Psoriasis Treatment and Tips From Dermatologist Dr.Hanish Babu, MD

What is Psoriasis?

Psoriasis is a non-contagious, genetic disease that results when faulty signals in the immune system prompt skin cells to regenerate too quickly, causing silvery white scales accumulate in red patches over the skin. It often affects the elbows, knees, nails, scalp and body folds but can appear anywhere on the body.

Though there is no cure yet for the disease, recent introduction of new biological therapies has provided a fresh ray of hope for psoriatic patients for a better quality of life ahead.

How common is psoriasis?

125 million people worldwide (up to 3% of the population) have psoriasis. Of these, about 10-30 % go on to develop psoriatic arthritis, a debilitating form of joint disease which causes pain, stiffness and swelling .. It is estimated that over seven million Americans (2.6%) have psoriasis, with more than 150,000 new cases reported each year.

Psoriasis occurs in both children and adults and may appear at any age, although it is most commonly diagnosed between the ages of 12 and 35. Males and females are equally affected.

The incidence of psoriasis is much lower in dark-skinned West Africans and African-Americans than in light-skinned people of European ancestry. Incidence is also low in Japanese and Eskimos, and is extremely low in Native Americans in both North and South America. Genetic, geographic and environmental factors may play a role in this racial disparity.

What are the causes for psoriasis? What triggers it?

The exact cause of psoriasis is not known; however, studies suggest that whether a person develops psoriasis or not may depend on a "trigger". Possible psoriasis triggers include emotional stress, skin injury, systemic infections, and certain medications.

Studies have also indicated that a person is born genetically predisposed to psoriasis, and multiple genes have been discovered over the past 5 years confirming this fact. Even so, not everyone with psoriasis will have a family history of the disease.

Psoriasis patients can develop lesions at the site of significant skin trauma, especially during a period of active disease. Psoriasis worsens in areas of skin scrapes, scratches, and cuts (such as surgical wounds). That’s why it is so important not to pick, scratch, or scrub the lesions and scales. The development of a psoriatic lesion at the site of skin trauma is called Koebner’s phenomenon.

There is no way of predicting who will develop psoriasis. 50-60% of people who first experience it do not know of anyone else in their family
who has had it.

How does skin lesions in psoriasis develop?

In psoriasis, a yet to be discovered fault in the immune system triggers excess cell production and movement towards the outer skin layers of these premature cells resulting in excessive scaling and redness of the superficial skin.

In healthy skin, epidermal cells which are formed in the basal layer, mature and are shed from the skin surface in about 28 days. This is an ongoing process and is not very visible in normal skin (except for the dry scales seen in people with dry skin, especially in cold weather). In people with psoriasis, this process is accelerated to 3 or 4 days. This excessive reproduction causes skin cells to build up and form abnormal scaling seen in psoriasis.

Click Here to View Skin in Psoriasis under microscope.

Compare the above with the normal skin under microscope Here.

What are the signs and symptoms of Psoriasis?

Due to the acceleration of the cell turn over, both dead and live cells accumulate on the skin surface in psoriasis. Often this causes red, flaky, crusty patches covered with silvery scales, which are shed easily.

It can occur on any part of the body although it is most commonly found on the elbows, knees, lower back and the scalp. It can also cause intense itching and burning sensations.

When the scales are scrapped off the skin, fine bleeding points become visible, this is known as Auspitz Sign and is diagnostic of psoriasis.

Is psoriasis contagious?

People with psoriasis quite often face discrimination in public places like swimming pools because others fear that psoriasis is contagious—psoriasis is not contagious.

What are the different types of presentation in psoriasis?

Depending upon the sites, extend and severity, the presentation in psoriasis may vary.

• Plaque psoriasis : About 80% of those who have psoriasis have this form. It is typically found on the elbows, knees, scalp and lower back, although it can occur on any area of the skin. See image.

• Guttate psoriasis :This often starts in childhood or young adulthood .A variety of conditions have been known to bring on an attack of guttate psoriasis, including upper respiratory infections, streptoccocal infections, tonsillitis, stress, injury to the skin and the administration of certain drugs (including antimalarials, lithium and beta blockers). This form of psoriasis may resolve on its own, occasionally leaving a person free of further outbreaks, or it may clear for a time only to reappear later as patches of plaque psoriasis.See image.

• Inverse psoriasis : Inverse psoriasis is found in the armpits, groin, under the breasts, and in other skin folds around the genitals and the buttocks.See Image.

• Erythrodermic psoriasis: Erythrodermic psoriasis ia a generalized inflammatory form of psoriasis. It is characterized by periodic, widespread, erythema and dermatitis of the skin. Erythrodermic psoriasis or exfoliative erythroderma can cause serious metabolic complications due to the protein and fluid loss. See Image.

• Pustular psoriasis: Primarily seen in adults, pustular psoriasis is characterized by white pustules (blisters of noninfectious pus) surrounded by red skin. This relatively unusual form of psoriasis affects fewer than 5% of all people with psoriasis. It may be localized to certain areas of the body, for example, the hands and feet. Pustular psoriasis also can be generalized, covering most of the body.See Image.

Related ailments:

Psoriatic arthritis is a painful disease characterized by both joint erosion and skin lesions. It causes inflammation in and around the joints and affects an estimated one million adults. People with psoriatic arthritis experience progressive joint pain and swelling, which is often coupled with scaly, red skin lesions. See Image.

Other risks associated with psoriasis

In a study released on October 10, 2006 in the Journal of the American Medical Association, Joel M. Gelfand and colleagues at the University of Pennsylvania School of Medicine, found that psoriasis patients are at increased risk for heart attack. Psoriasis patients have a collection of health risk factors that can include hypertension, diabetes, obesity, smoking and others. With these factors removed, the risk between psoriasis and heart attack remained, particularly for patients with severe psoriasis in their 40s and 50s.

Dr. Gelfand, lead author of the study, and medical director of the Penn Department of Dermatology's Clinical Studies Unit, stresses that psoriasis patients should not be alarmed. But they should examine their modifiable cardiovascular risk factors. "If you smoke, quit. If you experience high stress, learn stress management techniques. If you are obese, work toward maintaining a healthy body weight. And if you have high blood pressure, diabetes or high cholesterol, be sure that these are well-controlled," advises Dr.Gelfand.

Can Psoriasis be cured?

Unfortunately, no. The tendency to develop psoriasis is inherited through a person’s genes. Till a safe technology is discovered to manipulate these specific genes without side effects, psoriasis may remain incurable. Some patients who get remissions after proper treatment do not get further lesions for longer periods of time.

Management of Psoriasis

Management of psoriasis can be divided into Four basic categories:

Topical treatment: Treatments applied to the skin

Phototherapy or a combination of phototherapy and medications

Systemic treatment:Medications taken by tablet or injection

Life Style Management

A number of factors will determine which treatment will best suit a person with
psoriasis. These include:

The type of psoriasis

Its location on the body

Its severity

The person’s age and medical history

The person’s life style

The person’s response to previous therapy

Topical Therapy

Topical therapies are usually the first line of treatment for psoriasis. They generally work relatively quickly at clearing the immediate lesions after application and are also usually well tolerated. However, they can be messy.

Corticosteroids

• Topical corticosteroids – the most commonly prescribed treatments for psoriasis – are synthetic drugs that resemble naturally-occurring hormones in the body. They are available in many strengths and formulations including creams, lotions, solutions, emollients, sprays, gels, ointments and medicated tapes.

• They slow down the growth of skin cells and decrease the inflammation of lesions in patients with psoriasis.

• Side effects of prolonged corticosteroid use are numerous and include the formation of telangiectasia (elevated dark red blotches on the skin) and striae (stretch marks), the latter ‘scars’ are permanent.

Coal tars

• Topical coal tars have helped treat psoriasis for centuries and can be used by themselves or combined with UVB. By making the skin more sensitive to UV light, coal tar can cause a greater sensitivity to burning when combined with UV therapy.

• However, tars cause staining and coal is also a designated carcinogen

Dithranol (anthralin)

• Dithranol can be effective for mild to moderate psoriasis and is often used with ultraviolet B (UVB) treatments for more severe psoriasis.

• Side effects: it causes irritation and burning to the skin and it tends to stain anything it comes into contact with.

Vitamin D analogues

• The introduction of calcipotriol in the early 90s has provided an alternative to topical steroids, tars and dithranol. Calcipotriol has shown equal or superior efficacy to other agents and is cosmetically more acceptable and generally well tolerated.

• Local irritation does occur; however these agents are not associated with the cutaneous atrophy of corticosteroids or the messiness of tars and dithranol.

Salicylic acid

• Salicylic acid is a chemical that helps remove scale on lesions. It also helps topical medications to better penetrate the skin.

Retinoids – topical

• Retinoids (vitamin A derivatives) are the most recent developments for the topical treatment of psoriasis. Tazorotene is a retinoid used to treat mild to moderate plaque psoriasis, which can be used on most parts of the body, including the face, hairline and scalp.

• Local irritation caused by retinoids has limited their use.

Non-prescription skin treatments

• A variety of over-the-counter products including moisturizers, bath oil, Epsom salts and oiled oatmeal may be helpful in treating psoriasis in some people. They do not work for everyone, but they are unlikely to cause harmful side effects.

Phototherapy

Patients with psoriasis that does not respond to or is too widespread for topical treatments are candidates for phototherapy. This involves exposing the skin to wavelengths of UV light, which has a therapeutic benefit in psoriasis.

Different forms of phototherapy include:

Climatotherapy

• Sunlight can have a beneficial effect on psoriasis. Climatotherapy has been used for many years in the Dead Sea , and the Canary Islands, Spain, with good results.

Broadband and narrowband UVB

• This involves exposing the skin to a particular wavelength of UV light called UVB that is effective for treating psoriasis. UVB is present in natural sunlight.

PUVA (Psoralen plus UVA)

• PUVA, also called photochemotherapy, involves the combination of a light-sensitizing medication (psoralen) followed by irradiation with UVA (like UVB, UVA is found in natural sunlight).

• Bath PUVA is also practiced where the psoralen is put in a bath: the patient soaks before entering the UVA cabinet.

• Long-term PUVA therapy can lead to premature ageing of the skin and also increases significantly a person’s risk of skin cancer (basal cell carcinoma and squamous cell carcinoma). Consequently, the maximum recommended exposure should not be exceeded.

The Goeckerman regimen

• Patients with severe or disabling psoriasis may go to hospital or psoriasis treatment centres for concentrated treatment with UVB and topical coal tar. This is known as the Goeckerman regimen and usually takes at least three or four weeks of daily treatment.

Laser therapy

• The excimer laser is usually for mild to moderate levels of disease where lesions cover less that 10 per cent of the body.

• Pulsed dye lasers are also primarily used to treat small, localized areas of psoriasis. Instead of one continuous beam of light, they emit short bursts of high-intensity yellow light.

• Side effects of laser treatment include a small risk of scarring and bruising.

Grenz ray therapy

• Grenz rays are a form of very mild radiation with low penetration power: half of the rays are absorbed in the first half millimeter of the skin.

• It is used to calm down inflammation of the skin and will not cause damage as seen with prolonged use of corticosteroids.

• A typical course of Grenz treatment consists of weekly or biweekly treatments over three or four sessions.

Systemic Treatments

In patients who do not respond to phototherapy or who cannot comply with the frequent phototherapy visits needed to achieve clearing, several systemic drugs are available. Systemic drugs affect the whole body.

Methotrexate

• Methotrexate was initially developed as a treatment for cancer. It works by binding to an enzyme involved in the growth of cells and therefore slows down skin cell growth in psoriasis. Because of its mechanism of action, methotrexate also affects normal cells, including fetal cells, bone marrow and sperm cells.

• One of the biggest disadvantages of methotrexate is that its long-term use has been associated with liver damage.

Cyclosporin

• Cyclosporin appears to slow down the rate of skin growth by inhibiting the immune system (the immune system plays a critical role in the development of psoriasis).

• However, its long-term use is associated with kidney damage and the American Academy of Dermatology (AAD) guidelines stipulate a maximum use of one year.

Oral retinoids

• Retinoids are derivatives of vitamin A. They affect how cells regulate their behaviour, including how quickly they grow and shed from the skin’s surface. Oral retinoids are only moderately effective and are associated with numerous side effects such as hair loss and thinning of the nails.

• They have also been associated with birth defects, so they cannot be given to women who could potentially become pregnant.

Biological therapies

• Innovations in biotechnology have the potential to offer high efficacy and greater safety in the treatment of psoriasis by building targeted natural protein-based drugs that interfere with specific steps in the pathogenesis of psoriasis.

• The biologicals target the immune system by blocking the action of certain immune cells that play a role in psoriasis. Whereas other psoriasis treatments such as PUVA and methotrexate also affect the body’s immune system, the action of the biologicals is more specific and they have the potential to be a safer treatment option.

• Several biologicals are in development. These include efalizumab, alefacept, etanercept and infliximab. Efalizumab and etanercept are currently available in several countries.

• Biologicals are taken by injection and are mostly prescribed for moderate to severe psoriasis.

Risks and limits of medical treatments for psoriasis

David Margolis(2001) et al reported increased risk certain types of cancers in patients suffering from severe types of psoriasis treated with systemic drugs.

Corticosteroids are the most frequently prescribed treatment for mild to moderate psoriasis because they decrease the rate at which skin cells grow and reduce inflammation, thereby also relieving the itch that often accompanies psoriasis.

Topical corticosteroids vary in potency—from extremely mild to very strong—and come in several forms, including lotions and ointments. Topical corticosteroids are usually prescribed for a select purpose for a limited period of time due to potential side effects.

Two of the more serious side effects regarding the use of corticosteroids are adrenal suppression, where the adrenal glands would become unable to regulate hormones being released in the body; and tachyphylaxis, where the body develops immunity to a certain treatment regimen. Whether or not tachyphylaxis really occurs is controversial in many medical circles.

Life Style Management in Psoriasis

More and more studies are pointing towards the importance of life style changes in the management of psoriasis. Here are a few tips that include specific suggestions for life style management to control psoriasis:

1.Maintain desirable health habits

Psoriasis flare ups are common when you are weak or tired. Taking a balanced diet while reducing red meats and alcohol will go a long way in helping the skin to maintain a calm milieu interior. Patients should also drink plenty of water and get at least 7-8 hours of uninterrupted sleep every day. Do moderate exercises at least 3-4 times every week.

Remember that good nutrition, rest and exercise tune up your body and mind and keep up the equilibrium which is essential to reduce the psoriasis flare ups. These healthy habits will also reduce the chances of contracting infection, another important factor in psoriasis aggravations.

I always remind my patients that medications have only about 30% role in the management of psoriasis. Rest of the 70% involves lifestyle adjustments .

2.Quit Smoking

Many studies have pointed out that pustular psoriasis of the palms and soles, a variant of psoriasis, is aggravated by smoking. Patients who quit smoking found their lesions clearing up faster. Research also suggests that severity of psoriasis may be linked to smoking. Hence it is highly imperative that you totally give up smoking if you want to get rid of those itchy,scaly,red patches.

3.Avoid alcohol

Alcohol is a trigger for psoriasis. There is no doubt about it. Though some dermatologists allow moderate consumption of alcohol in psoriasis, it is my personal observation that even a small quantity of alcohol (like a glass of wine or beer) does cause flare ups in patients. Hence the verdict is - No Alcohol in any forms!

4.Learn to manage your stress

Stress has long been linked to the induction and exacerbation of all types of psoriasis. As mentioned above, psoriasis can be considered a life style disease (much like hypertension or increased blood pressure), a combination of genetic predisposition and psycho- neuro-immuno-hormonal triggers playing a significant role in the causation, initial triggering and maintenance of the disease.

Psoriatics should try to learn and master any one of the stress management techniques like progressive relaxation, biofeedback, yoga etc. Counselling sessions and psoriasis support group participations will be beneficial for those who find it difficult to relax by themselves.

According to the National Psoriasis Foundation, stress reduction works best when combined with appropriate medical treatment.

5.Avoid aggravating medications

Certain medications taken for other diseases can aggravate or even precipitate psoriasis. Medications that can trigger psoriasis are:

Anti-malarial drugs like chloroquine

Beta-blockers (medication used to treat high blood pressure) and heart medication.

Corticosteroids. Steroids are double edged swords. They can control severe psoriasis quickly, but sudden withdrawal can cause severe flare ups. Personally I avoid prescribing steroids to my patients unless it is absolutely necessary, that is, psoriasis is severely compromising their quality of life. Only after exhausting other treatment modalities do I take up this group of medications and most patients would do well to steer clear of steroids as a first line of treatment for psoriasis. Even topical steroids should be used very carefully and under medical supervision in psoriasis.

Non-steroidal anti-inflammatory drugs like indomethacin worsen psoriasis in most patients.

Lithium , the antipsychotic drug is a known aggravator of psoriasis.

If you have a family history of psoriasis or you are suffering from the disease, inform your physician if you are taking any of the above drugs. Your doctor may be able to substitute alternate medication.

6.Avoid Scratching, rubbing and picking at the lesions

Any injury to the skin in both involved and uninvolved areas can produce new psoriasis lesions by irritating the basal layer of the skin and switching on the spurting action of the epidermal cells. Research shows that about 50% of people with psoriasis experience the 'Koebner phenomenon' - developing a psoriatic lesion at the site of a skin injury.

Hence patients should carefully avoid any direct injury to the skin. Scrubbing to remove the scales is a mistake, as this can worsen the disease.

7.Treat any infectious foci at the earliest

Studies show that some infections can trigger psoriasis. Streptococcal throat infections often precedes an outbreak of guttate psoriasis(small drop like lesions), especially in children. Inverse or flexural psoriasis is frequently aggravated by a candidal infection in the folds. Severe generalized psoriasis recalcitrant to treatment is seen in immunodeficient conditions like HIV infection. Treating the infection lessens or clears the psoriasis in most cases.

Also look for signs of any infectious foci in your mouth(dental caries), throat(tonsillitis), sinusitis, gall bladder(cholecystitis), urinary bladder(cystitis) etc. Finding and treating these infections could give much better control over your psoriasis status.

8.Treat the disease before it worsens

Most effective way to stop the itching and appearance of new lesions in psoriasis is to treat the psoriasis properly as soon as the lesions appear. Consult your dermatologist at the earliest sign of a break out.

9.Take good care of your skin

Keeping the skin moist and supple is of paramount importance in psoriasis. Any dryness will increase the scaling, flaking and itching which will further aggravate the condition.

Soak in a luke-warm oatmeal bath. This relieves itching and hydrates the skin layers.

Pat your skin dry; do not rub or scrub. See tip number 6 above. Developing a habit of gently patting your skin dry is advisable.

Apply emollients and moisturizers. Emollients soften the skin. Moisturizers lock in the skin's own moisture to prevent dryness and cracking. One of the best ways to lock in moisture is to apply moisturizer after bathing. Regular use of moisturizers can help prevent the itch and pain of dry skin and reduce scaling and inflammation. A urea containing lotion is preferred during the day and a cream or ointment(if you don't mind a little messiness) at night to maintain the hydration of the epidermal layers.

Use sunscreen. Patients using retinoids should apply sunscreen 15 to 20 minutes before going outdoors and wear protective clothing. Sun exposure can cause sunburn, which can inturn trigger psoriasis. But complete avoidance of sun can cause more harm than good. A moderate supply of UV rays is indeed good for clearing up of the psoriatic lesions!

Wear cotton clothing.Synthetics will irritate and heat up the skin and worsen psoriasis and are best avoided. If you have to wear them, wear thick cotton undergarments beneath.

Look out for winter worsening. Cold, dry weather worsens psoriasis. Emollient creams and ointments should be used copiously during winter months. Before application of the moisturizer, remember to moist the skin with luke warm water.The use of humidifiers, both at home and work, can add moisture to the air in winter months and help in avoiding exacerbations. Remember that air-conditioning can dry out the skin and aggravate psoriasis just like winter! Keeping the AC to minimum required coolness and regular application of moisturizing creams can overcome this problem.

10.Learn to live with Psoriasis

While there is no permanent cure, psoriasis can be successfully managed so that one experiences more good days than bad. Numerous treatment options are available, and recent advances are revolutionizing the management and care of psoriasis. No single treatment will be effective for all patients. Hence a dermatologist will consider a patient's overall health, age, lifestyle, and the severity of the psoriasis and then decide on a treatment option that will achieve maximum effectiveness.

Psoriasis patients will do well to keep a positive mental attitude towards life and its happenings. Remember, any negative signals from the mind is an instant trigger for psoriasis!

Alternative therapies

Non-medical treatments for psoriasis, including over-the-counter skin creams, phototherapy, alternative treatments, herbal remedies, etc.

There is no scientific evidence that homeopathic treatments are effective for treating psoriasis. However, it’s not impossible that some of these treatments might be helpful. Scientific studies need to be done in order to resolve this issue.

Psoriasis, though quite a common disease, has not received the attention it deserves from the health authorities in most countries. As a result, the much needed awareness campaigns and funding of research projects have been lagging behind for decades. It was in this context that in 2004 the first World Psoriasis day was launched. Conceived by patients for patients, World Psoriasis Day is a truly global event that sets out to give an international voice to the 125 million psoriasis sufferers.

Visit http://www.worldpsoriasisday.com/ to learn more about the World Psoriasis Day on October 29th. There, you can also sign a petition calling on the World Health Organization to recognize psoriasis as a serious disease worth more attention and researches.