PUID: 58 || PLAB 2 Mock :: Dermatology: Psoriasis
- examiner mla
- Aug 12
- 2 min read
Updated: Aug 16
Summary
A PLAB 2 station involving the assessment, diagnosis, and management of a patient presenting with skin lesions later identified as psoriasis. The candidate must balance efficient history-taking with timely transition to examination and management, recognising key features, addressing patient concerns, identifying risk factors, and providing evidence-based treatment options.
Key Points
Dermatology – Psoriasis
Definition: Chronic autoimmune skin condition with rapid skin turnover, producing thick, scaly plaques.
Typical Sites: Extensor surfaces (elbows, knees), scalp, lower back.
Classic Signs:
Auspitz sign – punctate bleeding when scales are removed.
Koebner phenomenon – lesions appearing at trauma sites.
Risk Factors:
Non-modifiable: Family history, autoimmune tendency.
Modifiable: Stress, smoking, alcohol, certain drugs (β-blockers, lithium, antimalarials), infections, obesity, vitamin D deficiency, excessive UV exposure.
Psychosocial Aspects
Misconception about contagion.
Impact on self-esteem, daily life, and employment.
Stress both as a trigger and consequence of disease.
Important Considerations
Psoriasis is treatable but not curable.
Identify systemic involvement (psoriatic arthritis, uveitis, nail disease).
Always address patient concerns directly (use ICE – Ideas, Concerns, Expectations).
Avoid excessive time in history once working diagnosis is reached – marks shift to management.
Diagnostic Approach
Initial Data Gathering
Onset, duration, progression of rash.
Location, distribution, spread to other areas.
Associated symptoms: itching, pain, bleeding, systemic symptoms.
Previous episodes, treatments tried, and responses.
Exposure/contact history (to rule out contagious causes).
Risk Factor Screening
Family history of psoriasis or autoimmune disease.
Modifiable triggers: stress, smoking, alcohol, drugs, recent infections, new skincare products.
Complication Check
Joint pain/swelling, morning stiffness (psoriatic arthritis).
Eye redness/pain (uveitis).
Nail pitting, onycholysis.
Examination
Lesion morphology, size, distribution.
Check scalp, nails, joints, and eyes.
Assess severity and body surface area involvement.
Management
First-line GP Management
Education & Reassurance: Non-contagious nature, chronic course, treatment aims.
Skin Care:
Liberal emollients – apply before other treatments, leave 30 mins.
Potent topical corticosteroids – daily for up to 8 weeks (4 weeks for very potent), followed by steroid-free break.
Vitamin D analogues – use on ≤30% body surface area to avoid hypercalcaemia, rotate application sites, separate from steroid application to prevent inactivation.
Salicylic acid for thick scale removal.
Lifestyle Modifications
Stress reduction strategies (exercise, mindfulness, support groups).
Smoking cessation and alcohol moderation.
Weight management.
Maintain a trigger diary.
Safety Netting
Seek prompt review if:
Signs of infection in lesions.
New joint pain/swelling or morning stiffness.
Eye pain/redness.
Sudden worsening of skin symptoms.
Referral Criteria
Failure of primary care treatment.
Severe or extensive disease.
Systemic involvement.
Consider phototherapy or systemic therapy under dermatology.
Communication Skills
Start with open-ended questions to elicit patient’s perspective.
Avoid overusing rehearsed phrases; speak naturally.
Empathise without false emotion.
Check patient understanding after explanations.
Involve patient in decision-making and agree on management plan.
Ethical Considerations
Respect dignity, privacy, and autonomy.
Maintain professional boundaries.
Provide information in accessible, jargon-free language.
Follow Good Medical Practice by supporting self-care and providing safe, evidence-based treatment.
Additional Resources
NICE Clinical Knowledge Summary: Psoriasis.
BAD (British Association of Dermatologists) patient information leaflets.
GMC Good Medical Practice (2024) – Domains 1 & 2.
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