Symptoms of psoriasis

Psoriasis often begins between the ages of 20 and 30, and 75% of patients develop it before age 40. However, in general, psoriasis symptoms can appear at any age.

Psoriasis begins differently in different patients. The primary rash in vulgar psoriasis is a sharply delimited pink spot of a round shape the size of a pinhead (Pylnov's symptom). The color of the rash can be from bright pink to bright red. Already at the very moment of appearance, the surface of the spot is mostly covered partially or entirely with silvery-white scales.

In some cases, the primary element initially gives the impression of a papule when palpated, but if the scale is completely removed, this impression usually disappears, because at the beginning of its existence, the psoriatic primary rash is infiltrated so slightly that the infiltrate is not clinically felt when palpated. Gradually, the size of the rash increases, the infiltrate intensifies, there are more scales, and a monomorphic rash in the form of nodules (papules) is formed.

As a result of peripheral growth or fusion of elements, plaques of various shapes are formed. The preferred localization is the extensor surfaces of the upper and lower extremities, especially in the area of the elbows, knees, scalp, skin folds, and trunk. In some patients, the localization of psoriatic rash is the opposite of the usual one. This is the so-called inverse psoriasis (psoriasis inversa), since instead of the extensor surfaces, the flexor surfaces are affected. The following three phenomena are characteristic of psoriatic rash:

1. layering of a large number of silvery-white scales, which when scraped off reveal some resemblance to a stearin stain - the stearin stain phenomenon;
2. after the scales are completely removed, a thin, delicate, translucent film is revealed, covering the psoriatic element - the phenomenon of psoriatic film;
3. When the integrity of this film is violated by gently scraping it, pinpoint bleeding occurs in places - the phenomenon of the Polotebnov blood race, or the Auspitz phenomenon.

In the clinical course of psoriasis, three stages are distinguished:

1. a period of progression, when the elements of the rash increase in size, and this coincides with the appearance of new rashes;
2. stationary period, when the peripheral growth of the rash stops and the appearance of new elements is suspended;
3. a period of regression, when the rash begins to develop in reverse.

This division is conditional, since new elements may appear in one patient simultaneously with the regression of the rash. A pseudo-atrophic rim is typical, when around developed, no longer growing elements of the rash the skin is somewhat paler, more shiny than the surrounding healthy skin, the periphery of the elements is slightly depressed, folded, like tissue paper. The presence of Voronov's pseudo-atrophic rim indicates a cessation of growth of the psoriatic element.

Depending on the size of the psoriatic rash, psoriasis is divided into: punctate, when the rash is no larger than a pinhead; drop-shaped, when the rash is slightly larger than a pinhead; coin-shaped, when the plaque is large and round; figured, which is formed by the fusion of adjacent rashes and plaques, with the lesions varying in outline and forming figures; geographic, when the lesions merge to resemble a geographic map; annular, when the rash, as a result of fusion or resolution from the center, forms a ring-shaped form; serpiginous, when the lesion creeps in one direction or another.

A characteristic sign of psoriasis is an isomorphic irritation reaction, or the Koebner phenomenon, when psoriatic papules appear at the site of an injury or scratch after 10-14 days (sometimes later). The presence of an isomorphic irritation reaction in a patient indicates that his skin still has a predisposition to psoriatic rash.

When psoriasis is localized on the scalp, the rash is especially typical to spread to the areas of the forehead bordering the hairy areas - the “psoriatic crown”.

Mucous membranes are rarely affected, mainly in pustular and severe arthropathic psoriasis, but this does not have significant prognostic or diagnostic value.

Damage to the nail plates (usually on the hands, rarely on the feet) is one of the common symptoms of psoriasis. The most typical is the formation of point depressions, which make the nail plate look like a thimble (the "thimble" symptom). In addition, longitudinal and transverse grooves, changes in the color of the nail, clouding, deformation of the nail plate, fragility of the free edge, onycholysis or onychogryphosis can be observed. Of the subjective sensations, patients most often complain of itching in the affected areas, especially when the scalp is affected, and joint pain in arthropathic psoriasis.

The following clinical varieties of psoriasis are distinguished: common (vulgar), exudative, seborrheic, arthropathic, psoriatic erythroderma, pustular psoriasis and psoriasis of the palms and soles.

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Histopathology of psoriasis

The pathognomonic sign of psoriasis is significant acanthosis with the presence of elongated epidermal growths, somewhat thickened in their lower part.

Above the tops of the dermal papillae, the epidermis is sometimes thinned, parakeratosis is characteristic, and in old foci - hyperkeratosis. The granular layer is expressed unevenly, under the areas of parakeratosis it is absent. In the progressive stage, inter- and intracellular edema, exocytosis with the formation of focal accumulations of neutrophilic granulocytes are noted in the spinous layer, which, migrating into the stratum corneum or parakeratotic areas, form Munro microabscesses. Mitoses are often found in the basal and lower rows of the spinous layer. In accordance with the elongation of the epidermal outgrowths, the dermal papillae are elongated and widened, sometimes flask-shaped, edematous, the vessels in them are tortuous, overflowing with blood. In the subpapillary layer, a perivascular infiltrate of lymphocytes and neutrophilic granulocytes is noted.

Symptoms of exudative psoriasis

Exudative psoriasis differs from the clinical picture of common psoriasis by significant exudation, as a result of which there are yellowish scales and crusts on the surface of the psoriatic rash. When the latter are removed, a bleeding, weeping surface is exposed.

Symptoms of Seborrheic Psoriasis

In seborrheic psoriasis, the rash is localized on the scalp and other "seborrheic" areas and has a unique clinical picture. The scalp is affected most often. The process can be isolated for a long time and manifests itself not in the form of papular elements or plaques, but as abundant peeling without pronounced inflammatory changes. In this case, diagnosis is difficult if there are no rashes on other areas of the skin and there is no data on the presence of psoriasis in the patient's relatives. In addition, papules or plaques covered with layers of scales with less clear boundaries are found on the face, in the sternum area, especially in people prone to seborrheic reactions. The psoriatic triad is expressed less strongly than in ordinary psoriasis.

Symptoms of arthropathic psoriasis

Arthropathic psoriasis is the most severe form of the disease, often leading to disability, and sometimes even death of the patient from cachexia. Joint damage in psoriasis indicates a systemic process. Men suffer more often than women. The onset of the disease is different. Joint damage often joins existing skin manifestations. In other cases, the latter is preceded by joint phenomena, sometimes existing in isolation for a long time. Radiologically, various changes in the bone and joint apparatus are detected in most patients without clinical signs of joint damage. The most common are periarticular osteoporosis, narrowing of the joint spaces, osteophytes, cystic enlightenment of bone tissue, less common - bone erosion, often manifested by asymmetric oligoarthritis, limited to one or more joints of the hands and feet, often the spine is involved in the process (psoriatic spondylitis), mainly the thoracic and lumbar regions, sacroiliac joints (psoriatic sacroiliitis). Patients complain of severe spontaneous pain in the joints, increasing with movement. The area of the affected joints in the first period of the disease is hot and edematous. The general condition of patients worsens: body temperature rises in the evening, appetite decreases, the gastrointestinal tract is disrupted. These phenomena gradually subside and the process passes into a subacute, then into a chronic phase. From time to time, exacerbations of arthropathy and skin process occur. Later, there is a limitation, deformation of the joints, and sometimes - ankylosis.

Psoriatic erythroderma

Psoriatic erythroderma develops rarely and is a complication of psoriasis, in most cases developing as a result of excessively irritating local treatment or the action of some other unfavorable local influences (UV radiation, insolation). Erythroderma gradually occupies all or almost all of the skin. The skin becomes bright red and covered with large or small dry white scales. When the patient undresses, a huge number of silvery-white scales fall off. The skin of the face, ears and scalp seem to be sprinkled with flour. The skin is more or less infiltrated, edematous, hot to the touch, in places lichenified. Patients complain of more or less pronounced itching, tightening of the skin and burning. In some places, areas of clinically unchanged skin or papules and plaques of typical psoriasis remain.

Erythroderma significantly worsens the course of psoriasis. The general condition of patients is sharply impaired, the temperature rises to 38-39 degrees, the lymph nodes (usually femoral and inguinal) enlarge.

Symptoms of Pustular Psoriasis

There are two types of pustular psoriasis: generalized pustular psoriasis (Zumbush) and limited palmoplantar pustular psoriasis (Barber). The generalized form is severe, with fever, malaise, leukocytosis, and increased ESR. Small superficial pustules appear paroxysmally against a background of bright erythema, accompanied by burning and soreness, located both in the plaque area and on previously unchanged skin. Pustular psoriasis of the palms and soles is more common than the generalized form. The rashes are usually symmetrical and represent intraepidermal pustules against a background of severe hyperemia, infiltration, and lichenification. The rashes are located mainly in the area of the tener and hypotener, the arch of the foot.

Psoriasis of the palms and soles is more common in people engaged in physical labor, aged 30 to 50 years. In most cases, the palms and soles are affected simultaneously. The following forms of palmoplantar psoriasis are clinically distinguished: lenticular, plaque-fan-shaped, circular, horny and callous. At the same time, typical psoriatic rashes are found on other areas of the skin. The phenomena of terminal film and point bleeding are caused with greater difficulty than on other areas.

Psoriasis of the folds

Psoriasis of the folds is often found in children or the elderly, especially in patients with diabetes. The lesions are most often located in the armpits, under the mammary glands, around the navel, in the perineum. Flaking is usually insignificant or absent, the lesions are sharply outlined, their surface is smooth, deep red, sometimes slightly moist, macerated. In the depths of the folds, sinuses may appear.

Differential diagnosis of psoriasis

The symptoms of psoriasis should be distinguished from parapsoriasis, papular syphilis, lichen planus, erythrodermic mycosis fungoides, lichen pilaris, rheumatoid arthritis and Reiter's disease.

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