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Psoriasis or Eczema?

Similar symptoms may have you confused, so we talked with an expert about differentiating factors.

Psoriasis and eczema may present with similar symptoms: discolored skin, rash, and itching and burning sensations. Though they are sometimes mistaken for each other, in the majority of cases, the difference is striking to a health care provider.

“Usually, it is easy to distinguish the two. However, there are some sites, such as palms and soles and inguinal [groin or genital] areas where a rash could look like eczema, but it is psoriasis,” says Gil Yosipovitch, M.D., Director of the Miami Itch Center, Miami, Florida, and a professor in the Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami.

 Perhaps it is best if we begin with accurate definitions of both psoriasis and eczema:

  • Psoriasis is a chronic immune-mediated disease associated with systemic inflammation that can lead to comorbidities like cardiovascular disease, type 2 diabetes, anxiety, and depression.
  • Eczema, according to the National Eczema Association, “is the name for a group of conditions that cause the skin to become itchy, inflamed, or have a rash-like appearance. There are seven types of eczema: atopic dermatitis, contact dermatitis, dyshidrotic eczema, nummular eczema, seborrheic dermatitis, and stasis dermatitis.”

Psoriasis more commonly first occurs in adults ages 20 to 30 years old with a second peak around age 60, and among adults in the U.S. about 3% live with psoriasis. Only about 1% of children are diagnosed with psoriasis, while according to the National Eczema Association, atopic dermatitis – the most common type of eczema – typically begins in childhood and affects more than 9.6 million children and about 16.5 million adults. [1][2]

The National Health and Nutrition Examination Survey found that 19.3% of African-American children have atopic dermatitis, compared with 16.1% of white children and 7.8 percent of Asian children. [3] 

Plaque psoriasis or psoriasis vulgaris is the most common type and typically presents on lighter skin as red plaques with silvery scales. [5] On skin of color, plaque psoriasis can appear as purple or discolored skin. The plaques may be thick, raised, cover a large area of skin, and usually have very defined borders. The plaques can occur in any location but often present on the trunk, knees, or elbows, Dr. Yosipovitch explains. The plaques may also present on the scalp or hairline. [1]

Eczema presents as thinner patches of dry red or brown, bumpy skin, and the borders between affected and unaffected skin are less well-defined than with plaque psoriasis, he says. Infants with eczema may present with tiny bumps on the cheeks, while older children and adults may present with a rash in the creases and folds of the body, such as the inner elbow, or behind the knees. [4] The rash may also present on the neck and trunk. [1] Small, fluid-filled sacs may ooze or crust. Eczema on darker skin tones may look darker brown, purple, or grey and may show signs of skin swelling and dryness. [3]

Both eczema and psoriasis can affect the palms of the hands and soles of the feet, though psoriasis is more often the diagnosis when presentation occurs on the soles. [1]

With both, the skin may burn or feel very itchy, Dr. Yosipovitch says. Itching may be a more common complaint in patients with eczema. While itch is a complaint, those with psoriasis more commonly complain of soreness or pain due to the cracking skin [3] and may also complain of joint pain. [1] One in 3 people with psoriasis will develop psoriatic arthritis (PsA), which can permanently damage joints. That is why those with psoriasis should screen regularly for PsA using the five-question screener.

While the majority of the cases may be easily distinguished by a health care provider, Dr. Yosipovitch advises providers to be aware of atypical presentations of psoriasis and eczema, highlighting forms of psoriasis that present similarly to eczema and noting that it is possible that a patient could have both conditions. 

Psoriasis that presents on the palms of the hands, in the folds of the skin or on the scalp may not appear with the typical thick, silvery scales usually observed on lighter skin. These plaques may appear red, smooth and shiny, [6] and the rash may be more diffuse with less distinct edges. [5] In cases like these, it may be possible to mistake psoriasis for eczema, Dr. Yosipovitch says.

“If a patient has a well-demarcated plaque with vesicles on his palms and soles, most probably this is more dyshidrotic eczema than psoriasis. Although, in some cases, both could occur,” Dr. Yosipovitch says. “If a patient has pustules on his palms and or soles with erythema, it could be pustular psoriasis and not eczema.” 

Dr. Yosipovitch advises monitoring treatment progress. If, after beginning treatment for suspected eczema with either a topical corticosteroid or a biologic, the rash worsens or becomes more demarcated or defined, the individual probably has psoriasis, he notes.

The National Psoriasis Foundation (NPF) has several resources to help you better understand your psoriasis and treatment options. NPF has also partnered with the American Academy of Dermatology to update the guidelines for psoriasis treatment, so that your health care provider can stay up to date with current treatment options and best practices for managing psoriasis.

Need Help Getting the Right Diagnosis?

The NPF Patient Navigation center is ready to help you find a dermatologist in your area.

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References

1 Egeberg A, Griffiths CEM, Williams HC, Andersen YMF, Thyssen JP. Clinical characteristics, symptoms and burden of psoriasis and atopic dermatitis in adults. Br J Dermatol. 2020;183(1):128-138.

2 What’s the difference between eczema and psoriasis? American Academy of Dermatology Association website. https://www.aad.org/public/diseases/eczema/childhood/child-have/difference-psoriasis. Accessed July 2021/.

3 Hewett L. Eczema in skin of color: What you need to know. https://nationaleczema.org/eczema-in-skin-of-color. Accessed July 2021.

4 Nutten S. Atopic dermatitis: global epidemiology and risk factors. Ann Nutr Metab. 2015;66(Suppl. 1):8-16. 

5 Rendon A. Schakel K. Psoriasis Pathogensis and Treatment. IJMS. 2019;20(6):1475.

6 Inverse Psoriasis. National Psoriasis Foundation website. https://www.psoriasis.org/inverse-psoriasis. Accessed July 2021.

Author

Heather Onorati

Title

Freelance writer

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