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Skin Care and Diseases

Psoriasis care

08/04/2008

Question:

My husband was recently diagnosed with psoriasis. After talking to the doctor, I am still not exactly sure what it is. Would you be able to explain? The doctor also said there isn’t a cure. What are our options for caring for this condition?

Answer:

Psoriasis (pronounced sore-EYE-ah-sis) is a chronic immune skin condition that occurs both in men and women, and in most races. It can occur at any age. Onset of psoriasis often occurs later in childhood or in young adulthood. It is believed to have a genetic basis, however one does not have to have a family member with it to get it themselves.

Although it can present in various ways in the skin, the most common presentation (plaque psoriasis) is one of red thick scaling raised plaques on the elbows, knees, buttock, and scalp. Other ways it can present is as excessive dandruff, pus bumps on the skin surface, nail disease or full body redness.
 
It can occur anywhere on the body, including the scalp, face, torso, arms, legs, hands, feet, nails, buttock and genital areas, and can present as either a few plaques, or can be scattered all over and involve large surfaces areas of the body. It may be asymptomatic, or may itch, burn, bleed (usually from scratching at it), or crack open.

Psoriasis is not contagious and cannot be spread to anyone by touch or other forms of contact. Because of its genetic nature, it can be passed down to children however the risk of passing it on is hard to quantify. Psoriasis is not cancerous. However, although is is felt to be a benign condition, depending on the severity of the disease, it can have a noticeable effect on a person's social, mental, or physical quality of life. Fortunately, the majority of patients have mild or limited involvement. Approximately 20-30% may have moderate or severe involvement.

Psoriasis is predominantly a skin condition, however it may affect the joints (Psoriatic Arthritis). This inflammatory arthritis is different than the common degenerative or osteoarthritis that people get as they get older. Psoriasitic arthritis may occur in 10-20% of patients who have skin psoriasis, so it is important that patients with psoriasis get screened by their doctor for it.
 
In addition, there is some evidence that psoriasis patients, especially those with moderate to severe psoriasis, may have an increased risk of heart disease, depression, smoking and alcohol drinking tendencies, high cholesterol, obesity, and fatty liver. It is important that patients with psoriasis are monitored for these types of conditions by their doctors. Keeping one's weight low is important for treating and improving psoriasis or the associated conditions.

There is no cure for psoriasis. In most patients, it is chronic and persistent unless treated. At times, it may come and go without treatment, or sometimes can clear for years, but certain triggers can bring it back or make it worse.

Some aggravating factors include stress, illness, poor diet, sleep, and life style, infection (such as strep throat), and some medications. Like other chronic conditions such as diabetes, high blood pressure and heart disease, it needs chronic or intermittent chronic therapy to keep it suppressed. The sun, beach, certain climates, healthy life styles, bath soaks, and moisturizers are some things that can reduce it.

There are 4 major forms of treatment a doctor can prescribe: topical therapies, UV light (phototherapy or laser), oral therapy, or injectable biologic therapies. The therapies prescribed will depend upon the severity of the psoriasis, the distribution on the body, convenience factors, other medical factors, insurance coverage, patient preference, and experience of the physician.

Mild psoriasis is often managed by primary care physicians or general dermatologists. Optimal treatment of moderate to severe psoriasis requires the attention of physicians, preferably board certified dermatologists, experienced in all of the above options to best help manage this potentially life long condition.

It is important to realize that not all therapies work for every patient and one may have to go through trials of different therapies before finding one that is effective, safe, and tolerable for the situation.

Topical therapies include topical steroids (there are many types available), vitamin D like creams (such as Dovonex), vitamin A like creams (such as Tazorac), tar preparations, salicylic acid compounds, and anthralins. The most common prescribed topical therapy are steroids. Although steroids may work well for localized psoriasis, long term continuous use of them has potential skin, and rarely internal side effects. In general, topical therapies are used for limited, localized, or mild psoriasis.

Ultraviolet (UV) light therapies involve the delivery of light (part of which is found in sunlight) to the skin within a standing light box in the doctor's office. The most common light treatments involve using ultraviolet B wavelengths (UVB) or ultraviolet A wavelengths (UVA). The UVA light is often used with a photosensitizing medicine to make the UVA light more potent and effective. The initial clearing phase on medical light treatment requires 3 treatments per week at the doctors office for approximately 3 months. The psoriasis may stay improved for many months before recurring. Tanning beds (mostly UVA light) may be recommended if one is unable to undergo the more effective medical light treatment at the doctor's office. Long term use (years) of all these is associated with an increased risk of skin cancer.

A newer therapy, excimer laser, utilizes a wavelength in the UVB range that is much more potent. The laser is convenient mostly for localized or limited psoriasis and requires treatment 2x/week for approximately 12 treatments to get good results. The psoriasis in the treated areas may stay improved for a few months before recurring.

Standard psoriasis oral therapies include methotrexate, acitretin (Soriatane), cyclosporine. These medicines are used for moderate to severe psoriasis and have uncommon but potential severe internal side effects. They require a physician experienced with them to monitor for these side effects. They can be very effective in the properly chosen patient. If one also has psoriatic arthritis, methotrexate may be considered to treat both conditions. They have been in use for at least 15 - 35 years.

Injectable therapies (biologic therapies) are the latest in the treatment of psoriasis. These include Amevive, Enbrel, Humira, Raptiva, and Remicade. These are generally well tolerated and the most convenient for patients with moderate to severe psoriasis. Some of these are also effective treatments for psoriatic arthritis.

They are very expensive ($18,000 - $50,000 per year). They specifically target inflammation proteins or immune cells (T- lymphocytes) that play a role in forming psoriasis. As such, they may suppress a part of the immune system. Although uncommon, there is an increased risk of infection or other issues related to a modified immune system. Monitoring would be performed by your physician.

Psoriasis is a very manageable and treatable skin condition. The more informed the patient and family are, the more productive will be encounter with the physician. In the long run, treatment satisfaction will come from being realistic, being informed, and working as a team with the doctor in finding the right treatments for the situation.

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Response by:

Pranav   Sheth, MD Pranav Sheth, MD
Formerly:
College of Medicine
University of Cincinnati