guttate is from the Latin word meaning "drop." This form of psoriasis resembles small, red, individual spots on the skin. Guttate lesions usually appear on the trunk and limbs. These spots are not normally as thick or as crusty as lesions of plaque psoriasis. Guttate psoriasis often comes on quite suddenly. A variety of conditions have been known to bring on an attack of guttate psoriasis, including upper respiratory infections, streptoccocal infections, tonsillitis, stress, injury to the skin and the administration of certain drugs (including antimalarials and beta-blockers). A streptococcal infection of the throat (strep throat) is a common guttate psoriasis trigger. Strep throat can be present without symptoms and can still cause a flare of guttate psoriasis. Guttate psoriasis may persist despite clearance of the strep infection. Some doctors prescribe antibiotics to help prevent an occurrence of an infection that can cause the outbreak of guttate psoriasis. This form of psoriasis may resolve on its own, occasionally leaving a person free of further outbreaks, or it may clear for a time only to reappear later as patches of plaque psoriasis. Sometimes guttate psoriasis flares in children continue throughout childhood and into adulthood. Persistent cases of guttate psoriasis can be treated with moisturizers or stronger topical medications. Bland moisturizers, such as Eucerin, Cetaphil or petroleum jelly, are considered the preferred treatment during the acute eruptive stage of guttate psoriasis. People with guttate psoriasis often find it tedious to apply topical preparations to the multiple small "drops" on their skin. Phototherapy treatment with ultraviolet light B (UVB) or PUVA (the light-sensitizing drug psoralen plus ultraviolet light A) is very effective for guttate psoriasis.

Inverse psoriasis occurs on the flexural surfaces, armpit, groin, under the breast, and in the skin folds around the genitals and the buttocks and is characterized by smooth, inflamed lesions without scaling. Inverse psoriasis is related to increased sensitivity to friction and sweating and may be painful or itchy. This type of psoriasis first shows up as lesions that are very red and usually lack the scale associated with plaque psoriasis. It may appear smooth and shiny. Inverse psoriasis is particularly subject to irritation from rubbing and sweating because of its location in skin folds and tender areas. It is more common and troublesome in overweight people and people with deep skin folds. Treatment can be difficult due to the sensitivity of skin in these fold areas. Misuse of steroids, particularly in skin folds, can result in side effects, especially thinning of the skin and stretch marks. These areas are prone to yeast and fungal infections.

Pustular psoriasis presents as sterile pustules appearing on the hands and feet or, at times, diffusely, and may cycle through erythema, pustules, and scaling. It is characterized by pus-like blisters. Attacks of pustular psoriasis may be triggered by medications, infections, emotional stress, or exposure to certain chemicals. Primarily seen in adults, pustular [PUHS-choo-ler] psoriasis is characterized by white pustules (blisters of noninfectious pus) surrounded by red skin. The pus consists of white blood cells. It is not an infection, nor is it contagious. This relatively unusual form of psoriasis affects fewer than 5 percent of all people with psoriasis. It may be localized to certain areas of the body–for example, the hands and feet. Pustular psoriasis also can be generalized, covering most of the body. It tends to go in a cycle–reddening of the skin followed by formation of pustules and scaling.

Pustular psoriasis can appear suddenly as the first sign of psoriasis, or plaque psoriasis can turn into pustular psoriasis. Pustular psoriasis reportedly has been triggered by internal medications, irritating topical agents, overexposure to UV light, pregnancy, systemic (oral or injectable) steroids, infections, emotional stress and sudden withdrawal of systemic medications or potent topical steroids.
Several different types of pustular psoriasis exist. The course of any type of pustular psoriasis can vary widely from person to person.

Von Zumbusch: The onset of von Zumbusch pustular psoriasis can be abrupt. Widespread areas of reddened skin develop, and the skin becomes acutely painful and tender. Within as little as a few hours, the pustules appear. The pustules then dry and peel over the next 24 to 48 hours, leaving the skin with a glazed, smooth appearance. A fresh crop of pustules may then appear. Eruptions often come in repeated waves that last days or weeks. Von Zumbusch pustular psoriasis can be triggered by an infection; sudden withdrawal of topical or systemic steroids; pregnancy; and drugs such as lithium, propranolol (Inderal) and other high blood pressure drugs, iodides and indomethacin (Indocin).
A person can have a history of plaque psoriasis and then develop recurrent episodes of von Zumbusch. This form is associated with fever, chills, severe itching, dehydration, a rapid pulse rate, exhaustion, anemia, weight loss and muscle weakness. The goal of treatment is to restore the skin's barrier function, prevent further loss of fluid, stabilize the body's temperature and restore the skin's chemical balance. Chemical imbalances can put excessive stress on the heart and kidneys, especially in older people. Because this form can be life-threatening, medical care must begin immediately. If you are experiencing a flare of von Zumbusch pustular psoriasis, you should immediately take emergency steps or else patient has to be hospitalized immediately for requisite treatment.
People with von Zumbusch pustular psoriasis often require hospitalization for rehydration and initiation of emergency medication.
Von Zumbusch pustular psoriasis can be triggered by the sudden withdrawal of steroids. PUVA may be used once the severe stage of pustulosis and redness has passed.
Von Zumbusch pustular psoriasis rarely appears in children, although when it does, the prospect of improvement may be much better than for adults. It is important to take child to the Hospital as quickly as possible if he/she is suffering from a flare of von Zumbusch pustular psoriasis because of the potential for dehydration.

Palmo-plantar pustulosis (PPP) is a type of pustular psoriasis that generally affects people between the ages of 20 and 60 and causes pustules on the palms of the hands and soles of the feet. There are usually no known trigger factors although, as in guttate psoriasis, infections or stress may occasionally be a factor. This type of psoriasis affects females more than males.
PPP is characterized by multiple pencil eraser-sized pustules in fleshy areas of the hands and feet, such as the base of the thumb and the sides of the heels. The pustules appear in a studded pattern throughout reddened plaques of skin, then turn brown, peel and become crusted. The course of PPP is usually cyclical, with new crops of pustules followed by periods of low activity.
Those who are at risk for PPP should seriously consider not smoking, as some studies suggest that these patients may have an abnormal response to nicotine which can trigger flares of PPP.

Acropustulosis (acrodermatitis continua of Hallopeau)
This rare type of psoriasis is characterized by skin lesions on the ends of the fingers and sometimes on the toes. The eruption occasionally starts after an injury to the skin or infection. Often the lesions are painful and disabling, producing deformity of the nails. Occasionally bone changes occur in severe cases. This form has traditionally been hard to treat.

Erythrodermic [eh-REETH-ro-der-mik] psoriasis presents as generalized erythema, pain, itching, and fine scaling. It characterized by intense redness and swelling of a large part of the skin surface, is often accompanied by itching or pain. Erythrodermic psoriasis may be precipitated by severe sunburn, use of oral steroids (such as cortisone), or a drug-related rash. Erythrodermic psoriasis is a particularly inflammatory form of psoriasis that often affects most of the body surface. It may occur in association with von Zumbusch pustular psoriasis. It generally appears on people who have unstable plaque psoriasis, where lesions are not clearly defined. It is characterized by periodic, widespread, fiery redness of the skin. The erythema (reddening) and exfoliation (shedding) of the skin are often accompanied by severe itching and pain. Patients having an erythrodermic psoriasis flare should make an appointment to see a doctor immediately. Erythrodermic psoriasis "throws off" the body chemistry, causing protein and fluid loss that can lead to severe illness. Edema (swelling from fluid retention), especially around the ankles, may also develop along with infection. The body's temperature regulation is often disrupted, producing shivering episodes. Infection, pneumonia and congestive heart failure brought on by erythrodermic psoriasis can be life threatening. People with severe cases of this condition are often hospitalized. Erythrodermic psoriasis can occur abruptly as the initial sign of psoriasis, or come on more gradually in people with plaque psoriasis. The reason erythrodermic psoriasis appears is not understood, although there are some known triggers. These include abrupt withdrawal of systemic treatment; the use of systemic steroids (cortisone); an allergic, drug-induced rash that brings on the Koebner response (a tendency for psoriasis to appear on the site of skin injuries); and severe sunburns. Initial treatment usually includes moisturizers, combined with wet dressings, oatmeal baths and bed rest. Careful attention is paid to restoring and maintaining fluids in the body and acute correspondence from Homoeopathic Material Medica would help in controlling the episode. Once the erythrodermic flare passes, a person's psoriasis usually reverts to how it looked before the flare and then the features of constitutional disposition start showing the requirement of introducing Genetic Constitutional Similimun.

Scalp psoriasis affects approximately 50% of patients, presenting as erythematous raised plaques with silvery white scales on the scal

Nail psoriasis may cause pits on the nails, which may develop yellowish color and become thickened. Nails may separate from the nail bed. About 50 percent of persons with active psoriasis have psoriatic changes in fingernails and/or toenails. In some instances psoriasis may occur only in the nails and nowhere else on the body. Nail changes in psoriasis fall into general categories that may occur singly or all together:
• The nail plate is deeply pitted or depressed.
• The nail has a yellow to yellow-pink discoloration
• White areas appear under the nail plate. There may be reddened skin around the nail.
• The nail plate crumbles in yellowish patches (onychodystrophy)
• The nail may be entirely lost

Nail psoriasis is frequently associated with psoriatic arthritis
For the most part people with psoriasis can function normally. Sometimes people experience low self-esteem because psoriasis appears unsightly. Psoriasis is often misunderstood by the public, and this can make social interactions awkward. This may lead to emotional problems such as anxiety, anger, embarrassment, and depression.

Causes & Pathology:
It is very well understood about what happens to skin in psoriasis but it is very difficult to say why these changes develop. Although cold climate and some form of injury can aggravate the problem they cannot be labeled as the cause of disease. The precise cause of psoriasis continues to elude the medical fraternity. However, ongoing research in this field has improved our understanding of this disease to some extent. The recent discoveries point to an abnormality in the functioning of key white cells in the blood stream triggering inflammation in the skin. Because of the inflammation, the skin sheds too rapidly, every three to four days.
Psoriasis is not contagious—no one can "catch" it from another person. Because of their genes, certain people are more likely to develop it, but a "trigger" is usually necessary to make psoriasis appear. In realism psoriasis stem from internal disharmony of the body (in terms of disturbed immunity and genetic predisposition) topped with some environmental triggers. These triggers may include emotional stress, injury to the skin, some types of infection and reaction to certain drugs.

1. Defective immune system: Recent research indicates that psoriasis is likely to be a disorder of the immune system. This system includes a type of white blood cell, called a T cell, which normally helps protect the body against infection and disease. Scientists now think that, in psoriasis, an abnormal immune system causes activity by T cells in the skin. These T cells trigger the inflammation and excessive skin cell reproduction seen in people with psoriasis.

2. Genetics and heredity: In about one-third of the cases, psoriasis is inherited. Often, the person with psoriasis has a parent or grandparent who also has the condition. In terms of probability it has been estimated that a person with one affected parent has about a 10% chance of also being affected. Having two parents with psoriasis increases the chances to about 30%.
Researchers are studying large families affected by psoriasis to identify a gene or genes that cause the disease. (Genes govern every bodily function and determine the inherited traits passed from parent to child.)

1. Climate: Studies indicate that cold weather may be a predisposing effect or trigger for psoriasis, in contradistinction to hot and sunny climate that appears to be beneficial.

2. Infections: Both dermatological and systemic infections have been known to trigger the onset of psoriasis or a worsening of psoriasis. Systemic infections that have been associated with triggering include viral upper respiratory disease, streptococcal pharyngitis ("strep throat"), and human immunodeficiency virus (HIV). Staphylococcal skin infections (boils) have been a trigger.

3. Stress: Stress is a proven trigger in some people. It can cause psoriasis to flare for the first time or aggravate existing psoriasis Psychological stress is the cause as well as out come of disease like psoriasis. It is a well-known fact that there is inseparable bond between mind and body and psyche plays vital role in maintaining health or causing diseases. It is a common experience in practice of patient reporting the onset of psoriasis following major stress like divorce, death of close relatives, change of job, unhealthy family relationships etc and this perception of patients that psychological stress can worsen psoriasis has been supported in clinical studies. Relaxation and stress reduction may help people with psoriasis. For example, not only does relaxation help lower stress levels, but also it gives people a feeling of control. These techniques work best with homoeopathic constitutional treatments, instead of using the techniques alone.
Cope with the stigma: A stigma—a characteristic that other people think of as negative—can erode a person's self-esteem. Low self-esteem can lead to stress, and possibly a worsening of psoriasis. One way to overcome the stigma, however, is to understand how and why it occurs.
Hypnosis: This relaxation technique may help people who are using other treatments. For example, one study found that people who listen to meditation-based relaxation tapes while they are using light therapy may clear faster than those who don't listen to the tapes

4. Certain medicines: Certain medicines, most notably beta-blockers, which are used to treat high blood pressure, and lithium or drugs used to treat depression, may trigger an outbreak or worsen the disease. The drugs may be listed as: lithium, antimalarials, mepacrine, NSAIDs, beta-blockers,
alcohol.

5. Conception and Pregnancy: Women often wonder if their psoriasis will change because of pregnancy. For the most part, people who have psoriasis go through the childbearing phase of their lives just like other people. Psoriasis, in and of itself, does not affect the reproductive system of a woman or a man. Although some women report their psoriasis improves or worsens during pregnancy. Several studies have examined the effects of pregnancy on psoriasis.
One survey of almost 250 female psoriasis patients showed that during pregnancy, psoriasis improved in 35 percent of cases, worsened in 18 percent and did not change in 46 percent. In another study of 179 female patients, psoriasis got better in 67 percent of patients, worsened in 11 percent and did not change in 22 percent of pregnancies. In the postpartum phase, studies have reported that psoriasis usually gets worse, most often within four months of delivery.

5. Physical trauma: People often notice new spots 10 to 14 days after the skin is cut, scratched, rubbed, or severely sunburned. Analysis of patient records has indicated that up to 50 percent of persons with psoriasis have had a "Koebner’s phenomenon" experience—that is, have had a psoriatic lesion develop at the site of an injury or skin condition.
A broad range of skin injuries and skin conditions have been linked with Koebner’s phenomenon:

Skin Trauma:
• Acupuncture
• Bites, Cuts and scrapes
• Bruises, Burns
• Chemical irritation
• Pressure against the skin
• Shaving
• Sunburn and peeling
• Adhesive taping
• Tattoos
• Vaccinations

Skin Conditions:
• Boils
• Dermatitis
• Herpes blisters
• Lichen planus
• Skin parasites (scabies)
• Vitiligo

Lesions of psoriasis are caused by an increase in the turnover rate of dermal cells from the normal 23 days to 3-5 days in affected areas.

Silver scale on the surface of lesions is a layer of dead skin cells and may be scraped away from most lesions even if the scale is not apparent on visual inspection.

Patients with psoriasis have a genetic predisposition for the disease.

Gene locus has been determined.

The trigger event may be unknown in most cases but is likely an immunologic event.

Commonly, the first lesion appears after an upper respiratory infection, such as streptococcal pharyngitis.

Perceived stress can cause exacerbation of psoriasis. Psoriasis is a stress-related disease and offer findings of increased concentrations of neurotransmitters in psoriatic plaques.

Autoimmune function

Significant evidence is accumulating that psoriasis is an autoimmune disease.

Lesions of psoriasis are associated with increased activity of T cells in underlying skin.

Guttate psoriasis has been recognized to appear following certain immunologically active events, such as streptococcal pharyngitis, cessation of steroid therapy, and use of antimalaria drugs.

Superantigens and T cells

Psoriasis is related to excess T-cell activity. Experimental models can be induced by stimulation with streptococcal superantigen, which cross-reacts with dermal collagen. This small peptide has been shown to cause increased activity among T cells in patients with psoriasis but not in control groups.

Also of significance is that 2.5% of those with HIV develop psoriasis during the course of the disease.

Differential Diagnosis:
Dermatitis, Atopic
Dermatitis, Contact
Gout and Pseudogout
Pityriasis Alba
Pityriasis Rosea
Reiter Syndrome
Syphilis
Tinea

Other Problems to be considered:
Seborrheic dermatitis
Diaper dermatitis
Onychomycosis
Squamous cell carcinoma
Nummular eczema
Lichen planus
Lichen simplex chronicus
Mycosis fungoides
Subcorneal pustulosis
Pustular eruptions

Skin types chart

The U.S. Food and Drug Administration and the American Academy of Dermatology recognize six skin-type categories:

Skin types	Sun history	Example
I	Always burns easily, never tans, extremely sensitive skin	Red-headed, freckled, Celtic, Irish-Scots
II	Always burns easily, tans minimally, very sensitive skin	Fair-skinned, fair-haired, blue-eyed Caucasians
III	Sometimes burns, tans gradually to light brown, sun-sensitive skin	Average-skinned Caucasians, light-skinned Asians
IV	Burns minimally, always tans to moderate brown, minimally sun-sensitive	Mediterranean-type Caucasians
V	Rarely burns, tans well, sun-insensitive skin	Middle Easterners, some Hispanics, some African-Americans
VI	Never burns, deeply pigmented, sun-insensitive skin	African-Americans

Emergency Care:
Patients with guttate, erythrodermic, or pustular psoriasis may present to the emergency department.
In each of these cases, restoration of the barrier function of the skin is of prime concern. This can be performed with cleaning and bandaging.
Plaque and scalp lesions are frequently encountered in patients seeking care for other problems, and initial treatment of the lesions should be offered.
Solar or ultraviolet radiation may be helpful.
Oatmeal baths may be helpful.
Acute presenting form of disease may help in arriving at either Acute or Chronic constitutional remedy.

Usually the follow up of one to two year without recurrence is suggested as for labeling a patient CURED.

In some cases, psoriasis is so mild that it may go unnoticed. At the opposite extreme, there are victims having psoriatic patches almost everywhere on the body. People with psoriasis may suffer discomfort, including pain and itching, restricted motion in their joints, and emotional distress.
The unpleasant appearance of the patches, the chronic itching and flaking of psoriasis although is not life threatening, has definite impact on the self-esteem and life style of the psoriasis victim. Substantial time and money are spent trying to keep it under control.

For the past two years, international psoriasis organizations have joined forces to support and organize World Psoriasis Day. On Oct. 29, 2005, countries worldwide banded together to increase awareness about psoriasis and psoriatic arthritis.
Just as Psoriasis Awareness Month in August encourages the public in the United States to understand the impact of psoriasis, World Psoriasis Day spreads this message further: