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PsoriasisClinicalPresentation:History,PhysicalExamination,OcularManifestations

PsoriasisClinicalPresentation
Author:JeffreyMeffert,MDChiefEditor:WilliamDJames,MDmore...
Updated:Jan22,2015

History
Symptomsofpsoriasismayincludethefollowing:
Worseningofalongtermerythematousscalyarea
Suddenonsetofmanysmallareasofscalyredness
Recentstreptococcalthroatinfection,viralinfection,immunization,useof
antimalarialdrug,ortrauma
Familyhistoryofsimilarskincondition
Pain(especiallyinerythrodermicpsoriasisandinsomecasesoftraumatized
plaquesorinthejointsaffectedbypsoriaticarthritis)
Pruritus(especiallyineruptive,guttatepsoriasis)
Afebrile(exceptinpustularorerythrodermicpsoriasisinwhichthepatient
mayhavehighfever)
Dystrophicnails
Longtermrashwithrecentpresentationofjointpain
Jointpainwithoutanyvisibleskinfindings
Theskinalmostalwaysisaffectedbeforetheeyes.Ocularfindingsoccurin
approximately10%ofpatients.Themostcommonocularsymptomsareredness
andtearingduetoconjunctivitisorblepharitis.
Thenonocularsymptomsarerelatedtorashandpsoriaticarthritis.Therashcanbe
uncomfortableorevenpainful.Psoriaticarthritiscancausestiffness,pain,
throbbing,swelling,ortendernessofthejoints.Thedistaljoints,suchasthe
fingers,toes,wrists,knees,andankles,aremostoftenaffected.

PhysicalExamination
Findingsonphysicalexaminationdependonthetypeofpsoriasispresent.
Themostcommonskinmanifestationsarescalingerythematousmacules,papules,
andplaques.Typically,themaculesareseenfirst,andtheseprogressto
maculopapulesandultimatelywelldemarcated,noncoherent,silveryplaques
overlyingaglossyhomogeneouserythema.Theareaofskininvolvementvarieswith
theformofpsoriasis.
Chronicstationarypsoriasis(psoriasisvulgaris)isthemostcommontypeof
psoriasis.Thisinvolvesthescalp,extensorsurfaces,genitals,umbilicus,and
lumbosacralandretroauricularregions.
Plaquepsoriasisischaracterizedbyraised,inflamedlesionscoveredwithasilvery
whitescale.Thescalemaybescrapedawaytorevealinflamedskinbeneath.This
ismostcommonontheextensorsurfacesoftheknees,elbows,scalp,andtrunk.
Guttatepsoriasispresentsassmallsalmonpinkpapules,110mmindiameter,
predominatelyonthetrunkthelesionsmaybescaly(seetheimagebelow).It
frequentlyappearssuddenly,23weeksafteranupperrespiratoryinfection(URI)
withgroupAbetahemolyticstreptococci.

Guttatepsoriasiseruptedinthispatientaftertopicalsteroidtherapywaswithdrawnduringa
pregnancy.ContributedbyRandyPark,MD.

Inversepsoriasisoccursontheflexuralsurfaces,armpit,groin,underthebreast,
andintheskinfolds.Itischaracterizedbysmooth,inflamedlesionswithoutscaling

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duetothemoistnatureoftheareawherethistypeofpsoriasisislocated.
Pustularpsoriasispresentsassterilepustulesappearingonthepalmsandsolesor
diffuselyoverthebody.Pustularpsoriasismaycyclethrougherythema,pustules,
thenscaling.ThediffusevariantistermedvonZumbuschvariant,whichis
accompaniedbyfeverandintenseillfeelinginadditiontothewidespreadpustules.
AcrodermatitiscontinuaofHallopeauisconsideredaformofpustularpsoriasisthat
affectsthehandsandfeet.Itmayproveresistanttotopicalandothertherapies.
Erythrodermicpsoriasispresentsasgeneralizederythema,pain,itching,andfine
scalingvariouspustularformsalsoexist.Ittypicallyencompassesnearlytheentire
bodysurfacearea.Itmaybeaccompaniedbyfever,chills,hypothermia,and
dehydrationsecondarytothelargebodysurfaceareainvolvement.Patientswith
severepustularorerythrodermicpsoriasismayrequirehospitaladmissionfor
metabolicandpainmanagement.Olderpatientswitherythrodermicpsoriasismay
experiencecardiacinstabilityandhypotensionduetomassivevascularshuntingin
theskin.
Scalppsoriasisaffectsapproximately50%ofpatients.Itpresentsaserythematous
raisedplaqueswithsilverywhitescalesonthescalp.
Nailpsoriasismaycausepitsonthenails,whichoftenbecomethickenedand
yellowishincolor.Nailsmayseparatefromthenailbed.Psoriaticnailsmaybe
indistinguishablefromfungalnailsand,atthesametime,maybemoreproneto
developingonychomycosisbecauseofthenailseparationandsubungualdebris.
Aretrospectivestudyfrom2014reportsthatnailinvolvementinpsoriasisisa
significantpredictorofthepatientalsohavingpsoriaticarthritis. [30]Thestudylooked
atretrospectivedatafromthreeGermancrosssectionalindependentnational
studiesonpatientswithpsoriasisandpsoriaticarthritis.Dataonthepatientshistory
ofpsoriasisandpsoriaticarthritis,clinicalfindings,nailinvolvement,andpatient
andpractitionerreportedoutcomeswerecollectedfromstandardized
questionnaires.Intheresults,theregressionmodelof4146patientsindicatedone
ofthestrongestpredictorsofconcomitantpsoriaticarthritiswasnailinvolvement.
Psoriaticarthritisaffectsapproximately1030%ofthosewithskinsymptoms.The
arthritisisusuallyinthehandsandfeetand,occasionally,thelargejoints.It
producesstiffness,pain,andprogressivejointdamage.
Oralpsoriasismaypresentwithwhitishlesionsontheoralmucosa,whichmay
appeartochangeinseveritydaily.Itmayalsopresentasseverecheilosiswith
extensionontothesurroundingskin,crossingthevermillionborder.Geographic
tongueisconsideredbymanytobeanoralformofpsoriasis.
Eruptivepsoriasisinvolvestheuppertrunkandupperextremities.Mostoften,itis
seeninyoungerpatients.

OcularManifestations
Inadditiontoskinmanifestations,psoriasismayalsoaffectthelid,conjunctiva,or
corneaandgiverisetoocularmanifestations,includingectropionandtrichiasis,
conjunctivitisandconjunctivalhyperemia,andcornealdrynesswithpunctate
keratitisandcornealmelt. [3,4]
Blepharitisisthemostcommonocularfindinginpsoriasis.Erythema,edema,and
psoriaticplaquesmaydevelop,andtheycanresultinmadarosis,cicatricial
ectropion,trichiasis,andevenlossofthelidtissue.
Achronicnonspecificconjunctivitisisfairlycommon.Itusuallyoccursinassociation
witheyelidmargininvolvement.Psoriaticplaquescanextendfromthelidontothe
conjunctiva.Chronicconjunctivitiscanleadtosymblepharon,keratoconjunctivitis
sicca,andtrichiasis.Nodularepiscleritisandlimballesionsresemblingphlyctenules
alsocanbeseen.
Cornealdiseaseisrelativelyrare.Mostoften,itissecondarytolidorconjunctival
complications,suchasdryness,trichiasis,orexposure.Themostcommonfindingis
punctatekeratitis.Filaments,epithelialthickening,recurrenterosions,
vascularization,ulceration,andscarringcanoccur.Thevascularizationtendstobe
superficial,peripheral,andinterpalpebralorinferior.Rarely,peripheralinfiltration
andmeltingcanoccurintheabsenceoftrichiasisandexposure. [31]
Inonecase,recurrentnasolacrimalductocclusionwasobserved,presumably
causedbywashingofthescalesintothelacrimalsac.
Usually,anterioruveitiscanbeseeninassociationwithpsoriaticarthritis.Acute
psoriaticuveitistendstobebilateral,prolonged,andmoreseverethannonpsoriatic
cases. [32,33]

Complications
Complicationsofpsoriasismayincludethefollowing:
Secondaryinfections
Possibleincreasedriskoflymphoma
Possibleincreasedriskofcardiovascularandischemicheartdisease
Psoriaticarthritis
Mitralvalveprolapse

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DifferentialDiagnoses

ContributorInformationandDisclosures
Author
JeffreyMeffert,MDAssociateClinicalProfessorofDermatology,UniversityofTexasSchoolofMedicineatSan
Antonio
JeffreyMeffert,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofDermatology,
AmericanMedicalAssociation,AssociationofMilitaryDermatologists,TexasDermatologicalSociety
Disclosure:Nothingtodisclose.
ChiefEditor
WilliamDJames,MDPaulRGrossProfessorofDermatology,ViceChairman,ResidencyProgramDirector,
DepartmentofDermatology,UniversityofPennsylvaniaSchoolofMedicine
WilliamDJames,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofDermatology,
SocietyforInvestigativeDermatology
Disclosure:Nothingtodisclose.
Acknowledgements
RobertArffa,MDClinicalAssistantProfessor,UniversityofPittsburghSchoolofMedicine
RobertArffa,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofOphthalmology
Disclosure:Nothingtodisclose.
RichardGordonJr,MDStaffPhysician,DepartmentofEmergencyMedicine,DetroitReceivingHospital
UniversityHealthCenter
RichardGordonJr,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergency
Physicians,AmericanCollegeofPhysicians,AmericanMedicalStudentAssociation/Foundation,Emergency
MedicineResidentsAssociation,andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
RyanIHuffman,MDResidentPhysician,DepartmentofOphthalmology,YaleNewHavenHospital
Disclosure:Nothingtodisclose.
SimonKLaw,MD,PharmDClinicalProfessorofHealthSciences,DepartmentofOphthalmology,JulesStein
EyeInstitute,UniversityofCalifornia,LosAngeles,DavidGeffenSchoolofMedicine
SimonKLaw,MD,PharmDisamemberofthefollowingmedicalsocieties:AmericanAcademyof
Ophthalmology,AmericanGlaucomaSociety,andAssociationforResearchinVisionandOphthalmology
Disclosure:Nothingtodisclose.
RandyPark,MDChair,AssociateProfessor,DepartmentofEmergencyMedicine,DentonRegionalMedical
Center
Disclosure:Nothingtodisclose.
BrianAPhillpotts,MDFormerVitreoRetinalServiceDirector,FormerProgramDirector,ClinicalAssistant
Professor,DepartmentofOphthalmology,HowardUniversityCollegeofMedicine
BrianAPhillpotts,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofOphthalmology,
AmericanDiabetesAssociation,AmericanMedicalAssociation,andNationalMedicalAssociation
Disclosure:Nothingtodisclose.
ChristopherJRapuano,MDProfessor,DepartmentofOphthalmology,JeffersonMedicalCollegeofThomas
JeffersonUniversityDirectoroftheCorneaService,CoDirectorofRefractiveSurgeryDepartment,WillsEye
Institute
ChristopherJRapuano,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyof
Ophthalmology,AmericanSocietyofCataractandRefractiveSurgery,ContactLensAssociationof
Ophthalmologists,CorneaSociety,EyeBankAssociationofAmerica,andInternationalSocietyofRefractive
Surgery
Disclosure:AllerganHonorariaSpeakingandteachingAllerganConsultingfeeConsultingAlconHonoraria
SpeakingandteachingRPSOwnershipinterestOtherBausch&LombHonorariaSpeakingandteaching
MerckConsultingfeeConsultingBausch&LombConsultingMerckHonorariaSpeakingandteaching
AdamJRosh,MDAssistantProfessor,ProgramDirector,EmergencyMedicineResidency,Departmentof
EmergencyMedicine,DetroitReceivingHospital,WayneStateUniversitySchoolofMedicine
AdamJRosh,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergencyMedicine,
AmericanCollegeofEmergencyPhysicians,andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
HamptonRoySr,MDAssociateClinicalProfessor,DepartmentofOphthalmology,UniversityofArkansasfor
MedicalSciences
HamptonRoySr,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofOphthalmology,
AmericanCollegeofSurgeons,andPanAmericanAssociationofOphthalmology
Disclosure:Nothingtodisclose.

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PsoriasisClinicalPresentation:History,PhysicalExamination,OcularManifestations

DanaAStearns,MDAssistantDirectorofUndergraduateEducation,DepartmentofEmergencyMedicine,
MassachusettsGeneralHospitalAssistantProfessorofSurgery,HarvardMedicalSchool
DanaAStearns,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergencyPhysicians
Disclosure:Nothingtodisclose.
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment

References
1. HendersonD.Psoriasisseveritylinkedtouncontrolledhypertension.MedscapeMedicalNews.October27,
2014.[FullText].
2. TakeshitaJ,WangS,ShinDB,MehtaNN,KimmelSE,MargolisDJ,etal.EffectofPsoriasisSeverityon
HypertensionControl:APopulationBasedStudyintheUnitedKingdom.JAMADermatol.2014Oct15.
[Medline].
3. CatsarouCatsariA,KatambusA,TheodorpoylosP.Ophthalmologicalmanifestationsinpatientswith
psoriasis.ActaDermVenereol(Stock).1984.64:557559.
4. HuynhN,CervantesCastanedaRA,BhatP,GallagherMJ,FosterCS.Biologicresponsemodifiertherapy
forpsoriaticocularinflammatorydisease.OculImmunolInflamm.2008MayJun.16(3):8993.[Medline].
5. [Guideline]MenterA,KormanNJ,ElmetsCA,FeldmanSR,GelfandJM,GordonKB,etal.Guidelinesof
careforthemanagementofpsoriasisandpsoriaticarthritis:section4.Guidelinesofcareforthe
managementandtreatmentofpsoriasiswithtraditionalsystemicagents.JAmAcadDermatol.2009Sep.
61(3):45185.[Medline].
6. MrowietzU,deJongEM,KragballeK,LangleyR,NastA,PuigL,etal.Aconsensusreportonappropriate
treatmentoptimizationandtransitioninginthemanagementofmoderatetosevereplaquepsoriasis.JEur
AcadDermatolVenereol.2013Feb26.[Medline].
7. ChristophersE,SterryW.Psoriasis.FitzpatrickTB,EisenAZ,WolffK,eds.DermatologyinGeneral
Medicine.NewYork:McGrawHill1993.489511.
8. FarberEM,CoxAJ,eds.Psoriasis:ProceedingsoftheThirdInternationalSymposiumYorkeMedical.New
York:1981.
9. GulliverW.Longtermprognosisinpatientswithpsoriasis.BrJDermatol.2008Aug.159Suppl2:29.
[Medline].
10. KruegerJG,BowcockA.Psoriasispathophysiology:currentconceptsofpathogenesis.AnnRheumDis.
2005Mar.64Suppl2:ii306.[Medline].[FullText].
11. KeaneyTC,KirsnerRS.NewinsightsintothemechanismofnarrowbandUVBtherapyforpsoriasis.J
InvestDermatol.2010Nov.130(11):2534.[Medline].
12. KarabulutAA,YalvacIS,VahabogluH,NurozlerAB,DumanS.Conjunctivalimpressioncytologyandtear
filmchangesinpatientswithpsoriasis.Cornea.1999Sep.18(5):5448.[Medline].
13. PietrzakAT,ZalewskaA,ChodorowskaG,KrasowskaD,MichalakStomaA,NockowskiP,etal.Cytokines
andanticytokinesinpsoriasis.ClinChimActa.2008Aug.394(12):721.[Medline].
14. KellerJJ,LinHC.TheEffectsofChronicPeriodontitisandItsTreatmentontheSubsequentRiskof
Psoriasis.BrJDermatol.2012Jul3.[Medline].
15. RiveiraMunozE,HeSM,EscaramsG,etal.MetaAnalysisConfirmstheLCE3C_LCE3BDeletionasa
RiskFactorforPsoriasisinSeveralEthnicGroupsandFindsInteractionwithHLACw6.JInvestDermatol.
2011May.131(5):11059.[Medline].
16. GelfandJM,SternRS,NijstenT,FeldmanSR,ThomasJ,KistJ,etal.Theprevalenceofpsoriasisin
AfricanAmericans:resultsfromapopulationbasedstudy.JAmAcadDermatol.2005Jan.52(1):236.
[Medline].
17. GelfandJM,TroxelAB,LewisJD,KurdSK,ShinDB,WangX,etal.Theriskofmortalityinpatientswith
psoriasis:resultsfromapopulationbasedstudy.ArchDermatol.2007Dec.143(12):14939.[Medline].
18. HardingA.Extentofpsoriasistiedtoriskofcomorbidities.ReutersHealthInformation.August15,2013.
[FullText].
19. YeungH,TakeshitaJ,MehtaNN,etal.PsoriasisSeverityandthePrevalenceofMajorMedical
Comorbidity:APopulationBasedStudy.JAMADermatol.2013Aug7.[Medline].
20. PatelRV,ShellingML,ProdanovichS,FedermanDG,KirsnerRS.Psoriasisandvasculardiseaserisk
factorsandoutcomes:asystematicreviewoftheliterature.JGenInternMed.2011Sep.26(9):103649.
[Medline].
21. LiWQ,HanJL,MansonJE,RimmEB,RexrodeKM,CurhanGC,etal.Psoriasisandriskofnonfatal
cardiovasculardiseaseinU.S.women:acohortstudy.BrJDermatol.2012Apr.166(4):8118.[Medline].
22. WanJ,WangS,HaynesK,DenburgMR,ShinDB,GelfandJM.Riskofmoderatetoadvancedkidney
diseaseinpatientswithpsoriasis:populationbasedcohortstudy.BMJ.2013Oct15.347:f5961.[Medline].
23. LaidmanJ.ModerateandSeverePsoriasisLinkedtoHigherKidneyRisks.Medscape[serialonline].
Availableathttp://www.medscape.com/viewarticle/812730.Accessed:October21,2013.

http://emedicine.medscape.com/article/1943419clinical#showall

4/6

10/25/2015

PsoriasisClinicalPresentation:History,PhysicalExamination,OcularManifestations

24. RappSR,FeldmanSR,ExumML,FleischerABJr,ReboussinDM.Psoriasiscausesasmuchdisabilityas
othermajormedicaldiseases.JAmAcadDermatol.1999Sep.41(3Pt1):4017.[Medline].
25. KurdSK,TroxelAB,CritsChristophP,GelfandJM.Theriskofdepression,anxiety,andsuicidalityin
patientswithpsoriasis:apopulationbasedcohortstudy.ArchDermatol.2010Aug.146(8):8915.
[Medline].[FullText].
26. OostveenAM,deJagerME,vandeKerkhofPC,DondersAR,deJongEM,SeygerMM.Theinfluenceof
treatmentsindailyclinicalpracticeontheChildren'sDermatologyLifeQualityIndexinjuvenilepsoriasis:a
longitudinalstudyfromtheChildCAPTUREpatientregistry.BrJDermatol.2012May23.[Medline].
27. LuckaTC,PathiranaD,SammainA,BachmannF,RosumeckS,ErdmannR,etal.Efficacyofsystemic
therapiesformoderatetoseverepsoriasis:asystematicreviewandmetaanalysisoflongtermtreatment.J
EurAcadDermatolVenereol.2012Mar9.[Medline].
28. PetteyAA,BalkrishnanR,RappSR,FleischerAB,FeldmanSR.Patientswithpalmoplantarpsoriasis
havemorephysicaldisabilityanddiscomfortthanpatientswithotherformsofpsoriasis:implicationsfor
clinicalpractice.JAmAcadDermatol.2003Aug.49(2):2715.[Medline].
29. SampognaF,TabolliS,SoderfeldtB,AxteliusB,AparoU,AbeniD.Measuringqualityoflifeofpatients
withdifferentclinicaltypesofpsoriasisusingtheSF36.BrJDermatol.2006May.154(5):8449.[Medline].
30. LangenbruchA,RadtkeMA,KrenselM,JacobiA,ReichK,AugustinM.Nailinvolvementasapredictorof
concomitantpsoriaticarthritisinpatientswithpsoriasis.BrJDermatol.2014Nov.171(5):11238.[Medline].
31. MoadelK,PerryHD,DonnenfeldED,ZagelbaumB,IngrahamHJ.Psoriaticcornealabscess.AmJ
Ophthalmol.1995Jun.119(6):8001.[Medline].
32. DurraniK,FosterCS.Psoriaticuveitis:adistinctclinicalentity?.AmJOphthalmol.2005Jan.139(1):106
11.[Medline].
33. TakahashiH,SugitaS,ShimizuN,MochizukiM.AhighviralloadofEpsteinBarrvirusDNAinocular
fluidsinanHLAB27negativeacuteanterioruveitispatientwithpsoriasis.JpnJOphthalmol.2008Mar
Apr.52(2):1368.[Medline].
34. [Guideline]MenterA,GottliebA,FeldmanSR,VanVoorheesAS,LeonardiCL,GordonKB,etal.
Guidelinesofcareforthemanagementofpsoriasisandpsoriaticarthritis:Section1.Overviewofpsoriasis
andguidelinesofcareforthetreatmentofpsoriasiswithbiologics.JAmAcadDermatol.2008May.
58(5):82650.[Medline].
35. [Guideline]MenterA,KormanNJ,ElmetsCA,FeldmanSR,GelfandJM,GordonKB,etal.Guidelinesof
careforthemanagementofpsoriasisandpsoriaticarthritis.Section3.Guidelinesofcareforthe
managementandtreatmentofpsoriasiswithtopicaltherapies.JAmAcadDermatol.2009Apr.60(4):643
59.[Medline].
36. [Guideline]MenterA,KormanNJ,ElmetsCA,FeldmanSR,GelfandJM,GordonKB,etal.Guidelinesof
careforthemanagementofpsoriasisandpsoriaticarthritis:Section5.Guidelinesofcareforthetreatment
ofpsoriasiswithphototherapyandphotochemotherapy.JAmAcadDermatol.2010Jan.62(1):11435.
[Medline].
37. [Guideline]MenterA,KormanNJ,ElmetsCA,FeldmanSR,GelfandJM,GordonKB,etal.Guidelinesof
careforthemanagementofpsoriasisandpsoriaticarthritisSection6.Guidelinesofcareforthetreatment
ofpsoriasisandpsoriaticarthritis:Casebasedpresentationsandevidencebasedconclusions.JAmAcad
Dermatol.2011Feb7.[Medline].
38. MasonAR,MasonJ,CorkM,DooleyG,EdwardsG.Topicaltreatmentsforchronicplaquepsoriasis.
CochraneDatabaseSystRev.2009Apr15.CD005028.[Medline].
39. SternRS.Theriskofsquamouscellandbasalcellcancerassociatedwithpsoralenandultraviolet
Atherapy:A30yearprospectivestudy.JAmAcadDermatol.2012Jan18.[Medline].
40. CarrascosaJM,PlanaA,FerrandizC.EffectivenessandSafetyofPsoralenUVA(PUVA)TopicalTherapy
inPalmoplantarPsoriasis:AReporton48Patients.ActasDermosifiliogr.2013Mar6.[Medline].
41. SternDK,CreaseyAA,QuijijeJ,LebwohlMG.UVAandUVBPenetrationofNormalHumanCadaveric
FingernailPlate.ArchDermatol.2011Apr.147(4):43941.[Medline].
42. LermanS.Ocularsideeffectsofaccutanetherapy.LensEyeToxicRes.1992.9(34):42938.[Medline].
43. BrelsfordM,BeuteTC.Preventingandmanagingthesideeffectsofisotretinoin.SeminCutanMedSurg.
2008Sep.27(3):197206.[Medline].
44. Lowes,R.FDAApprovesApremilast(Otezla)forPlaquePsoriasis.MedscapeMedicalNews.Availableat
http://www.medscape.com/viewarticle/832211.Accessed:September23,2014.
45. Otezla(apremilast)[packageinsert].Summit,NJ:CelgeneCorporation.September,2014.Availableat
[FullText].
46. KlingJ.OralTofacitinibNotInferiortoEtanerceptforPsoriasis.MedscapeMedicalNews.Availableat
http://www.medscape.com/viewarticle/822565.Accessed:April1,2014.
47. LangleyRG,ElewskiBE,LebwohlM,ReichK,GriffithsCE,PappK,etal.Secukinumabinplaque
psoriasisresultsoftwophase3trials.NEnglJMed.2014Jul24.371(4):32638.[Medline].[FullText].
48. PappKA,GriffithsCE,GordonK,LebwohlM,etal.Longtermsafetyofustekinumabinpatientswith
moderatetoseverepsoriasis:finalresultsfromfiveyearsoffollowup.BrJDermatol.2013Jan10.
[Medline].
49. KimballAB,GordonKB,FakharzadehS,YeildingN,SzaparyPO,SchenkelB,etal.Longtermefficacyof
ustekinumabinpatientswithmoderatetoseverepsoriasis:resultsfromthePHOENIX1trialthroughupto
3years.BrJDermatol.2012Feb22.[Medline].

http://emedicine.medscape.com/article/1943419clinical#showall

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10/25/2015

PsoriasisClinicalPresentation:History,PhysicalExamination,OcularManifestations

MedscapeReference2011WebMD,LLC

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