Psoriasis | Part -2

Psoriasis is a common and chronic skin disorder. Plaque psoriasis is the most common type of psoriasis and is characterized by red skin covered with silvery scales and inflammation. Patches of circular to oval shaped red plaques that itch or burn are typical of plaque psoriasis. The patches are usually found on the arms, legs, trunk, or scalp but may be found on any part of the skin. The most typical areas are the knees and elbows.

Psoriasis is not contagious but can be inherited. Research indicates that the disease may result from a disorder in the immune system.

Factors such as smoking, sun exposure, alcoholism, and HIV infection may affect how often the psoriasis occurs and how long the flares up last.

Approximately 1-2% of people in the United States, or about 5.5 million, have plaque psoriasis. Up to 30% of people with plaque psoriasis also have psoriatic arthritis. Individuals with psoriatic arthritis have inflammation in their joints and may have other arthritis symptoms. Sometimes plaque psoriasis can evolve into more severe disease, such as pustular psoriasis or erythrodermic psoriasis. In pustular psoriasis, the red areas on the skin contain blisters with pus. In erythrodermic psoriasis, a wide area of red and scaling skin is typical, and it may be itchy and painful.

Psoriasis affects children and adults. Men and woman are affected equally. Females develop plaque psoriasis earlier than males. The first peak occurrence of plaque psoriasis is in people aged 16-22 years. The second peak is in people aged 57-60 years.

Psoriasis can affect all races. Studies have shown that more people in western European and Scandinavian populations have psoriasis than those in other population groups.

Causes

Research indicates that the disease may result from a disorder in the immune system. The immune system makes white blood cells that protect the body from infection. In psoriasis, the T cells (a type of white blood cell) abnormally trigger inflammation in the skin. These T cells also cause skin cells to grow faster than normal and to pile up in raised patches on the outer surface of the skin.

Those with a family history of psoriasis have an increased chance of having the disease. Some people carry genes that make them more likely to develop psoriasis. When both parents have psoriasis, the child may have a 50% chance of developing psoriasis. About one third of those with psoriasis have at least one family member with the disease.

Certain factors may trigger psoriasis.

Injury to the skin : Injury to the skin has been associated with plaque psoriasis. For example, a skin infection, skin inflammation, or even excessive scratching can trigger psoriasis.

Sunlight : Most people generally consider sunlight to be beneficial for their psoriasis. However, a small minority find that strong sunlight aggravates their symptoms. A bad sunburn may worsen psoriasis.

Streptococcal infections : Some evidence suggests that streptococcal infections may cause a type of plaque psoriasis. These bacterial infections have been shown to cause guttate psoriasis, a type of psoriasis that looks like small red drops on the skin.

HIV: Psoriasis typically worsens after an individual has been infected with HIV. However, psoriasis often becomes less active in advanced HIV infection.

Drugs: A number of medications have been shown to aggravate psoriasis. Some examples are as follows:

Emotional stress : Many people see an increase in their psoriasis when emotional stress is increased.

Smoking : Cigarette smokers have an increased risk of chronic plaque psoriasis.

Alcohol : Alcohol is considered a risk factor for psoriasis, particularly in young to middle-aged males.

Hormone changes : The severity of psoriasis may fluctuate with hormonal changes. Disease frequency peaks during puberty and menopause. A pregnant woman's symptoms are more likely to improve than worsen, if any changes occur at all. In contrast, symptoms are more likely to flare in the postpartum period, if any changes occur at all.

Symptoms

An individual with plaque psoriasis usually has patches of red, raised, scaly areas on the skin that may itch or burn. The patches are usually found on the knees, elbows, trunk, or scalp. Approximately, 9 out of 10 people with psoriasis have plaque psoriasis.

The flare-ups can last for weeks or months. The psoriasis goes away for a time and then returns (chronic).

General characteristics of the scaly skin of the most common type of psoriasis are as follows:

Plaques : The plaque areas on the skin are elevated. The plaque areas vary in size (1 to several centimeters) and may range from a few to many at any given time on the skin. The shape of the plaque is usually oval but can be irregular in shape. Smaller plaque areas may merge with other areas and form a large affected area.

The skin in these areas, especially when over joints or on the palms or feet, can split and bleed.

Plaques sometimes have an area around them that looks like a halo or ring (Ring of Woronoff).

Red color : The color of the affected skin is very distinctive. The rich, full red color is salmon colored. Sometimes the skin can have a blue tint when the psoriasis is on the legs.

Scale : The scales are dry, thin, and silvery-white. The thickness of the scales may vary. When the scale is removed, the skin underneath looks smooth, red, and glossy. This shiny skin usually has small areas that bleed (Auspitz sign).

Symmetry : Psoriatic plaques tend to appear on both sides of the body in the same places. For example, the psoriasis is usually on both knees or both elbows at the same time.

Other general symptoms of psoriasis are as follows :

Scalp : The scalp can have dry, scaly skin or crusted plaque areas. Sometimes psoriasis of the scalp is confused with seborrheic dermatitis. In seborrheic psoriasis, the scales are greasy looking, not dry.

Nails : Nail changes are commonly observed in those with plaque psoriasis. The nails may have small indentations, ridges, or pits in them. The nails can be discolored or separate from the nail bed.

Droplets on skin : Sometimes, the skin is red and looks like it has little drops on it. This may be guttate psoriasis.

Pus on patches : Sometimes, the patches of dry, scaly skin can crack and have pus on top of them. This may be pustular psoriasis.

Psoriasis in children : Plaque psoriasis looks slightly different in children compared to adults. In children, the plaques are not as thick, and the affected skin is less scaly. Psoriasis may often appear in the diaper region in infancy and in flexural areas in children. The disease more commonly affects the face in children as compared to adults.

Other areas : Although the most common body areas affected are the arms, leg, back, and scalp, psoriasis can be found on any body part. Psoriasis can be found on the genitals or buttocks, under the breasts, or under the arms. These areas can feel especially itchy or burning.

When to Seek Medical Care

You should see your doctor or health care practitioner if you have symptoms of psoriasis, such as red raised patches of skin with silvery scales, and do not feel comfortable with how your skin looks or feels. Psoriasis is usually a mild inconvenience to most people. However, for others, it may be disabling or painful. The doctor can prescribe treatments that help. If symptoms are treated when they first appear, the condition will usually not progress.

When someone with psoriasis visits the doctor, he or she is usually concerned about raised, itchy, red areas on the skin that are scaly or peeling. The individual is typically self-conscious about the plaques or scaly areas and uses clothing to cover the affected skin to avoid being embarrassed in public.

Those with psoriasis commonly recognize that new areas of psoriasis occur within 7-10 days after the skin has been injured. This has been called the Koebner reaction. Sometimes, the reverse occurs in which psoriasis clears after injury to the skin.

You should always see your doctor if you have psoriasis and develop significant joint pain, stiffness, or deformity. You may be in the reported 10% of individuals with psoriasis that develop psoriatic arthritis.

You also should always see your doctor if signs of infection develop. Common signs of infection are red streaks or pus from the red areas, fever with no other cause, or increased pain.

See your doctor if you have serious side affects from your medications.

Exams and Tests

Psoriasis is typically diagnosed after the doctor or health care practitioner does a physical exam. The doctor generally can tell if it is psoriasis just by observing the patches on the skin. The typical appearance of psoriasis is noted in Symptoms.

Skin biopsies can confirm the diagnosis of plaque psoriasis. However, they are usually used to evaluate unusual cases or to rule out other conditions when the diagnosis is not certain.

Treatment

Self-Care at Home

Medical Treatment

Psoriasis is a chronic skin condition. Any approach to the treatment of this disease must be considered for the long term. Treatment regimens must be individualized according to age, sex, occupation, personal motivation, other health conditions, and available resources. Disease severity is defined not only by the number and extent of plaques present but also by the patient's perception and acceptance of the disease. Treatment must be designed with the patient's specific expectations in mind, rather than focusing on the extent of body surface area involved.

Many treatments exist for psoriasis. However, the construction of an effective therapeutic regimen is not necessarily complicated.

There are 3 basic types of treatments for psoriasis: (1) topical therapy (drugs used on the skin), (2) phototherapy (light therapy), and (3) systemic therapy (drugs taken into the body). All of these treatments may be used alone or in combination.

Topical agents : Medications applied directly to the skin are the first course of treatment options. The main topical treatments are corticosteroids, vitamin D-3 derivatives, coal tar, anthralin, or retinoids. There isn't one topical drug that is best for all people with psoriasis. Because each drug has specific adverse effects, it is common to rotate them. Sometimes drugs are combined with other drugs to make a preparation that is more helpful than an individual topical medication. For example, keratolytics (substances used to break down scales or excess skin cells) are often added to these preparations. Some drugs are incompatible with the active ingredients of these preparations. For example, salicylic acid (a component of aspirin) inactivates calcipotriene (form of vitamin D-3). On the other hand, drugs such as anthralin (tree bark extract) require addition of salicylic acid to work effectively.

Phototherapy (light therapy) : The ultraviolet (UV) light from the sun slows the production of skin cells and reduces inflammation. Sunlight helps reduce psoriasis symptoms in some people. If psoriasis is widespread, as defined by more patches than can easily be counted, then artificial light therapy may be used. Resistance to topical treatment is another indication for light therapy. Proper facilities are required for the two main forms of light therapy. The medical light source in a physician's office is not the same as the light sources generally found in tanning salons.

UV-B: Ultraviolet B (UV-B) light is used to treat psoriasis. UV-B is light with wavelengths of 290-320 nanometers (nm). (The visible light range is 400-700 nm.) UV-B therapy is usually combined with one or more topical treatments. UV-B phototherapy is extremely effective for treating moderate-to-severe plaque psoriasis. The major drawbacks of this therapy are the time commitment required for treatments and the accessibility of UV-B equipment.

The Goeckerman regimen uses coal tar followed by UV-B exposure and has been shown to cause remission in more than 80% of patients. Patients may complain of the strong odor when coal tar is added.

In the Ingram method, the drug anthralin is applied to the skin after a tar bath and UV-B treatment.

UV-B therapy is usually combined with the topical application of corticosteroids, calcipotriene (Dovonex), tazarotene (Tazorac), or creams or ointments that soothe and soften the skin.

PUVA : PUVA is the therapy that combines a psoralen drug with ultraviolet A (UV-A) light therapy. Psoralen drugs make the skin more sensitive to light and the sun. Methoxsalen is a psoralen that is taken by mouth several hours before UV-A light therapy. UV-A is light with wavelengths of 320-400 nm. More than 85% of patients report relief of disease symptoms with 20-30 treatments. Therapy is usually given 2-3 times per week on an outpatient basis, with maintenance treatments every 2-4 weeks until remission. Adverse effects of PUVA therapy include nausea, itching, and burning. Long-term complications include increased risks of sensitivity to the sun, sunburn, skin cancer, and cataracts.

Systemic agents (drugs taken within the body) : These drugs are generally started only after both topical treatment and phototherapy have failed. For generalized pustular psoriasis, systemic agents such as retinoids may be required from the beginning of treatment. This may be followed by PUVA treatment. For milder and chronic forms of pustular psoriasis, topical treatment or light treatment may be tried first. Systemic agents may be considered for very active psoriatic arthritis. People whose disease is disabling because of physical, psychological, social, or economic reasons may also be considered for systemic treatment.

Medications

Medications applied directly to the skin are the first course of treatment options. The main topical treatments are corticosteroids, vitamin D-3 derivatives, coal tar, anthralin, or retinoids. For more detailed information on each medication, see Understanding Psoriasis Medications. Generic drug names are listed below with examples of brands in parentheses.

Topical medications

Vitamin D : Calcipotriene (Dovonex) is a form of vitamin D-3 and slows the production of excess skin cells. It is used in the treatment of moderate psoriasis. This cream, ointment, or solution is applied to the skin 2 times a day.

Coal Tar : Coal tar (DHS Tar, Doak Tar, Theraplex T) contains literally thousands of different substances that are extracted from the coal carbonization process. Coal tar is applied topically and is available as shampoo, bath oil, ointment, cream, gel, lotion, ointment, paste, and other types of preparations. The tar decreases itching and slows the production of excess skin cells.

Corticosteroids : Clobetasol (Temovate), fluocinolone (Synalar), and betamethasone (Diprolene) are commonly prescribed corticosteroids. These creams or ointments are usually applied twice a day, but the dose depends on the severity of the psoriasis.

Tree Bark Extract : Anthralin (Dithranol, Anthra-Derm, Drithocreme) is considered to be one of the most effective antipsoriatic agents available. It does have potential to cause skin irritation and staining of clothing and skin. Apply the cream, ointment, or paste sparingly to the patches on the skin. On the scalp, rub into affected areas. Avoid the forehead, eyes, and any skin that does not have patches. Do not apply excessive quantities.

Topical retinoid : Tazarotene (Tazorac) is a topical retinoid that is available as a gel or cream. Tazarotene reduces the size of the patches and the redness of the skin. This medicine is sometimes combined with corticosteroids to decrease skin irritation and to increase effectiveness. Tazarotene is particularly useful for psoriasis of the scalp. Apply a thin film to the affected skin every day or as instructed. Dry skin before using this medicine. Irritation may occur when applied to damp skin. Wash hands after application. Do not cover with a bandage.

Systemic medications (those taken by mouth or injection)

Psoralens : Methoxsalen (Oxsoralen-Ultra) and trioxsalen (Trisoralen) are commonly prescribed drugs called psoralens. Psoralens make the skin more sensitive to light. These drugs have no effect unless carefully combined with ultraviolet light therapy. This therapy, called PUVA, uses a psoralen drug with ultraviolet A (UV-A) light to treat psoriasis. This treatment is used when psoriasis is severe or when it covers a large area of the skin. Psoralens are taken by mouth several hours before PUVA therapy or sunlight exposure. They are also available as creams, lotions, or in bath soaks. More than 85% of patients report relief of disease symptoms with 20-30 treatments. Therapy is usually given 2-3 times per week on an outpatient basis, with maintenance treatments every 2-4 weeks until remission. Adverse effects of PUVA therapy include nausea, itching, and burning. These drugs cause sensitivity to sunlight, risk of sunburn, skin cancer, and cataracts.

Etanercept (Enbrel) : This is the first drug that the FDA approved for treating psoriatic arthritis. It is a manufactured protein that works with the immune system to reduce inflammation. Etanercept is given as an injection 2 times per week. The drug can be injected at home. Rotate the site of injection (thigh, upper arm, abdomen). Do not inject into bruised, hard, or tender skin. Enbrel affects your immune system and rarely is associated with heart failure.

Methotrexate (Rheumatrex) : This drug is used to treat plaque psoriasis or psoriatic arthritis. It suppresses the immune system and slows the production of skin cells. Methotrexate is taken by mouth (tablet) or as an injection once per week. Women who are planning to become pregnant or who are pregnant should not take this drug. Men must not take this drug if there is a possibility that they will impregnate their partners because it can go into the sperm. The doctor will order blood tests to check your blood cell count and liver and kidney function on a regular basis while on this medicine.

Cyclosporine (Sandimmune, Neoral) : This drug suppresses the immune system and slows the production of skin cells. Cyclosporine is taken by mouth once a day. Your doctor will order tests to check your kidney and liver function and levels of cyclosporine in your blood while you are on this medicine. Cyclosporine may increase the risk of infection or lymphoma, and it may cause high blood pressure.

Alefacept (Amevive) : In 2003, the FDA approved this drug for the treatment of psoriasis. It suppresses the immune system to slow down the production of skin cells. Alefacept is given as an injection once per week. Women who become pregnant while taking alefacept should be enrolled in the manufacturer's pregnancy registry by calling (866) 263-8483. Alefacept may increase the risk of malignancy or infection; may cause allergy or swelling of the throat or tongue; and may cause a hard lump, inflammation, or bleeding at the injection site.

Surgery

Surgery is not used to treat psoriasis.

Other Therapy

Conventional therapy has been tested with clinical trials. The FDA has approved conventional drugs for the treatment of psoriasis. Some look to alternative therapy, diet changes, supplements, or stress reducing techniques to help reduce symptoms. For the most part, alternative therapies have not been tested with clinical trials, and the FDA has not approved dietary supplements for treatment of psoriasis. However, some other therapies can be found on the National Psoriasis Foundation Web site. Individuals should check with their doctors before starting any therapy.

Next Steps

Follow-up

Prevention

Avoiding environmental factors that trigger psoriasis, such as smoking, sun exposure, and stress, may help prevent or minimize flare-ups of psoriasis. Sun exposure may help in many cases of psoriasis and aggravate it in others.

Alcohol is considered a risk factor for psoriasis in young to middle-aged men. Avoid or minimize alcohol use if you have psoriasis.

Specific dietary restrictions or supplements other than a well-balanced and adequate diet are unimportant in the management of plaque psoriasis.

Outlook

Psoriasis is more of an inconvenience in most cases than it is threatening. However, it is a chronic disease and reoccurs. The itching, peeling, and splitting of skin at joints can lead to significant pain and self-esteem issues. By far, the patient's quality of life is affected most with plaque psoriasis. Self-consciousness and embarrassment about appearance, inconvenience, and high costs of treatment options all affect one's outlook when living with psoriasis.

Complications of the disease are relatively uncommon. Many of the complications of plaque psoriasis are related to the treatments used for the disease. Overly aggressive use of topical steroids could lead to more severe forms of psoriasis (from plaque to pustular for example).

Bandages should not be used with topical steroids because inflammation and swelling may occur. Oversensitivity to the sun is possible with many of the treatment options (especially phototherapy).

About 10% percent of all cases of plaque psoriasis are associated with psoriatic arthritis.

Anxiety, depression, or stress may worsen symptoms and increase the tendency to itch.

Methotrexate, PUVA, cyclosporine, and oral retinoids all have helped to induce and maintain remission in severe cases of plaque psoriasis.

Support Groups and Counseling

Patient education is one of the foundations for managing this chronic and typically relapsing disorder. Patients should be familiar with the treatment options in order to make proper informed decisions about therapy. The National Psoriasis Foundation is an excellent organization that provides support to patients with psoriasis.

DR. F.I. BISWAS
Submitted By:
The author is a medical practitioner in Canada.

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