Psoriasis is a skin disease that causes red, itchy scaly patches, most commonly on the knees, elbows, trunk and scalp. Also, it is a dry, inflammatory and ugly skin disorder, which can involve the entire system and is not contagious.
Even though we consider psoriasis a skin disease, it is really the result of a disordered immune system. It occurs when skin cells suddenly rises from below the surface of the skin and pile up on the surface before they can mature. Generally this process (also called turnover) takes about a month, however in psoriasis it may occur in only a few days .
We worsen psoriasis areas by scratching and small skin injuries or irritations. Also, psoriasis may itch or burn. The skin may crack or split in areas that bend. Thus, we consider psoriasis as an autoimmune disease where genetic and environmental factors have a significant role.
There are several types of psoriasis, including:
Plaque psoriasis. The most common form, plaque psoriasis causes dry, raised, red skin patches (lesions) covered with silvery scales. Furthermore, the plaques might be itchy or tender, and there may be few or many. They usually appear on elbows, knees, lower back and scalp.
Nail psoriasis. Psoriasis can affect fingernails and toenails, causing pitting, abnormal nail growth and discoloration. Psoriatic nails might loosen and separate from the nail bed (onycholysis). Besides this, severe cases may cause the nail to crumble.
Guttate psoriasis. We characterize it by copious small oval (teardrop- shaped) spots. They appear over large areas of the body, such as the trunk, limbs, and scalp. Also, we associate guttate psoriasis with streptococcal throat infection.
Inverse psoriasis. It appears as smooth inflamed patches of skin. Furthermore, we find it in skin folds, mainly between the thigh and groin, the armpits, under an overweight stomach (pannus), and below the breasts (infra mammary fold).
Pustular psoriasis. This rare form of psoriasis causes clearly defined pus-filled lesions that occur in widespread patches (generalized pustular psoriasis) or in smaller areas on the palms of the hands or the soles of the feet.
Erythrodermic psoriasis. It involves the extensive inflammation and exfoliation of the skin over most of the body surface and may be accompanied by severe itching, swelling and pain. It is often the result of an exacerbation of unstable plaque psoriasis, particularly after the abrupt withdrawal of systemic treatment. Consequently, this type of psoriasis may be fatal, because more rigorous inflammation and exfoliation disturb the body’s ability to regulate temperature and for the skin to perform barrier functions.
Psoriatic arthritis. Psoriatic arthritis causes swollen, painful joints that are typical of arthritis. Sometimes the joint symptoms are the first or only symptom or sign of psoriasis. And at times only nail changes are seen. Symptoms range from mild to severe, and psoriatic arthritis can affect any joint. Furthermore, it can cause stiffness and progressive joint damage that in the most serious cases may lead to permanent joint damage.
Sebopsoriasis typically appears on the face and scalp as red bumps and plaques with greasy yellow scale. Moreover, this type is a cross between psoriasis and seborrheic dermatitis.
Many people who are predisposed to psoriasis may be free of symptoms for years until some environmental factor triggers the disease . Common psoriasis triggers include:
Weather, especially cold, dry conditions
Injury to the skin, such as a cut or scrape, a bug bite, or a severe sunburn
Smoking and exposure to secondhand smoke
Heavy alcohol consumption
Certain medications — including lithium, high blood pressure medications and antimalarial drugs
Rapid withdrawal of oral or systemic corticosteroids
Streptococcal throat infections frequently precede outbreaks of guttate psoriasis which can then result in chronic plaque psoriasis. Also, psychological stress plays a very crucial role.
It has been proved that psoriasis is an autoimmune disease. Studies show elevated levels of dermal and circulating TNF-α. Therefore, psoriatic lesions are accompanied by increased activity of T cells in the underlying skin.
Psoriasis signs and symptoms can vary from person to person. Common signs and symptoms include:
Small scaling spots (commonly seen in children)
Dry, cracked skin that may bleed or itch
Itching, burning or soreness
Thickened, pitted or ridged nails
Plaque psoriasis occurs in approximately 90% of the psoriasis patients. Lesions are erythematous, red-violet in color, at least 0.5 cm in diameter, well demarcated, and typically covered with silver flaking scales. Besides this, they may be seen as single lesions at pre-disposed areas (eg: knees and elbows) or generalized over a wide body surface area.
Psoriatic arthritis includes both psoriatic lesions and inflammatory arthritis like symptoms. Moreover, distal interphalangeal joints and adjacent nails are mostly involved, but knees, elbows, wrist and ankles may be affected.
How do I know if I have psoriasis?
Do regular skin self-exams to notice any changes in your skin. If you have a rash that’s not going away, contact your healthcare provider. They’ll look at the rash to figure out if it’s psoriasis or another condition. Thus, you may need to see a dermatologist, a skin care specialist, for a diagnosis.
What type of psoriasis treatment will I need?
Psoriasis treatments aim to stop skin cells from growing so quickly and to remove scales.
Ointments may be enough to improve the rash in small areas of skin. If the rash affects larger areas, or you also have joint pain, you may need other treatments. Joint pain may be a sign that you have arthritis.
Therefore, your provider will decide on a treatment plan based on:
Severity of the rash.
Where the rash is on your body.
Vitamin D analogues. Synthetic forms of vitamin D, such as calcipotriene and calcitriol (Vectical) slow skin cell growth. This type of drug may be used alone or with topical corticosteroids. Calcitriol may cause less irritation in sensitive areas. Calcipotriene and calcitriol are usually more expensive than topical corticosteroids.
Calcipotriene: This is a strong form of synthetic vitamin D. It’s known to control overactive skin cells. It is a synthetic vit D3 analogue which binds to vit D receptors which inhibit keratinocyte proliferation and enhance keratinocyte differentiation. It also inhibit T lymphocyte activity. Calcipotriene cream is useful in psoriasis because of its effect on calcium metabolism. The advantage of calcitriol (Vectical) is that it is not known to thin the skin like topical steroids. Since calcipotriene can irritate the skin, it is not recommended for use on the face or genitals. It is sometimes combined with topical corticosteroids to decrease irritation. There is a newer combination preparation of calcipotriene and a topical steroid called Taclonex. Calcipotriene 0.005% cream, ointment or solution is applied once or twice daily. Not all patients may respond to calcipotriene. Use of more than 100 grams of calcipotriene per week may elevate the amount of calcium in the body to unhealthy levels.
Moisturizers, especially with therapeutic concentrations of salicylic acid, lactic acid, urea, and glycolic acid may be helpful in psoriasis. These moisturizers are available as prescription and nonprescription forms. These help reduce the scales that impede the movement of topical medications into the deeper layers of the skin. Some available preparations include salicylic acid (Salex) and lactic acid (AmLactin, Lac-Hydrin). These may be used one to three times a day on the body.
Salicylic acid. Salicylic acid shampoos and scalp solutions reduce the scaling of scalp psoriasis. This can soften and thin scaly skin. It may be used alone, or to enhance the ability of other medications to more easily penetrate the skin. But it can also irritate your skin if you leave it on too long. Also, it might weaken your hair follicles and cause temporary hair loss, too. Furthermore, the body can absorb salicylic acid if you put it on large patches of skin.
Retinoids. Tazarotene (Tazorac, Avage) is available as a gel and cream and applied once or twice daily.
Tazarotene: Tazarotene is a third-generation retinoid. It mainly reduces scaling and plaque thickness, with limited effectiveness on erythema. It is available as 0.05% and 0.1% gels, and a cream. When used as mono therapy, a large proportion of patients develop local irritation (especially with the 1% formulations). Conversely, adverse effects include a high incidence of dose-dependent irritation at application sites which results in burning, stinging and erythema.
Also, the most common side effects are skin irritation and increased sensitivity to light.
Tazarotene isn’t recommended when you’re pregnant or breast-feeding or if you intend to become pregnant.
Anthralin: Anthralin has a direct antiproliferative effect on epidermal keratinocyte, normalizing keratinocyte differentiation. Anthralin (another tar product) is a cream used to slow skin cell growth. It can also remove scales and make skin smoother. A 15 to 30-minute application of anthralin ointment, cream, or paste once each day is prescribed to treat chronic psoriasis lesions. Afterwards, it must be washed off the skin to prevent irritation. This mode of treatment often fails to adequately improve the skin, and it stains skin, bathtub, sink, and clothing to brown or purple. It should not be used on the face or genitals. The stinging, possible irritation, and skin discoloration may make this less acceptable to use. In addition, the risk of skin irritation makes it unsuitable for acute or actively inflamed eruptions. Zinc oxide ointment or non medicated stiff paste must be applied to protect it from irritation.
Corticosteroids: These have anti-inflammatory, anti-proliferative, immunosuppressive and vasoconstrictive effect. They are available in different strengths. These slow down immune cells in your skin. Thus, they can ease swelling and redness. Steroids come in many different strengths, including stronger ones that are used for elbows, knees, and tougher skin areas and milder ones for areas like the face, underarms, and groin. We generally apply topical corticosteroids to the skin twice a day. Short-term treatment is often effective in improving, but not entirely eliminating psoriasis.
These drugs are the most frequently prescribed medications for treating mild to moderate psoriasis. Furthermore, they are available as ointments, creams, lotions, gels, foams, sprays and shampoos.
Topical corticosteroids (steroids, such as hydrocortisone) are very useful and often the first-line treatment for limited or small areas of psoriasis. We usually recommend mild corticosteroid ointments (hydrocortisone) for sensitive areas, such as your face or skin folds, and for treating widespread patches. We apply topical corticosteroids once a day during flares, and on alternate days or weekends only to maintain remission.
Your doctor may prescribe a stronger corticosteroid cream or ointment— triamcinolone (Acetonide, Trianex), clobetasol (Temovate) for smaller, less-sensitive or tougher-to-treat areas.
However, long-term use or overuse of highly potent (strong) corticosteroids can cause local adverse effects like thinning of the skin, acne, contact dermatitis, hypertrichosis, folliculitis, hypopigmentation and systemic effects include hypothalamic-pituitary-adrenal axis suppression and less commonly Cushing’s syndrome.
However, over time, topical corticosteroids may stop working.
Calcineurin inhibitors. Calcineurin inhibitors — such as tacrolimus (Protopic) and pimecrolimus (Elidel) — reduce inflammation and plaque buildup. These aren’t steroids, but they change how your immune cells work. Tacrolimus and pimecrolimus have also been used with some limited success in mild psoriasis. These have the advantage of not causing skin thinning. They can be especially helpful in areas of thin skin, such as around the eyes, where steroid creams or retinoids are too irritating or may cause harmful effects. Your doctor might give you these to use on sensitive areas such as your face, groin, or skin folds also. They may have other potential side effects, including skin infections and possible malignancies (cancers). The exact association of these immunomodulator creams and cancer is controversial.
We do not recommend calcineurin inhibitors when you’re pregnant or breast-feeding or if you intend to become pregnant. This drug is also not intended for long-term use because of a potential increased risk of skin cancer and lymphoma.
Bath salts or bathing in high-salt-concentration waters like the Dead Sea in the Middle East along with careful exposure to sunlight can be beneficial to psoriasis patients.
Goeckerman therapy. Some doctors combine coal tar treatment with light therapy, which we know it as Goeckerman therapy. Consequently, the two therapies together are more effective than either alone because coal tar makes skin more receptive to UVB light.
Coal tar: It is keratolytic and may have anti-proliferative and anti-inflammatory effects. Coal tar is known to ease psoriasis-related inflammation, itching, and scales. A major advantage with tar is lack of skin thinning. Formulations include crude coal tar and tar distillates (liquor carbonis detergents) in ointment, creams, and shampoos.These products can irritate the skin.It can cause side effects such as skin redness and dryness. They’re also messy, stain clothing and bedding, and can have a strong odor. Coal tar is used rarely due to limited efficacy and poor patient adherence and acceptance .It has a slower onset of action than calcipotriene. It can also make your skin more sensitive to UV light.
Conversely, coal tar treatment isn’t recommended for women who are pregnant or breast-feeding.
Prescription retinoid. These are ointments made with synthetic vitamin A. Your doctor might want you to use a steroid at the same time. Consequently, that can lower your odds of skin irritation caused by the retinoid.
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Nikitha Abraham, Neethu Krishnan* and Anjana Raj
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Medically Reviewed by Debra Jaliman, MD on June 22, 2021