Browse categories and answer follow-up questions to refine your symptom profile.
Approach to the Critical Patient
Triage and immediate risks
Immediate severity screen
Airway compromise
Oropharyngeal edema
Stridor
Shock physiology
SBP < 90 mmHg
Lactate elevation
Systemic toxicity
Temperature ≥ 38.0 C
Rigors
Extensive skin failure patterns
Erythroderma with BSA > 90%
Generalized pustular eruption
SJS TENS concern
Mucosal involvement
Skin pain out of proportion
Immediate actions if unstable
Escalate to resuscitation bay for hypotension
Large bore IV access
Crystalloid bolus 20 ml/kg
If temperature ≥ 38.0 C with hypotension, sepsis pathway
Broad spectrum antibiotics per local protocol
Blood cultures before antibiotics if feasible
If SJS TENS concern, stop all non essential medications immediately
Burn unit or ICU consultation
Dermatology consultation
High risk phenotypes and triggers
High risk flare identification
Erythrodermic psoriasis
Thermoregulatory failure risk
Fluid and protein loss risk
Generalized pustular psoriasis
Sepsis mimic risk
Electrolyte derangement risk
Palmoplantar pustulosis with functional impairment
Ambulation limitation
Secondary infection risk
Trigger review
Systemic corticosteroid exposure
Withdrawal rebound risk
Pustular conversion risk
Infection triggers
Streptococcal pharyngitis
Viral illness
Medication triggers
Lithium
Antimalarials
Interferon
Beta blockers
Lifestyle and mechanical triggers
Recent skin trauma
Sunburn
Alcohol excess
Smoking
Coding anchors
ICD-10 L40.0 psoriasis vulgaris
ICD-10 L40.1 generalized pustular psoriasis
ICD-10 L40.8 other psoriasis
ICD-10 L40.9 psoriasis unspecified
ICD-10 L40.5 psoriatic arthropathy
SNOMED CT term psoriasis
SNOMED CT term pustular psoriasis
SNOMED CT term erythrodermic psoriasis
Initial monitoring and targets
Monitoring bundle for severe flare
Continuous pulse oximetry
Target SpO2 ≥ 94%
Cardiac monitoring if tachycardia
Heart rate trend
Temperature trend
Hypothermia risk in erythroderma
Strict intake output
Urine output target ≥ 0.5 ml/kg/hour
Weight trend if admitted
Fluid balance marker
History
Presentation and course
Symptom pattern
Onset timing
Sudden onset within 72 hours
Subacute onset over weeks
Pruritus severity
Sleep disruption
Excoriation behavior
Pain severity
Skin pain
Fissure pain
Functional impact
Work or school impairment
Ambulation limitation
Flare context
Prior psoriasis diagnosis
Chronic plaque history
Prior pustular episodes
New diagnosis consideration
First episode
Family history
Systemic symptoms
Fever
Measured temperature at home
Antipyretic use
Malaise
Reduced oral intake
Dehydration symptoms
Arthralgia
Morning stiffness
Back pain pattern
Exposures and comorbidities
Medication and treatment history
Recent systemic corticosteroids
Indication
Stop date
Current topical regimen
Potency class
Application frequency
Systemic psoriasis therapies
Methotrexate use
Cyclosporine use
Acitretin use
Biologic therapy use
New medications within 8 weeks
Antibiotics
Antiepileptics
Infection risk and recent infections
Sore throat
Household strep exposure
Skin infection history
Prior impetigo
Prior cellulitis
Comorbid disease screening
Cardiometabolic disease
Diabetes
Hypertension
Hyperlipidemia
Liver disease risk
Alcohol use pattern
Viral hepatitis history
Kidney disease history
Baseline creatinine knowledge
Mental health impact
Anxiety
Depression
Special situations
Pregnancy possibility
Last menstrual period timing
Contraception use
Immunosuppression
Transplant history
HIV risk
Physical Exam
Skin and mucosa
Morphology and distribution
Plaques
Well demarcated erythematous plaques
Silvery scale
Guttate pattern
Drop like papules
Trunk predominant
Pustular lesions
Sterile appearing pustules
Coalescent lakes of pus
Erythroderma pattern
Diffuse erythema
Generalized scaling
Intertriginous involvement
Inverse psoriasis pattern
Maceration
BSA estimation
Palm method
Patient palm equals 1% BSA
Severe extent thresholds
BSA ≥ 10% moderate to severe
BSA > 90% erythroderma
Mucosal findings
Oral erosions
SJS TENS concern marker
Conjunctival injection
Ocular involvement marker
Secondary infection signs
Honey colored crust
Impetigo pattern
Purulence
Abscess pattern
Warmth and tenderness
Cellulitis pattern
Vitals and systemic assessment
Hemodynamic status
Tachycardia
Dehydration marker
Infection marker
Hypotension
Sepsis concern
Volume depletion concern
Hydration and perfusion
Dry mucous membranes
Volume depletion marker
Capillary refill delay
Hypoperfusion marker
Temperature regulation
Fever
Infection or inflammatory flare
Hypothermia
Skin failure marker in erythroderma
Musculoskeletal and nails
Joint findings
Dactylitis
Diffuse digit swelling
Synovitis
Warm swollen joint
Axial tenderness
Sacroiliac pain
Nail findings
Pitting
Psoriatic nail dystrophy
Onycholysis
Distal nail separation
Subungual hyperkeratosis
Thickened nail bed
Differential Diagnosis
Life threatening and cannot miss
Dangerous mimics
Stevens Johnson syndrome toxic epidermal necrolysis
Mucosal involvement
Skin pain
Recent high risk medication
Sepsis with rash
Hypotension
Altered mental status
Necrotizing soft tissue infection
Severe focal pain
Rapid progression
Psoriasis emergencies
Erythrodermic psoriasis
BSA > 90%
Thermoregulatory instability
Generalized pustular psoriasis
Fever with pustules
Leukocytosis
Common mimics and overlaps
Papulosquamous mimics
Atopic dermatitis
Flexural predominance
Lichenification
Contact dermatitis
Clear exposure pattern
Vesiculation
Tinea corporis
Annular plaques
Central clearing
Pityriasis rosea
Herald patch
Christmas tree distribution
Seborrheic dermatitis
Greasy scale
Scalp and face predominance
Pustular mimics
Acute generalized exanthematous pustulosis
Recent drug exposure
Facial edema
Impetigo
Honey colored crust
Erythroderma differentials
Drug eruption
New medication timing
Cutaneous T cell lymphoma
Chronic refractory course
Laboratory Tests
Core labs for severe flare
Severity and systemic inflammation set
Complete blood count for leukocytosis
Neutrophilia in pustular flare
Eosinophilia in drug eruption
Electrolytes for skin failure
Sodium abnormality with dehydration
Potassium abnormality with GI loss
Creatinine for renal perfusion
AKI risk in erythroderma
Cyclosporine eligibility marker
Liver enzymes for systemic therapy safety
Methotrexate eligibility marker
Acitretin eligibility marker
CRP for inflammatory burden
High value supports systemic flare
Very high value supports infection differential
Infection evaluation when febrile
Infection workup set
Blood cultures for fever with systemic toxicity
Two sets from separate sites
Before antibiotics if feasible
Lactate for shock assessment
Rising trend marker
Target downtrend with resuscitation
Urinalysis when urinary symptoms
Pyuria marker
Bacteriuria marker
Throat testing when guttate pattern with sore throat
Rapid strep test
Throat culture
Pre treatment screening for systemic escalation
Systemic therapy screening set
Pregnancy test for childbearing potential
Required before retinoids
Required before methotrexate
Hepatitis B screening for biologic consideration
HBsAg
Anti HBc
Hepatitis C screening for biologic consideration
Anti HCV
RNA if antibody positive
HIV screening when risk factors
Baseline immunosuppression marker
TB screening for biologic consideration
IGRA test
Chest radiograph if positive
Diagnostic Tests
Scoring Systems
Psoriasis severity metrics
BSA percentage
Mild BSA < 3%
Moderate BSA 3% to 10%
Severe BSA > 10%
PASI score
Erythema component
Induration component
Scaling component
PGA score
Clear to severe scale
Treatment response tracking
DLQI score
Quality of life impairment marker
Systemic therapy justification support
MRI
MRI indications
Suspected psoriatic arthritis with axial symptoms
Sacroiliitis evaluation
Enthesitis evaluation
Suspected osteomyelitis under chronic plaques
Deep pain
Ulcer over bony prominence
MRI limitations
Limited utility for cutaneous flare diagnosis
Clinical diagnosis predominance
Dermatology exam primacy
CT
CT indications
Deep soft tissue infection concern under plaques
Fluctuance with systemic signs
Severe focal pain
Alternate diagnosis evaluation when uncertain
Abscess mapping
Necrotizing infection adjunct
CT limitations
Not a routine psoriasis test
Radiation exposure
Limited cutaneous specificity
Ultrasound
Point of care ultrasound uses
Soft tissue infection evaluation
Abscess vs cellulitis
Guidance for drainage planning
Musculoskeletal evaluation in psoriatic arthritis
Effusion detection
Enthesitis detection
Ultrasound limitations
Limited role in plaque diagnosis
Clinical morphology predominance
Dermoscopy or biopsy when unclear
Disposition
Admission and higher level of care
Admit criteria
Erythrodermic psoriasis
BSA > 90%
Temperature instability
Generalized pustular psoriasis with systemic symptoms
Fever
Leukocytosis
Hemodynamic instability
Hypotension
Persistent tachycardia with dehydration
Significant dehydration
Inability to maintain oral intake
AKI
Superimposed serious infection
Cellulitis with systemic signs
Bacteremia
ICU or monitored bed triggers
Shock physiology
Vasopressor requirement
Rising lactate
Severe electrolyte derangement
Sodium abnormality with symptoms
Potassium abnormality with ECG changes
Discharge and follow up
Discharge criteria
Stable vitals
Afebrile
Normal blood pressure
No SJS TENS features
No mucosal lesions
No skin pain out of proportion
Limited extent flare
BSA not in erythroderma range
No generalized pustules
Reliable follow up
Dermatology appointment plan
Primary care follow up plan
Follow up timing
Dermatology within 1 to 2 weeks for moderate flare
Systemic therapy discussion
Phototherapy consideration
Dermatology within 24 to 72 hours for pustular flare
Escalation to systemic rescue therapy
Infection exclusion confirmation
Treatment
Supportive care and skin barrier
Barrier restoration bundle
Emollients
Petrolatum based ointment
Apply at least twice daily
Apply after bathing
Thick fragrance free cream
Apply after hand washing
Apply to fissures
Bathing and scale softening
Lukewarm short baths
Avoid hot water
Pat dry
Occlusion options
Plastic wrap short contact over thick plaques
Avoid occlusion if infection concern
Pruritus control
Non sedating antihistamine
Cetirizine 10 mg PO daily
Loratadine 10 mg PO daily
Sedating antihistamine at night when needed
Hydroxyzine 10 mg to 25 mg PO at bedtime
Drowsiness counseling
Pain control bundle
Acetaminophen
15 mg/kg PO every 6 hours as needed
Maximum 4000 mg per day adult
NSAID when no contraindication
Ibuprofen 10 mg/kg PO every 6 hours as needed
Maximum 2400 mg per day adult
Topical anti inflammatory therapy
Topical corticosteroids by site
Trunk and extremities
Clobetasol 0.05% ointment
Thin layer once to twice daily
Maximum continuous use 2 weeks
Betamethasone dipropionate 0.05% ointment
Thin layer once to twice daily
Taper frequency when improved
Face and intertriginous areas
Hydrocortisone 1% to 2.5% cream
Thin layer once to twice daily
Short course 7 to 14 days
Tacrolimus 0.03% ointment
Thin layer twice daily
Steroid sparing option
Scalp
Fluocinonide 0.05% solution
Apply once to twice daily
Avoid dripping into eyes
Clobetasol 0.05% shampoo
Contact time 15 minutes
Use daily for up to 4 weeks
Steroid adverse effect mitigation
Skin atrophy risk
Avoid high potency on face
Avoid prolonged occlusion
HPA axis suppression risk
Avoid large area high potency long duration
Pediatric higher risk
Non steroid topical adjuncts
Vitamin D analogs
Calcipotriol 0.005% cream
Apply twice daily
Avoid face and folds
Calcipotriol betamethasone combination
Apply once daily
Adherence improvement option
Keratolytics for scale
Salicylic acid 3% to 6% preparations
Apply to thick scale
Avoid large area use in young children
Urea 20% to 40% cream
Apply to hyperkeratotic plaques
Fissure softening
Tar preparations
Coal tar shampoo for scalp
Adjunct for scale
Odor counseling
Systemic rescue therapy for severe flare
Systemic escalation principles
Dermatology consultation for systemic initiation
Same day for generalized pustular psoriasis
Same day for erythrodermic psoriasis
Avoid systemic corticosteroids as routine psoriasis flare therapy
Rebound flare risk
Pustular conversion risk
Cyclosporine
Dosing range
2.5 mg/kg/day PO divided twice daily
5 mg/kg/day PO divided twice daily
Monitoring
Creatinine baseline and repeat
Blood pressure monitoring
Contraindications
Uncontrolled hypertension
Significant renal dysfunction
Methotrexate
Dosing
7.5 mg PO weekly
25 mg PO weekly
Folic acid supplementation
1 mg PO daily
5 mg PO weekly on non methotrexate day
Monitoring
CBC monitoring
Liver enzymes monitoring
Contraindications
Pregnancy
Significant liver disease
Acitretin
Dosing
0.3 mg/kg/day PO
0.5 mg/kg/day PO
Contraindications
Pregnancy
Severe hypertriglyceridemia
Monitoring
Lipid panel monitoring
Liver enzymes monitoring
Biologic rapid control options for pustular crisis under specialist care
Infliximab
5 mg/kg IV once
Repeat per induction schedule under specialist plan
IL 36 receptor antagonist for generalized pustular psoriasis under specialist care
Spesolimab 900 mg IV once
Repeat dosing per protocol if persistent disease
Evidence and recommendation notes
Recommendation strength mapping used in this reference
Class I recommendation
Benefits clearly outweigh risks
Strong consensus among guideline bodies
Class IIa recommendation
Benefits likely outweigh risks
Moderate quality evidence or consensus
Class IIb recommendation
Benefits possibly outweigh risks
Limited evidence
Topical corticosteroids for localized plaque flare
Class I recommendation
First line for most localized flares
Rapid symptom control
Systemic rescue therapy for erythrodermic or generalized pustular flare
Class I recommendation
Dermatology led systemic therapy
Hospital level supportive care when unstable
Special Populations
Pregnancy
Pregnancy considerations
Safer first line options
Emollients
Liberal use
Fragrance free
Low to medium potency topical corticosteroids
Short courses
Small area preference
Narrowband UVB phototherapy
Steroid sparing option
Folate supplementation consideration
Avoided therapies
Methotrexate
Teratogenicity
Contraindicated
Acitretin
Teratogenicity
Contraindicated
Severe flare escalation under specialist care
Cyclosporine consideration
Maternal blood pressure monitoring
Renal function monitoring
TNF inhibitor continuation or initiation consideration
Placental transfer counseling by trimester
Neonatal live vaccine timing discussion
Geriatric
Geriatric considerations
Comorbidity burden
Heart failure risk with severe erythroderma stress
Diabetes impact on skin infection risk
Medication safety
Renal dosing awareness for cyclosporine
Hepatic reserve awareness for methotrexate
Skin fragility
Steroid atrophy risk
Tear risk with adhesives
Pediatrics
Pediatric considerations
Potency selection
Low potency on face and folds
Short duration high potency only with specialist input
Systemic absorption risk
Higher BSA to weight ratio
Occlusion avoidance unless directed
Guttate psoriasis association
Recent streptococcal infection pattern
Throat evaluation consideration
Weight based dosing for systemic therapies
Specialist led initiation
Monitoring plan required
Background
Epidemiology
Epidemiology overview
Chronic immune mediated inflammatory skin disease
Relapsing remitting course
Multisystem comorbidity associations
Common phenotypes
Chronic plaque psoriasis
Guttate psoriasis
Pustular psoriasis
Psoriatic arthritis association
Joint disease screening importance
Nail disease correlation
Pathophysiology
Pathophysiology framework
Immune axis
IL 23 pathway activation
Th17 cytokines
Keratinocyte hyperproliferation
Thickened stratum corneum
Scale formation
Koebner phenomenon
Lesions at trauma sites
Mechanical trigger relevance
Therapeutic Considerations
Therapeutic goals
Barrier restoration
Reduce transepidermal water loss
Reduce fissuring
Inflammation suppression
Topical anti inflammatory for localized disease
Systemic therapy for severe disease
Trigger modification
Infection treatment
Medication reconciliation
Systemic corticosteroid caution rationale
Rebound inflammation risk
Flare after taper
Pustular shift
Alternative rapid control options
Cyclosporine for crisis under specialist care
Biologic rapid onset options under specialist care
Patient Discharge Instructions
copy discharge instructions
Psoriasis flare care at home
Moisturizer
Thick fragrance free ointment or cream at least twice daily
Apply right after bathing
Topical medication use
Apply exactly as prescribed
Avoid high potency steroid on face or groin unless directed
Bathing
Lukewarm water
Gentle unscented cleanser
Triggers
Avoid skin trauma and picking
Avoid new non prescribed creams on plaques
Follow up
Dermatology appointment as arranged
Primary care follow up for long term plan
Return to ED now
Fever
Temperature ≥ 38.0 C
Chills or feeling very unwell
Rapidly spreading redness
Whole body redness
New widespread peeling
Blisters or sores on lips or eyes
Mouth sores
Eye pain or redness
Trouble breathing
Wheeze
Throat tightness
Severe weakness or dizziness
Fainting
Signs of dehydration
Increasing pain or pus
Possible skin infection
Red streaking
References
Clinical guidelines and evidence sources
Guideline sources
American Academy of Dermatology National Psoriasis Foundation guidelines for topical therapy
Topical corticosteroids
Vitamin D analogs
American Academy of Dermatology National Psoriasis Foundation guidelines for systemic non biologic therapy
Methotrexate
Cyclosporine
Acitretin
American Academy of Dermatology National Psoriasis Foundation guidelines for biologic therapy
TNF inhibitors
IL 17 inhibitors
IL 23 inhibitors
British Association of Dermatologists psoriasis guidelines
Severity assessment
Treatment escalation
Evidence grading notes
ACEP Level A B C framework
Not psoriasis specific
Included for system wide consistency
Class I IIa IIb framework
Not a universal dermatology standard
Used here to communicate recommendation strength
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.