74%, skin pain in 62%, bleeding in 58%, redness in 57%, flare-ups in 49%, joint pain in 42%, skin cracking in 39%, dry skin in 34%, physical discomfort in 32%, burning in 28% and nail problems in 22% (7). Female, South Africa: “I have had psoriasis from the age of 26 and I am now 54. At first I thought it was dandruff as it started on my scalp. My colleagues at work will suggest all sorts of shampoos as it was visible (‘the dandruff’). Then it started on my body and I went to a dermatologist and I was told it was psoriasis. I got ointments that I felt did not help. I hid my skin from everyone and started wearing a scarf at work. I felt like an outcast cause in most work environments you were not allowed to wear a scarf at that time. At the time I felt like psoriasis was the unspoken disease as people were ignorant and pulled their faces or asked stupid questions or looked at you funny. It still happens today.” Source: South Africa Psoriasis Association. Global report on psoriasis 14 Table 2. Common types of psoriasis and their manifestations Psoriasis vulgaris (plaque psoriasis) n The most common type of psoriasis, affects between 58% (79) and 97% (45) of all patients. n Inflammatory red, sharply demarcated, raised, dry, differently sized plaques, usually covered by silvery or white scales. n Involves the scalp and the area behind the ears, the extensor surfaces of the forearms and shins (especially elbows and knees), trunk, face, palms, soles and nails. Psoriasis vulgaris in adult patients. ©Ulrich Mrowietz, Psoriasis Center Kiel. Intertriginous psoriasis (psoriasis in folds and genital areas) n Affects between 12% (105) and 26% (21) of all cases of psoriasis. n Deep-red or white, flat, sharply demarcated, wet patches or plaques, scales are usually absent. n Affects almost exclusively flexural body sites – axillae, antecubital fossae, inframammary creases, umbilicus, groins, genital area, gluteal cleft, popliteal fossae and other body folds. Intertriginous psoriasis in adult patients. ©Ulrich Mrowietz, Psoriasis Center Kiel. Guttate psoriasis (droplet psoriasis) n Affects between 0.6% (45) and 20% (8) of individuals diagnosed with psoriasis and usually occurs in childhood and adolescence. n Reddish, drop-like papules and plaques, mainly involving the trunk, arms and legs. n Onset is associated with streptococcal infection of the upper respiratory tract and prior skin symptoms (106). Guttate psoriasis in an 8-year-old girl. ©Michael P. Schön, Universitätsmedizin Göttingen. Pustular psoriasis n Affects between 1.1% (45) and 12% (105) of all cases of psoriasis. n Coalescing pustules, filled with non-infectious pus. n Involves either small areas such as palms of the hands, fingertips, nails and soles of the feet, or the entire body surface can occur as a single episode after a trigger. Generalized pustular psoriasis in an adult female patient. ©Michael P. Schön, Universitätsmedizin Göttingen. Erythrodermic psoriasis n Affects between 0.4% (45) and 7% (105) of all cases of psoriasis. n Fiery redness and exfoliation of most of the body surface. n The most serious type of psoriasis, potentially lifethreatening, because it can lead to hypothermia, hypoalbuminemia and high output cardiac failure. Erythrodermic psoriasis in adult male patient. © Matthias Augustin, University Medical Center Hamburg. Global report on psoriasis 15 Based on a review of the literature, the prevalence of nail psoriasis ranges between 4.2% (8) and 69% (9) of all patients suffering from psoriasis. Nail psoriasis may occur with the involvement of the skin or it may occur alone, being the only symptom of psoriasis. Nail psoriasis is not only a problem of an aesthetic nature, but can also restrict manual dexterity. The nail disease may be acute or chronic, with varied severity. There may be involvement of only a single nail or of all nails associated with severe nail destruction or loss (Figure 5). Figure 5. Nail psoriasis ©Matthias Augustin, University Medical Center Hamburg. Nail psoriasis may be a predisposing factor for fungal or bacterial infections, which occur in 4.6% to 30% of cases of nail psoriasis (107). Patients suffering from nail psoriasis have significantly worse psoriasis severity scores, compared to patients without nail involvement (108). In addition, they report poorer QoL and a greater number of days unfit for work (108). These patients were also more likely to be admitted to the hospital and more often suffered from psoriatic arthritis. Psoriatic arthritis In addition to the skin, psoriasis can be associated with an inflammatory arthritis known as psoriatic arthritis, which involves the joints of the spine and other joints. This occurs without presence of specific antibodies in the blood (seronegative spondyloarthropathy). The rheumatoid factor (antibody occurring in rheumatoid arthritis) is also negative. A review of the literature showed that psoriatic arthritis affects between 1.3% (6) and 34.7% (7) of patients diagnosed with psoriasis. There are no data on sex predilection. In a United States population, it was observed that psoriatic arthritis occurred more frequently in Caucasian patients than in other ethnic groups (109). Two large consecutive German studies from dermatological practices that assessed the prevalence of arthritis from examinations by rheumatologists in 2005 and 2007 was 20.6% (10) and 19.6% (110), respectively. The clinical symptoms are variable, however, peripheral arthritis, spondylitis, enthesitis (inflammation of the sites where tendons insert into the bone), arthritis in the fingers and dactylitis (profuse swelling of the fingers or toes) are considered to be most common (Figure 6). Psoriatic arthritis can lead to chronic pain and change in physical appearance. Patients suffering from psoriatic arthritis have reduced physical fitness, compared to psoriasis patients without it (22). Typically, psoriatic arthritis occurs in conjunction with longstanding skin lesions, although rarely it occurs alone, in the absence of psoriasis. Global report on psoriasis 16 Figure 6. Psoriasis arthritis ©Matthias Augustin, University Medical Center Hamburg. Associated diseases Numerous studies have reported the coexistence of psoriasis and other serious systemic diseases, most often mentioned are cardiovascular diseases, metabolic syndrome, including hypertension, dyslipidemia and diabetes mellitus, and Crohn’s disease. Even children show increased rates of comorbidity compared to unaffected infants, or those with atopic eczema (11,49). Most publications discuss the association between cardiovascular disease and psoriasis. Patients diagnosed with psoriasis have an increased burden of subclinical atherosclerosis and vascular inflammation (111). They also have significantly higher levels of serum lipids, including triglycerides and total cholesterol, compared to healthy individuals (112). Moreover, psoriasis is associated with atrial fibrillation and stroke, which may be aggravated in young patients (113). However,