5 Shades of Psoriasis: Not All Psoriasis Types Look The Same

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Psoriasis is a chronic autoimmune condition. Autoimmune conditions are ones that are caused by an abnormal functioning of the immune system. With psoriasis, the inflammation in a person’s body causes symptoms that affect the skin in various ways.¹

Let's break down the different types of psoriasis

There are several types of psoriasis. While some people have just one type of psoriasis, others have more than one type at once. Different types include:¹

Plaque psoriasis
Guttate psoriasis
Inverse psoriasis
Pustular psoriasis
Erythrodermic psoriasis

What is plaque psoriasis?

plaque

The most common form of psoriasis is plaque psoriasis. With plaque psoriasis, a person will experience plaques on their skin which are patches of raised skin that are red and dry and often have a layer of silvery scales.^1,2

What is guttate psoriasis?

guttate

Guttate psoriasis is the second most common type of psoriasis. The skin symptoms of guttate look different than the skin symptoms of plaque psoriasis. With guttate psoriasis, a person will experience small plaques that resemble shapes like rain or teardrops, they are often pink in color.^1,3

While the teardrop or raindrop plaques may not start scaly, they may become more scaly over time. The triggers associated with guttate are typically different than the triggers associated with plaque psoriasis.^1,3

What is inverse psoriasis?

inverse

Inverse psoriasis occurs in the folds of the body, such as in the armpit, in or around the genitals, or under the breasts. It is estimated that 21 to 30 percent of people with psoriasis develop inverse psoriasis.^1,4

Unlike the raised scales that are found with plaque psoriasis, inverse psoriasis may appear smooth and shiny. Inverse psoriasis may appear on skin of color as purple, brown, or darker lesions. On Causaian skin, it often looks like bright-red lesions.^1,4

What is pustular psoriasis?

pustular

Symptoms of pustular psoriasis may be triggered by medicines, infections, stress, or some chemicals. There are different types of pustular psoriasis, depending on where the symptoms appear.^1,5

Localized pustular psoriasis impacts different areas of the hands and feet. Palmoplantar pustular psoriasis (PPP) is one subtype that usually affects the base of the thumbs and the sides of the heels. Another subtype, acrodermatitis continua of Hallopeau (ACH) occurs when symptoms affect only the tips of the fingers or toes, especially the nails. ACH is very rare.^1,5

Generalized pustular psoriasis (GPP) impacts large areas of the skin. It is also known as von Zumbusch psoriasis. GPP usually develops suddenly and comes with a range of symptoms, such as fever, chills, severe itching, fatigue, and muscle weakness. GPP flares immediate medical care.^1,5

What is erythrodermic psoriasis?

erythrodermic

Erythrodermic psoriasis is a rare form of psoriasis that causes people to develop extremely red and scaly skin that resembles a severe burn or sunburn on more than 90 percent of the body. Symptoms of erythrodermic psoriasis may cause extreme itchiness, a burning sensation, and peeling skin that comes off in large sheets.^1,6

People who experience flare-ups of erythrodermic psoriasis require urgent medical care and may require hospitalization since it disrupts the body's normal temperature and fluid balance.^1,6

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The PlaquePsoriasis.com team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

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DianeT Member

Hello <inline-mention username="Editorial Team" user-id="3324648"/>, I got erythrodermic years ago. Had to go to the emergency room and everything. During my healing process, my psoriasis turned into plaque, inverse, guttate, and erythrodermic all in one week. It was the weirdest thing ever. Diane (Team Member)
sho50 Member

I have fairly mild guttate psoriasis with a few larger plaques, mostly on my scalp, elbows, knees, and oddly my left only foot insole & heal. But my psoriasis, especially on my scalp, is complicated by comingling with actinic keratoses (AKs), most usually caused by UV damage from sunlight, sunburns, and tanning beds, which look a whole lot like guttage spots, except according to my dermatologist the vascularity (seen in her dermascope) is different. Treatments for AKs and guttate psoriasis are both very different and NOT compatible with each other. Regretfully, AKs are pre-cancerous and therefore far more dangerous than the guttate spots, so their treatment always takes precedent. I am just now recovering from a 4-week course of 5-fluorouracil solution treatment for the numerous AKs on my scalp (including one particular spot that was already developing into another basal cell carcinoma). That treatment is true torture with stinging, oozing, and interminable intense itching. The scabs and dead skin are peeling off now, but I know that a serious psoriasis flare up is just now beginning. It's a nasty double-whammy! I suspect this comorbidity is more common than mentioned in this blog site. Others should be aware of the real possibility that their assumed guttate psoriasis spots may actually be far more dangerous AKs that, if not treated properly, may develop into dangerous basal or squamous cell skin cancers. These skin cancers are easily treated if caught early, but - like any cancer - may metastasize and become life threatening if left to fester or mistakenly and ineffectively treated as if they're "only" psoriasis. 
1. CathyD Member
 
 <inline-mention username="sho50" user-id="7016129"/>, always good to hear from you! I wish you didn't have to deal with this AK complication in addition to your psoriasis. Just one of these issues is more than a person should have to cope with. I know you've previously shared your frustrations with how the treatments are not compatible, and how difficult it is to distinguish between the AKs and guttate psoriasis patches. I'm sorry to hear that a psoriasis flare is revving up after your completion of the latest 5-fluorouracil treatment. That feels very unfair. Thank you for sharing your experiences here - I'm sure you sharing will help raise awareness of these AKs and their potential to develop into basal or squamous cell skin cancers. I wouldn't be surprised if this comorbidity is more common, especially with the sun being utilised by many as a way of managing their psoriasis. I'm curious - do you know much about this vascularity difference between the guttate patches and the AKs? I've noticed that if a patch of my psoriasis clears up, I can almost always see a complex "map" of what I assume to be blood vessels just under the skin. I don't use topical steroids anymore, so I don't think that it's due to skin thinning. I'll have to look into this a bit further but would love to know if you have any more insights. Warmly, -Catherine, Community Moderator
sho50 Member

<inline-mention username="CathyD" user-id="3335781"/> Thanks Catherine, Yes, the comorbidity is complicated and frustrating, esp. regarding steroid usage and sunlight exposure. I think management has to be deferred to professional dermatologists, with both the expertise and medical tools to safely and properly handle these complexities. Regarding seeing the vascularity... The dermascope is a highly specialized (and very expensive) medical tool. It is sensitive to the UV spectrum and converts the image to our (human eye) visible spectrum. This makes the vascularity appear to "light up" in much the same way that a "Black Light" bulb makes fluorescent and phosphorescent paints "glow in the dark." With this conversion, the subtle vascularity differences become discernable to the trained eye. (Interestingly, this process is very similar to how the James Webb Space Telescope works!) One more note. Regretfully, the skin thinning caused by prolonged steroid use is PERMANENT. I.e., the thinned skin never significantly recovers! I found out the hard way with my left arm. Overuse of Clobetasol several decades ago to treat guttate plaques (probably many were actually AKs masquerading as plaques) has caused permanent problems with spontaneous bruising and very low-trauma or even spontaneous bleeding. The skin tears about as easily as tissue paper. My arm is now a patchwork of scars and purplish brown areas. Strong advise: take those warnings about not using this most potent steroid for more than two weeks very seriously! 
1. CathyD Member
 
 <inline-mention username="sho50" user-id="7016129"/>, we hear your frustrations and you're welcome to vent here anytime. It does sound like a professional dermatologist is required to navigate these issues. I'm curious to know whether you've reached out to the <a href='https://skincancer.net/' target='_blank' rel='noopener noreferrer ugc'>https://skincancer.net/</a> community at all, to see if anyone over there is dealing with guttate psoriasis and AKs? Thank you for helping me understand the dermascope a bit better. I think I've had one used on me a couple of times, but I never really thought about how it works or what the dermatologist is actually looking at through it. Now I'm feeling like I want to look through one and see what my skin is doing! How fascinating that the James Webb Space Telescope works in the same way. Oh yes, that's a good point about the skin thinning from areas that I have previously used steroid topicals on... I definitely used them on my elbows and I have seen these blood vessel maps there. I don't think I ever used steroid ointments on a particular area of my foot, where I have also seen these blood vessels. I could be wrong though - after 35-plus years of psoriasis, everything kind of blurs into everything else at times! I definitely overused steroid ointments though, Dovobet in particular. I'm pretty sure I was told to use it for four weeks and then have a week off (during which my psoriasis all flared up again). I wonder what the guidance is now? I'll have to see if I can find out. I also ended up using Dovobet for a longer period of time when I was trying to wean off of it without causing a flare. I remember you mentioning that you really struggle with the skin thinning. Have you been able to ask your dermatologist if there's anything that can be done to help make the skin on your left arm a bit less fragile? Thank you, as always, for sharing your experiences and insights here. We appreciate you! Warmly, -Catherine, Community Moderator
sho50 Member

<inline-mention username="CathyD" user-id="3335781"/> At my age now, I just don't worry much about appearances. But the thinned skin is a royal pain in the... arms. No, there's nothing that can be done other than to avoid as many scrapes and bumps as possible. Once thinned, it's done. The bruising? I get them doing just about anything even remotely resembling work, such as carrying a box, vacuuming, clipping bushes, or putting on or taming off a backpack. And when doing nothing at all. New ones develop while others are fading, but they don't seem to ever fully disappear, so my arms kinda look like they have a weirdly mottled purplish tan (in sharp contrast to my otherwise near-albino, ultra-pale, never-sees-sunlight complexion). It's most distasteful when bruises just "pop open" and bleed: that makes such a mess on my shirts! Dovobet is rated as a "moderate potency" steroid with the addition of a vitamin D derivative. It is recommended for use in 4-week cycles, with rest periods between them, for up to a year. It is similar in autoimmune suppression to Triamcinolone,with similar treatment duration recommendations. These are stronger than Dssonide and much stronger than OTC hydrocortisone products. But all carry at least some risk of skin thinning with prolonged use. In contrast, Clobetasol is rated as an "ultra-high-potency" corticosteroid and carries a much greater risk of causing serious skin thinning. It is only recommended for a maximum usage duration of 2-weeks, period. I.e., it is for acute use only and is not to be used as a maintenence treatment. I, foolishly, used it for more than several months about 10 years ago and it caused the permanent problems described above. That was a lesson learned the hard way! ------------------------------------ According to my current dermatologist, AKs, BCCs, and psoriasis comorbidities require close, ongoing professional monitoring and treatment. Of course, she is far more concerned with the AKs and BCCs than with the annoying, ugly, irritated but benign psoriatic lesions. C'est la vie! 
1. CathyD Member
 
 <inline-mention username="sho50" user-id="7016129"/>, I'm sure the thinned skin is a real pain! I had to chuckle at your "pain in the... arms" comment. It must be very challenging to deal with, especially the bruises popping open. Did your doctors ever warn you about the skin thinning? I don't think I was ever explicitly warned, and nobody took the time to explain to me why the breaks from steroid topicals are important. Of course, it does mention skin thinning as a side effect in the patient information leaflet, but I don't think I fully appreciated why thin skin would be a problem. I definitely used the Dovobet for much longer than a year anyway. I did not realise that clobetasol was one of the ultra-high-potency steroid topicals. It seems to be prescribed so commonly - I guess because it works so well due to its strength. I would not be surprised if more people don't find themselves in the situation you are in, with the permanently thinned skin. Thank you, again, for sharing here and using your experiences to help raise awareness of these issues. I can understand why your dermatologist is more concerned with the AKs and BCCs, although I do wish that there was some focus on your psoriasis. It's not like psoriasis is easy to deal with! Have you ever tried any alternative remedies for your psoriasis? I found turmeric helpful for a guttate flare that I had, although I know we're all different and turmeric isn't suitable for everyone (due to other conditions or medication interactions). If you're interested, we have an article which looks at some common home remedies for psoriasis: <a href='https://plaquepsoriasis.com/clinical/common-home-remedies' target='_blank'>https://plaquepsoriasis.com/clinical/common-home-remedies</a> Warmly, -Catherine, Community Moderator
sho50 Member

<inline-mention username="CathyD" user-id="3335781"/> Hi again, To briefly answer your questions: Yes, the skin thinning side-effect was mentioned, but definitely not emphasized enough. I no longer use Clobetasol anywhere consistently and then only on dlare ups of the big plaque on my left heel/insole where the skin is naturally very thick. I do take a daily turmeric supplement, have for years, but primarily for other benefits. Has it helped with guttate psoriasis? I think so - some - since most of my recent lesions have been typical plaques (left foot, knees & elbows, and behind my ears). Guttate on my arms is definitely much better now, but not so much on my scalp. 
1. CathyD Member
 
 <inline-mention username="sho50" user-id="7016129"/>, I definitely feel that this skin thinning issue should be emphasized more. Managing the clobetasol usage and using it sparingly sounds like a sensible idea. That's a good point about the skin being thicker on the feet though. I have a matching insole patch on my right foot! I don't really use anything on it, although I have been tempted to try a 1% hydrocortisone ointment and see if that does anything. It's good to hear that the turmeric seems to have made a difference to your guttate psoriasis. I always find it so interesting (and irritating) that different types of psoriasis (and even the same type in different areas of the body) can respond differently to treatments. The scalp really seems to be terribly stubborn. I find calcipotriene/calcipotriol - basically Dovobet but without the steroid component - quite helpful for my plaques and scalp psoriasis. It helps keep them manageable anyway. I hope there's a way for you to find the relief you deserve. Warmest wishes, -Catherine, Community Moderator
sho50 Member

<inline-mention username="CathyD" user-id="3335781"/> Since you brought it up, here's another interesting tidbit... Several years ago, my dermatologist added calcipotriene to both my AC and psoriasis treatments. It helped a lot for about 4 months, then very suddenly it caused an allergic response (an extremely itchy eczema-like contact dermatitis). Apparently, it's not uncommon to experience delayed allergic reactions with topical treatments. It took several weeks of steroids (triamcinolone) to resolve the inflammation. Once sensitized, allergies are usually permanent. So calcipotriene (and other similar vitamin D compounds) are out, which means I cannot use the accelerated combined AC treatments... Another bummer! 
1. CathyD Member
 
 <inline-mention username="sho50" user-id="7016129"/>, oh goodness, that allergic response must have been horrible! I have heard that calcipotriene can irritate the skin, but that sounds like it was much more than an irritation. How awful. I didn't know that these reactions could be so delayed - thank you for enlightening me on that. What a pain, especially as you found it helpful. You've been through so much with your skin. Hugs! -Catherine, Community Moderator
2. DianeT Member
 
 <inline-mention username="sho50" user-id="7016129"/> , thanks for sharing some great information with the community. I wasn't told about some of these creams and their effects. I learned most of this from others, not from my healthcare team. You have been through a lot with medications, but you seem to be on top of it. Thanks for all the good tips. Diane (Team Member)
sho50 Member

<inline-mention username="CathyD" user-id="3335781"/> Yet I rate both my psoriasis and UV damage as only mild-to-moderate. I have seen many much worse cases of both than mine. The psoriasis has been lifelong. The AKs and BCCs have been problems for about the last 35+ years (there was, of course, the typical long latency). So these conditions have actually been much more persistent than severe. 
1. CathyD Member
 
 <inline-mention username="sho50" user-id="7016129"/>, that's so interesting, especially as you've been through so much with these issues. Would you rate your psoriasis in the past as any more severe? I know you've mentioned having a rough time with it when you were younger. My psoriasis was severe as a child but it's definitely on the milder side these days (knock on wood!). I definitely hear you on the severity vs persistence issue. Psoriasis (and the AKs/BCCs by the sounds of things) can certainly be stubborn and persistent. Even though my psoriasis is milder now, it's still ever-present. I thought you might be interested to browse/chime in on the following forum discussion on psoriasis severity: <a href='https://plaquepsoriasis.com/forums/how-severe-is-your-psoriasis' target='_blank'>https://plaquepsoriasis.com/forums/how-severe-is-your-psoriasis</a> Warmest wishes, -Catherine, Community Moderator
sho50 Member

 <inline-mention username="CathyD" user-id="3335781"/> I don't know if my psoriasis was any more or less severe when I was young, but it definitely bothered me more then, both cosmetically and irritation-wise when I "had to dress appropriately" for work & social events. E.g., I've NEVER been able to wear neckties or closed collars, but now I'm old enough and independent enough to be able to just flat-out refuse! Plus social conventions are far less strict now, thankfully. 
1. CathyD Member
 
 <inline-mention username="sho50" user-id="7016129"/>, oh yes, I remember you mentioning before that you really struggled with collars and ties. When I step back and think about it, these dress codes and conventions do seem rather silly and redundant. I'm so glad that you feel able to refuse to wear these sorts of things these days. Feeling comfortable and not irritating our skin any further is so important. I wonder if not wearing collars and ties would be classed as a reasonable accommodation these days when it comes to working? I'll have to look into this and see what I can find out. Thank you, as always, for sharing with us! Warmly, -Catherine, Community Moderator