CONDITIONS

What Is Psoriasis

Psoriasis is an autoimmune disease in which skin cells grow too quickly, causing them to rapidly accumulate on the surface of the skin. These excess cells can result in patches of red skin or thick, silvery scales that can itch, sting, or burn. Psoriasis can also affect nail growth and appearance, or even cause skin sores. Psoriatic skin patches are most commonly visible on a person’s torso, knees, elbows, and scalp, but they can develop elsewhere, including on the palms, soles, knees, genitals, nails, or even on the face. The abnormal patches of skin are often symmetrical, appearing in the same areas on both the right and left sides of the body. This chronic condition is the most common autoimmune disease in the U.S. The National Psoriasis Foundation estimates that up to 7.5 million Americans (a little more than 1 in 50 people) have it.

There are 8 types of psoriasis:

  • Plaque psoriasis is the most common kind, causing red, dry skin lesions, covered with silvery scales. These can occur anywhere on the body.
  • Nail psoriasis can make nails grow abnormally and become discolored or pitted. The nails may also separate from the nail bed, or be crumbly.
  • Scalp psoriasis causes red, itchy patches covered with silvery scales, possibly visible beyond the hairline. Flakes of dead skin may frequently fall on the person’s shoulders or lodge in their hair. Scalp psoriasis bears some similarity to dandruff (seborrheic dermatitis). Both cause itching, but dandruff is more superficial; flakes come off easily from the scalp, and it is easily treated with over the counter products.
  • Guttate psoriasis is more common in kids and young adults, often after they’ve had a bacterial infection such as strep throat. The telltale symptoms are small sores, shaped like water droplets, on the trunk, limbs, and scalp. The sores aren’t as thick as typical psoriasis plaques are, and their scales are finer. While the person may suffer repeated outbreaks, guttate psoriasis can also be a one-time event.
  • Inverse psoriasis makes patches of skin become red, smooth, and inflamed. It’s mostly seen in the armpits, groin, around the genitals and under a person’s breasts. It may often be triggered by a fungal infection, and can worsen with friction or perspiration.
  • Pustular psoriasis is uncommon and occurs on either large skin patches or small ones around the hands, feet, or the tips of the fingers. It generally comes on quickly: First skin becomes red and tender, then, within hours, pus-filled blisters form. These blisters may come and go frequently; and flare-ups may be accompanied by itching, fever, chills, and diarrhea.
  • Psoriatic arthritis not only can cause scaly, inflamed skin and pitted and discolored nails, but can make a patient have painful, swollen joints. This can potentially lead to stiffness or even deformity in the most severe cases.
  • Erythrodermic psoriasis is the rarest, consisting of a red rash that peels, and can severely itch or burn. It may cover the patient’s entire body.

What Causes Psoriasis

Scientists still don’t completely know the root cause of psoriasis. Popular theories suggest that psoriasis is tied to an immune system malfunction that makes a type of white blood cell in the body called T lymphocytes (or T cells) become overactive. Usually, T cells attack bacteria, viruses, and other potentially harmful foreign substances that enter the body. In psoriasis sufferers, however, the T cells attack healthy skin cells, triggering a series of other immune reactions. Blood vessels around some areas of skin expand, letting other white blood cells enter the skin’s outermost layer. The presence of white blood cells in the skin speeds up the production of healthy skin cells, white blood cells, and T cells. Because of the rate of cell production, new skin cells move to the skin’s outermost layer much quicker – in a span of days rather than weeks. As new cells move to the surface, dead skin and white blood cells can’t be shed quickly enough from these areas, causing the characteristic abnormal patches of skin to emerge.

Risk Factors For Psoriasis

Psoriasis can strike anyone, but the following factors increase people’s chances of developing the condition and/or trigger a flare – up:

  • A family history of psoriasis. One third of all psoriasis patients have a relative with the disease. If one parent has psoriasis, the risk is of a child developing the disease is 10%; if both parents have psoriasis, the risk increases to 50%. If a brother or sister has the condition, the risk of developing the disease is 20%. These numbers are significantly higher than the 1 – 2% risk of psoriasis in the general population.
  • Stress. The effects of stress on the immune system can trigger attacks and play a key role in the development of the disease.
  • Viral and bacterial infections. Because psoriasis is so closely tied to the immune system, recurring infections, especially strep throat, can leave both kids and adults at higher risk for psoriasis flare – ups.
  • Taking certain medicines. For unknown reasons, taking certain medications including lithium, indomethacin, Inderal, quinidine, antimalarial drugs, iodides, and beta blockers can worsen or cause the development of psoriasis.
  • Exposure to cold, dry weather. Some people first experience psoriasis after exposure to harsh, wintry environmental conditions. The dry, cold air of winter can dry out skin and make psoriasis symptoms worse.
  • Getting a bad sunburn, cut, or scratch. Trauma to the skin is known to trigger psoriasis flare – ups.
  • Smoking may help the disease develop, and can make it more severe.
  • Obesity creates skin folds and creases where psoriasis can thrive. Data outcomes from a 2013 study done in Denmark suggest that losing excess weight can help psoriasis. Patients were kept on a low calorie diet, lost on average 30 pounds, and reported an improvement in psoriasis symptoms and overall health.

Diagnosing Psoriasis

To determine if you have psoriasis, your physician or a dermatologist will usually do the following:

  • Take your medical history. It will be helpful if you know whether either of your parents has been diagnosed with psoriasis.
  • Examine your skin, scalp, and nails for signs of discoloration or scaling.
  • Ask about what’s recently gone on in your life, to learn if you’ve experienced any of the psoriasis risk factors listed in the previous section of this guide.

Occasionally, a doctor may take a small skin sample (biopsy) – this is done after a local anesthetic is applied, so it shouldn’t hurt – and send it to a lab for further testing. This can help determine whether a patient has psoriasis, and if so, what kind of psoriasis it is.

Symptoms of Psoriasis

Symptoms of psoriasis can include any of the following:

  • Raised, red patches of skin
  • Smooth, red, raw skin patches
  • Patches of skin that look scaly and silver – colored
  • Raw, red patches only where skin touches skin (i.e. the armpits or groin)
  • Burned-looking skin over most or all of the body
  • Thick patches of skin that may itch
  • Nails that crumble, come loose from their beds, or have pits or discoloration
  • Small, red skin spots, especially on the trunk, arms, and legs
  • Red, swollen skin speckled with pus – filled sores, perhaps accompanied by fever, chills, exhaustion, rapid pulse, weakness, itching, diarrhea and loss of appetite
  • Bumps on only a person’s palms and the soles of their feet
  • Intense pain
  • Intense itching
  • Inability to maintain a steady body temperature, in conjunction with skin abnormalities
  • Rapid heartbeat, along with skin abnormalities

People who have psoriasis run a higher risk of developing other diseases as well, including:

  • Psoriatic arthritis – Can cause joint damage and loss of function in some joints.
  • Eye problems, including:
  • Conjunctivitis – redness and swelling of the membrane that lines the eye’s surface and eyelid.
  • Blepharitis – eyelid inflammation.
  • Uveitis – inflammation of the eye’s middle layer, between the retina and the whites.
  • Doctors aren’t sure why psoriasis and obesity can be linked—it could be because the discomfort of psoriasis makes people less active.
  • Type 2 diabetes. Severe cases of psoriasis are associated with an even greater risk of this disease.
  • High blood pressure
  • Cardiovascular disease
  • Metabolic syndrome – a combination of problems including abnormal cholesterol levels, raised levels of insulin, and high blood pressure. Together, they raise a person’s risk of heart disease.
  • Other immune disorders including Crohn’s disease (inflammatory bowel syndrome) and celiac disease (an autoimmune disorder that can damage the small intestine).
  • Parkinson’s disease – a neurological disorder.
  • Kidney disease
  • Depression

Prognosis

While living with psoriasis can be challenging, the good news is that doctors are more aware of and sensitive to it than ever, and researchers are intensely focused on finding more answers and remedies. Your physician can help you explore treatment options and lifestyle changes to ease your symptoms and minimize their impact on your quality of life. Stress-reduction techniques are useful, and so is the support of loved ones and fellow psoriasis patients.

Living With Psoriasis

These strategies can all help you better manage your psoriasis:

  • Find ways to cut down on stress. Meditation and exercise can help.
  • Work with your physician to minimize the itching associated with psoriasis. Both prescriptions and some home remedies can help; check with your doctor before trying something new.
  • Don’t be afraid to talk about your feelings with close friends and family – their emotional support may give you a valuable psychic boost.
  • Speak to your doctor if you feel depressed. According to the National Psoriasis Foundation, psoriasis patients are twice as likely to suffer from depression as the rest of the population. Your doctor can help you find ways to overcome this common complication.
  • Meet with your boss or manager at work and find ways to accommodate your condition (for example, setting up your workspace ergonomically).

Screening

Unfortunately, psoriasis isn’t preventable, but there’s plenty you can do to minimize the occurrence and severity of outbreaks. If you are experiencing a psoriasis flare up or feel you may be at risk of developing psoriasis, talk to your doctor about treatment options and lifestyle changes.

Prevention

Unfortunately, psoriasis isn’t preventable, but there’s plenty you can do to minimize the occurrence and severity of outbreaks. If you are experiencing a psoriasis flare up or feel you may be at risk of developing psoriasis, talk to your doctor about treatment options and lifestyle changes.

Medication And Treatment

Fortunately, many medications are available to treat psoriasis. These include:

Topical medicines applied to the skin can reduce psoriasis-related inflammation and slow or stop the production of abnormal cells. Topical treatments can come in the form of creams, foams, and solutions, and can include:

  • Corticosteroids, also known as “steroid creams”.
    • Betamethasone (Diprolene)
    • Mometasone (Elocon)
    • Triamcinolone (Kenalog)
  • Calcipotriene (Dovinex, Sorilux), a cream form of synthetic vitamin D.
  • Retinoids, close relatives of vitamin A, include:
      • Acitretin (Soriatane)
      • Isotretinoin (Amnesteem, Claravis, Sotret)
      • Tazarotene (Tazorac)

    Calcipotrienes and Retinoids can be combined with light therapy. See below for more details.

  • Anthralin, a synthetic substance that duplicates powder derived from the Brazilian rubber tree. Anthralin can be combined with coal tar treatment for more complete relief (see below)
  • Coal tar (Elta tar, Ionil T Plus, Psoriasin, T/Gel, Zetar)
  • Over-the-counter topicals are also available. Their active ingredients, coal tar and salicylic acid, are FDA-approved. They may also contain soothing ingredients such as jojoba or aloe vera. These products can help reduce itching, flaking, and burning associated with psoriasis patches.

Common side effects of topical medications include:

  • Worsening of psoriasis patches
  • Staining of skin or clothing
  • Irritated, painful, or burning sensation of skin

Systemic medications such as work throughout the entire body. Systemic medication can be taken in pill form, liquid form, or by injection. These include:

Retinoids, which are close relatives of vitamin A. These include:

  • Acitretin (Soriatane) works by slowing the growth of skin cells and the keratinization process (the process in which skin cells thicken). Acitretin works best for pustular and erythrodermic psoriasis, and it can be effective for plaque psoriasis in combination with light therapy (see below). Acitretin should not be taken by women who are pregnant or who are thinking of getting pregnant. Pregnancy tests should be administered before this medication is prescribed and 2 forms of effective birth control should be used while taking this medication.

Common side effects include: 

  • Redness
  • Itching
  • Flaking of the skin.

More serious side effects include:

  • Blurred vision
  • Liver disease
  • Pancreatitis (inflammation of the pancreas)
  • Severe changes in mood
  • Swelling

Methotrexate works by suppressing the immune system, thereby decreasing the activity of problematic T cells.

Common side effects of Methotrexate include:

  • Nausea
  • Fatigue

More serious side effects include:

  • Liver damage
  • Blood cell damage

Methotrexate should not be taken by individuals with liver disease, pregnant women, women who are thinking of getting pregnant, or male partners of women who are pregnant or who are thinking of getting pregnant. Alcohol should not be consumed with methotrexate and regular blood tests should be conducted by your doctor to check for liver and blood cell damage.

Cyclosporine (Neoral, Sandimmune) works by suppressing the immune system and slowing skin cell growth.
Common side effects include:

  • Headache
  • Nausea
  • Vomiting
  • Diarrhea
  • Stomach Pain
  • Increased hair growth
  • Tremor
  • Acne
  • Cramps
  • Flushing
  • High blood pressure
  • Dizziness

More serious side effects include:

  • Hearing problems
  • Changes in mood
  • Yellowing of the skin/eyes
  • Irregular heartbeat
  • Liver disease
  • Confusion
  • Chest Pain
  • Seizures

Biologics are protein-based drugs that block the inflammatory process of psoriasis. These are given via injection or IV infusion and are usually used to treat moderate to severe psoriasis. Popular biologics include:

  • Etanercept (Enbrel). 

Common side effects include:

  • Changes in mood
  • Nausea
  • Vomiting
  • Headache
  • Redness
  • Heartburn
  • Cough
  • Weakness

More serious side effect include:

  • Weakness
  • Bleeding/bruising
  • Rash/blistering skin
  • Swelling
  • Difficulty breathing/swallowing
  • Seizures
  • Etanercept should not be used by individuals undergoing cyclophosphamide therapy. Patients taking etanercept are at high risk of potentially lethal infections and should not receive any live vaccine while on this medication

Adalimumbab (Humira)

Common side effects include:

  • Itching, swelling, or redness at the injection site
  • Upper respiratory infection
  • Headaches
  • Nausea

More serious side effects include:

  • Headaches
  • Serious infections such as tuberculosis, hepatitis C, and other viral, fungal, or bacterial infections
  • Bleeding/bruising
  • Dizziness/confusion
  • Heart failure

Infliximab (Remicade)

Common side effects include:

  • Stomach pain
  • Headache
  • Rash
  • Flushing

More serious side effects include:

  • Extreme weakness
  • Vision problems
  • Swelling of ankles and feet
  • Chest pain
  • Bruising/bleeding
  • Seizures

Golimubab (Simponi)

Common side effects include:

  • Upper respiratory infections
  • Redness or swelling at the injection site

More serious side effects include:

  • Serious infection viral, bacterial, or fungal infection such as tuberculosis
  • Confusion/Dizziness
  • Congestive heart failure

Complementary and Alternative Treatment

According to the National Center for Complementary and Alternative Medicine and the National Center for Health Statistics, more than 36 percent of all Americans seek complementary treatments for chronic conditions, including psoriasis. Some psoriasis patients report the following strategies are helpful in addressing their condition (be sure to tell your doctor you are considering any of them):

  • Eating a healthy, balanced diet
  • Applying herbal/natural remedies to the their skin, including aloe vera, tea tree oil, oat paste, diluted apple cider vinegar (scalp), creams containing capsaicin (the component that makes chili peppers hot), or creams containing the herb Mahonia Aquifoloium
  • Soaking in baths containing oats, Dead Sea salts, or Epsom salts
  • Eating foods containing turmeric, or taking it in pill form
  • Practicing aromatherapy
  • Meditating
  • Having acupuncture or acupressure treatments
  • Getting a massage
  • Practicing reiki
  • Doing yoga
  • Practicing Tai Chi
  • Getting exercise

Questions For Your Doctor

Finding a board-certified dermatologist (and/or a board-certified rheumatologist if you have psoriatic arthritis) is vital. Ask your primary-care physician for a referral, or find a practicing doctor in your area through the American Board of Dermatology and/or the American College of Rheumatology).

Additionally, the National Psoriasis Foundation maintains a Health Care Provider Directory. These physicians support efforts to help people with psoriasis and psoriatic arthritis through advocacy, education, and research.

Interview several doctors, if necessary, to find ones who make you feel comfortable and have experience treating your type of psoriasis.

Questions For A Doctor

Some good questions to ask your doctor include:

  • What kind of psoriasis do I have?
  • Why do I have psoriasis?
  • What treatments are available? What treatments do you recommend? What are the side effects of each?
  • How fast will each treatment work?
  • Are there any lifestyle changes I can make?
  • Do you recommend any alternative-health treatments?
  • How will my treatment for psoriasis interact with any other conditions and medications I have?

Resources

To read more about all things psoriasis, visit The National Psoriasis Foundation, a non-profit agency dedicated to finding a cure for psoriasis and psoriatic arthritis. Its website includes information, research updates, a healthcare provider directory, and more.

To find a doctor who specializes in psoriasis or to learn more about psoriasis, visit The American Academy of Dermatology.

For links to medical journals on psoriasis and a directory of recent and ongoing clinical studies as well as Psoriasis Q&A, visit The National Institute of Arthritis and Musculoskeletal and Skin Diseases, part of the National Institutes of Health.

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