PSORIASIS

Psoriasis

Psoriasis is a lifelong skin condition caused by changes in the immune system. The rash of psoriasis is very distinctive. There have been many strides in the use of biologic medications that make psoriasis less of a "heartbreak".

Psoriasis affects 2.2% of the United States population and 1% to 3% of the world's population. It's a chronic skin disorder that is characterized by periodic flare-ups of well defined, red patches covered by a silvery, flaky skin on the extensor surfaces and the scalp. Psoriasis is a chronic skin disorder that affects 1% to 3% of the world's population. It is characterized by periodic flare-ups of well defined, red patches covered by a silvery, flaky scale on the extensor surfaces and the scalp. There are several variations of psoriasis but the most common type is chronic plaque psoriasis. The exact cause of psoriasis is unknown, but it is believed that a combination of several factors contributes to the development of this disease.

What Causes Psoriasis

The exact cause of psoriasis is unknown, but most researchers believe that a combination of several factors contributes to the development of this disease. Some contributing factors include:

  • Gene mutations
  • Overactive immune system
  • Environmental causes

Genetic Causes of Psoriasis

Researchers have found 9 gene mutations that may be involved in causing psoriasis. One of these mutations on chromosome 6, called PSORS-1, appears to be a major factor that can lead to psoriasis. Mutations on genes cause certain cells to function differently. With psoriasis, these mutations seem to largely affect T-helper cells.

Immune System Causes of Psoriasis

In a normally functioning immune system, white blood cells produce antibodies to foreign invaders such as bacteria and viruses. These white blood cells also produce chemicals that aid in healing and fighting infective agents. But with psoriasis, special white blood cells called T-cells become overactive.

These T-cells "attack" the skin and set off a cascade of events that make the skin cells multiply so fast they start to stack up on the surface of the skin. Normal skin cells form, mature, then are sloughed off every 30 days. But in plaque psoriasis the skin goes through this whole process in 3-6 days.

Normally T-cells produce chemicals that help heal the skin. In psoriasis, T-cells produce an abnormally large amount of these chemicals and actually cause more inflammation in the skin and joints.

Environmental Causes of Psoriasis

Not everyone who has these gene mutations gets psoriasis and there are several forms of psoriasis that people can develop. Certain environmental triggers play a role in causing psoriasis in people who have these gene mutations. Learn more about other psoriasis triggers.

What Triggers Psoriasis

Environmental causes can trigger a psoriasis flare in people who have psoriasis. The good news is that avoiding these triggers can cut down of the number or severity of the flares. The bad news? Some are hard to avoid. Some of the more common psoriasis triggers include:

  • Skin injury
  • Weather
  • Stress
  • Infection
  • Low levels of calcium

Types of Psoriasis Part of the reason psoriasis is such a complicated disease is that there are several different types of psoriasis. A person with psoriasis can have one or more of them, and the type could change throughout the person's lifetime.

The types of psoriasis include:

Plaque psoriasis

Scalp psoriasis

Nail psoriasis

Inverse psoriasis

Guttate psoriasis

Pustular psoriasis

Chronic Plaque Psoriasis

Chronic plaque psoriasis is the most common type of psoriasis. It occurs in 0.6 to 4.8% of people in the United States, and it is slightly more common in men. These psoriasis lesions are the best examples of plaques, hence the name.

Characteristics of Plaque Psoriasis

Plaque psoriasis lesions are fairly typical and have the following features:

  • The outline of the lesion is either circular, oval, or polycircular (overlapping circles)
  • The borders of the lesion are well-defined
  • There are thick, silvery-white scales on top of a red, irritated base
  • If the scale is scraped off, tiny bleeding spots appear underneath (Auspitz sign)
  • Areas most often involved include the knees, elbows, scalp, and just above the buttocks
  • Once a plaque forms it may get bigger, but when it reaches a certain size it stops growing and stays the same size for months to years without treatment.

Pictures of Plaque Psoriasis

  • Picture of a characteristic plaque
  • Plaque psoriasis on the elbows
  • Plaque psoriasis in the gluteal cleft

Diagnosis of Plaque Psoriasis

Plaque psoriasis is diagnosed mainly by its typical appearance. It can sometimes be confused with ringworm or eczema, and when the diagnosis is uncertain, a skin biopsy can be done to diagnose a lesion.

Scalp Psoriasis

The scalp is the most common place for people with psoriasis to get a rash. Some people will have only a small area affected, especially on the back of the head or upper neck, while other people may develop a rash covering the entire scalp.

Appearance of Scalp Psoriasis

The borders of the rash are well-defined and can advance down the neck or in front of the ears. The scales are often very thick and white and they can be tightly attached to the hair. Scalp psoriasis does not usually cause hair loss but the hair is often thinner in the areas involved because there is more shedding in the telogen phase.

Nail Psoriasis

The nails are often affected by psoriasis. In fact, 80 to 90% of people with psoriasis will have nail changes at some point in their lives. The fingernails are more often affected than the toenails. Psoriasis can affect all aspects of the nail, causing various abnormalities.

Nail Abnormalities

The following are common abnormalities associated with nail psoriasis:

  • Pitting - This is the most frequent nail abnormality with psoriasis. The nail has tiny, punched-out depressions that grow out with the nail.
  • Nail Separation - Psoriasis can cause the nail bed to pull away from the nail itself. The nail plate may turn yellow, resembling a fungal nail infection.
  • Oil Spots - Skin debris and fluid often collects in the spaces caused by nail separation. This results in brownish-yellow spots, hence the fitting name.
  • Nail Deformity - Psoriasis can affect the nail matrix, the area of the finger where the fingernail is made. This can cause the nail to crumble and break easily.

Similar Nail Changes with Other Rashes

Other rashes cause nail changes and may be confused with psoriasis. The following are the most common:

  • Eczema
  • Fungal infections
  • Alopecia areata

Inverse Psoriasis

Inverse psoriasis is an unusual type of psoriasis that occurs in skin folds. These patches look different than other types of psoriasis. They are usually smooth, deep red, and glistening without any scale. Sometimes there is a crease in the center of the patch that may be cracked open.

Common Places for Inverse Psoriasis

Inverse psoriasis is commonly found in these areas:

  • Armpits
  • Groin
  • Crease between the buttocks
  • Below the breasts
  • Behind the ears

Similar Rashes

Inverse psoriasis may be confused with intertrigo, a yeast infection in the skin folds. Pustules that extend beyond the main patch indicate a yeast infection of the psoriasis patch.

Guttate Psoriasis

uttate psoriasis is a common form of psoriasis in children, but it is seen in less than 2% of psoriasis patients. The name is derived from the Latin word gutta, which means droplet.

Features of Guttate Psoriasis

Important features of guttate psoriasis include:

  • Small, discrete, teardrop-shaped lesions usually on the trunk, but often on the arms, legs, and scalp
  • The lesions start small and grow over time
  • Often occurs 1 to 3 weeks after a viral or bacterial (often streptococcus) respiratory infection
  • In children, the rash typically resolves on its own in weeks to months
  • In adults, the rash tends to be more chronic

Guttate Psoriasis Pictures

  • Guttate psoriasis on the trunk
  • Guttate psoriasis on the face

Diagnosing Guttate Psoriasis

Guttate psoriasis is usually diagnosed based on the appearance of the rash. Because a streptococcus infection such as strep throat is often the cause, a throat culture or blood test for strep called antistreptolysin O may be done. Interestingly, these tests are recommended but treating with antibiotics is controversial.

Pustular Psoriasis

Pustular psoriasis (also known as von Zumbusch psoriasis) is rare, but sometimes fatal. Several different patterns have been described but the main features of generalized pustular psoriasis are the same.

Appearance of Pustular Psoriasis

The rash starts with redness on flexor surfaces such as the armpits or the bend of the elbow. This redness spreads to other parts of the body, then many tiny pustules develop in the red skin. It is common for a person with pustular psoriasis to have a fever with chills and feel ill. The skin can be very painful at the beginning of the rash. After several days, the pustules are replaced by extensive scaling. The rash can cause the body to loose protein and calcium, which in rare cases causes death.

Triggers for Pustular Psoriasis

Pustular psoriasis can be triggered by the following:

  • Pregnancy (which can trigger the rash impetigo herpetiformis)
  • Stopping corticosteroids like prednisone
  • Low calcium levels
  • Infections

Localized Pustular Psoriasis

This is a type of pustular psoriasis that does not develop over the majority of the body. Instead, the pustules develop in small areas inside or just outside an existing psoriatic plaque. This can occur with the application of irritants like coal tar.

Confused with Seborrheic Dermatitis

Scalp psoriasis and seborrheic dermatitis are often confused. Even biopsied sections of scalp can look similar. In general, the patches of scalp psoriasis are more well-defined than those of seborrheic dermatitis. In cases where it is difficult to determine the difference, some doctors call the rash "seborrhiasis."

Psoriasis Appearance

Each type of psoriasis has a particular appearance, but there are characteristics of the rash that are shared by the majority of the types:

  • Thick, silvery scales on a very red base
  • Sharply outlined borders; the difference between normal skin and rash is distinct
  • Healing from the inside out, resembling ringworm

Psoriasis Treatment

There are numerous treatment options for psoriasis, some of which have been around for decades and others for less than 5 years. The majority of psoriasis cases can be treated with medications you apply to the skin (topicals), but the more severe cases may require oral or injected medicine. Types of medicine used to treat psoriasis include:

  • Topical medications
  • Phototherapy
  • Traditional oral medications
  • Immunobiologic medications

If you suspect psoriasis, see a dermatologist before attempting to self-treat.

All about childhood psoriasis

(LifeWire) - If you notice scaly red patches on your child's skin, they may be due to the chronic skin condition called psoriasis. About one-third of all people with psoriasis develop it before age 20.

What Causes Childhood Psoriasis?

Psoriasis at all ages seems to occur due to a combination of genetic and environmental factors. Your child is much more likely to develop psoriasis if other members of the family have the condition. Generally, a trigger in your child's environment (such as a strep infection or injury) prompts the immune system to swing into overdrive. So new skin cells that usually take nearly a month to develop begin forming much more quickly. In psoriasis, skin cells mature within days, resulting in a pile up of excess skin cells and symptoms characteristic of psoriasis.

What Are Its Symptoms?

Psoriasis begins as red bumps on the skin, which merge into patches called plaques. The top of each plaque is often silver-gray, thick and scaly.

Psoriasis frequently shows up in areas of skin that have been injured or sunburned, especially the knees and elbows. Other commonly affected areas include the scalp, around the navel, between the buttocks and around the genitalia. Fingernails and toenails can also be affected, becoming ridged, pitted and discolored - and sometimes detaching. Children with stiff, painful joints may have psoriatic arthritis.

Are There Different Types of Childhood Psoriasis?

Children, like adults, may develop any of the several types of psoriasis:

  • Plaque psoriasis. The classic (and most common) type of psoriasis, characterized by swollen, scaly, reddened patches of skin.
  • Guttate psoriasis. Marked by teardrop-shaped, light pink or salmon-colored lesions, often occurring during or after an infection (especially strep throat), an injury or sunburn. This form is particularly common in childhood. It may occur only once or may recur with future infections. It can also develop over time into other forms of psoriasis.
  • Pustular psoriasis. Blisters filled with white fluid appear on the skin, sometimes only on the palms of the hands and the soles of the feet.
  • Inverse psoriasis. Smooth, swollen, reddened areas are located in folds of skin, especially areas that tend to stay moist or rub together.
  • Erythrodermic psoriasis. A potentially severe form of psoriasis in which large areas of skin become very red and swollen and may peel off. Children with erythrodermic psoriasis have a high risk of fever, dehydration and infection during the condition's flare-ups.
  • Psoriatic arthritis. Swollen, painful, stiff, reddened joints, especially in the fingers and toes. Over time, joints may actually become deformed due to chronic inflammation. Fingernails and toenails may be ridged and pitted.

How Is The Condition Diagnosed?

Psoriasis is usually diagnosed when a doctor recognizes its characteristic appearance. If there is any confusion as to the diagnosis, a small sample, or biopsy, of a skin lesion may be examined in a laboratory to verify that the symptoms are those of psoriasis.

How Is It Treated?

Unfortunately, there is no cure for psoriasis. However, a number of effective treatments can help improve your child's symptoms, including:

Topical treatments.

Applied directly to affected area, topicals include steroid creams; Dovonex ointment (with calcipotriene, a vitamin D preparation); Tazorac (tazarotene), a retinoid compound related to vitamin A; Psoriatec (anthralin); and preparations that contain coal tar. Psoriasis of the scalp can be treated with special coal tar-containing shampoos; Baker Cummins P&S Shampoo (a phenol and saline preparation); or steroid creams, foams, gels or ointments. Shampoos containing salicylic acid are also commonly recommended to help control he scaling common in scalp psoriasis. Getting rid of scales helps treat dandruff and helps other medicines penetrate better.

Phototherapy.

Exposes affected areas of skin to special ultraviolet B (UVB) light over 3 to 5 weekly sessions.

Systemic treatments.

These travel through the bloodstream, affecting cells throughout the body. For example, anyone who develops psoriasis in response to an active strep infection will need to take antibiotics.

On the other hand, only children with particularly severe cases will need more potent medications that slow new skin cell growth - Soriatane (acitretin) or Accutane (isotretinoin) - or that suppress the immune system to reduce damage to skin and joints, such as Trexall (methotrexate), Neoral or Sandimmune (cyclosporine) or Enbrel (etanercept).

What Other Kinds of Support Might My Child Need?

As with anyone who has a chronic condition, children with psoriasis need extra support and understanding, especially if the psoriasis crops up in a visible or cosmetically difficult location.

Children with psoriasis may need help understanding their condition, accepting the treatment(s) or coping with the frustrations of feeling different from their peers. During flares, they may feel embarrassed by unwanted questioning or stares from peers or strangers.

In seeking to help your child, you should consult with health professionals as needed. In addition, the following points are important:

  • Children with psoriasis should understand - and be able to explain to others when necessary - that psoriasis is neither contagious nor life-threatening.
  • They may need help in striking a healthy balance between choosing clothes that conceal affected areas and developing a healthy self-image that includes acceptance of their own appearance.
  • Stress management can help children with psoriasis feel better emotionally. Practices that may help include yoga, meditation, guided imagery, exercise, deep breathing and relaxation techniques.
  • Support groups for children with chronic conditions can help prevent them from feeling alone.
  • Children who are deeply distressed or sad about their condition for a prolonged period of time should be evaluated for depression.

Psoriasis Triggers

Psoriasis is a complicated, chronic skin disorder. We are still struggling to understand what goes on at the molecular level in this frustrating disease. Psoriasis is caused by one or more mutations in certain genes that then trigger cells in the immune system to attack the skin. But not everyone with these mutations gets psoriasis. The following are environmental factors that can trigger a psoriasis flare.

Skin Injury

Sometimes an injury to the skin can cause the formation of a psoriasis patch. This is known as the Koebner Phenomenon, and it can occur in other skin diseases, such as eczema and lichen planus. It can take 2 to 6 weeks for a psoriasis lesion to develop after an injury. Types of injuries that can trigger a flare include:

  • Abrasion - even mild abrasion
  • Increased friction from clothing or skin rubbing against skin in folds, such as armpits or under breasts
  • Sunburn
  • Viral rashes
  • Drug rashes

Weather

Weather is a strong factor in triggering psoriasis. Exposure to direct sunlight, which usually occurs in the warmer months, often improves the rash. On the other hand, cold, short days seen in the winter months can trigger the rash to worsen.

Stress

Psychological stress has long been understood as a trigger for psoriasis flares, but scientists are still unclear about exactly how this occurs. Studies do show that not only can a sudden, stressful event trigger a rash to worsen, daily hassles of life can also trigger a flare. In addition, one study showed that people who were categorized as "high worriers" were almost two times less likely to respond to treatment compared to "low worriers."

Infection

Infections caused by bacteria or viruses can cause a psoriasis flare. Streptococcal infections that cause tonsillitis, or strep throat, tooth abscesses, cellulitis, and impetigo can cause a flare of guttate psoriasis in children. The human immunodeficiency virus (HIV) does not increase the frequency of psoriasis, but it does increase the severity of the disease.

Low Vitamins

Low levels of calcium have been reported as a trigger for psoriasis. Oddly enough, even though medications made from vitamin D are used to treat psoriasis, low levels of vitamin D do not trigger a flare-up.

Drug Triggers

The following drugs are known to either worsen psoriasis or induce a flare-up:

  • Chloroquine -- used to treat or prevent malaria
  • ACE inhibitors -- used to treat high blood pressure. Examples include monopril, captopril, and lisinopril.
  • Beta blockers - also used to treat high blood pressure. Examples include lopressor and atenolol.
  • Lithium -- a medication used to treat bipolar disorder.
  • Indocin -- an anti-inflammatory medication used to treat a variety of conditions, including gout and arthritis.
  • Corticosteroids, such as prednisone or solumedrol, can actually dramatically improve psoriasis. However, abruptly stopping the drug or rapidly tapering off of it can trigger a flare-up.

Psoriasis Flare

One of the more distressing features of psoriasis is the occasional sudden and severe worsening of symptoms, often without any obvious cause. A closer look however may yield several clues as to possible inciting factors. Treatment of flares can be challenging, and in worst cases, may require a brief hospitalization. Most psoriasis flares however can be handled with systemic medications in the setting of the doctor's office.

Causes of Flares

Several triggering factors have been identified as contributing to worsening psoriasis:

  • External Factors: Nearly any injury to the skin can result in the development or worsening of psoriasis including sunburn, other rashes like allergic reaction to drugs, surgery, cuts or scratches, and viral rashes. The worsening of psoriasis after injury is known as the Koebner phenomenon.
  • Infections: Most notoriously, streptococcal infections such as strep throat can trigger the disease, especially an outbreak of guttate psoriasis. HIV infection is another condition known to aggravate psoriasis.
  • Psychological Stress: Job loss, divorice, death or other major emotional upsets have been known to flare psoriasis weeks or months after the stressful event.
  • Medications: Many medications are known to trigger psoriasis and should be avoided in patients with the disease.

Treating Psoriasis Flares

At one time, hospitalization for psoriasis flares was common. Due to changes in insurance reimbursement (Medicare only allows so many days of hospitalization for a skin condition) and more powerful and faster acting drugs, most flares are treated in the outpatient setting.

Drugs commonly used for severe flares include cyclosporine, Remicade (infliximab), and for pustular flares, Soriatane (acetretin). When psoriasis flares, don't delay -- seek treatment urgently with a qualified dermatologist.

Common Psoriasis Drug Interactions

( LifeWire ) < - When it comes to battling the red, itchy scales of psoriasis, some treatments work better in tandem. But what drug interactions work against healing?

Fortunately, negative drug-to-drug or drug-to-nutrient interactions are relatively unusual. That's good news all age people who cope with psoriasis, a chronic skin disease caused by a faulty immune system that allows skin cells to reproduce 10 times faster than normal. The result is crusty, silver-scaled patches, or plaques, that can occur on any part of the body.

Which psoriasis therapies are employed depends a great deal on the location of plaques and how extensively they cover the body. Although two-thirds of patients with psoriasis, known as "psoriatics," have mild or moderate forms of the disease. The rest endure patches on 20% or more of their skin surface. These severely affected patients are perhaps more prone to negative drug interactions because the types of medications they use are quite powerful and are sometimes injected or taken orally, extending their effects to the entire body.

The immunosuppressant cyclosporine, for example, which is also used in patients with organ transplants, has many potential drug interactions. Some prescription antibiotics, anticonvulsants, anti-inflammatory agents and calcium channel blockers interact negatively with cyclosporine, as well as aspirin, naproxen and ibuprofen, which are available over the counter (OTC). Naproxen and ibuprofen, which are classified as NSAIDs (non-steroidal anti-inflammatory drugs), are particularly toxic to the kidneys when paired with cyclosporine.

These and other combinations may affect how cyclosporine combats psoriasis, causing either too much or too little of the drug to be available in the bloodstream. Oral contraceptives, for example, strengthen in concentration when taken with cyclosporine, while effects of the mood-elevating herb St. John's Wort weaken.

Cyclosporine also has a well-documented interaction with grapefruit juice. Some chemicals in grapefruit juice, as well as the highly acidic juices made from tangelos and Seville oranges, interfere with the enzymes that digest medications for a variety of ailments (not just psoriasis), resulting in excessively high concentrations of the drug in the bloodstream.

Because cyclosporine lowers a patient's immunity, it should also be noted that anyone planning on receiving disease vaccinations -- including flu shots -- should first check with their doctors. Sometimes the psoriasis drug can be discontinued for a few weeks surrounding the time of the vaccination. Patients taking cyclosporine should also avoid people recently vaccinated with live viruses, including polio and the nasal-administered flu vaccine.

As noted earlier, psoriatics -- particularly those with mild or moderate cases -- are often prescribed medications, many of them topical, which prove beneficial in tandem. Corticosteroid creams, for example, can be used sequentially with creams made from vitamin D derivatives to optimize the results of both. Salicylic acid, however -- an ingredient in many scale-reducing creams, ointments and shampoos -- will inactivate vitamin D creams. And when natural sunlight or ultraviolet lamps are prescribed to combat psoriasis (by slowing skin cell growth), patients need to take care. Several psoriasis drugs -- as well as medicines for other conditions -- increase light sensitivity and can result in sunburns.

Care should be taken using sun lamps and the following drugs: coal or pine tar products, most of which are OTC; prescription vitamin A derivatives, such as tazarotene (Tazorac); and some antibiotics and high blood pressure medications. Check with your doctor to learn which of your prescriptions increase photosensitivity.

Since it's impossible to cover all potential medication interactions and risks, especially those associated with cyclosporine, patients with further questions should consult their doctor.

Biologics in Children

(LifeWire) - For many people afflicted with psoriasis, relief has finally arrived from a group of drugs called biologics - injectable medications developed over the last decade that are hailed for their ability to clear up even severe cases of psoriasis.

But biologics are among several successful psoriasis treatments for adults that have yet to be approved for children.

Approximately 10% of the 6 million psoriasis patients in the United States are children age 17 or younger. Usually, the red, scaly patches associated with psoriasis appear on the knees, elbows and lower back, or the scalp and face. In children, these lesions are often confused with other skin conditions, such as diaper rash.

As with adults, children who develop psoriasis have a genetic predisposition to the chronic immune system disorder, and can expect to suffer outbreaks that vary in length and severity throughout their lives.

Topical creams and ointments are the first choice treatments for outbreaks, followed by phototherapy, which uses ultraviolet light to slow down the overproduction of skin cells. But if these remedies do not work - and the stubborn nature of psoriasis means that even if they do, they might not work for long - doctors often turn to medications such as pills or biologics that treat the entire body.

Biologics have not yet been approved for use by children by the FDA, requiring physicians who choose to prescribe this class of drugs to do so "off-label." However, a 2008 study published in the New England Journal of Medicine showed that one biologic drug -- Enbrel (etanercept) -- significantly improved psoriasis symptoms in children with moderate or severe cases.

In this study, the first such trial of biologics done with children, researchers found that 57% of the 211 child subjects experienced at least a 75% reduction in their symptoms and an improved quality of life. Only 11% of children who received a placebo had the same result.

Enbrel hinders both the overproduction of skin cells and the inflammation of the skin that's seen with psoriasis, much like Amevive (alefacept). The medication is injected with a pre-dosed, pen-like syringe that a psoriasis sufferer can give him- or herself.

Since biologics act by suppressing some functions of the immune system, doctors must take care in prescribing them for certain people, including those whose immune systems are already weakened because of other illness or infection. Potential side effects of these medications include injection-site reactions (redness, swelling), flu-like symptoms and respiratory infections, though these tend to be mild.

Another reason biologics are prescribed with care is that long-term side effects are still being studied. In June 2008, the FDA announced that it was investigating the development of cancers in 30 children and young adults who use a class of drugs called tumor necrosis factor (TNF) inhibitors, which includes Enbrel. The youths were taking the TNF inhibitor drugs to treat a form of juvenile arthritis and Crohn's disease.

The Dermatologic FDA Advisory Committee has recommended Enbrel for approval for the treatment of psoriasis in children age 4 to 17. However, because its safety in children is still under review, final FDA approval is still pending.

Only a few psoriasis therapies are FDA-approved for pediatric use, including Dovonex (calcipotriene) and Protopic (tacrolimus), which are topical ointments, and ultra violet B (UVB) phototherapy, which is permitted for use in children as young as age 14.

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