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  Psoriasis

Psoriasis is a chronic and recurrent autoimmune, non-contagious skin and joint disease derived from the Greek word psora which means to itch. The pathology of Psoriasis lies at the innermost layer of the epidermis known as the stratum germinativum or basale. This is the most mitotically active layer where there is rapid production of keratinocytes, the cells that secrete keratin.

Psoriasis
Psoriasis


Psoriasis skin lesions commonly manifests as red scaly patches called psoriasis plaques which are actually areas of excessive skin cell production and inflammation. These plaques are frequently seen on the elbows and knees, but can also affect other areas of the body such as the scalp, genitals and even the nails of the fingers and toes.

There are several types of psoriasis namely: plaque, pustular, guttate, flexural, nail, erythrodermic psoriasis and psoriatic arthritis. The most common form is the plaque psoriasis also known as psoriasis vulgaris which affects around 80 to 90% of patients suffering from psoriasis. Plaque psoriasis typically appears as elevated areas of inflamed skin with silvery white scales on the topmost area. Flexural psoriasis is also called inverse psoriasis which has smooth patches of inflammed skin and vulnerable to fungal infections. Guttate psoriasis is described as eruptions of many small oval or teardrop-shaped spots which are associated with streptococcal throat infection. Pustular psoriasis appears as circumscribed elevated lesions that are filled with non-infectious pus. Nail psoriasis causes discoloration and thickening under the nail plate, pitting and formation of lines going across the nails and finally, loosening, and breaking down of the nail called onycholysis. Psoriatic arthritis involves inflammation of the joints and connective tissues. Any joint may be affected such as the spine, hip and knee joints but is most common in the joints of the fingers and toes resulting to its swollen, sausage-shaped appearance known as dactylitis. When there is widespread inflammation and exfoliation of most of the body surface of the skin, the condition is known as erythrodermic psoriasis. This can be fatal because of impairment of the body’s ability to perform its barrier and thermoregulation function.

The diagnosis of psoriasis is based on the pathognomonic clinical appearance of the skin lesions. There are no available special blood tests or definitive diagnostic procedures for psoriasis. In some cases, a skin biopsy or scraping may be requested by the dermatologists just to rule out other skin disorders and to confirm the diagnosis.

Psoriasis is usually graded as mild, moderate or severe depending on the amount of the body surface area affected. Psoriasis has no sex predilection and may affect both male and female, occurring at any age although it is most common between 15 and 25 years old. There are conditions that have been reported to aggravate the disease process namely: streptococcal infections, skin injury, physical and mental stress, changes in season and climate, certain medicines such as lithium salt and beta blockers. Consumption of too much alcohol, smoking and obesity may cause acute exacerbations of psoriasis which tend to make the treatment more difficult. The finding of the most appropriate treatment for patients with psoriasis is usually customized and based on a trial-and-error approach. The following are taken into consideration before employing a particular treatment: type of psoriasis, location, extent and severity, age of the patient, gender, quality of life, accompanying morbidities, and lastly, the attitude toward risks associated with the treatment.

The dictum followed by most dermatologists is the preferential use of initial medications with the least adverse reactions. This is known as the “psoriasis treatment ladder”. If the initial therapy fails or the treatment goal is not achieved then they will proceed in using medications with greater potential toxicity. The usual first step in the treatment is making use of topical ointments or creams containing coal tar, dithranol (anthralin), corticosteroids, vitamin D3 analogues, and retinoids. The next step after failed topical treatment would be ultraviolet (UV) radiation exposure to the affected skin known as phototherapy. Another alternative is the combination of the oral or topical psoralen and exposure to ultraviolet A phototherapy (PUVA) although the exact mechanism of action with PUVA treatment is not known. Some of the side effects of PUVA are: nausea, headache, fatigue, burning, and pruritus. Malignant skin cancers such as melanoma and squamous cell carcinoma are also associated with long-term PUVA therapy. The last step in managing psoriasis involves the use of oral and injectable drugs, a systemic treatment reserved for resistant cases of psoriasis which are unresponsive to topical treatment and phototherapy. Other traditional systemic treatments for psoriasis include immunosupressants (e.g. methotrexate and cyclosporin) and retinoids, the synthetic forms of vitamin A; however, patients undergoing systemic therapy must have regular blood and liver function tests because of possible toxicity brought about by the medication.

In time, psoriasis can become resistant to a specific therapy thus; rotating the treatment options may be done to prevent development of resistance known as tachyphylaxis. In doing this, the adverse reactions will likewise be reduced. Other alternative therapies may include the following: antibiotics (for those with concomitant streptococcal infection); climatotherapy; outdoor spas; healthy lifestyle and diet; herbal products; psychological programme and Epsom salt. Psoriasis is a condition that may worsen over time and has presently no cure. Some individuals may experience flare ups and remissions all throughout their lives hence; may also require life-long therapy. The various aforementioned treatment options can only help to control the symptoms associated with the disease.

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