What is psoriasis?
As many as 7.5 million Americans have psoriasis, and they spend between $1.6 billion and $3.2 billion each year to treat the disease of autoimmunity, according to the National Psoriasis Foundation (NPF). Between 150,000 and 260,000 new cases are diagnosed each year, including 20,000 in children younger than 10. Though seldom disabling, the red welts, pustules, and scaling skin that mark the disease can be painful and extremely embarrassing.
A chronic, non-contagious disease, psoriasis [pronounced sore-EYE-ah-sis] varies in its severity and how it responds to treatment. It results from inappropriate responses of the body’s immune system to essentially attack the body itself and can occur on any part of the body that’s covered by skin. The resulting inflammation can be as mild as something resembling dandruff or as radical as a body covered with thick, crusted plaques. Less than 10 percent of sufferers have an extreme form of the disease; it is a mild form in 65 percent of cases. Everything else is in between mild and serious.
Though it usually doesn’t get any worse over time, about 10 percent to 30 percent of people with psoriasis also develop psoriatic arthritis, which causes pain, stiffness and swelling in and around the joints.
Psoriasis is a disease which takes different forms. Among them:
At least half of all people who have psoriasis have it on their scalp. As with psoriasis elsewhere on the body, skin cells grow too quickly and cause red lesions covered with scale. In severe cases of thick, crusted plaques covering the entire scalp, the hair may fall out. The affected area can extend beyond the hairline onto the forehead, the back of the neck and around the ears. Treatments, as with any type of psoriasis, are often combined and rotated because it can become resistant to medications after repeated use. Many treatment options can help control scalp psoriasis and its symptoms:
- Tar products and salicylic acid are generally sufficient for treating very mild scalp psoriasis.
- Topical medications (applied to the skin).
- Ultraviolet (UV) light treatments.
- Systemic (oral or injected) treatments may be tried if psoriasis is present elsewhere on the body and/or the psoriasis is severe.
Although it usually responds well to various treatments, the sensitive nature of the skin around the genitals requires a cautious approach to genital psoriasis:
- Protopic and Elidel. Both of these drugs reduce skin inflammation much as topical steroids do, but they do not cause thinning of the skin. They may cause some irritation when they are first used, but they do not promote yeast or bacterial growth, which may further help with inflammation and itching.
- Ultraviolet (UV) light. Overexposure to UV light can burn the skin, especially the thinner skin around the genitals, so it is therefore used only in special circumstances and in very low doses. Psoriasis in the pubic area may respond well to UV light treatment if the pubic hair is cut short or shaved. Men should wear briefs or athletic supporters to protect their genitals while receiving UV light treatment on other parts of the body.
- Dovonex. Though this synthetic form of vitamin D3 has the potential for irritation, it does not have any of the drawbacks of topical steroids, and mixing it with petroleum jelly may minimize irritation.
- Tazorac. Because of its potential for irritation, some doctors alternate its use with a low-strength topical steroid.
- Steroids. Prolonged use of topical steroids can permanently thin the skin and cause stretch marks. Furthermore, psoriasis may become resistant to clearing with continuous long-term use of steroids.
- Over-the-counter (OTC) moisturizers. The skin in affected genital areas should be continuously moisturized, but choose wisely: moisturizers with fragrance and perfumes may irritate.
Areas of the face most often affected are the eyebrows, the skin between the nose and upper lip, the upper forehead, and the hairline. Because other skin diseases resemble the symptoms of psoriasis on the face, a biopsy may be needed to positively identify it.
Rashes may also appear on the eyelids, around the ears, mouth, and on the nose. Treating eyelid inflammation may involve washing the edges of the eyelids and eyelashes with a solution of water and baby shampoo. An over-the-counter product, Ocusoft, can help with removing scales on the lids and eye margins. But a doctor must carefully supervise the treatment because eyelid skin can be easily damaged, and the use of topical steroids there can lead to glaucoma and/or cataracts.
In addition to Dovonex, Tazorac, and ultraviolet light, Protopic may be used in treating facial psoriasis. This and Elidel, both drugs used to treat eczema, have also been found effective in treating psoriasis. Topical steroids may be used, but prolonged use of them may cause enlarged capillaries (spider veins) on the face.
Psoriasis scaling can also block the ear canal and produce temporary hearing loss; it should be removed by a doctor. Psoriasis in and around the mouth or on the lips causes discomfort and may present difficulty in chewing and swallowing food. Improving hygiene and rinsing frequently with a saline solution can help relieve oral discomfort, and there are effective topical steroids that have been designed to treat moist areas.
Psoriasis lesions, usually white or gray, may also appear on the gums, the tongue, inside the cheek, or inside the nose.
Psoriasis of the hands and feet
Because of their frequent use, hands or feet suffering from acute psoriasis need to be treated promptly and carefully. There may be cracking, blisters, pustules, and swelling. A typical course of treatment recommended by a doctor may look like this:
- Soak the hands or feet in warm water to reduce swelling. Oilated oatmeal powder or bath oil may be added to the water to reduce built-up layers of skin and making medications and phototherapy more effective.
- Gently rub the affected skin with a sponge to remove scales.
- Apply medications or moisturizers. Traditional topical treatment of palm and sole psoriasis includes tar products, salicylic acid, and steroids. Combinations of these three agents may be superior to each one used individually.
- When directed by a doctor, some topical medications may be used with occlusion to intensify the effect of the cream or ointment. Cotton or plastic gloves are worn over creams or moisturizers on the hands. Feet can be occluded by putting each foot in a plastic bag and then putting a sock on over the bag before going to bed. A regimen alternating Dovonex and potent topical steroids may be beneficial.
Other approaches may also be recommended:
- PUVA. This is a procedure which involves taking orally or applying topically a light-sensitizing drug, psoralen, before having the affected areas exposed to UVA – ultraviolet light A.
- Systemic medications like Methotrexate taken orally or injected can clear most cases of severe palm and sole psoriasis within four to six weeks, though this drug has the potential for causing side effects to the liver; cyclosporine, similarly effective, has the potential for kidney side effects.
- Biologics, drugs obtained from human and animal sources, have been effective in treating all forms of psoriasis. These include Amevive, Enbrel, Hurmira, Raptiva, and Remicade. All but Amevive and Remicade can be injected by patients themselves.
- Oral retinoids (derivatives of Vitamin A) such as Soriatane thin out plaques over a period of days or weeks, enabling topical treatments to become more effective. However, they do cause birth defects and should be avoided by women of child-bearing age. The combination of retinoids with PUVA is one of the most effective treatments available for palm and sole psoriasis.
Psoriasis of the nails affects up to 50 percent of people with psoriasis and at least 80 percent of people with psoriatic arthritis.
Typically, people have only one type of psoriasis at a time, but occasionally two or more different types of psoriasis can occur at the same time. Triggers may “convert” some forms of psoriasis, such as plaque, to another form, say, pustular.
Primarily seen in adults, pustular psoriasis is characterized by white pustules (blisters of noninfectious pus) surrounded by red skin. It is not an infection, nor is it contagious. It tends to go in a cycle wherein the skin reddens before pustules form, followed by scaling.
It may be localized or cover most of the body.
Palmo-plantar pustulosis (PPP), for example, causes pustules on the palms of the hands and soles of the feet. Topical treatments are usually prescribed first, but PPP often proves stubborn to treat. PUVA, ultra violet, and cyclosporine may be employed. Soriatane and methotrexate in combination produce a rapid remission in the acute state of pustular psoriasis and an eventual clearing of the skin.
The painful and disabling lesions of acropustulosis, another type, appear on the ends of the fingers and sometimes on the toes. They cause deformity of the nails, and sometimes bone is affected in severe cases. It is hard to treat.
With other forms, such as von Zumbusch pustular psoriasis, the pustules cover broad swaths of skin. Von Zumbusch is serious enough to be life-threatening. Eruptions of pustules often come in repeated waves that last days or weeks. The onset can be abrupt. There is fever, chills, severe itching, dehydration, a rapid pulse rate, exhaustion, anemia, weight loss, and muscle weakness.
Treatment is aimed at preventing further loss of fluid, stabilizing the body’s temperature, and restoring the skin’s chemical balance because chemical imbalances can put excessive stress on the heart and kidneys, especially in older people. Medical care must begin immediately; hospitalization may be necessary to rehydrate the patient and initiate topical and systemic treatments, which typically include antibiotics.
About 10-to-30 percent of people with psoriasis also develop arthritis that causes pain, stiffness, and swelling in and around joints. Without treatment, psoriatic arthritis can potentially be disabling and crippling.
One or more of the following symptoms indicates psoriatic arthritis:
- Generalized fatigue
- Tenderness, pain and swelling over tendons
- Swollen fingers and toes
- Stiffness, pain, throbbing, swelling and tenderness in one or more joint
- A reduced range of motion
- Morning stiffness and tiredness
- Nail changes—separating from the nail bed, becoming pitted, or mimicking fungus infections
- Redness and pain of the eye, such as conjunctivitis. (Read how to get rid of conjunctivitis)
The disease can develop in a joint after an injury and may mimic a cartilage tear. The diagnosis of psoriatic arthritis may sometimes be made only after repeated episodes. Muscle or joint pain can occur without joint inflammation (swelling), and tendonitis and bursitis may be prominent features. Swelling of the fingers and toes lend a “sausage-like” appearance known as dactylitis.
Psoriatic arthritis usually affects the distal joints (those closest to the nail) in fingers or toes, and the lower back, wrists, knees, or ankles also may be affected. Psoriatic arthritis may be of five types:
- Symmetric arthritis, much like rheumatoid arthritis but generally milder and with less deformity, usually affects multiple symmetric pairs of joints (that is, it occurs in the same joints on both sides of the body). It can be disabling.
- Asymmetric arthritis can involve a few or many joints and does not occur in the same joints on both sides of the body. It can affect any joint.
- Distal interphalangeal predominant (DIP) involves the distal joints of the fingers and toes (the joint closest to the nail). Sometimes it is confused with osteoarthritis, but nail changes are usually prominent.
- Spondylitis is inflammation of the spinal column – inflammation with stiffness of the neck, lower back, sacroiliac, or spinal vertebrae, making motion painful and difficult. Peripheral disease can be present in the hands, arms, hips, legs and feet.
- Arthritis mutilans. A severe, deforming and destructive arthritis that principally affects the small joints of the hands and feet.
Other Forms of Psoriasis
- Guttate. Appearing as small red spots on the skin, usually on the trunk and limbs, this often starts in childhood or young adulthood.
- Inverse. Occurs anywhere there are skin folds where rubbing and sweating irritate it. It is more common and troublesome in overweight people and others with deep skin folds.
- Erythrodermic. A particularly inflammatory – and potentially life-threateneing – form of psoriasis affecting most of the body surface and accompanied by severe itching and pain, erythrodermic psoriasis causes protein and fluid loss that can lead to severe illness. Edema (swelling from fluid retention), especially around the ankles, may also develop along with infection, shivering, pneumonia, and congestive heart failure.
What causes psoriasis?
Although the disease has genetic aspects, some kind of trigger is usually necessary to make psoriasis appear. The trigger can be:
- Stress. Various relaxation and stress reduction techniques seem to work best in combination with traditional medical treatments, instead of using the techniques alone. It does not help, of course, that disfiguring psoriasis creates low self-esteem that leads to more stress and possibly a worsening of the psoriasis.
- Injury to skin. Vaccinations, sunburns, and scratches can all trigger what’s called a Koebner response. It can be treated if it is caught early enough.
- Medication reactions. Lithium, used to treat manic depression and other psychiatric disorders, is one of a number of drugs that aggravate psoriasis. Others include antimalarial drugs, the high blood pressure medication, Inderal, the heart medication Quinidine, and Indomethacin – used to treat arthritis.
- Allergies. Some people suspect that allergies trigger their psoriasis. Others believe that a change in diet has helped their conditions. (Learn how to get rid of allergies)
- Strep infection.
- Weather. Dry conditions can make skin more susceptible to a psoriasis outbreak.
What can I do to make my psoriasis less noticeable?
- Wear long sleeves, pants, turtlenecks, hats or scarves in public on days when you don’t have the emotional energy to accept the stares and questions.
- Use a body makeup like Dermablend to cover rashes; however, no cosmetic cover-up should ever be applied to open skin lesions, unhealed cuts, raw or irritated skin, or if you have skin allergies. Likewise, masking pustular or erythrodermic psoriasis is not a good idea because minor irritants in cosmetics can produce stinging and redness in skin that’s already inflamed.
- Using moisturizers regularly may ease the redness and scaling of psoriasis lesions.
- Remove as much scale as possible if you are going to use a cosmetic cover-up. Use occlusion and hydration techniques:
- Occlusion. Coat each plaque with a thick layer of heavy, over-the-counter emollient cream and then cover it overnight with a plastic wrap. In the morning, wash away the scales in the shower.
- Hydration: After soaking for 10 to 15 minutes in warm water and bath oil, gently rub your skin with a towel to remove the scales.
Are there any alternative treatments for psoriasis?
Yes. Some may work to speed a resolution of a breakout of psoriasis, some may have a soothing effect, and others may have, if anything, a placebo effect.
- Sunlight and water. Eighty percent of the people who use regular daily doses of sunlight enjoy improvement or clearing of their plaque psoriasis. Water can help soften psoriasis lesions.
- Balneotherapy. Water-based treatments involving natural thermal springs, hot springs, mineral water, or seawater are widely used throughout Europe and Asia, and spas that feature balneotherapy are being introduced in the U.S.
- Climatotherapy is a term used to describe the combination of natural sunlight and water, such as the ocean or other bodies of water, to treat psoriasis. In particular, climatotherapy refers to certain locations around the world, like the Dead Sea in Israel, where the environment and natural elements are said to be especially therapeutic for psoriasis and/or psoriatic arthritis.Being at the lowest point on the earth’s surface allows people to sunbathe for long periods without burning. The Dead Sea water’s high salt and mineral content of 33 percent is said to have a therapeutic effect on the skin.
Claims are made for the effectiveness of acupuncture, herbal remedies, prayer, and meditation in treating psoriasis, but with no scientific data to back these claims, they may be benefiting from placebo effect.
Are There Any New Treatments on the Horizon?
A new drug, Ustekinumab, targets mechanisms that produce inappropriate responses of the body’s immune system. In trials involving more than 1,200 patients with chronic plaque psoriasis, there was at least a 75 percent reduction in psoriasis at week 12. Also after 12 weeks, 42 percent of patients had a 90-percent reduction in symptoms, considered to be an indicator of nearly complete clearance of psoriasis. The drug can be self-injected every three months.
At least until this new drug comes on the market, neither psoriasis nor psoriatic arthritis have a cure. But until there is a “magic bullet,” many different therapies can reduce, or nearly stop, the symptoms of psoriasis. No single treatment works for everyone, but something is likely to work in most cases. You may need to experiment before you find a treatment that works for you.
Click here for more information on how to get rid of psoriasis.