Psoriasis - NYSORA

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Learning objectives

  • Define and classify the different types of psoriasis
  • Describe psoriasis triggers
  • Anesthetic management of a patient with psoriasis

Definition and mechanisms

  • Psoriasis is a chronic skin disorder characterized by an accelerated epidermal turnover and epidermal hyperplasia
  • Autoimmune disease resulting from an increased rate of epidermal protein synthesis, rapid epidermal cell growth, shortened epidermal cell cycle, and increase in the proliferative cell population
  • Lesions consist of sharply demarcated, loosely adherent, thickened, noncoherent, silver skin scales with increased vascularity → they most commonly appear on the extensor surfaces (i.e., elbows and knees), lumbar-sacral area, and scalp 
  • Injury to the skin can trigger psoriatic skin changes at that spot (Koebner’s phenomenon) 


  • Plaque psoriasis or psoriasis vulgaris
    • Most common type (85-90%)
    • Causes dry, itchy, raised skin patches (plaques) covered with scales
    • Most commonly found on the elbows, knees, scalp, and back
  • Nail psoriasis
    • Affecting fingernails and toenails
    • Causes pitting, abnormal nail growth, and discoloration
    • Nails might loosen and separate from the nail bed (onycholysis)
  • Guttate psoriasis
    • Primarily affects young adults and children
    • Triggered by a bacterial infection (e.g., strep throat)
    • Marked by small, drop-shaped, scaling spots on the trunk, arms, or legs
  • Inverse psoriasis
    • Mainly affects the skin folds of the armpits, groin, buttocks, and breasts
    • Causes smooth patches of inflamed skin that worsen with friction and sweating
    • Fungal infections may trigger this type of psoriasis
  • Pustular psoriasis
    • Causes clearly defined pus-filled blisters
    • Occur in widespread patches or on small areas of the palms or soles
  • Erythrodermic psoriasis (erythroderma)
    • Least common type
    • Widespread inflammation and exfoliation of the skin over most of the body surface (>90% of the body surface area)
    • Accompanied by severe dryness, itching, swelling, and pain
    • Can develop from any type of psoriasis

Signs and symptoms

  • Patchy rash ranging from spots of dandruff-like scaling to major eruptions across the entire body
  • Rashes that vary in color (purple with gray scale to pink-red with silver scale)
  • Small scaling spots
  • Dry, cracked skin that may bleed
  • Itching, burning, or soreness
  • Cyclic rashes that flare for a few weeks or months and then subside
  • Psoriatic lesions become colonized by bacteria (especially Staphylococcus aureus) 
  • Severe psoriasis may be associated with hyperuricemia, anemia, negative nitrogen balance, iron loss, and hypoalbuminemia


Risk factors

  • Genetic (HLA-Cw6)
  • Family history
  • Smoking

Psoriasis triggers

  • Infections (e.g., strep throat or skin infections)
  • Weather (cold and dry)
  • Injury to the skin (e.g., cut or scrape, bug bite, or severe sunburn)
  • Stress
  • Smoking and exposure to secondhand smoke
  • Obesity
  • Heavy alcohol consumption
  • Certain medications (e.g., lithium, beta-blockers, calcium channel blockers, antimalarial drugs, NSAIDs)
  • Rapid withdrawal of oral or injected corticosteroids


  • Topical therapy
    • Corticosteroids (i.e., hydrocortisone)
    • Vitamin D3 analogs (i.e., calcipotriene and calcitriol) to slow skin cell growth
    • Retinoids/vitamin A derivatives (i.e., tazarotene)
    • Calcineurin inhibitors (i.e., tacrolimus and pimecrolimus) to calm the rash and reduce the scaly buildup
    • Salicylic acid to reduce the scaling of scalp psoriasis
    • Coal tar to reduce scaling, itching, and inflammation
    • Anthralin to slow skin cell growth
  • Phototherapy
    • Sunlight
    • UVB broadband and narrowband
    • UVB
    • PUVA
  • Oral or injected (systemic) medications
    • Corticosteroids 
    • Retinoids/vitamin A derivatives
    • Biologics (i.e., apremilast, etanercept, infliximab, adalimumab, etc.) to suppress the immune system
    • Methotrexate to decrease the production of skin cells and suppress inflammation
    • Cyclosporine to suppress the immune system


psoriasis, preoperative, management, history, examination, investigations, hypovolemia, erythroderma, temperature, immunosuppressants, steroids, airway assessment, awake fiberoptic intubation, blood count, anemia, leukopenia, thrombocytopenia, urea, electrolytes, methotrexate, calcium, hypoalbuminemia, liver function tests, ECG, chest X-ray, echocardiography, crossmatch blood, blood loss

psoriasis, intraoperative, management, premedication, general anesthesia, regional anesthesia, monitoring, steroid supplementation, nitrous oxide, methotrexate, infection, erythroderma, hypervolemia, hypovolemia, congestive heart failure, hypoalbuminemia, renal blood flow, cardiac output, bleeding, hyperthermia, postoperative pruritus, opioids, morphine, fentanyl, ECG electrodes, pulse oximeter, central venous pressure, fluid replacement, temperature, Koebner phenomenon

Suggested reading

  • Pollard BJ, Kitchen G. Handbook of Clinical Anaesthesia. 4th ed. Taylor & Francis group; 2018. Chapter 9 Connective tissue, Lomas JP.

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