What is psoriasis?

Psoriasis is a noncontagious common skin condition that causes rapid skin cell reproduction resulting in red, dry patches of thickened skin. The dry flakes and skin scales are thought to result from the rapid buildup of skin cells. Psoriasis commonly affects the skin of the elbows, knees, and scalp. Some people have such mild psoriasis (small, faint dry skin patches) that they may not even suspect that they have a medical skin condition. Others have very severe psoriasis where virtually their entire body is fully covered with thick, red, scaly skin. Psoriasis is considered a non-curable, long-term (chronic) skin condition. It has a variable course, periodically improving and worsening. Sometimes psoriasis may clear for years and stay in remission. Some people have worsening of their symptoms in the colder winter months. Many people report improvement in warmer months, climates, or with increased sunlight exposure. Psoriasis is seen worldwide, in all races, and both sexes. Although psoriasis can be seen in people of any age, from babies to seniors, most commonly patients are first diagnosed in their early adult years. Patients with more severe psoriasis may have social embarrassment, job stress, emotional distress, and other personal issues because of the appearance of their skin. What causes psoriasis? The exact cause remains unknown. There may be a combination of factors, including genetic predisposition and environmental

factors. It is common for psoriasis to be found in members of the same family. The immune system is thought to play a major role. Despite research over the past 30 years looking at many triggers, the "master switch" that turns on psoriasis is still a mystery. What does psoriasis look like? What are the symptoms? Psoriasis typically looks like red or pink areas of thickened, raised, and dry skin. It classically affects areas over the elbows, knees, and scalp. Essentially any body area may be involved. It tends to be more common in areas of trauma, repeat rubbing, use, or abrasions. Psoriasis has many different appearances. It may be small flattened bumps, large thick plaques of raised skin, red patches, and pink mildly dry skin to big flakes of dry skin that flake off. There are several different types of psoriasis including psoriasis vulgaris (common type), guttate psoriasis (small, drop like spots), inverse psoriasis (in the folds like of the underarms, navel, and buttocks), and pustular psoriasis (liquid-filled yellowish small blisters). Additionally, a separate entity affecting primarily the palms and the soles is known as palmoplantar psoriasis. Sometimes pulling of one of these small dry white flakes of skin causes a tiny blood spot on the skin. This is medically referred to as a special diagnostic sign in psoriasis called the Auspitz sign. Genital lesions, especially on the head of the penis, are common. Psoriasis in moist areas like the navel or area between the

buttocks (intergluteal folds) may look like flat red patches. These atypical appearances may be confused with other skin conditions like fungal infections, yeast infections, skin irritation, or bacterial Staph infections. On the nails, it can look like very small pits (pinpoint depressions or white spots on the nail) or as larger yellowishbrown separations of the nail bed called "oil spots." Nail psoriasis may be confused with and incorrectly diagnosed as a fungal nail infection. On the scalp, it may look like severe dandruff with dry flakes and red areas of skin. It may be difficult to tell the difference between scalp psoriasis and seborrhea (dandruff). However, the treatment is often very similar for both conditions. Can psoriasis affect my joints? Yes, psoriasis is associated with joint problems in about 10%35% of patients. In fact, sometimes joint pains maybe the only sign of the disorder with completely clear skin. The joint disease associated with psoriasis is referred to as psoriatic arthritis. Patients may have inflammation of any joints (arthritis), although the joints of the hands, knees, and ankles tend to be most commonly affected. Psoriatic arthritis is an inflammatory, destructive form of arthritis and is treated with medications to stop the disease progression. The average age for onset of psoriatic arthritis is 30-40 years of age. In most cases, the skin symptoms occur before the onset of the arthritis.

The diagnosis of psoriatic arthritis is typically made by a physician examination, medical history, and relevant family history. Sometimes, lab tests and X-rays may be used to determine the severity of the disease and to exclude other diagnoses like rheumatoid arthritis and osteoarthritis. Can psoriasis affect only my nails? Yes, psoriasis may involve solely the nails in a limited number of patients. Usually, the nail symptoms accompany the skin and arthritis symptoms. Nails may have small pinpoint pits or large yellowish separations of the nail plate called "oil spots." Nail psoriasis is typically very difficult to treat. Treatment option are somewhat limited and include potent topical steroids applied at the nail-base cuticle, injection of steroids at the nail-base cuticle, and oral or systemic medications as described below for the treatment of psoriasi Is psoriasis curable? No, psoriasis is not currently curable. However, it can go into remission and show no signs of disease. Ongoing research is actively making progress on finding better treatments and a possible cure in the future. Is psoriasis contagious? No. Research studies have not shown it to be contagious from person to person. You cannot catch it from anyone, and you cannot pass it to anyone else by skin-to-skin contact. You can directly touch someone with psoriasis every day and never catch the skin condition.

Can I pass psoriasis on to my children? Yes, it is possible. Although psoriasis is not contagious from person to person, there is a known genetic tendency, and it may be inherited from parents to their children. It does tend to run in some families, and a family history is helpful in making the diagnosis. What kind of doctor treats psoriasis? Dermatologists specialize in the diagnosis and treatment of psoriasis, and rheumatologists specialize in the treatment of joint disorders and psoriatic arthritis. Many kinds of physicians may treat psoriasis, including dermatologists, family physicians, internal medicine physicians, rheumatologists, and other medical doctors. Some patients have also seen other allied health professionals such as acupuncturists, holistic practitioners, chiropractors, and nutritionists. The American Academy of Dermatology and the National Psoriasis Foundation are excellent references to help find physicians who specialize in this disease. Not all dermatologists and rheumatologists treat psoriasis. The National Psoriasis Foundation has one of the most up-to-date databases of current psoriasis specialists. How is psoriasis treated? There are many effective treatment choices for psoriasis. The best treatment is individually determined by the treating physician and depends, in part, on the type of disease, the severity, and the total body area involved.

For mild disease that involves only small areas of the body (like less than 10% of the total skin surface), topical (skin applied) creams, lotions, and sprays may be very effective and safe to use. Occasionally, a small local injection of steroids directly into a tough or resistant isolated psoriasis plaque may be helpful. For moderate to severe disease that involves much larger areas of the body (like 20% or more of the total skin surface), topical products may not be effective or practical to apply. These cases may require systemic or total body treatments such as pills, light treatments, or injections. Stronger medications usually have greater associated possible risks. For psoriatic arthritis, systemic medications that can stop the progression of the disease may be required. Topical therapies are not effective. It is important to keep in mind that as with any medical condition, all medications carry possible side effects. No medication is 100% effective for everyone, and no medication is 100% safe. The decision to use any medication requires thorough consideration and discussion with your physician. The risks and potential benefit of medications have to be considered for each type of psoriasis and the individual patient. Some patients are not bothered at all by their skin symptoms and may not want any treatment. Other patients are bothered by even small patches of psoriasis and want to keep their skin clear. Everyone is different and, therefore, treatment choices also vary depending on the patient's goals and expressed wishes. A particularly effective approach to psoriasis has been commonly called "rotational" therapy. This is a common

practice among some dermatologists who recommend changing cycles of psoriasis treatments every six to 24 months in order to minimize the possible side effects from any one type of therapy or medication. For example, if a patient has been using oral methotrexate for two years, then it may be reasonable to take them off of methotrexate and try light therapy or a biologic injectable medication for a while. By rotating to a medication that doesn't affect the liver, the potential of cumulative liver damage may be reduced. In another example, a patient who has been using strong topical steroids over large areas of their body for prolonged periods may benefit from stopping the steroids for a while and rotating onto a different therapy like calcipotriene (Dovonex), light therapy, or an injectable biologic. What creams or lotions are available? Topical (skin applied) medications include topical corticosteroids, vitamin D analogue creams (Dovonex), topical retinoids (Tazorac), moisturizers, topical immunomodulators (tacrolimus and pimecrolimus), coal tar, anthralin, and others.

Topical corticosteroids (steroids, such as hydrocortisone) are very useful and often the first-line treatment for limited or small areas of psoriasis. These come in many preparations, including sprays, liquid, creams, gels, ointments, and mousses. Steroids come in many different strengths, including stronger ones are used for elbows, knees, and tougher skin areas and milder ones for areas like

the face, underarms, and groin. These are usually applied once or twice a day to affected skin areas. Strong steroid preparations should be limited in use. Overuse or prolonged use may cause problems including potential permanent skin thinning and damage called atrophy.

A vitamin D analogue cream called calcipotriene (Dovonex) has also been useful in psoriasis. The advantage of calcipotriene is that it is not known to overly thin the skin like topical steroids. It is important to note that this drug is not regular vitamin D and is not the same as taking regular vitamin D or rubbing it on the skin. Calcipotriene may be used in combination with topical steroids for better results. There is a newer two-in-one combination preparation of calcipotriene and a topical steroid called Taclonex. Results with calcipotriene alone may be slower and less than results achieved with typical topical steroids. Not all patients may respond to calcipotriene as well as to topical steroids. A special precaution with calcipotriene is that it should not be used on more than 20% of the skin in one person. Overuse may cause absorption of the drug and an abnormal rise in body calcium levels.

Moisturizers, especially with therapeutic concentrations of salicylic acid, lactic acid, urea, and glycolic acid may be helpful in psoriasis. These moisturizers are available as prescription and nonprescription forms. These help moisten and lessen the appearance of thickened psoriasis scales. Some available preparations include Salex (salicylic acid), AmLactin (lactic acid), or Lac-Hydrin (lactic acid) lotions. These may be used one to three times a day on the body and do not generally have a risk of problematic skin thinning (atrophy). Overuse or use on broken, inflamed skin may cause stinging, burning, and more irritation. These stronger preparations should not be used over delicate skin like eyelids, face, or genitals. Other bland moisturizers including Vaseline and Crisco vegetable shortening may also be helpful in at least reducing the dry appearance of psoriasis.

Immunomodulators (tacrolimus and pimecrolimus) have also been used with some success in limited types of psoriasis. These have the advantage of not causing skin thinning. They may have other potential side effects, including skin infections and possible malignancies (cancers). The exact association of these immunomodulator creams and cancer is controversial.

Bath salts or bathing in high-salt-concentration waters like the Dead Sea in the Middle East may help some psoriasis patients. Epsom salt soaks (available over the counter) may

also be helpful for a number of patients. Overall, these are quite safe with very few possible side effects.

Coal tar is available in multiple preparations, including shampoos, bath solutions, and creams. Coal tar may help reduce the appearance and decrease the flakes in psoriasis. The odor, staining, and overall messiness with coal tar may make it harder to use and less desirable than other therapies. A major advantage with tar is lack of skin thinning.

Anthralin is available for topical use as a cream, ointment, or paste. The stinging, possible irritation, and skin discoloration may make this less acceptable to use. Anthralin may be applied for 10-30 minutes to psoriatic skin.

What oral medications are available? Oral medications include acitretin, cyclosporine, methotrexate, mycophenolate mofetil, and others. Oral prednisone (corticosteroid) is generally not used in psoriasis and may cause a disease flare if administered to many patients.

Acitretin (Soriatane) is an oral drug used for certain types of psoriasis. It is not effective in all types of the disease. It may be used in males and females who are not pregnant and not planning to become pregnant for at least three years. The major side effects include dryness of skin and

eyes and temporarily elevated levels of triglycerides and cholesterol (fatty substance) in the blood. Blood tests are generally required before starting this therapy and periodically to monitor triglyceride levels. Patients should not become pregnant while on this drug and usually for at least three years after stopping this medication.

Cyclosporine is a potent immunosuppressive drug used for other medical uses, including organ-transplant patients. It may be used for severe, difficult-to-treat cases of widespread psoriasis. Improvement and results may be very rapid in onset. It may be hard to get someone off of cyclosporine without flaring their psoriasis. Because of the potential cumulative toxicity, cyclosporine should not be used for more than one to two years for most psoriasis patients. Major possible side effects include kidney and blood-pressure problems.

Methotrexate is a common drug used for rheumatoid arthritis and, in high doses, for cancer treatment. For psoriasis, it has been used effectively for many years. It is usually given in small weekly doses (5 mg-15 mg). Blood tests are required before and during therapy. The drug may cause liver damage in some patients, particularly if there is preexisting liver disease or if given for prolonged periods of time. Close physician monitoring and monthly to quarterly visits and labs are generally required.

Psoriasis At A Glance

Psoriasis is a chronic inflammatory skin disease. Psoriasis has no known cause. The tendency toward developing psoriasis is inherited in genes. Psoriasis is not contagious. Psoriasis gets better and worse spontaneously and can have periodic remissions (clear skin). Psoriasis is controllable with medication. Psoriasis is currently not curable. There are many promising therapies including newer biologic drugs. Future research for psoriasis is promising.