PSORIASIS

What Is Psoriasis?

Psoriasis is a genetically programmed inflammatory disease that primarily affects the skin in about 3% of individuals in the United States. Psoriasis is characterized by skin cells that multiply up to 10 times faster than normal. When these... cells reach the surface and die, raised, red plaques covered with white scales form. Psoriasis begins as a small scaling papule. When multiple papules coalesce, they form scaling plaques. These plaques tend to occur in the scalp, elbows, and knees.

Psoriasis Symptoms

Although psoriatic plaques can be limited to only a few small areas, the condition can involve widespread areas of skin anywhere on the body. Psoriasis symptoms vary depending on the type of psoriasis you have. Common psoriasis symptoms can include the following:

• Red patches of skin covered with silvery scales
• Small scaling spots
• Dry, cracked skin
• Itching, burning, or soreness
• Itchy plaques
• Small bleeding points when the scale is peeled away

Types of Psoriasis

Plaque Psoriasis

Plaque psoriasis is the most common type of psoriasis and it gets its name from the plaques that build up on the skin. There tend to be well-defined patches of red raised skin that can appear on any area of the skin, but the knees, elbows, scalp, trunk, and nails are the most common locations. There is also a flaky, white build up on top of the plaques, called scales. Possible plaque psoriasis symptoms include skin pain, itching, and cracking.
There are plenty of over-the-counter products that are effective in the treatment of plaque psoriasis. 1% hydrocortisone cream is a topical steroid that can suppress mild disease and preparations containing tar are effective in treating plaque psoriasis.

Scalp Psoriasis

Scalp psoriasis is a common skin disorder that makes raised, reddish, often scaly patches. Scalp psoriasis can affect your whole scalp, or just pop up as one patch. This type of psoriasis can even spread to the forehead, the back of the neck, or behind the ears. Scalp psoriasis symptoms may include only slight, fine scaling. Moderate to severe scalp psoriasis symptoms may include dandruff-like flaking, dry scalp, and hair loss. Scalp psoriasis does not directly cause hair loss, but stress and excess scratching or picking of the scalp may result in hair loss.
Scalp psoriasis can be treated with medicated shampoos, creams, gels, oils, ointments, and soaps. Salicylic acid and coal tar are two medications in over-the-counter products that help treat scalp psoriasis. Steroid injections and phototherapy may help treat mild scalp psoriasis. Biologics are the latest class of medications that can also help treat severe scalp psoriasis.

Guttate Psoriasis

Guttate psoriasis looks like small, pink dots or drops on the skin. The word guttate is from the Latin word gutta, meaning drop. There tends to be fine scales with guttate psoriasis that is finer than the scales in plaque psoriasis. Guttate psoriasis is typically triggered by streptococcal (strep throat) and the outbreak will usually occur two to three weeks after having strep throat.
Guttate psoriasis tends to go away after a few weeks without treatment. Moisturizers can be used to soften the skin. If there is a history of psoriasis, a doctor may take a throat culture to determine if strep throat is present. If the throat culture shows that streptococcal is present, a doctor may prescribe antibiotics.

Nail Psoriasis

Many patients with psoriasis have abnormal nails. Psoriatic nails often have a horizontal white or yellow margin at the tip of the nail called distal onycholysis because the nail is lifted away from the skin. There can often be small pits in the nail plate, and the nail is often yellow and crumbly.
The same treatment for skin psoriasis is beneficial for nail psoriasis. However, since nails grow slow, it may take a while for improvements to be evident. Nail psoriasis can be treated with phototherapy, systemic therapy (medications that spread throughout the body), and steroids (cream or injection). If medications do not improve the condition of nail psoriasis, a doctor may surgically remove the nail.

Psoriatic Arthritis

Psoriasis can be associated with a destructive arthritis called psoriatic arthritis. Damage can be serious enough to permanently damage the affected joints. Prevention of joint damage in such cases is very important.

What is Psoriatic Arthritis?

Psoriatic arthritis is a chronic disease characterized by a form of inflammation of the skin and joints. About 15%-25% of patients with psoriasis also develop an inflammation of their joints. Psoriatic arthritis is a systemic rheumatic disease that can not only cause inflammation of the skin, but in the eyes, heart, kidneys, and lungs as well. Currently, the cause of psoriatic arthritis is unknown, but a combination of genetic, immune, and environmental facts is likely involved.

Psoriatic Arthritis Symptoms

Typically, a patient will have psoriasis months or years before they develop psoriatic arthritis. Psoriatic arthritis usually involves the knees, ankles, and joints in the feet. There may also be a loss of range of motion of the involved joints as well as joint stiffness. Psoriatic arthritis can also cause inflammation of the spine and the sacrum, which causes pain and stiffness in the low back, buttocks, neck, and upper back.

Psoriatic Arthritis Treatment

Treatment for psoriatic arthritis generally involves anti-inflammatory medications and exercise. It is important to stretch or take a hot shower before exercise in order to relax the muscles. Ice application after exercise can help minimize soreness and inflammation. Nonsteroidal anti-inflammatory drugs may also reduce joint inflammation, pain, and stiffness.

What Causes Psoriasis?

It is now clear that there is a genetic basis for psoriasis. This hereditary predisposition is necessary before the disease can be triggered by environmental factors. White blood cells called T-cells mediate the development of the psoriatic plaques that are present in the skin. When someone has psoriasis, their body is unable to offer protection from invaders. Instead, inflammation is promoted and skin cells are on overdrive. When cell growth is increased, old skin cells pile up instead of flaking off, causing psoriasis to occur. Currently, most experts conclude that environmental, genetic and immunologic factors interact to cause the disease.

Psoriasis Triggers

If you have the genetic basis of psoriasis, a trigger can cause psoriasis to flare up. The following are triggers that may set off one’s psoriasis:

• Streptococcal (sore throat)
• Trauma to the skin(cut, scrape, bug bite, infection, sunburn)
• Certain drugs (lithium, high blood pressure and heart medications, beta blockers, antimalarial, indomethacin)
• HIV
• Stress
• Obesity

Is Psoriasis Contagious?

No, psoriasis is not contagious. People used to believe that psoriasis was the same as leprosy, but that is not the case. You cannot get psoriasis by touching, kissing, or having sex with someone who has psoriasis. People get psoriasis because of their genes, not their hygiene, diet, lifestyle, or any other habits.



 

Psoriasis Diagnosing

Psoriasis is often diagnosed or at least suspected on the basis of its appearance and distribution. However, psoriasis may resemble eczema or other skin diseases and further tests may be required. It may be necessary to remove a small piece of skin (a biopsy) and have it examined by a pathologist to confirm the diagnosis. If there are joint symptoms, X-rays and other laboratory tests may be in order. Psoriasis cannot be cured, but like many other medical conditions, it is controllable with treatment. Your doctor may have you seen by a consultant such as a dermatologist, rheumatologist or immunologist to help diagnose and treat your form of psoriasis.



Psoriasis Treatment: Topical Medications

Since psoriasis mainly affects the skin, topical treatments are very useful because they are relatively safe, fairly effective, and can be applied directly to the affected skin. They take the form of lotions, foams, creams, ointments, gels, and shampoos. They include topical steroids, tar preparations, and calcium- modulating drugs. The precise drug used and the form in which it is delivered depends on the areas involved. In widespread disease in patients with more than 10% of the body surface involved, it may not be practical to use topical medication alone.

Psoriasis Treatment: PhototherapyFor more extensive psoriasis, a useful option is ultraviolet (UV) light exposure. UV light can treat large areas of skin with few side effects, if performed in the physician’s office. It should be kept in mind that all UV light causes mutational events, which can lead to skin cancer. At this time, the most popular type of UV light for psoriasis is called narrow-band UVB. Only a small portion of the UV light spectrum is used, which seems to be particularly beneficial for psoriasis and may be less carcinogenic. This UVB is quite different from the UVA, the wavelength available in tanning salons, which is not effective in psoriasis. Phototherapy can be used alone or with medications when treating psoriasis.

Psoriasis Treatment: Laser Therapy

Excimer lasers or pulsed dye lasers are used in laser therapy. A pulsed dye laser will create a concentrated beam of yellow light. When this light hits the skin, it converts to heat. The heat then destroys the extra blood vessels in the skin that contribute to psoriasis. Excimer lasers will deliver ultraviolet light to localized areas of the skin that help treat psoriasis. These lasers produce UV light in wavelengths similar to narrow-band UVB. Laser therapy uses intense doses of laser light to help control areas of mild to moderate psoriasis without damaging surrounding healthy skin. These can be quite effective for small plaques of psoriasis, but since only small areas of skin can be treated at once, they are not practical for extensive disease.

Psoriasis Treatment: Oral MedicationsThere are a variety of drugs administered systemically that are useful in controlling psoriasis. As a generalization, most oral medications act by targeting portions of the immune system. The only exception currently is a drug called acitretin (Soriatane), which is structurally similar to vitamin A. Since the immune system is necessary in order to survive, systemic treatments do have a downside. Drugs like methotrexate and cyclosporine are administered orally and can affect the liver, kidney, and bone marrow. A new oral medication recently approved for treatment of psoriasis is called Otezla® (apremilast). Otezla selectively targets molecules inside immune cells and adjusts (reduces) the processes of inflammation within the cell, which in turn helps treat psoriasis. This drug appears to be considerably safer that most of its predecessors but is also quite expensive. 

Psoriasis Treatment: BiologicsA new class of drugs has recently been developed called biologics; they're called biologics because living cells synthesize them. Since these drugs are proteins, they cannot be administered orally and must be given by injection through the skin or by an intravenous infusion. This treatment is recommended in patients with moderate to severe psoriasis. These drugs target the immune response that leads to the rapid skin cell growth of psoriasis. This seems to have increased their safety profile as well as their effectiveness when compared to older drugs. On the other hand, they are quite expensive costing up to $30,000 a year.

Home Remedies for Psoriasis

There are many home remedies that can be used in the treatment of psoriasis. It is very important to keep the skin moist to avoid dryness. Petroleum jelly, shortening, or olive oil can be used as a moisturizer. Take fewer showers and baths to avoid stripping the skin of its natural oils. Adding salts, oil, or finely ground oatmeal to the bath can soothe the skin. Heliotherapy (medicinal sunbathing) can be effective in controlling psoriasis. There is also evidence that increased body mass is associated with psoriasis and that heavier individuals are more difficult to treat.

Climatotherapy for Psoriasis

At the edge of Israel's Dead Sea, there are a group of resorts that cater to psoriasis patients by offering a combination of graded solar exposure and the application of crude coal tar along with a spa-like experience. The Dead Sea is the lowest point on earth, more than 400 meters below sea level. Once the sun’s rays pass through the haze, the harmful ultraviolet rays are filtered out and the remaining rays are highly effective in treating psoriasis. For those with the time and the money, this is a reasonable alternative to standard medical treatment.

Psoriasis and Stress

Although there is no doubt that psoriasis is a potent inducer of stress, the evidence that stress causes psoriasis is sparse. However, stress can make psoriasis worse, and psoriasis can make one stressed. Dealing with stress with or without psoriasis is a challenge for most people living in the 21st century. The following are tips to reduce stress:

• Deep breathing
• Meditation
• Tai chi
• Yoga
• Get a massage (eases muscle tension, lowers stress)
• Trust your doctor

Living with Psoriasis

Learn to Cope

Not only are the physical effects of psoriasis frustrating, but the emotional effects of psoriasis can be much worse. Psoriasis may cause your relationships to change and people may treat you differently. Unfortunately, this may lead to stress, which then leads to worsening psoriasis. A doctor may prescribe antidepressant medications if psoriasis is diminishing your quality of life. Support groups can also help you cope with psoriasis by talking to other people who are suffering from the same disease.

Tips to Prevent Psoriasis Flare-Ups

• Use moisturizing lotions
• Take care of your skin and scalp- never pick at patched or scales
• Avoid dry, cold weather
• Use a humidifier
• Avoid medications that cause flare-ups (lithium, propranolol, and quinidine)
• Avoid scrapes, cuts, bumps, and infections
• Get some sun, but not too much- use sunscreen and soak up the sun in 20 minute increments
• Reduce stress- join a yoga class or get a massage
• Reduce alcohol consumption
• Exercise and maintain a healthy weight

Psoriasis During Fall and Winter

Fall and winter may bring shorter days, colder temperatures, and dry air. These can all lead to worsening psoriasis symptoms. The sun’s ultraviolet light hinders the rapid growth of skin cells that is characteristic of psoriasis. Therefore, spending less time in the sun may cause psoriasis symptoms to flare. The dry weather may remove moisture in your skin so it is important to use moisturizer and/or a humidifier at home.

Alternative Medicine for Psoriasis Symptoms

There are many different remedies that may ease psoriasis symptoms. The following is a partial list of alternative medicine to help treat psoriasis:

• Aloe Vera gel
• Apple cider vinegar to relieve itch from scalp psoriasis
• Turmeric concentrated in pill or supplement form
• Acupuncture for stress reduction
• Reiki for stress reduction

Consult your doctor before trying new medications.

Psoriasis Stigma

There is plenty of evidence that extensive psoriasis can have a very significant negative effect on a patient’s self-image and emotions. This is especially true in social situations, although all aspects of life can be disturbed. Inverse psoriasis, which affects the genital skin, and scalp psoriasis can be particularly troubling. Psoriasis affecting the hands may make it impossible to interact normally with others. It is important to remember that there are ways to manage and treat psoriasis flares. It may seem as if one’s quality of life has diminished, but there are many organizations that offer support to psoriasis patients. The National Psoriasis Foundation is an excellent source of accurate information as well as emotional support for afflicted patients.

Prepared By Dr Salim Amour

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