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What is Psoriasis:
Psoriasis, is pronounced as “səˈraɪəsɪs”, affects the skin and joints. This is not a contagious disease. Psoriasis is a lifelong multi-factorial condition. There is currently no complete cure but various treatments can help to keep in control the symptoms. It is classified recently as an immune-mediated inflammatory disease (IMID). An individual’s genetic profile influences their type of psoriasis and its response to treatment. Genome-wide association studies report that the histo-compatibility complex HLA-C*06:02 (previously known as HLA-Cw6) is associated with early-onset psoriasis and guttate psoriasis. This major histo-compatibility complex is not associated with arthritis, nail dystrophy or late-onset psoriasis.
World Psoriasis Day is celebrated globally on October 29th. Each year, the global psoriatic disease community unites for action to raise awareness of psoriatic disease. The theme for year 2022 is mental health.
On the skin, rash / discoloured skin presents frequently as red scaly patches are seen for psoriasis which also causes itch. The scaly areas produced due to psoriasis are referred to as psoriatic plaques. Plaques can affect any area of the body, but frequently occur on the skin of the elbows and knees. The scalp and genitals may also be involved even. Psoriasis is hypothesized to be an immune-mediatedcondition. Fingernails and toenails may even be commonly affected instead of skin (aka: psoriatic nail dystrophy) and may be seen as an isolated finding. Psoriasis can also cause inflammation of the joints, known as psoriatic arthritis. Ten to fifteen percent of people with psoriasis have psoriatic arthritis.
For images on psoriasis, I recommend you to visit this link for good understanding. Link is in next line :
https://dermnetnz.org/topics/psoriasis
Causes of Psoriasis:
The disorder is a chronic recurring condition which varies in severity from minor localized patches to complete body coverage. The cause of psoriasis is exactly not known, but it is thought to have some genetic component. Hence psoriasis may run in families. There may be a genetic component to psoriasis as biological parents may pass this condition down to their offspring.
An over-reactive immune system triggering inflammation in the skin usually causes psoriasis. If one has psoriasis, his immune system is supposed to destroy foreign invaders, like bacteria, to keep him healthy and prevent from getting sick. Instead, the immune system can mistake healthy cells for foreign invaders. As a result, the immune system responses and result is inflammation or swelling, which one can see on the surface of the skin as skin plaques. It usually takes up to four weeks for the new skin cells to grow and replace old skin cells. The over-reactive immune system causes the timeline of new skin cell development to change to only within 3 – 5 days. The scales are the result of the speed of new cells replacing old cells. Frequent skin shedding on top of skin plaques is observed.
Several factors are attributed to aggravate the condition. These include emotional stress, excessive alcohol consumption, smoking, skin injury like cuts, scrapes or surgery, Certain medications, such as lithium and beta-blockers etc.
Individuals with psoriasis may suffer from depression and loss of self-esteem. As such, quality of life is an important factor during evaluation and assess the severity of the disease. There are many treatments available but because of its chronic recurrent nature psoriasis is always challenging to treat for cure.
Myths explained: psoriasis and eczema – the same or not?
Psoriasis and eczema are two pretty different skin conditions. Both conditions undoubtedly cause similar symptoms like discolored skin, a rash and itching. Psoriasis plaques cause areas of thick skin covered in scales with a silvery-white appearance. But eczema causes a rash of dry and bumpy skin. And eczema causes more intense itching than psoriasis.
Types of psoriasis:
The symptoms of psoriasis can manifest in a variety of forms. Variants include plaque, pustular, guttate and flexural psoriasis. This section describes each type with ICD-10 code.
Plaque psoriasis (psoriasis vulgaris) (L40.0) is the most common of all forms of psoriasis. It affects 80 to 90% of cases with psoriasis. Plaque psoriasis typically appears as raised areas of inflamed skin covered with an appearance of silvery white scaly skin. These areas are called plaques.
Flexural psoriasis (inverse psoriasis) (L40.83-4) appears classically as smooth inflamed patches of skin. It occurs in skin folds, particularly around the armpits (axilla), the genitals (between the thigh and groin), under an overweight stomach (pannus), and even under the breasts (inframammary fold). It is aggravated by friction between the skins and sweat, and is also vulnerable to fungal infections.
Guttate psoriasis (L40.4) is diagnosed by numerous small oval (teardrop-shaped) spots on skin. These numerous spots of psoriasis appear usually over the large areas of the body, such as the trunk, limbs, and scalp. Guttate psoriasis is also associated with streptococcal throat infection.
Pustular psoriasis (L40.1-3, L40.82) appears as raised bumps that are filled with non-infectious pus (pustules). The skin under and surrounding pustules is red and painful on touch. Pustular psoriasis can be localized, commonly to the hands and feet (palmoplantar pustulosis), or generalized with widespread patches occurring randomly on any part of the body.
Nail psoriasis (L40.86) results in different types of changes in the appearance of finger and toe nails. These changes include discolouring under the nail plate, pitting of the nails, the loosening or breaking of the nail (onycholysis), lines going across the nails, thickening of the skin under the nail, or crumbling of the nail.
Psoriatic arthritis (L40.5) is also an autoimmune condition, which involves joint and connective tissue, causing inflammation. Psoriatic arthritis can affect any joint but is most common in the joints of the fingers and toes. This can result in a sausage-shaped swelling of the digits (fingers and toes) known as dactylitis. Psoriatic arthritis can even affect the hips, knees and spine (spondylitis). About 10-40% people diagnosed with psoriasis can develop psoriatic arthritis. Its proved that early diagnosis and treatment of psoriatic arthritis can reduce damage to the joints.
Pustular psoriasis: Pustular psoriasis has small, pus-filled bumps on top of plaques.
Sebopsoriasis: is a type typically appears on face and scalp as bumps and plaques with a greasy, yellow scale. This is a cross between psoriasis and seborrheic dermatitis.
Erythrodermic psoriasis (L40.85) results from a widespread inflammation and exfoliation of the skin over most of the body surface. It may be accompanied by intense itching, swelling and pain. It is often the result of an exacerbation of unstable plaque psoriasis, specifically following the abrupt withdrawal of a systemic treatment. This form of psoriasis can be fatal, as the extreme inflammation and exfoliation disrupt the body’s ability to regulate the body temperature and for the skin to perform the usual barrier functions.
Epidemiology:
Psoriasis can occur at any age, although it most commonly appears for the first time between the ages of 15 and 25 years. It affects both sexes equally. The prevalence of psoriasis in Western populations is rising and is estimated to be around 2-3%. A survey conducted by the National Psoriasis Foundation (a US based psoriasis education and advocacy group) found a prevalence of 2.1% among adult Americans. The prevalence of psoriasis among 7.5 million patients who were registered with a general practitioner in the United Kingdom was 1.5%. In a study, some researchers found that 35% of people with psoriasis could be classified as having moderate to severe psoriasis.
Around one-third of people with psoriasis report a family history of the disease, and researchers have identified genetic loci associated with the condition. Studies of monozygotic twins suggest a 70% chance of a twin developing psoriasis if the other twin has psoriasis. The concordance is around 20% for dizygotic twins. These findings suggest both a genetic predisposition and an environmental response in developing psoriasis.
Onset before age of 40 years usually indicates a high rate of genetic susceptibility and a more severe courses or recurrent episodes of psoriasis.
According to one study, psoriasis is linked to a 2.5-fold increased risk for non-melanoma skin cancer in men and women, with no preponderance of any specific histologic subtype of cancer. This could be linked to the anti-psoriatic treatment even.
Diagnosis:
A diagnosis of psoriasis is usually based on the skin appearance. There are no special blood tests or diagnostic procedures for psoriasis. Sometimes a skin biopsy, or scraping, may be needed to rule out other disorders and to confirm the diagnosis. Skin from a biopsy will show clubbed Rete pegs if positive for psoriasis. Another sign of psoriasis is that when the plaques are scraped, one can see pinpoint bleeding from the skin below (Auspitz’s sign).
Severity of psoriasis is an important issue to evaluate during the patient visit when it is diagnosed. Psoriasis is usually graded as mild (affecting less than 3% of the body), moderate (affecting 3-10% of the body) or severe. Several scales exist for measuring the severity of psoriasis. The Psoriasis Area Severity Index (PASI) is the most widely used measurement tool for psoriasis. PASI combines the assessment of the severity of lesions and the area affected into a single score in the range 0 (no disease) to 72 (maximal disease). But there is also some limitations as well.
The degree of severity is generally based on some factors like the proportion of body surface area affected; disease activity (degree of plaque redness, thickness and scaling); response to previous therapies; and the physical and psychological impact of the disease on the person. Effect on the quality of life is an emerging issue in recent years. Psoriasis has been shown to affect health-related quality of life (QOL) to an extent similar to the effects of other chronic diseases such as depression, myocardial infarction, hypertension, congestive heart failure or type 2 diabetes etc. Depending on the severity and location of outbreaks, individuals may experience significant physical discomfort and some disability. Itching and pain can interfere with basic QOL and common functions, such as self-care, walking, sitting, sleep. Plaques on hands and feet can prevent individuals from working in some specific occupations, playing some sports, and caring for family members or a home. The frequency of medical care required is costly in terms of repeated patient visit and necessary drugs. So, this condition can interfere with even an employment or school schedule.
Individuals with psoriasis may also have psychological concerns as well. One with this condition feel self-conscious about their appearance and have a poor self-image that stems from fear of public rejection and psychosexual concerns. Psychological distress can lead to significant depression and social isolation, as reported in several studies.
Management:
Historical treatment: The history of psoriasis is littered with treatments of dubious effectiveness and high toxicity. These treatments received brief popularity at particular time periods or within certain geographical regions. The application of cat faeces to red lesions on the skin, for example, was one of the earliest topical treatments employed in ancient Egypt. Onions, sea salt and urine, goose oil and semen, wasp droppings in sycamore milk, and soup made from vipers have all been reported as being ancient treatments.
In the more recent past Fowler’s solution, which contains a poisonous and carcinogenic arsenic compound, was used by dermatologists as a treatment for psoriasis during the 18th and 19th centuries. Grenz rays (also called ultra-soft X-rays or Bucky rays) was a popular treatment of psoriasis during the middle of the 20th century. This type of therapy was superseded by ultraviolet therapy.
Undecylenic acid was investigated and used for psoriasis some 40 years ago. All these treatments have fallen out of favour. Sulphur was fashionable as a treatment for psoriasis in the Victorian and Edwardian eras. It has recently re-gained some credibility as a safe alternative to steroids and coal tar.
Treatment options now-a-days:
The management is challenging. There can be substantial variation between individuals in the effectiveness of specific psoriasis treatments. Because of this, dermatologists often use a trial-and-error approach to finding the most appropriate treatment for their patient. The decision to employ a particular treatment is based on the type of psoriasis, its location, extent and severity. The patient’s age, gender, quality of life, comorbidities, and attitude toward risks associated with the treatment are also taken into consideration.
Medications:
with the least potential for adverse reactions are preferentially employed. If the treatment goal is not achieved, then therapies with greater potential toxicity may be used. Medications with significant toxicity are usually kept as reserved for severe unresponsive psoriasis. This is called the psoriasis treatment ladder. As a first step, medicated ointments or creams are applied to the skin. This is called topical treatment. If topical treatment fails to achieve the desired goal, then the next step would be to expose the skin to ultraviolet (UV) radiation. This type of treatment is called phototherapy. The third step involves the use of medications which are taken internally by pill or injection. This approach is called systemic treatment.
Over time, psoriasis can even become resistant to a specific therapy. Treatments may be periodically changed to prevent the resistance to develop (tachyphylaxis) and to reduce the chance of adverse reactions occurring. This is called treatment rotation.
Topical treatment:
Moisturizers, bath solutions etc. help to provide a soothing affect to the skin and reduce the dryness which accompanies the build-up of skin on psoriatic plaques. Medicated creams and ointments applied directly to psoriatic plaques can help reduce inflammation, remove built-up scale, reduce skin turn over, and clear affected skin of plaques. Ointment and creams containing coal tar, dithranol (anthralin), corticosteroids, vitamin D3 analogues (for example, calcipotriol), and retinoids are routinely used. Argan oil has also been used with some promising results. The mechanism of action of each is different but
they all help to normalize the skin cell production and reduce inflammation. Activated vitamin D and its analogues are highly effective inhibitors of skin cell proliferation.
The disadvantages of topical agents are variably that they can often irritate normal skin, can be time consuming and awkward to apply, cannot be used for long periods, can stain clothing or have a strong odour. As a result, it is sometimes difficult for people to maintain the regular application of these medications. Abrupt withdrawal of some topical agents, particularly corticosteroids, may result in an aggressive recurrence of the condition and hence should be informed while counselling during starting of the steroid therapy. This is known as a rebound phenomenon of the condition. Some topical agents are used in conjunction with other therapies, especially phototherapy.
Phototherapy:
It has long been recognized that daily, short, non-burning exposure to sunlight helped to clear or improve psoriasis. Niels Finsen was the first physician to investigate the therapeutic effects of sunlight scientifically and to use sunlight in clinical practice. This became known as phototherapy.
Sunlight contains many different wavelengths of light. It was during the early part of the 20th century that it was recognised that for psoriasis the therapeutic property of sunlight was due to the wavelengths classified as ultraviolet (UV) light.
Ultraviolet wavelengths are subdivided into UVA (380–315 nm) UVB (315–280 nm), and UVC (< 280 nm). Ultraviolet B (UVB) (315–280 nm) is absorbed by the epidermis and has a beneficial effect on psoriasis. Narrowband UVB (311 to 312 nm), is that part of the UVB spectrum that is most helpful for psoriasis. Exposure to UVB several times per week, over several weeks can help people attain a remission from psoriasis. Ultraviolet light treatment is frequently combined with topical (coal tar, calcipotriol) or systemic treatment (retinoids) as there is a synergy in their combination (Photochemotherapy). The Ingram regime, involves UVB and the application of anthralin paste. The Goeckerman regime combines coal tar ointment with UVB.
Psoralen and ultraviolet A phototherapy (PUVA) combines the oral or topical administration of psoralen with exposure to ultraviolet A (UVA) light. Precisely how PUVA works is not known. The mechanism of action probably involves activation of psoralen by UVA light which inhibits the abnormally rapid production of the cells in psoriatic skin. There are multiple mechanisms of action associated with PUVA, including effects on the skin immune system. PUVA is associated with nausea, headache, fatigue, burning, and itching. Long-term treatment with Psoralen may be associated with squamous-cell and melanoma like skin cancers.
Systemic treatment:
Many treatments are getting resistance and Psoriasis is not also a condition of exception. Psoriasis resistant to topical drug treatment and phototherapy is treated by medications that are taken as oral pill or injection which is known as the systemic treatment. Patients undergoing systemic treatment are required to have regular blood and liver function tests because of the toxicity of the medication. Pregnancy must be avoided for the majority of these treatments. Most people experience a recurrence of psoriasis after systemic treatment is stopped. It’s also worth to keep in mind that many of the most effective agents used to treat severe psoriasis carry an increased risk of significant morbidity including skin cancers, lymphoma and liver disease.
The three main traditional systemic treatments are methotrexate, cyclosporine and retinoids. Methotrexate and cyclosporine are immunosupressant drugs; retinoids are synthetic forms of vitamin A. Other additional drugs, not specifically licensed for psoriasis, have been found to be effective. These include the antimetabolite tioguanine, the cytotoxic agent hydroxyurea, sulfasalazine, the immunosupressants mycophenolate mofetil, azathioprine and oral tacrolimus. These have all been used effectively to treat psoriasis when other treatments have failed.
Apremilast is an oral small-molecule inhibitor of phosphodiesterase 4 (PDE4) specific for cyclic adenosine monophosphate (cAMP). PDE4 inhibition results in increased intracellular cAMP levels. The specific mechanism(s) by which apremilast exerts its therapeutic action is not well defined. Otezla® is one of the most popular brand for Apremilast in the USA. It’s also one of the most expensive. Since its initial FDA approval in 2014, Otezla® (apremilast) has been prescribed to more than 250,000 patients with moderate-to-severe plaque psoriasis or active psoriatic arthritis in the USA. Otezla® (apremilast) is approved for three indications in the USA, including adult patients with plaque psoriasis who are candidates for phototherapy or systemic therapy, adult patients with active psoriatic arthritis and for adult patients with oral ulcers associated with Behçet’s Disease.
Biologics:
These are manufactured proteins that interrupt the immune process involved in psoriasis. Unlike generalized immunosuppressant therapies such as methotrexate, biologics focus on specific aspects of the immune function leading to psoriasis. These drugs (interleukin antagonists) are relatively new, and their long-term impact on immune function is unknown. They are very expensive and only suitable for very few patients with psoriasis. Ustekinumab (IL-12 and IL-23 blocker) shows fruitful results.
A new natural systemic option, XP-828L, for mild to moderate psoriasis relief has been developed by a Canadian life science and technology company. This oral product with clinically proven efficacy and safety is extracted through a patented process from whey and has immuno-modulatory effects.
Alternative therapy:
Antibiotics are not indicated in routine treatment of psoriasis. However, antibiotics may be employed when an infection, such as that caused by the bacteria Streptococcus, triggers an outbreak of psoriasis, as in certain cases of guttate psoriasis.
Climatotherapy involves the notion that some diseases can be successfully treated by living in a particular climate. Several psoriasis clinics are located throughout the world based on this idea. Example is “The Dead Sea”, which is one of the most popular locations for this type of treatment.
Future drug development:
Historically, the agents used to treat psoriasis were discovered by experiments or just by accident. In contrast, current novel therapeutic agents are designed from a better understanding of the immune processes involved in development and progression of psoriasis and by the specific targeting the molecular mediators. Examples can be seen in the use of biologics which target T cells and TNF inhibitors.
It has been recently observed that cannabis might treat psoriasis, due to the anti-inflammatory properties of its cannabinoids, and the regulatory effects of THC on the immune system. cannabis induced adverse drug effects might be overcome by use of more specific cannabinoid receptor medications, to inhibit keratinocyte proliferation.
Future innovation should see the creation of additional drugs that refine the targeting of immune-mediators further. Research into antisense oligonucleotides carries the potential to provide novel therapeutic strategies for treating psoriasis. ABT-874 is a human anti-IL-12 monoclonal antibody being developed by Abbott Laboratories in conjunction with Cambridge Antibody Technology for the treatment of multiple autoimmune diseases including psoriasis.
Recent updates:
New studies have shown that smoking cessation can improve the outcome of psoriasis, and also decrease the incidence of its occurrence. Some people expresses that psoriasis can be effectively managed through a healthy lifestyle based on anecdotal evidence. Minimising stress and consuming a healthy diet, combined with rest, sunshine and swimming in saltwater keep lesions to a minimum. A number of patients have reported significant improvements from sun and sea water, not by alone of either of these two. A psychological symptom management programme has also been reported as being a helpful adjunct to traditional therapies in the management of psoriasis.