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26- Psoriasis




Classically, eruption of circumscribed, and confluent, reddish, silvery-scaled maculopapules; the lesions occur predominantly on the elbows, knees, scalp, and trunk.  Common and often severe for HIV patients.  ("...Psoriasis in AIDS is most pronounced at intermediate levels of immunodeficiency, and is diminished or lost in terminal profound immunodeficiency…  " Oxford's textbook citation) Pruritus is not systematic associated but common in severe psoriasis.  It is sometimes possible to observe "circles" of "pseudo vesicles" (pxx067).  It looks like Tinea but Tinea treatment is useless


(Texts of right column are extracted from Oxford textbook and adapted for our needs/feeling)

Nummular discoid ="Normal psoriasis"

pxx018// pxx067, 068, 091// pxx360, 361, 362, 363, 364, 365// pxx409, 402, 403, 404, 405, 408, ptx064//

The commonest form of psoriasis and coin-shaped lesions of various sizes are scattered over the body in a symmetrical distribution.  Such lesions are usually well defined and chronic.

Guttate psoriasis

pxx092, 093, 094, 095//

The skin looks as though it has been splashed by the psoriasis.  It often follows a streptococcal sore throat.  The lesions are scattered over the entire body and tend to be no more than a few millimeters in diameter.  They may include the face and are often red slightly scaly spots.  They appear less well defined and less obviously covered by silvery scales than in classic types of psoriasis. 

Palmar and plantar psoriasis


This may be typical of lesions elsewhere but there is often a modification of the psoriasis due to the nature of the palmer and plantar skin.  The scales tend to be more adherent and less silvery and they are more likely to develop deep cracks because of the thickness of the epidermis at these sites.  Neutrophils tend to collect into larger abscesses trapped by the thicker surface layers of the stratum corneum.  The sterile pustules so formed are often the most obvious feature.  This pattern may be seen as part of a more generalized disease but in many cases it affects only the hands and feet.

Psoriasis of the nails

pxx089// pxx354// pxx358// pxx375...// pxx314...//

Pinpoint pitting is usual but can be seen in other disorders affecting nail growth.  Onycholysis with a salmon-pink discoloration of the base of the uplift of the nail is probably even more characteristic.  Sometimes the nail growth is distorted, thickened and friable, and difficult to distinguish from a fungus disorder affecting the nail... For Onychomycosis see "30-onychomycosis"

Flexural psoriasis

ghx086// pxx407//

When psoriasis affects the groins, natal cleft, or axillae, it is usually less scaly.  The bright red plaques are shiny and liable to cracking and maceration.  They may be very well defined.

Erythrodermic psoriasis

ptx033- pxx215- pxx216- pxx217- // pxx025-// pxx069- pxx070-// pxx131- pxx132-// pxx164-// pxx234- pxx235- pxx236- pxx237- pxx238- pxx239- pxx240-

See also pxx024-

This may present as a medical emergency due to fluid loss, septicemia, or loss of body temperature.  Oedema is a consequence of capillary leak, low albumin, and heart failure.  // pxx022- pxx023// pxx241// Generalized redness, the well-defined margins are lost and the scales are exfoliated profusely.  The erythrodermic psoriasis may be indistinguishable from Erythroderma.  When the normal protective function of the skin is lost, bacteriemia is common.  The loss of water is difficult to estimate and prerenal failure can develop very rapidly.  The vasodilatation and the obstruction to the sweat ducts by the proliferating epidermis results in impaired thermoregulation.  Hyperthermia is very common in hot climates; hypothermia can occur in cold climates.  Internal organs such as the gut and liver may be impaired and loss of protein both from the skin and the gut is an important complication.

Arthropathic psoriasis

//pxx355,356,357, 358//pxx359//

Psoriatic arthritis is a severe deforming arthritis involving the multiple small joints of the hands and feet and spine.  The hips, cervical, and sacroiliac joints are frequently affected and a complete ankylosing type of spondylitis can occur.

Generalized pustular psoriasis

//pxx314, 315, 316, 317, 318, 319, 321, 322, 343, 344, 345, 346, 347, 348, 349, 350, 351, 352, 353, we recommend to start with photo"314"//

In this condition, which is relatively rare, myriads of pustules quickly develop and equally quickly disappear.  This disorder may occur in the absence of a previous history of psoriasis and even occasionally as a viral exanthema.  However, most commonly it is only a complication of psoriasis that has been treated by systemic or local steroids.  It is an acute rebound phenomenon of steroid withdrawal.


Vaseline/clotrimazole/betamethasone cream (clotrimazole is to avoid secondary mycotic infection with chronic use of topic corticoids) or topical coal tar derivative and/or topical vitamin E derivative or other "traditional medicines" all may be effective, but if serious generalized condition or the classic generalized erythrodermic psoriasis (pxx025...) an intensive course of 4-5 days of high dose dexamethasone has impressive results! (IM 4cc morning + 2cc midday, add fluconazole 150mg daily during the treatment for prevention of fungal infections)

It is important to know that some allergic problems will induce the first eruption of generalized psoriasis.  (See also "6-Allergy")

In case of pustular psoriasis (rare) go slowly in reducing dexa... pustular psoriasis can be a symptom of dexa withdrawal syndrome...  Here we can make distinction between "normal" doctors and "artist of medical practice"!  Good luck!

Important note about "erythrodermic psoriasis" versus "acquired erythroderma"

  • It is often impossible to make clinically a differential diagnosis between "erythrodermic psoriasis" and "acquired erythroderma" (= "acquired ichthyosis").  Both can be induce by a "drug allergy" but; in practice there is one important difference: unlike "acquired erythroderma"; "erythrodermic psoriasis" will often relapse over a lifetime, even if you stop the drug that induced the problem.  Treatment of both diseases is basically the same in a poor hospice...  (See "30-Erythroderma")
  • Generalized infected "erythrodermic psoriasis / acquired erythroderma" can be an emergency!  Patients are sometimes sent to the hospice because of alarming looking skin diseases (severe generalized skin edema, fissures of skin because edema, pus...).  However, these patients often still have a high CD4 count and could potentially live for many more months/years.  Treat with dexamethasone IM (4cc morning + 2cc midday + gentamycin 160mg IM daily (+ fluconazole 200 2x/day for prevention of fungal infection if patient is still able to take it) pxx022- pxx023- pxx241-


More information about PSORIASIS (connect or not connect with HIV) see the dedicated website Psoriasiszone.com. This Psoriasis Directory is designed to help its users find the psoriasis information, articles, source, companies, products and services.








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