What is Psoriasis?
Psoriasis is a chronic skin condition which affects approximately 7.5 million people in the United States alone. It is a chronic, inflammatory condition affecting the skin, nails, and joints, but the cause of it is due to specific changes in the immune system. In a nutshell, faulty genetic signals (and sometimes other triggers) program the immune system to send white blood cells into the skin and joints. These cells produce substances which cause inflammation (often resulting in redness, thickening, itching or burning in the skin); these substances also tell the skin cells to grow too quickly and to pile up on the surface of the skin, rather than being shed (causing red, thickened, and scaly spots on the skin). Likewise, these cells may also cause pain, swelling, and sometimes destruction of joints, termed psoriatic arthritis. Despite its characteristic appearance, psoriasis is not contagious.
Psoriasis occurs in all age groups, but predominantly in adults. It most commonly develops between 15 to 30 years of age; it may also begin between 50-60 years. Caucasians are more affected than other ethnicities, but it may still occur in the other races as well. Many people with psoriasis have family members who also have psoriasis, but scientists have shown that not everyone who inherits the genes for psoriasis will actually get the disease. A person may have to inherit the “right” combination of genes. After inheriting , the affected person needs exposure to a trigger for the skin and joint lesions to develop. Eighty percent of those affected have mild to moderate skin involvement, while 20% have moderate to severe disease, involving 5% or more of the skin’s surface area. Additionally, psoriatic arthritis may affect up to 40% of patients with psoriasis. The psoriasis skin disease precedes the arthritis in 60-80% of those affected, while in 15-20%, the arthritis may manifest first. The onset of both may be simultaneous as well.
Several conditions may trigger psoriasis lesions to develop. These include trauma to the skin, such as a cut, scratch, or even a severe sunburn; cold, dry weather; strep throat or viral infection; a stressful event (physical or emotional); and finally, taking certain medications such as those that prevent malaria, or lithium. Psoriasis may itch or burn, causing the urge to scratch. Scratching or picking may worsen the psoriasis, make it thicker, and may even cause hair loss.
There are several types of psoriasis:
- Plaque – large, red, thick/raised, scaly lesions on the skin (called plaques) occur. These are most common on the elbows, knees, lower back, and scalp, but can occur anywhere on the body. This is the type that most often involves the nails, but not in all patients.
- Guttate – small, red, sometimes scaly spots usually occur on the trunk, arms, and legs, but again, may occur anywhere on the body. This type often erupts after an illness, such as strep throat, and may resolve in weeks to months.
- Inverse – red, moist, raw patches of skin develop in fold, where skin touches skin, such as armpits, groin, buttocks, under the breasts, or on the genitals. The skin is irritated and sometimes painful in these areas.
- Pustular – red, swollen, painful skin with pus-filled bumps (called pustules) develop, most often on the palms and soles. These pustules will burst and dry, leaving brown dots or scale afterwards. Patients with an eruption of pustular psoriasis may also feel sick and exhausted, may have fever, chills, severe itching, skin pain, rapid pulse, and sometimes even weakness.
- Erythrodermic – bright red, itchy, or tender skin on most or all of the body surface. This is the most serious type of psoriasis. The skin has a burned appearance, and the body is unable to maintain normal body temperature. They may also lose fluids through the skin. This form may be life-threatening, and if extensive, should prompt referral of the patient to the hospital immediately.
How is it diagnosed?
A dermatologist will first do a physical examination of the skin, nails, and scalp. He or she will ask about family members having psoriasis, about recent stressors or illnesses, about medications (both oral and topical), and about joint pains. Sometimes the doctor will take a bit of skin to confirm the diagnosis, although this is not always necessary.
Is psoriasis life-threatening?
In most cases, psoriasis is not life-threatening. However, there are some other diseases or conditions associated with psoriasis that patients should be aware of. Persons with psoriasis may be at an increased risk for heart and blood vessel disease, stroke, Type II diabetes, high blood pressure, obesity and metabolic syndrome , inflammatory bowel disease (such as Crohn’s disease or ulcerative colitis), and lymphoma (a blood cancer that can affect the skin). Psoriasis is also associated with smoking, alcohol use, depression, and suicide. Studies show that psoriasis patients may experience emotional and physical distress on a level similar to those with diabetes, cancer, arthritis, and heart disease.
How is it treated?
There are many treatment options available. Research over the past 10-15 years has resulted in many newer treatment options, providing better relief and quality of life for those affected.
- Topical treatments – these treatments are helpful for localized or mild to moderate psoriasis, but are not likely to be helpful for more severe or widespread cases. These include topical corticosteroids, Vitamin D derivatives, coal tar, anthralin, salicylic acid, tazarotene, and moisturizers. These are applied directly to the psoriasis lesions as directed by the physician. There are various strengths and formulations available in addition to the traditional creams and ointments: solutions, oils, foams, tapes, and sprays are now available.
- Phototherapy/laser – such therapies use ultraviolet light (UVA or UVB) to improve psoriasis, especially when widespread or in difficult to treat areas, such as scalp or hands and feet. These methods are monitored and strictly dosed to minimize burning and maximize response. It is not recommended to attempt using tanning booths to achieve the same effect; without proper training and experience, the risks of burning and blistering are higher, which can actually worsen the psoriasis, and can drastically increase one’s risk for skin cancers, especially melanoma, which may be deadly. Natural sunlight, on the other hand, may be helpful, when done according to doctor’s orders.
- Traditional systemic therapies – these are medications that are generally taken orally, such as acitretin, cyclosporine, methotrexate, and apremilast. It is important to note that all medications have side effects, and that most of these in particular will require frequent visits and blood testing to monitor for these adverse events. Though most patients tolerate them quite well, some of the side effects can be serious, and it is critical that patients adhere to physician’s instructions so as to identify them early if they occur. But if handled correctly, these medications can work quite well for some patients, without needing to apply topical medications to a large surface area.
- Biologics – this is a newer class of medications that has emerged over the last 15-20 years. These therapies target specific points in the immune system that are involved in the mechanism of psoriasis. These are generally given by self-injection or intravenously (IV). Although most patients tolerate these well, monitoring for potential serious adverse effects is critical with these medications as well.
- Non-drug treatments – these may help in combination with other therapies listed above to manage the lesions of psoriasis and minimize the symptoms. UV treatments from natural sunlight are mentioned above. Others include stress reduction, biofeedback, seabathing, moisturizers and anti-itch treatments, and wet-wraps, to name a few.
Where do I start?
Studies have shown that psoriasis may significantly impact a person’s abilities physically, emotionally, and socially, thereby affecting their overall quality of life. The disability may be equivalent to or exceed that of patients with cancer, arthritis, depression, heart disease, or diabetes. Depression and suicide, smoking, and alcohol consumption are all more common in psoriasis patients. Treatments should be aimed not only at reducing the visual aspect of the disease, but also at improving one’s quality of life. A couple of good resources for more information include the American Academy of Dermatology website (www.aad.org) and the National Psoriasis Foundation website (www.psoriasis.org). These websites contain a wealth of medical information, links to other resources, information on support groups, and updates on new therapies and clinical trials. You should also visit your dermatologist, who will discuss with you your treatment options and assist you in navigating your management course. With the myriad of exciting options available today, it is possible to improve not only the visual aspects of your condition, but also lend a sunnier outlook as well.
Dr. Melody Vander Straten is a board certified dermatologist practicing at ADC Steiner Ranch. She welcomes teen and adult patients to her practice. Call 512-681-5900 for more information or to make an appointment.