<p>Plaque psoriasis is common yet frequently misdiagnosed, especially when it presents in atypical sites and in patients with skin of color. A structured approach integrating history, distribution, itch, biopsy when warranted, and comorbidity awareness helps clinicians recognize when a patient’s disease might signal deeper systemic inflammation and cardiometabolic risk.</p> <p><br></p> <p><em>Following the Society of Dermatology Physician Associates (SDPA) 23rd Annual Fall Dermatology Conference, featured expert Diego Ruiz Dasilva, MD, FAAD, was interviewed by</em> Conference Reporter<em> Associate Editor-in-Chief Christopher Ontiveros, PhD. Clinical perspectives from Dr Dasilva are presented here.</em></p>

Plaque psoriasis is quite common. I see approximately 10 to 20 patients with plaque psoriasis each week. The most interesting part about it is that you have your very classic plaque psoriasis presentations (ie, well-demarcated, thick, silvery plaques), but you may also have atypical presentations. I think that there is still a great deal of misdiagnosis that occurs, even though plaque psoriasis is so common.

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Certainly, the morphology clues me in to a possible plaque psoriasis diagnosis. Beyond that, I ask about the patient’s medical history and whether anyone in their family has ever been diagnosed with psoriasis. I also ask about joint pain, which can present with plaque psoriasis, usually in the form of psoriatic arthritis, although not always. In the past, if the skin was itchy, dermatologists were less likely to think of plaque psoriasis. That paradigm has shifted, particularly in the last several years, as we have seen that many patients with plaque psoriasis have significantly itchy lesions. So, I do ask about itching. Beyond that, I also consider location. If there is a substantial amount of scalp involvement compared with the rest of the skin, I am more likely to consider a diagnosis of plaque psoriasis. Extensor surfaces such as the elbows, knees, lower back, intergluteal cleft, and hands are common places for plaque psoriasis as well.

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When the diagnosis is uncertain, I am a big fan of performing a skin biopsy, particularly in someone in whom I am considering using systemic medication. This is because some systemic agents for plaque psoriasis may require special treatment considerations. For me, atypical presentations (eg, some cases in patients with skin of color; location in skin folds, nails, or palmoplantar areas; or cases that are similar in appearance to dermatitis) are the cases in which I really push for doing a biopsy early in the disease course, even if the patient is not yet a candidate for systemic treatment. This may also typically be when the patient has smaller papules and plaques that are not fully formed, or when they also have some background erythema and some itching but perhaps with other features that make me think of plaque psoriasis, such as a family history, significant scalp involvement, or joint pain.

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Regarding comorbidities with plaque psoriasis, their presence in my diagnostic formulation can be equivocal because the ones that you most worry about—obesity, diabetes, cardiac disease, or other cardiometabolic comorbidities—are conditions that anyone can have; you do not have to have plaque psoriasis to have these conditions. But certainly, it is well known that patients with plaque psoriasis are at a higher likelihood of having these conditions, as well as experiencing heart attacks, strokes, and even death from cardiovascular comorbidities. I think that there is a huge misconception that skin diseases are just skin deep. However, we know now that if you treat patients with moderate to severe plaque psoriasis with effective systemic therapies, you can decrease their risk of major adverse cardiovascular events and even lower their all-cause mortality. It is very important to let these patients know that and to offer them effective treatment.

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Our dermatology physician assistants and nurse practitioners are essential because there are not enough board-certified dermatologists to take care of all the skin that we have in the United States. We function as colleagues. I personally have trained 2 nurse practitioners and 1 physician assistant. We work very closely together. They see their own cohort of patients and know what to look for specifically when it comes to plaque psoriasis. They know the importance of discussing available treatment options, how plaque psoriasis is more than just skin deep, how there are many presentations, and how to stay on top of the literature in terms of reviewing journals and going to meetings such as the SDPA 23rd Annual Fall Dermatology Conference to learn more about the most cutting-edge advances in managing plaque psoriasis.