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The following updates to this chapter were made on November 6, 2020:

  • Addition of section of Coronavirus Disease 2019 (COVID-19) risk in patients receiving biologics for psoriasis.


For the Chapter in the Schwinghammer, Handbook (not Wells Handbook anymore) please go to Chapter 17, Psoriasis.



  • image Patients with psoriasis have a lifelong illness that may be very visible and emotionally distressing. There is a strong need for empathy and a caring attitude in interactions with these patients.

  • image Psoriasis is a progressive T-lymphocyte–mediated systemic inflammatory disease that results from a complex interplay between multiple genetic factors and environmental influences. Genetic predisposition and precipitating “trigger” factors play a role in the “march of psoriasis.” This march of innate and adaptive immune responses results in clinical expressions (eg, keratinocyte proliferation) and is possibly responsible for psoriatic comorbidities.

  • image Diagnosis of psoriasis is usually based on recognition of the characteristic psoriatic lesion and not based on laboratory tests.

  • image Treatment goals for patients with psoriasis are to minimize signs such as plaques and scales, alleviate symptoms such as pruritus, reduce the frequency of flare-ups, ensure appropriate treatment of associated comorbid conditions such as metabolic syndrome, psoriatic arthritis or clinical depression, and minimize treatment-related morbidity.

  • image Management of patients with psoriasis generally involves both nonpharmacologic and pharmacologic therapies.

  • image Nonpharmacologic alternatives such as stress reduction and the liberal use of moisturizers may be very beneficial and should always be considered and initiated when appropriate.

  • image Pharmacologic alternatives for psoriasis include topical agents, phototherapy, and systemic agents (both traditional and newer biologic agents).

  • image Pharmacologic therapy is generally guided by the severity of disease, advancing from topical agents to phototherapy to systemic agents as needed.

  • image Rotational therapy (ie, rotating systemic drug interventions) is a means to minimize drug-associated toxicities. However, continuous treatment has replaced rotational or sequential therapy and is now the standard of care for many dermatologists. Sequential therapy may be needed for biologics.

  • image Some biologic agents have proven efficacy for psoriasis; however, there are differences among these agents, including mechanism of action, duration of remission, and adverse-effect profile. Biologics are often used for moderate-to-severe psoriasis and may be first-line therapy especially if comorbidities exist.


Preclass Engaged Learning Activity

What does psoriasis look like? Search online for images of the skin manifestations of the various types of psoriasis (as described in Table 114-1). In particular, for plaque psoriasis (the most common phenotype), search for images of scalp, trunk/limb, hands, and nail involvement (oil spots).


Psoriasis is a chronic disease that waxes and wanes. It is never cured, and it is now known to be associated with multiple comorbidities including heart disease, diabetes, and metabolic syndrome. The signs and symptoms of psoriasis may subside ...

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