Dr. Lyn Guenther
On October 22, 2010 at the 19th Regional Conference of Dermatology 2010 and 2nd annual meeting of the Asian Academy of Dermatology and Venereology in Koto Kinabalu Malaysia, Dr. Guenther gave a presentation on facial, flexural and nail psoriasis.
In patients with psoriasis, the face is often spared. When the face is involved, the psoriasis is often more severe. Compared to patients without psoriasis on the face, patients with facial psoriasis tend to have a longer duration of psoriasis with earlier onset, as well as nail and joint disease. Three different variants have been described: a peripherofacial form next to the scalp which may be a result of severe scalp psoriasis, a centrofacial form affecting the central part of the face, which may be a marker of severe body psoriasis, and a mixed form with features of both of the other two variants.
Intertriginous psoriasis, also referred to as ‘flexural’ or ‘inverse’ psoriasis, occurs in the skin fold and in approximately 2-6% of patients with psoriasis. The lesions are well demarcated with minimal scale. Pain, itching and irritation from sweat and rubbing are common. The 2009 US National Psoriasis Foundation treatment recommendations include low- to mid-potency topical steroids for short-term therapy, and calcipotriol (a vitamin D analogue) and calcineurin inhibitors (pimecrolimus, tacrolimus) for long-term therapy. Low- to mid-potency topical steroids in combination with antimicrobial therapy (i.e. imidazole or antibiotic) were also included as first line therapy, and emollients and tar as second line therapies based on anecdotal evidence.
The lifetime incidence of nail psoriasis is in the order of 80-90%. It is more common in males, patients with disease of longer duration, patients with psoriatic arthritis and patients with extensive psoriasis. The severity often correlates with the severity of skin and joint disease. Quality of life is significantly impacted with 93% reporting a significant cosmetic handicap, 48% indicating that their nail disease restricted professional activities, 59% noting a negative impact on normal daily activities and 52% reporting pain in one study. Nail changes include pitting, leukonychia (whitening), redness of the lunula, crumbling of the nail, ‘oil drop’ discoloration, splinter hemorrhages, separation of the nail plate from the nail bed (onycholysis) and excessive scaling and thickening of the skin under the nail plate.Treatment of nail disease is challenging since it is difficult to deliver drug to the site of inflammation, and nails are often refractory to treatment and slow to heal. Many topical agents have been tried. Intralesional corticosteroids are very painful. PUVA, pulsed dye laser, traditional systemic agents (e.g. methotrexate, acitretin, cyclosporine) and biologics may be considered for recalcitrant or more severe disease.