Psoriasis

General Illness Information

Medical Term: PSORIASIS

Common Name: None Specified

Description: Psoriasis is a recurrent skin condition which is characterized by macules and patches (flat areas of altered coloration), as well as papules and plaques (elevated areas of skin). It is recognizable by silvery scaling bumps and various sized plaques. There are many different forms of psoriasis, including: Plaque psoriasis; Guttate psoriasis; Erythrodermic psoriasis; Pustular psoriasis; Psoriatic arthritis; Psoriasis is common, affecting 2 to4% of whites. It is less common in the blacks. All age groups are susceptible, but begins most often between the ages 10 to 40.

Causes: Psoriasis is an autoimmune disease with excess cellular proliferation and inflammation with a lack of differentiation.

There are hereditary factors involved in psoriasis, and 1/3 of patients with psoriasis have a relative with the disease. Streptococcal infection may trigger an outbreak, especially of the guttate form Other aggravating factors include: Physical trauma; Stressful situations; Excessive alcohol intake; Some drugs: e.g. Beta-–blockers, ACE Inhibitors, lithium, antimalarials, and non-steroidal anti-inflammatory drugs (NSAIDS); Lack of sun and humidity (i.e. worse in winter); Obesity.

Prevention: Patients with psoriasis can prevent flare-ups by avoiding aggravating factors including: Excessive alcohol intake

Physical trauma; Stress; Certain drugs: Beta-blockers, ACE Inhibitors, antimalarials, lithium, and non-steroidal anti-inflammatory drugs (NSAIDS) Before starting a new medication be sure to tell your physician if you have psoriasis.

Signs & Symptoms

The skin changes and their location vary depending on the type of psoriasis the patient has:

Plaque Psoriasis: Dry, well circumscribed, silvery, scaling papules and plaques mostly in locations of repeated trauma and pressure points. Common sites: scalp, extensor surfaces of elbows and knees, trunk, nails, pressure areas

Guttate (“drop like”) Psoriasis: Scattered salmon pink scaling papules (elevated areas of skin). Common sites: the trunk and proximal limbs (usually sparing the palms and soles. Often follows a streptococcal infection.

Erythrodermic Psoriasis: Generalized (i.e. not well demarcated) redness (erythema) with fine scaling of dead skin on surface, with islands of spared skin. May occur in patients with previously mild plaque psoriasis Associated symptoms include joint pains and extreme itchiness (pruritis)

Pustular Psoriasis:

Sudden onset of red areas of elevated (papular) and non-elevated (macular) skin. These areas evolve into elevated skin with a discharge of pus (pustules)

Psoriatic Arthritis:

  • Arthritis may have many different forms from mild to severe. This type of arthritis is associated with skin and/or nail changes of psoriasis.
  • Symptoms and signs that are a feature of most types of psoriasis include:
  • Mild to severe itching;
  • Pitting of the nails;
  • Oncholysis (separation of the nail from the nail bed).

Risk Factors

  • Family history of psoriasis;
  • Local trauma;
  • Infection ( streptococcal throat infection can stimulate guttate psoriasis, HIV);
  • Endocrine changes;
  • Stress ( physical or emotional stress);
  • Sudden withdrawal of systemic or potent local steroids;
  • Alcohol use;
  • Obesity.

Diagnosis & Treatment

Diagnosis is made clinically by a physician (i.e. no lab tests are necessary).

General Measures:

  • Avoid excessive alcohol intake, stress, physical trauma and drugs which may aggravate psoriasis
  • Lubricate the area once or twice daily.
  • Ultraviolet light also can be beneficial. In the summer months exposed areas of of the affected skin may clear up spontaneously. Ultraviolet  light , under controlled conditions can be used to treat psoriasis.
  • Medication to soften scale, followed by soft brush while bathing.
  • Oatmeal baths for itching. Wet dressing may also help relieve itching.
  • Desert climates are favorable for some patients.
  • Tar shampoos.

Medications:

Topical Treatment:

  • available in creams, ointments, lotions and shampoos;
  • topical steroids are the most commonly used medications to treat psoriasis. Calcipotriol (a derivative of Vitamin D) may be prescribed, but cannot be used on the face, or genitalia. Keratolytic agents- Salicylic acid 6% gel (or 2-10% ointment ) applied twice daily for several weeks help remove scales and allows for better penetration of the topical medications. Other topical treatments for psoriasis include tars, anthralin and topical retinoids.

Intralesional Therapy:

  • Small plaques of psoriasis may be injected with Triamcinolone( a steroid preparation)
  • These plaques will usually disappear within a week of the injections.

Ultraviolet B Phototherapy:

  • This therapy is reserved for very extensive psoriasis, or for psoriasis which is localized, but resistant to topical therapy
  • UVB phototherapy can be delivered to the whole body or to localized areas. Possible Complications/Adverse Effects: Exposure to ultraviolet light increases the chances of developing skin cancer;
  • Changes in skin pigmentation may occur;
  • Aging of the skin may occur.

Systemic Therapy (delivered to the whole body):

  1. PUVA (Psoralen and Ultraviolet A): Psoralen is a medication which can be taken in pill form or applied topically over the area to be treated with UVA (ultraviolet A); it increases the effect of the UVA by acting as photosensitizer Ultraviolet A therapy is then delivered to the whole body. Possible Complications/Adverse Effects: It is important to wear protective sunglasses for two days after the treatment in order to prevent the development of cataracts redness of the skin may occur (phototoxic erythema) aging of the skin may occur pigmentary changes of the skin may occur PUVA treatment increases the chance of developing skin cancer
  2. ACITRETIN
    citretin is a retinoid which is very effective for the treatment of pustular psoriasis. Possible Complications/ Adverse Effects: TERATOGENICITY (i.e. it is an agent which causes physical defects in a developing embryo). THUS, its use is limited to men and post-menopausal females only. Dryness of the skin may occur. Dryness of the mucous membranes (i.e. dry mouth) may occur Elevation of blood lipids may occur. Liver toxicity may occur. Abnormalities of the bones may occur.
  3. RE-PUVA
    This therapy is a combination of Acitretin therapy and PUVA therapy so that lower amounts of both may be used to decrease adverse effects. Acitretin is started first for a few weeks and then PUVA treatment is added
  4. METHOTREXATE
    This is an oral medication which is effective for treating the skin disease and arthritis. Possible Complications/Adverse Effects: Nausea; Mouth ulcers; Changes in amounts of cellular components of the blood and immune system due to bone marrow depression; Long term use may be associated with liver toxicity.
  5. CYCLOSPORINE
    This is a very effective oral medication for the treatment of psoriasis but due to its side effects, its use is generally reserved for those patients whose psoriasis has not responded to all the other therapies mentioned above.

Possible Complications/Adverse Effects:

  • Kidney toxicity;
  • Hypertension;
  • Tingling of the fingers and toes (pins and needles/burning sensations = “paresthesias”);
  • Increased hair growth on the body (hirsutism);
  • Lymphomas.

Activity:

No restrictions

Diet:

No special diet.

Possible Complications:

  •  Topical steroids can be used safely short-term, but long term use may lead to degeneration of the skin, bruising, decreased effectiveness of the treatment and/or worsening of the psoriasis
  • Calcipotriol may cause irritation and is therefore not used on the face, genitalia and flexural regions (i.e. regions of the body subject to bending, like the elbows and knees). May also cause hypercalcemia ( increased levels of calcium in the blood).
  • Tars may be associated with staining of the clothing, lingering odors, irritation, folliculitis (inflammation of the hair follicles), increased sensitivity to sunlight and an increased risk of skin cancer
  • In order to prevent folliculitis, tars should be applied in the direction of the hair growth
  • Anthralin can stain the skin and clothing, and irritation is common. For this reason, anthralin should only be applied to the plaques of Psoriasis and not to normal skin. Due to irritation, anthralin should not be used on the face, genitalia or flexural regions.
  • Rebound of the psoriasis after corticosteroids are discontinued.

Prognosis

  • Psoriasis is generally a lifelong condition which is characterized by remissions and flare-ups.
  • It is important to recognize the role which aggravating factors play in exacerbating this disease.  Most types of psoriasis respond well to the treatments mentioned above.

Other

Nothing Specified.

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