Summary

Psoriasis is an auto-immune condition that affects the skin primarily. It is marked by scaly or flaky skin with patches in various colours. In addition to the discomfort and pain caused by the condition, the patient suffers from social withdrawal due to the same. Psoriasis can neither be cured nor prevented. However, with medication and lifestyle changes, the symptoms can be kept under check, so that the person can live a normal, active, social life.

Introduction

Like any other part of the body, the cells of the skin also go through a cycle of birth, growth and death. This cycle lasts a month generally. Which means, every single skin cell that dies in a month’s time is replaced by a new one. This is the healthy and normal cycle.

An auto-immune disorder is one in which the body’s immune system mistakes the body’s cells for foreign bodies or pathogens and attacks them vigorously. There are various auto-immune disorders which target different tissues or organs in the body, in different ways. Psoriasis is just one of them.

In Psoriasis, the body’s immune system (especially a type of white-blood-cells called T-cells), mistakes the skin cells as pathogens and starts attacking them. Skin cells start dying out, after which they have to be replaced with new ones. The normal cycle now gets accelerated from 1 month to 3-4 days. Which means, every 3 to 4 days, new sets of skin cells are generated by the body. This happens from deep within the layers of skin. However, the existing skin cells have not yet completed their normal lifecycle of 1 month. So now, we have 2 sets of skin cells competing for space in the same spot. They get crowded into patches and bumps which cause various symptoms and complications.

Psoriasis can neither be classified as acute nor chronic. The disease erupts with some trigger, then subsides, and may be inactive for a long time (called remission). Till the next trigger happens. Such cycles happen again and again in the person’s life. All lifestyle changes are aimed at eliminating or minimizing triggers, while all therapies are aimed at managing or minimizing the symptoms.

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Risk Factors and Triggers

• Genetic: Having one or both parents with psoriasis increases the risk greatly. So also, having parents and close family members with any auto-immune disorder can also increase the risk. This is because of genetic mutations that the person may have inherited.
• Smoking: People who smoke tobacco in any form (cigarette, beedi, cigar, cheroot, pipe and hookah) are not only at high risk but can also develop a severe version of psoriasis. Even long-term exposure to second-hand smoke is a big risk factor.
• Heavy alcohol consumption also increases the risk greatly
• Infections such as skin infections or strep throat (an infection caused by a bacteria called Group A streptococcus)
• Weather is a huge trigger, especially cold and dry weather
• Injuries to the skin such as cuts, scrapes, nicks, bruises, bug-bites and severe sunburn
• Certain medications — including lithium, hypertension drugs, antimalarial drugs, NSAIDs, antibiotics and mood stabilizers
• If the person is prescribed oral or injected corticosteroids, and suddenly if that is stopped one day, it can act as a trigger
• Emotional stress and anxiety
• Hormonal changes due to various reasons

Types of Psoriasis

• Plaque psoriasis: The most common type of psoriasis: This is marked by dry, itchy and raised patches of skin covered with scales (called plaques). The number of plaques may be few or many. They appear on the scalp, elbows, lower-back and knees. The patches also vary in colour, depending on the skin tone.
• Nail psoriasis: As the name implies, this affects the fingernails and toenails, causing pitting or discoloration in them along with abnormal nail-growth. The affected nails may loosen up and separate from the nail bed, a condition called onycholysis. In severe cases, the nail may start crumbling.
• Guttate psoriasis: This type affects young adults and children more than it affects middle-aged people or seniors. The trigger is a bacterial infection such as strep throat. The symptoms include small, tear-drop-shaped, scales or spots on the abdomen and back, arms or legs.
• Inverse psoriasis: This develops in the skin folds of the groin, breasts and buttocks. It is marked by smooth, silky patches of inflamed skin whose condition worsens with sweating (hot weather basically) and friction from clothes. Fungal infections are a possible trigger for this type of psoriasis.
• Pustular psoriasis: A rarer type, in which there are blisters filled with pus. They can be seen in wide patches anywhere in the body, or in small spots on the palms or soles.
• Erythrodermic psoriasis: The rarest type. It is marked by a peeling rash that covers the entire body, and causes itching or burning sensation.

It is important to mention that the condition is not contagious. So, friends, family and caregivers need not shy away from interacting with psoriatic persons.

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Also Read: PSORIASIS – A FEW BASIC FACTS

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Common locations of the body affected by Psoriasis

• Scalp
• Face and inside of the mouth
• Lower back
• Genitals
• Elbows and knees
• Palms and feet
• Fingernails and toenails

Symptoms

• A patchy rash that looks differently from person to person. It can range from spots of dandruff-like scales, to widespread eruptions all over the body
• Rashes that vary in colour: they can be purple patches with grey scales on brown or black skin, and pink or red patches with silvery-white scales on white skin
• Small spots with scales on them, which is commonly seen in children
• Dry and cracked skin that can bleed after some time
• Itching, burning and sore feeling in the skin
• Rashes and patches that flare up for a few weeks or months and then subside or disappear for some time, to return later
• Nails that are cracked, pitted or crumbling
• Pain and swelling in the bone-joints

Complications

Having psoriasis can increase the risk for developing a range of complications such as:

• Psoriatic arthritis: the most common consequence of psoriasis: there will be pain, swelling and stiffness in and around the joints
• Temporary changes in skin colour wherever the plaques have healed. This is called post-inflammatory hypopigmentation (lightening of skin tone) or hyperpigmentation (darkening of skin tone).
• Vision problems and eye conditions such as uveitis, blepharitis and conjunctivitis
• Obesity, especially in women
• Type 2 diabetes
• Hypertension (high BP)
• Cardiovascular disease (CVD) and heart attacks
• High cholesterol
• Brain strokes
• Anxiety, depression, low self-esteem, mental health and behavioural issues
• Other autoimmune disorders such as inflammatory bowel disease, celiac disease, Crohn’s disease and sclerosis
• Certain cancers

Diagnosis

A dermatologist will first conduct a visual examination of the person followed by a detailed questionnaire on personal and family history of disease, lifestyle and habits, as well as soaps, shampoos and cosmetics used by the person. This will be followed by a biopsy. In a biopsy, skin samples of the person are collected and examined under a microscope. This will help determine the type of psoriasis, the severity, and to rule out any other condition which could be causing the symptoms.

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Treatment

Topical therapy

• Corticosteroids: These come in the form of oils, shampoos, ointments, sprays, creams, foams, lotions and gels. They are prescribed for mild to moderate psoriasis.
• Vitamin D analogues: These slow down skin-cell growth and may be used alone or given along with topical corticosteroids.
• Retinoids: These come in the form of gel or cream to be applied once or twice every day.
• Calcineurin inhibitors: These calm down the rash and reduce build-up of scales. They are preferred in soft or sensitive spots such as around the eyes.
• Salicylic acid: Lotions and shampoos made of this substance help reduce the scaling in case of scalp psoriasis. They may be used alone or with other topical applications.
• Coal tar: This comes in the form of oil, cream and shampoo, and help reduce inflammation, itching and scaling.
• Anthralin: This is a tar cream that slows down growth of skin-cells. It also removes the scales and makes skin smooth. It’s not to be used on the face or genitals.

Light therapy

• Sunlight: This involves daily exposures to sunlight (heliotherapy) for brief periods of time.
• Goeckerman therapy: This combines coal-tar-based medication with light therapy
• UVB broadband: This involves exposure to controlled doses of UVB light emitted by an artificial light source
• UVB narrowband: Similar to above, but the bandwidth of light used is UVB narrowband
• Psoralen plus ultraviolet A (PUVA): The patient is given light-sensitizing medication such as psoralen, and then affected areas of skin are exposed to UVA light.
• Excimer laser: Here powerful UVB light is shone on the affected areas of the skin.

Oral or injected medications

• Steroids: For patients with lesser, or smaller patches, and includes triamcinolone injections
• Retinoids: These pills reduce the production of skin-cells and include Acitretin
• Biologics: These modify the immune system and disrupt the disease cycle so as to minimize symptoms
• Methotrexate: This reduces the production of skin-cells and eliminate inflammation.
• Cyclosporine: This too suppresses the immune system.
• Others: Includes drugs such as hydroxyurea (Droxia, Hydrea) and Thioguanine (Tabloid)

Alternative medicine

• Aloe extract cream: This is derived from the aloe vera plant’s gel, and helps reduce scaling, inflammation and itching.
• Fish-oil supplements: Consuming fish oil orally or applying on the skin topically is combined with UVB therapy to reduce rashes.
• Oregon grapes: Also called barberry, these are ground into a paste and applied on the affected areas to reduce rashes

Lifestyle and home remedies

• Take daily baths using warm water and mild soaps. Affected scalp must be gently massaged with a medicated shampoo. The skin must be washed gently as against scrubbing. To dry, dab gently using a soft towel, and avoid rubbing.
• Keep the skin moist by applying moisturizer once or twice a day, every day.
• Use a humidifier if you live in a cold and dry place.
• Cover affected areas while sleeping: Apply moisturizer to affected areas, wrap with a plastic wrap and sleep. Upon waking, remove the plastic wrap and gently wash the scales.
• Avoid too much sunlight: If you are not comfortable using sunscreen, stay in the shade as much as possible and allow exposure for brief periods of time.
• Avoid scratching: Do not scratch affected areas with fingernails or other objects. Wear soft fabrics that do not scratch the skin.
• Avoid all triggers: Triggers have been listed earlier. Avoid them as much as possible
• Stay cool: Hot weather is a trigger, so use air-conditioning, fans and cold packs applied topically on affected areas, to stay cool. Moisturizers can be stored in the refrigerator.
• Maintain a healthy lifestyle by eating healthy, sleeping well, managing weight and avoiding alcohol consumption.

 Kauvery Hospital is globally known for its multidisciplinary services at all its Centers of Excellence, and for its comprehensive, Avant-Grade technology, especially in diagnostics and remedial care in heart diseases, transplantation, vascular and neurosciences medicine. Located in the heart of Trichy (Tennur, Royal Road and Alexandria Road (Cantonment), Chennai (Alwarpet & Vadapalani), Hosur, Salem, Tirunelveli and Bengaluru, the hospital also renders adult and pediatric trauma care.

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