Eczema and psoriasis are chronic skin conditions that can significantly impact quality of life. Due to their similar appearances, they may easily be confused. Eczema affects 31.6 million Americans and leads to itchy, inflamed patches of skin, while psoriasis, which affects about 8 million people in the U.S., causes thick, scaly plaques due to rapid skin cell turnover.
Despite their overlapping symptoms, these conditions stem from different underlying causes and require distinct treatment approaches. By exploring the nuances of these conditions, healthcare providers and patients can work together to achieve better health outcomes.
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What Is Eczema?
Eczema is a chronic inflammatory skin condition characterized by itchy, red, and inflamed patches. It typically begins in childhood but can affect individuals at any age.
The condition results from a complex interaction between genetic, environmental, and immune system factors. Immune dysregulation (characterized by an overactive immune response) leads to the breakdown of the skin's protective barrier, which normally retains moisture and shields against irritants. Genetic mutations in the filaggrin gene, which helps maintain the skin's moisture barrier, are also linked to the disease. As a result of compromised skin barrier function, individuals with eczema experience dry, itchy skin that is prone to infection. (29)
There are seven types of eczema, the most common being atopic dermatitis. Other forms include contact dermatitis, dyshidrotic eczema, neurodermatitis, nummular eczema, seborrheic dermatitis, and stasis dermatitis.
Common symptoms of eczema include:
- Dry, scaly skin
- Red or inflamed patches of skin
- Intense itching
- Oozing or crusting of affected areas in more severe cases
What Is Psoriasis?
Psoriasis is a chronic autoimmune disorder that causes rapid skin cell turnover and thick, scaly patches or plaques on the skin. This skin disease is driven by an abnormal immune response, leading to excessive inflammation and rapid skin cell proliferation. Normally, skin cells take about a month to renew, but in psoriasis, this process is shortened to just a few days (35).
The inflammation and excessive buildup of skin cells leads to the characteristic symptoms of psoriasis:
- Patches of thick, red skin with silvery-white scales
- Dry, cracked skin that itches, burns, and bleeds
- Thick, ridged, and pitted nails
Key Differences Between Eczema and Psoriasis
Recognizing the fundamental differences between these two skin conditions assists in making an accurate diagnosis and implementing effective treatments.
Onset and Development
Eczema is one of the most common skin disorders in children, affecting 10-20% of the pediatric population. Of those affected, 65% will begin showing signs by age 1 and 90% by age 5. Many children will outgrow eczema, but it can persist through adulthood. It is considered to be part of the "atopic triad;" up to 80% of children with eczema will also develop allergic rhinitis (hay fever) and asthma. (17, 19)
Psoriasis is a less common pediatric condition, affecting only 1% of children. Instead, psoriasis symptoms typically manifest in adulthood, between the ages of 20 and 30 or 50 and 60 (4).
Causes and Triggers
Eczema, especially atopic dermatitis, is typically triggered by exposure to environmental allergens and irritants. Examples of common eczema triggers include:
- Foods, especially eggs and milk
- Pollen
- Mold
- Dust mites
- Chemical irritants in soaps, detergents, skincare products, and cigarette smoke
- Heavy or tight clothing
Being an autoimmune disease, psoriasis can be triggered by anything that can stimulate the immune system. Common triggers include:
- Stress
- Skin injury
- Infection
- Medications, including lithium, prednisone, and hydroxychloroquine
- Cold, dry weather
- Tobacco
- Alcohol
Appearance and Symptoms
Eczema often appears as poorly demarcated patches of dry, scaly skin. Depending on the patient's skin tone, the rash may vary in color from pink to gray. More severe eczema rashes may ooze, weep, and crust over. The location of eczema often changes with age. In children, it is often located on the cheeks, outside of the elbows, and on the knees. In adults, eczema usually presents on the hands, feet, arms, and back of knees. (6, 19)
Eczema can vary in presentation depending on the type:
- Atopic Dermatitis: red, inflamed, and itchy patches
- Contact Dermatitis: red, itchy, and inflamed skin localized to area of exposure to irritant or allergen
- Dyshidrotic Eczema: small, fluid-filled blisters on the palms of the hands, sides of the fingers, and soles of the feet
- Neurodermatitis: raised, rough patches of skin that are violet or red, commonly on the back of the neck
- Nummular Eczema: round, coin-shaped patches
- Seborrheic Dermatitis: red, greasy patches with yellow scales, commonly on the scalp, face, and in skin folds
- Stasis Dermatitis: redness, swelling, and scaling of the lower legs
Eczema also involves intense itching, which often flares at night and can interfere with sleep.
Psoriasis presents with more well-defined patches. They can be silver, white, or red and tend to be thicker and more raised than those seen with eczema. These plaques most often appear on the elbows, knees, hands, feet, back, and scalp. The quality of discomfort associated with psoriasis is more often described as burning or stinging rather than itching.
Like eczema, the appearance of psoriatic skin lesions can vary slightly depending on the type:
- Plaque Psoriasis: raised, red patches covered by silvery-white scales
- Guttate Psoriasis: small, red dots on the torso or limbs
- Pustular Psoriasis: pus-filled bumps surrounded by red skin on the hands and feet
- Inverse Psoriasis: smooth, red patches in skin folds
- Erythrodermic Psoriasis: red, scaly skin covering most of the body
If psoriasis affects the nails, finger- and toenails can appear pitted and discolored and may separate from the nailbed.
Similarities Between Eczema and Psoriasis
Despite these differences, eczema and psoriasis can be difficult to differentiate due to their similarities.
Both conditions are chronic and currently incurable, necessitating long-term management strategies aimed at alleviating symptoms and preventing flare-ups. The fundamental principles of treatment for both eczema and psoriasis include:
- Maintaining proper skincare
- Avoiding known triggers
- Managing symptoms
- Preventing secondary infections (9, 10)
Symptoms of eczema and psoriasis can fluctuate between periods of remission and relapse. Shared triggers, such as stress, changes in weather, intestinal dysbiosis, and irritants, can cause flares in symptoms. (3, 31)
Research highlights the significant negative impact of eczema and psoriasis on quality of life. Studies have found that individuals with these conditions are at higher risk for mental health issues, including anxiety and depression. This likely stems from multiple factors, including:
- Chronic physical symptoms
- Negative impact on self-esteem and body image
- Healthcare costs
Diagnosis: How to Tell the Difference
Eczema is a clinical diagnosis based on medical history and physical exam. The American Academy of Dermatology has developed diagnostic criteria to streamline the diagnostic process of atopic dermatitis that differentiate essential features that must be present for diagnosis (e.g., itching), important features that support the diagnosis (e.g., early age of onset), and associated nonspecific features that suggest the diagnosis (e.g., thick, leathery skin). (23)
Similarly, psoriasis is usually diagnosed clinically based on observance of distinct clinical patterns. In cases of diagnostic uncertainty, a skin biopsy can confirm the diagnosis. Histological findings consistent with psoriasis include:
- Acanthosis (thickening of the epidermis)
- Parakeratosis (retention of cell nuclei in the stratum corneum layer of skin)
- Munro microabscesses (collections of neutrophils within the stratum corneum or epidermis)
- Elongation of dermal papillae (small, upward projections of the dermis into the epidermis)
- Hypervascularity (an increase in the number and size of blood vessels)
- Infiltration of inflammatory cells, particularly lymphocytes
Many patients with eczema and psoriasis can be diagnosed and managed effectively in a primary care setting (23, 32). However, dermatologists have specialized expertise and access to advanced diagnostic tools that differentiate between eczema and psoriasis, especially in cases with overlapping symptoms.
Treatment Options: Eczema vs. Psoriasis
Eczema treatment options include the following (21, 43):
- Avoidance of environmental and dietary triggers
- Enhance skin barrier function with regular use of moisturizers/emollients
- Use topical corticosteroids as first-line treatment for symptomatic areas not responsive to emollients
- Alternative topical pharmaceutical options to corticosteroids include calcineurin inhibitors, phosphodiesterase 4 (PDE-4) inhibitors, and a Janus kinase (JAK) inhibitor.
- Patients who do not respond to topical therapies are candidates for systemic immunosuppressant therapy and/or phototherapy.
Psoriasis treatment options include the following:
- Restore a healthy skin barrier with regular use of emollients
- Topical corticosteroids are the first-line treatment for mild plaque psoriasis
- Vitamin D analogs are pharmaceutical alternatives to topical corticosteroids
- Narrow-band ultraviolet B phototherapy can be considered for cases with moderate-to-severe plaque psoriasis that is not responsive to topical therapy.
- Systemic medications that act to modulate the immune system are available for patients with moderate-to-severe psoriasis that is unresponsive to other forms of therapy (45)
Living with Eczema or Psoriasis
Implementing a daily routine that incorporates skincare and complementary and integrative medicine modalities can help lessen disease severity and prevent flares of eczema and psoriasis. (5, 38)
Patients can consider utilizing the following evidence-based therapeutic interventions:
- Use hypoallergenic skincare products
- Moisturize your skin at least twice daily with creams and ointments that seal in moisture. Aloe vera and coconut oil can moisturize the skin and reduce scaling, itching, and inflammation (47).
- Bathe in warm, not hot, water
- Take supplements that support skin health and reduce inflammation, including vitamin D and fish oil (9, 16)
- Eat an anti-inflammatory diet
- Mind-body practices, such as yoga, meditation, and cognitive-behavioral therapy, help reduce stress, improve quality of life, and reduce symptom severity (25).
For those looking for additional resources and support, check out these resources:
- National Eczema Association
- Eczema Exchange
- Support for Eczema Caregiver Program
- Allergy and Asthma Network
- Asthma and Allergy Foundation of America
- The Psoriasis Association
- The National Psoriasis Foundation
- Inspire
When to See a Doctor
Schedule an appointment with a doctor if:
- Symptoms persist or worsen despite at-home treatments
- New symptoms develop
- You experience severe and frequent symptom flare-ups
- There are signs of infection, including increased redness, swelling, warmth, or pus
- Symptoms significantly impact daily activities, sleep, or overall quality of life
- You are unsure of your diagnosis (5, 37)
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Key Takeaways
- Eczema and psoriasis are chronic skin conditions that can present with similar symptoms, yet they have distinct characteristics that set them apart.
- Effectively managing these skin conditions requires an accurate diagnosis. Given their complexity, consulting a dermatologist can provide valuable insights and a personalized treatment plan, ensuring better control of symptoms and improving overall quality of life.
- If you experience persistent or severe symptoms or are unsure about your diagnosis, it is highly recommended that you seek specialized care from a qualified healthcare provider.
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