Psoriasis

Key facts:

  • A common inflammatory condition primarily affecting the skin
  • Characterised by raised, red and very scaly rashes on the skin
  • May be accompanied by a form of arthritis · Cause is not known
  • Managed with a combination of topical therapies (steroid creams, moisturisers, tar products, other prescription creams), light therapy, and tablet or injection therapies when it is more severe

WHAT IS PSORIASIS?

Psoriasis is a common inflammatory condition affecting the skin. It affects around 2% of the population, affects men and women equally, and can occur at any age, though it is less common in childhood. It tends to come and go unpredictably.

The appearance of Psoriasis is of patches (called plaques) of red, scaly, dry skin, which is often very itchy and can be painful. It is not contagious, though some people will see the affected skin and think it is. While it is predominantly a condition of the skin, the joints can also be affected.

WHAT CAUSES PSORIASIS

Psoriasis is a complex disease, with both genetic and environmental contributors. The precise cause is not yet understood, in fact even the genetics of the disease are not fully understood. It is an inflammatory condition though, which means your immune system is reacting to stimuli to cause the characteristic patches seen on the skin. Environmental factors play a role too, with stress, infections, alcohol, smoking, medications and obesity all potentially contributing to the condition and causing flare-ups.

The scaly appearance is caused by the outer layer of skin cells multiplying and shedding too quickly – in a matter of 3 or 4 days instead of the usual 3-4 weeks. This causes the dead cells to build up, forming the scaly appearance.

SYMPTOMS AND SIGNS

The skin symptoms of psoriasis are a red, scaly, dry rash. There are several types of psoriasis that each has a different appearance:

1. Chronic plaque psoriasis – the most common kind. Affects the elbows, knees, trunk (chest and back) and scalp most often, though other areas can also be affected

2. Guttate psoriasis – characterised by small, drop sized plaques spread over the trunk, arms and legs. It can be triggered by bacteria called Streptococcus, which often causes throat infections

3. Palmoplantar psoriasis – which affects predominantly the soles and palms, though may involve other areas too

4. Pustular psoriasis – a rare type where the plaques on the trunk, arms and legs are studded with tiny pus spots, and can flare up very rapidly

5. Other

The skin is often itchy, and may also be painful.

In addition to the skin, psoriasis also affects the nails in ~50% of sufferers. The typical nail changes seen are:

  • Pitting – little dimples in the nail surface
  • Pinkish discolouration of the nail
  • Thickening of the nail
  • Separation of the nail plate (the nail itself) from the nail bed (the skin that the nail covers)

People with moderate and severe psoriasis frequently get a form of arthritis called psoriatic arthritis, which produces pain, swelling and stiffness in one or more of the joints, particularly in the morning. This affects approximately 33% of people with moderate and severe psoriasis, and usually needs the involvement of a rheumatologist as well as the dermatologist.

TREATMENTS

Psoriasis is usually managed by a dermatologist. The information provided here is intended to help you understand the condition better, and is not a substitute for the advice, guidance, and management by your doctor. The treatment tends to vary by the severity of the disease, and involves the use of three main approaches:

  1. Topical (applied to the skin)
  2. Light-based (phototherapy)
  3. Tablet and injection therapies

The level of severity of psoriasis is calculated based on well-established clinical and patient-impact measurement scales; this guides the choice of treatments used, so it is important to realise that you may require a different treatment regimen from others with psoriasis.

Unfortunately as of now, there is still no cure for psoriasis, but with good management of both medical treatment and environment triggers, we can try to control the condition and limit its impact on your life. You shouldn’t underestimate the additional stress that coping with psoriasis creates, and so it is really essential that you create a solid support network for yourself, including family, friends, as well as professionals to help you – there is no shame in asking for help, in fact it is the smart way to deal with the condition.

If you have moderate or severe psoriasis you are at an increased risk of heart disease and stroke – and treatment may reduce this risk. You are also at risk of anxiety and depression, and may be at increased use of harmful use of alcohol, obesity and diabetes; so if you experience these symptoms or conditions, seek the advice and help of a healthcare professional.

Psoriasis cream solution

Topical treatments

These are the creams, gels, lotions, shampoos, etc applied to the skin or scalp. Below is a brief discussion of the most commonly used.

Emollients and moisturisers

These are intended to re-hydrate the skin, reduce the scaling. Removing the scale is important as it allows other topical products to work better. They are also often used as gentle soap free cleansers, though these days specific cleansers for sensitive skin are also available. The key with all of these products is that they need to be applied frequently, as frequently as is required to keep the skin moist. There is no role here for the beauty moisturiser that claims “lasts 24 hours” – this might be great for a beauty product, but is useless for those of us with psoriasis.

Moisturisers have evolved a lot in recent years. The earliest moisturisers aimed to form a thick barrier on top of the skin, to make up for the defect in the barrier function of the affected skin in psoriasis. However, more recent advances in the understanding of the key components of the molecular structure of the skin barrier have led to the development of more advanced ingredients which help to repair your own skin’s barrier function. Ceramide is one of the best examples of these newer ingredients. Ceramides are key ingredients of the “glue” which holds together the outer layer of skin cells, just like the mortar holding together the bricks in a wall. However, in psoriasis the ceramides level are affected, which leads to a loss of function of the skin barrier, and loss of moisture. Suu Balm has a high level of ceramides, which not only means it is a highly effective moisturiser, but it also allows the cream to be formulated to be light and easy to apply, which makes it easy and comfortable to use often, even up to four or five times a day.

Itch relief

Itch is a significant issue for many people with psoriasis. The itch can be very intense, and scratching the itch only makes it worse – this is the itch-scratch cycle, a negative feedback loop that drives repeated scratching, which ultimately leads to tearing of the skin, more frequent skin infections, and in the long run, thickening of the skin (lichen sclerosis). Menthol, applied to the skin in a cream, is one of the most effective ingredients for relieving itch, because it works very quickly, typically within minutes of application. Creams containing menthol (between ~1% and 3%) relieve itch without irritating the skin, or leaving a strong menthol smell. Suu Balm is one such menthol containing product, and has been shown to relieve itch rapidly and in the longer term when used daily. Typical moisturisers only relieve itch slowly, they may take days to exert an effect… which is clearly not so helpful if you are unable to sleep due to itch in the middle of the night!

Steroids

Topical steroids are used to reduce and control the inflammation in the skin. Steroids are mostly prescription-only medicines, meaning that you will only be able to get these treatments after seeing a doctor. This is because, while very useful in controlling inflammation, they require careful selection and close monitoring to ensure that the benefits of usage outweigh the risk or occurrence of side effects.

There are different strengths of steroids, and your doctor will choose one that is appropriate for the severity of your skin condition and the part of the body (for example milder steroids are used on the face, where the skin is very thin).

Tar preparations

Tar containing creams, lotions, bath oils and shampoos have been used for many years in the management of psoriasis. However, the smell and their tendency to stain clothing, and the emergence of other therapies means that these days they are less commonly used.

Dithranol

This is another traditional treatment, typically used on the thicker skin of the elbows and knees, to try to manage stubborn plaques of psoriasis. The treatment is applied for varying lengths of time and then washed off, and repeated daily. Again Dithranol can stain clothing and bathroom ceramic ware, so needs to be cleaned off immediately after use. It can also irritate normal skin around the plaques of psoriasis, and is not suitable for thinner, more sensitive skin such as the face.

Vitamin D analogues (calcipotriol, tacalcitol, and calcitriol)

These ingredients help slow the overgrowth of the outer layer of the skin. They are smell free, do not stain clothes, so are a popular choice for many people. They can be used longer term, though your doctor needs to keep an eye on your blood calcium levels in this scenario. Sometimes they are mixed together with steroids in a cream, and in this case you cannot use continuously for the long term, so check with your doctor or pharmacist which product you have been recommended and how to use it correctly. Note they are not usually prescribed during pregnancy or breastfeeding, and are not usually used on the face.

Vitamin A analogue (tazarotene)

This comes as a once-daily gel application. Again it is not used on the face, and must not be used during pregnancy or breastfeeding.

Topical calcineurin inhibitors

These are another type of anti-inflammatory agent, like steroids except with fewer side effects. They were initially developed to treat eczema, and can also help in psoriasis, particularly on more sensitive areas such as the face and skin folds. They can give a burning / tingling sensation when applied, but this goes away. They can also be used long term.

Specific topical treatments used on the scalp

Medicated shampoos often contain tar, and are used to remove build-up of skin and manage milder cases of scalp psoriasis.

Descaling ointments, which contain salicylic acid and coconut oil, are applied to the scalp for a few hours or overnight, then washed out with a medicated shampoo. They help to remove the build-up of scaly skin which allows other treatments to work better.

Topical steroids are sold in scalp-specific formulations which are less sticky for use on the scalp.

Vitamin D lotions and gels are also available in scalp specific formulations.

Phototherapy

Phototherapy is light therapy. It uses certain wavelengths of light, namely Ultraviolet A (UV-A) and Ultraviolet B (UV-B) in a precisely controlled way to treat psoriasis. UV-A therapy needs a sensitiser, taken as a tablet or added to a bath taken prior to treatment. Each course of treatment lasts around 8-10 weeks, with two or three sessions per week, and is usually administered in the hospital clinic. It is used to both clear plaques of psoriasis, and then to keep them away for a period after treatment.

Tablet and injection treatments

Tablets (oral medications) and injections tend to be reserved for moderate and severe cases of psoriasis where the condition hasn’t been controlled with topical treatments, or comes back very quickly after stopping topical treatments.

There are four main tablet treatments for psoriasis:

  1.    Methotrexate: this drug has two beneficial effects. Firstly it slows down the rate of replication of the skin cells, and secondly it reduces inflammation. However one of its side effects is liver toxicity, so you will need to have regular blood tests to monitor for this.
  2.    Ciclosporin: this medication was developed to prevent people who have received organ transplants from rejecting the transplant – it is an immunosuppressant. It is also effective in controlling severe psoriasis, though it can take several weeks to show an effect.
  3.    Acitretin: this is a relative of Vitamin A, and is used when Methotrexate and Ciclosporin have failed. It is not typically used in women of childbearing age.
  4.    Apremilast: a relatively newer drug, it affects the way the immune system functions, and again is typically used after other drugs have failed to work.

In recent years a number of new “biological” drugs have become available for the treatment of severe psoriasis. They work by altering the behaviour of the immune system. They are given by injection – either as an intravenous infusion (“a drip”) in the case of infliximab, or as injections in the case of adalimumab, etanercept and ustekinumab.

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