Psoriasis

Psoriasis is a chronic skin condition that affects an estimated 1 – 4% of the world population. It can vary in severity from smaller, localized silvery white patches to almost total coverage of the body that results from a speeded-up lifecycle and accumulation of skin cells... It can manifest as a relatively minor nuisance -- or a disabling arthritic condition. It may cycle through periods of remission to flare-ups that last for weeks or months and most commonly appears in people between 10 and 40 years.

The disorder usually runs in families, and light-skinned people seem to be at a higher risk of developing the disease. Flare-ups are most active between the ages of 15 – 24 years and 56 – 60 years. Several different types of the disease have been identified. They include:

• Plaque Psoriasis -- also referred to as Psoriasis Vulgaris -- is the most prevalent form of the disease affecting between 80 – 90% of psoriasis sufferers.
• Flexural Psoriasis -- also referred to as Inverse Psoriasis -- usually occurs in skin folds, especially around the genitals, stomach flab, armpits and under the breasts – and is more common in overweight people.
• Guttate Psoriasis which is characterized by many small round spots, can appear over large portions of the body. This condition is often associated with a streptococcal throat infection.
• Psoriatic Arthritis usually affects joints and connective tissue, particularly in the fingers and toes. 10 – 20% of sufferers can exhibit symptoms of this variant of psoriasis.
• Pustular Psoriasis as the name suggests usually appears as pus filled non-infectious bumps on the hands and feet, but is rarely seen in sufferers.
• Nail Psoriasis affects the nail beds of the fingers and toes.
• Erythrodermic Psoriasis is the least common form of the disease that can cover the entire body.

Depending upon the type(s) of psoriasis present, symptoms can vary from type to type and person to person. It is quite common for the severity of symptoms to wane and wax over a period of weeks to months.

• Plaque Psoriasis usually appears as symmetrically distributed red skin lesions covered with silvery white scales that usually appear on the truck, limbs and scalp. Scale amount and thickness can vary – and they may itch or feel sore. Extensor surfaces (i.e. elbows and knees) are more involved where fissuring and bleeding may also occur.
• Flexural Psoriasis usually manifests as red areas in skin folds around the genitals, armpits, breasts and stomach. The presence of scales is minimal and it does not usually attack the typical extensor surfaces (i.e. elbows and knees).
• Guttate Psoriasis primarily affects younger aged people (<30 years) and is thought to be triggered by the onset of strep throat. A significant number of round spots can appear over large portions of the body such as the trunk, limbs, neck, face and scalp.
• Psoriatic Arthritis involves inflammation of connective tissue around joints of the fingers and toes, but can also affect the hips, knees and spine. This “sausage shaped” swelling of the digits is commonly referred to as dactylitis. Although usually not as severe as other forms of arthritis, it can in the most serious cases lead to progressive joint damage and permanent deformity.
• Pustular Psoriasis is identified by patches of pus-filled blisters that usually appear on the palms, fingertips and/or soles of the feet. These patches can cover large areas (generalized) or be more localized in nature. The pustules are non-contagious and usually dry within a day or two after first appearing, but may reappear in days or weeks. Attendant less common symptoms accompanying the “generalized” version can include fever, chills, weight loss, fatigue and itching.
• Nail Psoriasis causes pitting, discoloration, loosening and/or crumbling of the nail.
• Erythrodermic Psoriasis although the least common -- is the most serious form of this skin disease. Widespread inflammation and exfoliation of the skin can proceed in certain instances from Plaque Psoriasis. The effects can leave the body unable to regulate temperature and fend off secondary infections – and can sometimes become fatal. Severe itching and burning may accompany the widespread inflammation.

Although the exact cause of the disease is not fully understood, a well accepted theory suggests that the disease is related to an immune system disorder in which T-lymphocytes (T-cells), a type of white blood cell – mistakenly attack healthy skin cells. This immune response triggers an increased production of skin cells and more T-cells.

The result is that the lifecycle of skin cells (normally weeks long) is shortened to just a few days. The rapid accumulation of dead skin and T-cells on the skin surface form thick, scaly patches. Other factors seem to affect the duration, frequency and severity of this disease and include:

• Climatic/seasonal changes – the condition seems to worsen during the winter months
• Stress (mental or physical can impact immune system function)
• Skin injury (i.e. severe sunburn, bug bites, cut/scrap)
• Streptococcal infection
• Drugs, primarily lithium (medications for bipolar disorders), beta blockers (medications for high blood pressure), antimalarial and iodides
• Smoking
• Alcohol consumption (heavy)
• Obesity (Inverse variety)

Treatment

Treatment options include topicals, phototherapy and systemic (oral or injected medications). Usually, depending on the severity of the disease or resistance to treatment, topicals are first used, followed by phototherapy, followed by systemic treatments.

Topicals

Treatment with topical creams and ointments are commonly used to treat symptoms gauged to be mild to moderate in severity. The primary effect of these medications is to reduce skin cell turnover, remove scale build-up and reduce inflammation and itching.

• Corticosteroids are the most frequently prescribed for this level of severity. By acting to suppress immune system response, skin cell turnover and inflammation is decreased.
• Vitamin D analogues (i.e. calcipotriol, calcipotriene) are used to inhibit skin cell production and reduce inflammation
• Anthralin (e.g. dithranol) can help to remove the scaly build-up, but will stain just about anything it comes in contact with – including the skin. Usually prescribed for short durations after which it is washed off.
• Retinoids (i.e. tazarotene), a vitamin A derivative, helps to normalize DNA activity in skin cells, but may result in mild skin irritation
• Coal tar is one of the first and oldest treatments used, but it can stain clothing – and has a strong odor.
• Moisturizers are commonly used in conjunction with other OTC and prescription medications to help reduce skin dryness and soothe redness

Phototherapy

It is well documented that exposure to direct sunlight can reduce the symptoms associated with the disease. Likewise, it has been shown that the beneficial properties exist in the “UV” light spectrum, particularly in the UV “B” spectrum of 315 – 280 nm. Wideband or narrowband UVB is commonly used in conjunction with topical or systemic treatments, particularly when large areas of affected skin are involved.

One version of phototherapy termed PUMA (or psoralen and UV “A”) therapy incorporates the use of a psoralens (increases skin sensitivity to the use of ultraviolet light) and UV “A” band light. However, this older treatment option is considered to be less safe than the equally effective UVB “narrowband” treatment described above due to increased sensitivity to direct sunlight. PUVA treatments can also have other undesirable side effects including nausea, headache, fatigue, burning and itching.

A final phototherapy treatment option for moderate to severe cases includes a recently FDA approved Excimer laser light therapy. This treatment is similar to UVB, except that the light energy is more precise (targeted at specific areas of plaque buildup) and of higher intensity. Side effects can include redness and blistering.

Systemic

This oral or injected prescription medication regimen is reserved for the most severe, or treatment resistant cases, and comes with the risk of severe side effects. The three most commonly preferred options include retinoids, methotrexate, and cyclosporine. Since disease symptoms usually return once treatment is stopped, long-term (or alternating) treatment is usually required to help control the disease symptoms. However, due to the toxicity of these medications, periodic blood and liver tests are required.

• Retinoids (i.e. acitretin) are a synthetic form of Vitamin A. They have been found to reduce the production of skin cells. However, there seems to be evidence that this drug can lead to birth defects in women who become pregnant.
• Methotrexate also helps sufferers by reducing skin cell and histamine production. It also suppresses associated inflammation. Protracted use of this drug can lead to liver damage and reduced production of red and white blood cells.
• Cyclosporine is an immunosuppressant and is generally as effective as methotrexate. However, long-term use and higher dosages can lead to a higher risk of serious side effects including infection, kidney problems, high blood pressure – and even cancer. Biologics are manufactured proteins that can help to reduce the immune response. They differ from “generalized” immunosuppressants (i.e. methotrexate) by focusing on specific immune function pathways. These injected medications can be used in patients who have not responded to other therapies, or have the psoriatic arthritis variant of the disease. They are however expensive.

Homeopathic Options

Daily bathes with lukewarm water and the addition of Epsom salts and bath oil can help to remove scales and soothe the skin. Use liberal amounts of thick, ointment type moisturizers after bathing on affected areas. Covering affected areas with plastic wrap overnight can also enhance the removal of scaling when you take your morning shower.

Exposure to limited amounts of sunlight can help improve the skin’s appearance, but be careful not to overdo it. OTC cortisone used for limited durations on affected areas can help to reduce inflammation. Avoid drinking alcohol as this may negatively affect any treatments your doctor prescribes.

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