Psoriasis

• What is Psoriasis?

Psoriasis is a chronic autoimmune disease that mainly affects the skin. It is non-contagious. A reddish, scaly rash - often referred to as red, scaly patches - is commonly found over the surfaces of the scalp, around or in the ears, the elbows, knees, navel, genitals and buttocks.

The scaly patches, also known as psoriatic plaques, are areas of inflammation and excessive skin production. Skin quickly builds up in the affected area, because skin production is faster than the body’s ability to shed it. Areas with psoriatic plaques take on a silvery-white appearance.

Unlike eczema, psoriasis is more commonly found on the extensor aspect of a joint.

Psoriasis varies in severity - some patients may only have minor localized patches, while others are affected all over the body. Psoriatic nail dystrophy is common among patients with psoriasis - where the fingernails and toenails are affected. Psoriasis may also result in inflammation of the joints, as may be the case with psoriatic arthritis, which affects approximately 10% to 15% of all psoriasis patients.

Experts are not sure what causes psoriasis. Most believe there is a genetic component that can be triggered by a prolonged injury to the skin. Excessive alcohol consumption, smoking, mental stress, and withdrawal of systemic corticosteroid medications are said to be factors that may aggravate psoriasis.

• Types Of Psoriasis
• Plaque psoriasis (psoriasis vulgaris) - about 80% to 90% of people with psoriasis have this type. Signs and symptoms include raised areas of inflamed skin covered with silvery white scaly skin (plaques). A flaky white build up of dead skin cells accumulates on the plaques; this is called scale. 
  
  Plaque psoriasis can appear on any skin surface. Most commonly affected areas are the knees, scalp, trunk, nails and elbows. This scale becomes dislodged and sheds from the plaques. Affected areas of skin are usually extremely dry, itchy. Sometimes there is pain and cracking of the skin. Psoriasis vulgaris means “common psoriasis”.
• Flexural psoriasis (inverse psoriasis) - psoriasis occurs in skin folds (flexion creases), especially in the armpits, genitals, pannus (under the stomach of an overweight person), under the breasts (inframammary fold) and buttocks. The affected areas appear as smooth, dry areas of skin that are inflamed and red. However, they do not have the scaling which is common with plaque psoriasis. This type of psoriasis is more common in overweight/obese individuals - people who have more skin folds; skin folds which are susceptible to irritation from sweating and rubbing. Individuals with flexural psoriasis are susceptible to fungal infections.
• Guttate psoriasis - characterized by red, scaly patches of inflamed skin all over the body, especially the trunk, limbs and scalp. It is often linked to streptococcal throat infection.
• Pustular psoriasis - appears as pustules (non-infectious pus filled raised bumps). The skin surrounding and under the pustules is tender and red. This type of psoriasis can be localized, for example to the feet and hands (palmoplantar pustulosis), or generalized in which patches occur randomly on any part of the body. 
  
  Psoriatic arthritis - includes inflammation of the skin (psoriasis) and the joints and connective tissue (arthritis). Any joint may be affected, but most commonly the finger and toe joints, resulting in dactylitis (sausage-shaped swelling of the fingers/toes). The hips and knees may also be affected. Some patients develop spondylitis (the spine is affected). According to the National Psoriasis Foundation, USA, approximately 10% to 30% of people with psoriasis suffer from this type of psoriasis. 
  
  Treatment of psoriatic arthritis is similar to that of rheumatoid arthritis. This type of psoriasis tends to develop about 10 years after the first signs and symptoms of psoriasis. Most people develop psoriatic arthritis between the ages of 30 and 50 years, but it can affect people of any age, including children. In a minority of cases arthritis symptoms may occur before skin symptoms.  
   
• Erythrodermic psoriasis - the rarest form of psoriasis. An especially inflammatory psoriasis, involving widespread inflammation and exfoliation (shedding) of the skin (over most of the body’s surface). This type of psoriasis appears most commonly on individuals who have unstable plaque psoriasis, where lesions are not clearly defined. It may develop after abrupt withdrawal of systemic treatment (treatment that reaches all parts of the body through the bloodstream). It is characterized by intermittent, widespread fiery redness of the skin. During exfoliation and reddening of the skin the patient may experience severe itching and pain; and also swelling. 
  
  As this form of psoriasis undermines the body’s ability to regulate temperature, as well as the skin’s barrier functions, it can be fatal.
• Nail psoriasis - there is discoloring under the nail plate that resembles a drop of oil beneath it, pitting of the nails, lines seen across the nails, and thickening of the skin under the nail. The nail thickens at the tip, with ridges and pits. The nail may also loosen and crumble (onycholysis). This type of psoriasis is common among patients suffering from psoriasis - reported incidences vary from 10% to 78%. It is more common among individuals who have psoriatic arthritis, as well as elderly patients.
• Signs of Psoriasis

• A symptom is something the patient feels and reports, while a sign is something other people, such as the doctor detect. For example, pain may be a symptom while a rash may be a sign.

  In cases of psoriasis, the signs and symptoms vary from patient to patient. In the majority of cases patients find their symptoms are cyclical – with problems occurring for a few weeks or months, and then easing or disappearing for a while.

  Even though it is possible to sometimes have two types occurring simultaneously, most patients generally have just one form of psoriasis at a time.

  The signs and symptoms of the different types of psoriasis are:

• Plaque psoriasis
  • Raised, inflamed, red lesions (plaques) covered in a silvery white scale
  • Typically found on the elbows, scalp, knees and lower back. They can, however, appear anywhere on the surface of the body.
  • Plaques are typically itchy, sore (or both).
  • Skin around the joints may crack and bleed in severe cases.
• Nail psoriasis
  • Yellow-red nail discoloring. It likes like a drop of oil (or blood) under the nail plate. Health care professionals sometimes refer to this as an oil drop or salmon patch.
  • Pits in the nails, also known as pitting of the nail matrix. Pitting is the result of the loss of cells from the surface of the nail.
  • Lines across the nails – often referred to as Beau line by health care professionals. The lines go side-to-side, rather than from top-to-bottom. The lines are caused by inflammation of the cells.
  • Leukonychia (midmatrix disease) – areas of white on the nail plate.
  • Subungual hyperkeratosis – the skin under the nail thickens.
  • The nail loosens – health care professionals may use the terms onycholysis of the nail bed and nail hyponychium. Where the nail separates from the skin under it, a white area may develop, starting at the nail’s tip and extending downwards. The skin under the nail (nail bed) may become infected.
  • Nail crumbling – health care professionals may refer to nail plate crumbling at the nail bed or nail matrix. As the structures that support the nail are not working properly, the nail weakens.
  • Splinter hemorrhage – also known as dilated tortuous capillaries in the dermal papillae. These are small black lines that go from the tip of the nail to the cuticle. Tiny capillaries (very small blood vessels) between the nail and the skin under it bleed, causing the lines to appear.
  • Spotted lunula – the lunula is the crescent-shaped whitish area of the bed of a fingernail or toe. It is the visible part of the nail matrix (root of the nail). The lunula becomes red when the capillaries under the nail are congested.
  • Nail changes with arthritis of the fingers – at least half of all patients with psoriatic arthritis experiences nail changes.
  • Onychomycosis – this is a fungal infection of the nails. Sometimes linked to nail psoriasis.
  • Paronychia – inflammation of the folds of tissue around the nail, caused by an infection. It may be a bacteria (staph or strep) or fungal infection. Sometimes linked to nail psoriasis.
• Guttate psoriasis – sometimes known as teardrop psoriasis or raindrop psoriasis.
  • Plaques are usually small, no more than 1cm in diameter.
  • Plaques are fairly widespread. They may develop anywhere in the body, except the soles of the feet and palms of the hands. Most commonly affects the chest, arms, legs and scalp.
  • Some signs and symptoms of nail psoriasis may also be present.
  • Usually occurs after a strep infection (throat infection) and is more common among teenagers and children.
  • There is a good likelihood that the guttate psoriasis eventually disappears completely. However, some young patients eventually develop plaque psoriasis.
• Scalp psoriasis
  • Usually affects the back of the head. However, it can occur on the whole scalp, or other parts of the scalp.
  • Red patches of skin
  • The red patches are covered in thick silvery-white scales.
  • Can be extremely itchy (sometimes it isn’t itchy).
  • Can cause hair loss in severe cases.
• Inverse psoriasis (Flexural psoriasis) – more common among overweight/obese individuals
  • As opposed to plaque psoriasis, inverse psoriasis is not characterized by scaling.
  • Inverse psoriasis is characterized by inflamed, bright red, smooth patches of skin.
  • Can be very itchy
  • Can be very painful
  • If the skin rubs together in the folds, symptoms will be aggravated.
  • Sweating in the skin folds may also aggravate affected areas.
  • Most commonly affected areas include the armpits, groin, skin between the buttocks, and skin under the breasts.
  • In obese/overweight patients, there may be symptoms under the belly (where it folds over).
• Pustular psoriasis – a much rarer type of psoriasis. There are three main types, and they affect different areas of the body:
  • Von Zumbusch psoriasis
    • pustules appear across a wide area of skin
    • pustules develop rapidly
    • the pus is made up of white blood cells
    • the pus is not infected
    • within a couple of days the pustules dry and peel off, after which the skin is shiny and smooth
    • pustules may appear in cycles of weeks, or even a few days
    • at the start of a cycle the patient may experience fever, chills, fatigue and weight loss
• Palmaplanter pustular psoriasis
  • pustules may appear on the soles of feet or the palms of the hands
  • pustules develop into round, brown, scaly sports
  • pustules eventually dry and peel off
  • there may be cycles of recurrence, every few weeks or even days
• Acropustulosis
  • pustules appear on fingers and/or toes
  • pustules burst
  • burst pustules leave bright red areas that may become scaly, or
  • burst pustules leave bright red areas that ooze
  • sometimes symptoms of nail psoriasis appear
• Erythrodermic psoriasis – the most uncommon form of psoriasis.
  • Whole body can be covered with a fiery red rash
  • There is usually intense itching
  • There is typically an intense burning sensation
  • There is widespread inflammation
  • There is widespread exfoliation (shedding of skin), during which time itching, burning and swelling is more severe.
  • Body more susceptible to losing proteins and fluid, leading to dehydration and malnutrition (as well as heart failure).
  • Hypothermia is possible – the patient’s body temperature becomes too low; 35C (95 F) or below.
• Psoriatic arthritis
  • The majority of patients develop psoriasis first, and are diagnosed with psoriatic arthritis at a later date. However, arthritis may sometimes develop before the skin lesions appear.
  • Joint pain
  • Stiffness, especially first thing in the morning, or after resting
  • Redness, swelling around the affected joints and tendons
  • Finger(s) swells around the affected joints and tendons
  • Reduced range of movement at the affected joint
  • Symptoms of nail psoriasis
  • Flaking silver patches of skin. Inflammation under the skin, usually red
  • Iritis – inflammation of the iris. The eye becomes reddened. There may be sensitivity to light.
  • Uveitis - inflammation involving the uvea - the iris, choroid, and ciliary body (parts of the eye). Symptoms may include redness of the eye, blurred vision, unusual sensitivity to light, and eye pain.
  • Inflammation of the skin and the symptoms of psoriasis
  • Spondylitis - inflammation of one or more of the vertebrae of the spine. Inflammation can also occur where ligaments and tendons attach to your spine. Symptoms may include pain and stiffness in the lower back, upper buttock area, neck, and the rest of the spine. Symptoms are usually worse on waking up, or after long periods of inactivity.
  • Treatment For Psoriasis

  • Although there is no current cure for psoriasis, there is effective therapy that can control the condition by either reducing or clearing the patches. In the majority of cases, the patient can be treated by a GP (general practitioner, primary care physician).

    If symptoms are severe, or if the patient has not responded well to treatment, the GP may refer them to a dermatologist (specialist skin doctor).

    The aim of psoriasis treatment is to:

  • Halt the cycle that causes increased skin cell production, leading to a reduction of inflammation and plaque production.
  • Remove scale and smooth the skin.

  • The type of treatment depends on three main factors:

  • The type of psoriasis
  • The severity of symptoms
  • Which areas of skin are affected

  • Most doctors will start with mild treatment, such as topical creams, see how the patient responds, and gradually introduce stronger treatments if necessary.

    There are many treatment options. However, it is not always easy find the right one straight away. Patients should tell their doctor straight away if a treatment does not seem to be working, or if there are unpleasant side effects.

    There are three main types of treatments, which are often used in combination:

  • Topical - medications that are applied to the skin and are intended to affect only a specific area of skin. Examples include creams and ointments.
  • Phototherapy - the skin is exposed to specific types of light.
  • Oral or injected medications - used mainly to reduce skin cell production.

  • Although there is no current cure for psoriasis, there is effective therapy that can control the condition by either reducing or clearing the patches. In the majority of cases, the patient can be treated by a GP (general practitioner, primary care physician).

    If symptoms are severe, or if the patient has not responded well to treatment, the GP may refer them to a dermatologist (specialist skin doctor).

    The aim of psoriasis treatment is to:

  • Halt the cycle that causes increased skin cell production, leading to a reduction of inflammation and plaque production.
  • Remove scale and smooth the skin.

  • The type of treatment depends on three main factors:

  • The type of psoriasis
  • The severity of symptoms
  • Which areas of skin are affected

  • Most doctors will start with mild treatment, such as topical creams, see how the patient responds, and gradually introduce stronger treatments if necessary.

    There are many treatment options. However, it is not always easy find the right one straight away. Patients should tell their doctor straight away if a treatment does not seem to be working, or if there are unpleasant side effects.

    There are three main types of treatments, which are often used in combination:

  • Topical - medications that are applied to the skin and are intended to affect only a specific area of skin. Examples include creams and ointments.
  • Phototherapy - the skin is exposed to specific types of light.
  • Oral or injected medications - used mainly to reduce skin cell production.
  • Sunlight - exposing the skin to limited amounts of direct sunlight can alleviate symptoms. However, too much sunlight may cause skin damage and worsen symptoms.
    UV (ultraviolet) light is a light wavelength that is too short for our eyes to see. When our skin is exposed to UV rays the activated T cells in the skin die, resulting in a more normal skin cell turnover, as well as less scaling and inflammation.
    Patients should embark on sunlight treatment only under the supervision and advice of their doctor.
  • UVB (ultraviolet B) phototherapy - treatment takes place at a hospital under the supervision of a dermatologist. This therapy can slow down the production of skin cells. It is effective for the treatment of guttate or plaque psoriasis, especially if the patient has not responded to topical treatments.
    The patient receives controlled doses of UVB light from an artificial source.
    In the short-term there may be redness, itching and dry skin in the treated area. A moisturizer may help minimize these side effects.
  • PUVA (psoralean plus ultraviolet A) - the patient is first given a psoralean tablet, a light-sensitizing medication (it makes the skin more sensitive to light). The skin is then exposed to controlled doses of ultraviolet A (a type of light). Ultraviolet A penetrates more deeply into the skin, compared to UVB light. 
    PUVA treatment is typically used if the patient has severe symptoms, which have not responded to other treatments.
    
    Side effects may include:
    • Headaches
    • Nausea
    • Itching
    • Burning

    Long-term use of PUVA treatment may increase the risk of skin cancer. Typically, treatment involves two to three sessions per weeks for a prescribed number of weeks.

  • Combination light therapy - the effectiveness of phototherapy is often enhanced if other treatments are given at the same time. Combination light therapy is typically used when phototherapy on its own has not been effective. Examples include phototherapy combined with:

  • Coal tar therapy (Goeckerman treatment) - coal tar makes the skin more receptive to the phototherapy.
  • Anthralin (UK: Dithranol) therapy.
  • Ingram regimen - a combination of UVB therapy with a coal tar bath and an anthralin-salicylic acid paste that remains on the patient’s skin either overnight or for several hours.

  • Oral and injected medication - doctors may prescribe oral tablets or injections if symptoms are severe and other treatments have not been effective. Although oral medications are very effective, they have potentially serious side effects. Therefore, treatment courses need to be short.

    According to The National Health Service, UK, all oral and injected medications for the treatment of psoriasis have both benefits and risks. It is important that the doctor explains both the benefits and risks, both verbally and in writing, before treatment begins.

  • Methotrexate - this medication is an antimetabolite. It is a folic acid antagonist that slows down the synthesis of DNA, RNA and protein. It is used to treat diseases in which cell growth is excessive, such as psoriasis and some tumors. It is also helpful in treating autoimmune diseases, such as dermatomyositis and rheumatoid arthritis.
    As far as psoriasis patients are concerned, methotrexate decreases the production of skin cells and suppresses inflammation. It is especially useful in the treatment of pustular psoriasis, psoriatic erythoderma, and extensive plaque psoriasis.
    
    In the short-term and in lower doses it is not known to have side effects. However, in higher doses, or in the long term, it can cause serious liver damage.
    
    The most common reactions (undesirable side effects) are:
    • Possible liver damage
    • Mouth sores
    • Stomach upset
    • Low white blood count

    The following characteristics of methotrexate should also be borne in mind:

    • Patients with any history of liver disease should not be given methotrexate
    • Women should be especially careful not to get pregnant while taking methotrexate (and for three months after stopping treatment), because it can cause serious birth defects.
    • Males should not attempt to get a partner pregnant with their sperm during treatment, and for three weeks after stopping treatment. Methotrexate may affect the development of sperm cells.
  • Acitretin (Soriatane) - this is an oral retinoid, which is a synthetic form of vitamin A. In the USA Soriatane is the only oral retinoid approved by the Food and Drug Administration (FDA) specifically for the treatment of psoriasis.
    Acitretin helps control the multiplication of cells (reduces the rate at which skin cells are produced). It is used to treat severe psoriasis that has not responded to other treatments.
    
    Acitretin should NOT be taken if:
    • The patient is pregnant or planning to become pregnant. Because of the risk of serious birth defects, women of childbearing potential usually have to have two negative pregnancy tests before starting treatment with this drug. Women should also use two effective forms of birth control for at least one month before treatment begins, and for three years after treatment is over. While taking acitretin, progestin-only birth control pills should not be used as a primary form of birth control, because they may not work.
    • The patient is breastfeeding.
    • The patient has severe liver or kidney disease
    • The patient has high triglycerides.
    • The patient is allergic to retinoids.
    • During treatment and for three years after it is over, the patient should not donate blood; because it could expose pregnant women to acitretin.

    The following side effects are possible:

    • Dryness and cracking of lips
    • Dryness in the nasal passages
    • Hair loss
    • Hepatitis (rare)
  • Ciclosporine (ciclosporin) - this is an immunosuppressant medication (it reduces the immune system) that is commonly prescribed to organ transplant patients to prevent rejection. It is also used in psoriasis, severe atopic dermatitis, pyoderma gangrenosum, chronic autoimmune urticaria, and, infrequently, in rheumatoid arthritis and related diseases.
    
    Ciclosporin has been shown to be effective for all types of psoriasis. It is similar to methotrexate in effectiveness. As it reduces the patient’s immune system, patient may have a higher risk of infection, as well as cancer.
    
    The risk of kidney disease and hypertension (high blood pressure) is also higher when taking this medication - the risk grows if dosages are higher, or therapy is longer lasting.
  • Biologic treatments - biologics or biological products are made from living organisms; from living animal or human proteins. Biologics have recently emerged as a new treatment for patients with severe psoriasis symptoms. They work by targeting the immune system - they target the overactive cells in the body that play a role in psoriasis.
    
    According to the National Health Service, biologic treatments are very expensive; so they are only recommended for patients with severe psoriasis symptoms who have not responded adequately to other treatments.
    Examples of biologic treatments (immunodilator drugs) for psoriasis include:
    • Enbrel (etanercept)
    • Amevive (alefacept)
    • Remicade (infliximab)
    • Stelara (ustekinumab)

    These drugs are given by:

    • Intravenous infusion - injecting into the vein.
    • Intramuscular injection - injecting into muscle.
    • Subcutaneous injection - injecting just under the skin.

    Biologics block interactions between certain immune system cells. Even though they are derived from natural sources, as opposed to chemical ones, they may have strong side effects on the immune system and should be used with caution.