Psoriasis

Pathophysiology

Autoimmune: Activated T-cells stimulate abnormal keratinocyte proliferation and epidermal capillary growth
Rapid turnover can increase uric acid levels, sometimes mimicking gout
Plaque psoriasis (80%): Red circular lesions with silvery scale on trunk, elbows, knees
Guttate: Teardrop-shaped, triggered by infection (especially strep throat)
Pustular: Non-infectious pus-filled blisters with high secondary infection risk
Inverse: Red, shiny patches in skin folds. Vulnerable to secondary fungal infections
Erythrodermic: Medical emergency — widespread inflammatory shedding with fluid/electrolyte loss
Psoriatic arthritis: Affects 10-30% of patients

Thick, red plaques with overlying silvery-white scale
Auspitz sign: Pinpoint bleeding when scale is removed (dilated capillaries close to surface)
Kobner reaction: New lesions appearing 10-14 days after minor skin wound
Symmetrical distribution (e.g., both elbows)
Nail changes: pitting, thickening, onycholysis
Morning stiffness or joint pain (psoriatic arthritis)

Erythrodermic psoriasis: Medical emergency — widespread inflammatory skin shedding, fluid/electrolyte loss
Open/oozing lesions: Locally contraindicated (portal for infection)
Pustular psoriasis: High secondary infection risk despite being non-infectious
Inverse psoriasis in skin folds with moisture, odor: Suspect secondary yeast/fungal infection — refer
Distinguish from eczema: Psoriasis on extensor surfaces with silvery scale. Eczema in flexor creases

Intact skin: Safe for massage. Open or oozing lesions are locally contraindicated
Massage increases circulation, which may exacerbate itching — monitor response
Stress reduction: General relaxation massage is highly beneficial, as stress is a primary trigger
Hypoallergenic lubricants: Avoid triggering sensitivities
Psoriatic arthritis: Address like RA — reduce muscle guarding, maintain joint mobility
Inverse psoriasis: If skin in folds looks moist, shiny, or has odor, avoid and refer
Biologic medications: Clients on adalimumab/Humira, secukinumab/Cosentyx, or JAK inhibitors (tofacitinib/Xeljanz) are immunosuppressed. Ask about injection sites and avoid direct pressure over recent sites. Do not treat if therapist has active infection

Auspitz sign and Kobner reaction are diagnostic hallmarks
Erythrodermic psoriasis is a medical emergency
Morphology determines management: open/oozing = contraindicated. Dry/intact = safe with precautions
Screen for psoriatic arthritis (10-30%)
Distinguish psoriasis (extensor surfaces, silvery scale) from eczema (flexor creases)

Psoriasis is an autoimmune disorder with keratinocyte proliferation every 3-4 days creating silvery-white plaques
Auspitz sign and Kobner reaction are the diagnostic hallmarks. Erythrodermic psoriasis is a medical emergency
Open or oozing lesions are locally contraindicated. Intact skin is safe with hypoallergenic lubricants
Stress reduction through relaxation massage is a primary therapeutic strategy
Screen for psoriatic arthritis (10-30%) and metabolic syndrome comorbidities