4 Clinical Diagnosis Psoriasis often appears as somewhat elevated skin lesions, a few or several centimetres in diameter. These lesions commonly are termed plagues. The term is derived from the Greek word plax or French plaque, meaning plate. A typical psoriasis plaque is red, infiltrated, well demarcated, and shows a scaly surface. The scales may be coarse and thick, but, on the other hand, are not always immediately apparent. The appearance of an untreated psoriatic plaque might vary considera- bly as shown by Figs. 1-6, For the clinical diagnosis of psoriasis a ‘matic procedure in four steps is worthwhile and usually makes possible a positive identification - or exclusion - of psoriasis. A very cheap diagnos- tic tool is used: a thin wooden stick (a "cotton applicator”; but use the end without cotton!). You should choose a fresh but well-developed lesion, preferably a red patch without very obvious sca. ling, Scrape the surface repeatedly with light pressure. In psoriasis these signs should appear: 1) Scratching of the apparently smooth and even red surface reveals a loose hyperkeratosis as a scaly surface is produced. Scaling is much more marked than you might expect from the primary appearance of the lesion. 2) The abundant fine scales that appear will have a characteristic silvery hue ("candle grease phenomenon”). Of course, some experience by the investigator is needed for a correct interpreta- tion of this sign. 3) Upon continued seraping the layers of scaly material suddenly finish and a glossy red surface appears. This means that the underlying living 1-6 These six pictures of untreated psoi illustrate the wide variations of of one and the same disease. epidermis is exposed and reveals the "Bulklc membrane”. However, it is not a real membr. in the biologic meaning of the word, but the “membrane” denotes the visual impression th the surface may give 4) Further slight scraping will result in the appearance of multiple small points of heeding (Auspitz's sign) which are due to injury to the superficial capillary vessels in the dermal papil when the very thin overlying epithelium is torn he size of psoriatic lesions vary considera) and in text books psoriasis is often classified in {ant0us clinical types according to the size of Kesions: nummular psoriasis, punctate psoriasis €te: Such a classification hardly fulfills any prac: + Durpose = with one exception: "guttte” (m: Tung “drop-like”) is an important particular for (Chapter 7), jonasis usually does not cause itch, but som Bibents complain of itching now and then. Pali: Plantar puse is - especially of the feet (Chap' )- sometimes causes severe itching. Diagnostic procedure when psoriasis is suspecte’ 1A rel patch vith minimal scaling suspected 4 Pe the rather smsoth red surface a lose bor peek upon seratching silvery scales appear. 2 is te “an even red surface beco™: Pama ‘membrane bing of this membranc-like surface rel rma oe ‘bleeding points from injured