Psoriasis – Causes, Symptoms, Diagnosis & Treatment

What is Psoriasis?

Psoriasis is a common chronic skin disease. It is characterized by forming silvery-whitish scales covering the red and inflamed skin.

The plates are round or oval, often itchy, and are positioned mainly on the forearms, lower legs, trunk, and scalp, but also affecting other parts of the body.

The most typical areas where plaques form are knees and elbows. Psoriasis is not contagious but can be transmitted in the family [1].

Research indicates that the disease may be due to abnormalities in the immune system. Factors such as smoking, sun exposure, alcoholism, HIV – infection, can affect the incidence of the disease and also the duration of the plaques.

Psoriasis occurs in both men and women. It affects children and adults. Women develop psoriasis at earlier stages of life, as opposed to men.

The disease occurs in people of all races, but studies have shown that more people from Western Europe and Scandinavian countries develop such condition.

According to the Global report on Psoriasis made by the World Health Organisation „The reported prevalence of psoriasis in countries ranges between 0.09% and 11.43%, making psoriasis a serious global problem with at least 100 million individuals affected worldwide.” [2]

The first symptoms may occur at different ages, but most often it occurs in young adults or about 50-60 years old. Symptoms may differ from person to person and depend on the type of psoriasis.

Types

Plaque psoriasis

This is the most common type of psoriasis. 8 out of 10 people with psoriasis suffer from plaque psoriasis. It is also called psoriasis Vulgaris. It appears as raised, red patches covered with a silvery white buildup of dead skin cells or scale. These patches or plaques most often appear on the scalp, knees, elbows and lower back. They can be itchy or lead to a burning sensation. In more severe cases this type of psoriasis may even cause bleeding.

Plaque Psoriasis
Psoriasisplaque; Eisfelder 12-2004, GNU FDL
Source: https://commons.wikimedia.org

It appears as raised, red patches covered with a silvery white buildup of dead skin cells or scale. These patches or plaques most often appear on the scalp, knees, elbows and lower back. They can be itchy or lead to a burning sensation. In more severe cases this type of psoriasis may even cause bleeding.

They can be itchy or lead to a burning sensation. In more severe cases this type of psoriasis may even cause bleeding.

Guttate psoriasis

It often starts suddenly in childhood or about after puberty. This is the second most common type of psoriasis, after plaque psoriasis.

About 10 percent of people who get psoriasis develop guttate psoriasis. It occurs with small, pink-red spots on the skin, most often affecting the upper arms, thighs, scalp and torso.

Guttate Psoriasis
Figure 0001: Small, red, drop-like lesions of Guttate psoriasis located at the hand (A) and the arm (B) of the patient
Source: https://openi.nlm.nih.gov

Guttate psoriasis can be triggered by infection of the upper respiratory tract, such as pharyngitis or tonsillitis, stress, injury to the skin, medications such as beta blockers. This type of psoriasis can disappear within weeks, but there exist more severe cases.

Inverse psoriasis

It shows up as bright red, smooth, shiny lesions.

There is no peeling of the skin. This type of psoriasis usually affects the armpits, groin, the inframammary fold, around the genitals and the buttocks.

Inverse Psoriasis

Inverse psoriasis involving genital skin folds: successful therapy with dapsone.; Fig4: Perineal fold with complete clearance of psoriasis plaques 2 years after systemic therapy
Source: https://openi.nlm.nih.gov

Because of the specific locations where Inverse psoriasis occurs, the symptoms worsen in case sweating or friction.

The condition is difficult to treat when people are overweight. Often, inverse psoriasis is triggered by

Pustular psoriasis

This is a rare skin condition, most often affecting adults. It is manifested by small bumps filled with pus (pustules) surrounded by red skin. This type of psoriasis can affect limited areas,

This type of psoriasis can affect limited areas, palms, and feet, but can also spread over a larger area. Pustular psoriasis can be very serious and requires increased medical attention.

Pustular Psoriasis
Pustulosis palmaris et plantaris
Source: https://commons.wikimedia.org/

Generalized pustular psoriasis may cause fever, chills, nausea, rapid heartbeat (tachycardia), muscle weakness.

Pustular psoriasis may occur during administration of local or systemic medications (especially steroids), as well as their sudden withdrawal, excessive UV exposure, pregnancy, infections, stress, exposure to certain chemicals.

Erythrodermic psoriasis

This is the rarest, still extremely serious type of psoriasis. It affects almost the entire body, causing extensive redness of the skin.

The skin may even look like it is badly burned.

Erythrodermic psoriasis

Erythrodermic psoriasis with bullous pemphigoid: combination treatment with methotrexate and compound glycyrrhizin.; Figure 1: Topical rash before treatment and normal condition after treatment on his limbs and feet. (a) Diffuse flushing, tense, transparent vesicles, and blisters on his limbs and feet. Skin lesions showing diffuse flushing, infiltrative swelling, a large number of branlike scales on his limbs, and tense, transparent vesicles and blisters on his feet. (b) Diffuse flushing and infiltrative swelling has subsided. Skin lesions cleared and normal condition restored.
Source: https://openi.nlm.nih.gov

Additionally, severe itching, burning or peeling of the skin, acceleration of heart rate, change in body temperature may be experienced. Erythrodermic psoriasis can lead to loss of protein and dehydration.

It is a serious condition, should be monitored by a doctor and is usually treated in hospital. Complications which may develop include infection, pneumonia and even heart failure.

Nail psoriasis

Half of the patients with psoriasis observed changes in the nails.

Such changes usually occur with the appearance of holes in the nail plate, changes of the nail shapes, thickening, separation of the nail from the nail bed, discoloration of the nail.

Nail Psoriasis
Nail Psoriasis; Figure 6: Onycholysis along with pitting and salmon patches in fingernails
Source: https://openi.nlm.nih.gov

Nail psoriasis is often combined with fungal infection. The condition is difficult to treat. It is highly recommended to maintain nails as short as possible.

Psoriatic arthritis

There are both psoriasis and arthritic manifestations.

The condition typically affects the large joints, especially those of the lower extremities, distal joints of the fingers and toes, and also can affect the back and sacroiliac joints of the pelvis.

Psoriatic Arthritis
Pictures of a patient with psoriasis (and arthritis) before (baseline) and 8 weeks after initiation of infliximab therapy.
Source: https://commons.wikimedia.org

Usually, the nail plates are also affected. Psoriatic arthritis is manifested by pain and stiffness in the joints, swelling of fingers and toes, warming in the joints.

Psoriatic arthritis
Activated Heberden arthritis of the right finger
Source: https://commons.wikimedia.org/

Causes

Studies have shown that psoriasis may be due to abnormalities in the immune system response. T-cells are related to the white blood cells and their role is very important: to protect the body from infection. These cells are abnormal and lead to inflammation of the skin areas in patients affected by psoriasis. They can lead to an increased growth of the skin cells and their accumulation forming plaques on the skin surface.

T-cells are related to the white blood cells and their role is very important: to protect the body from infection. These cells are abnormal and lead to inflammation of the skin areas in patients affected by psoriasis. They can lead to an increased growth of the skin cells and their accumulation forming plaques on the skin surface.

They can lead to an increased growth of the skin cells and their accumulation forming plaques on the skin surface.

People who have relatives suffering from psoriasis have an increased risk of developing the disease.

About one-third of people with psoriasis have at least one family member, affected by the disease. When both parents are suffering from psoriasis, the risk for the child is about 50% increased.

Some factors can also provoke psoriasis:

Skin injuries – associated mostly with the development of plaque psoriasis. These include skin infections, inflammation or excessive scratching of the skin. [3]

Sunlight – most psoriasis patients indicate that the sun improves the condition of their skin [4]. In a small percentage of people, however, sunlight can exacerbate the symptoms, especially in case of sunburn.

Streptococcal infections – those bacterial infections have been associated with the occurrence of guttate psoriasis [5].

 HIV – infection – usually leads to a worsening of symptoms, but in advanced stages of the disease (probably because of the destruction of the immune system), the symptoms of psoriasis can be significantly improved.

Medications – some medications may worsen the condition. Such include lithium, a psychiatric drug, antimalarials such as hydroxychloroquine and chloroquine Inderal, a high blood pressure medicine, quinidine, a heart medication, indomethacin, a nonsteroidal anti-inflammatory drug often used to treat arthritis.

Emotional stress.

Smoking. [6]

Alcohol [7]– is considered a risk factor for developing psoriasis, especially in middle-aged men.

Hormonal changes – the disease is usually exacerbated during puberty and menopause, while during pregnancy the symptoms usually improve. In the postpartum period, however, the symptoms may recur and worsen dramatically. [8]

Symptoms

People with plaque psoriasis usually have red, raised and scaly areas on the skin that may itch or burn. These areas are located on the knees, elbows, trunk, and scalp.

The plates are raised above the surrounding healthy skin. They can have the size of a centimeter to several centimeters.

Their form is usually oval, but can also be irregularly shaped. The smaller sized plates can be merged into bigger ones.

The skin in the affected areas can be scaly and bleeding. Plaques sometimes have an area around them that looks like a halo or ring (Ring of Woronoff) that is especially noticeable after effective treatment as the lesions are resolving.

The scales are dry, thin and silvery-whitish. If removed the skin beneath is smooth and shiny red, with small areas of bleeding.

Psoriatic plaques tend to appear on symmetrical places of the body – for example, on both knees and elbows.

The scalp can have dry, scaly areas and plaques. Sometimes psoriasis of the scalp can be misdiagnosed as seborrheic dermatitis. In seborrheic dermatitis, however, the scales are greasy, not dry.

Nails are often involved, especially in plaque psoriasis. Changes include recesses, grooves or holes on the nail plate, and nails can be separated from the nail bed.

In guttate psoriasis, redness resembles droplets. In pustular psoriasis, large areas of your body can be covered with painful red skin and pus-filled blisters within a day or two.

In children, psoriasis occurs differently than in adults.

The plates are not as thick and scaly skin is less pronounced. In young children the affected skin areas in the diaper area ( but are not caused by the diaper) and skin folds. In children, the condition usually affects the face.

The disease has a chronic course. Peeling can last from several weeks to several months.

Note that even if you might never be able to completely control psoriasis and hold off a flare-up indefinitely, you can certainly try to keep psoriasis in remission as long as possible.

Diagnosis

The diagnosis of psoriasis is usually placed during the physical examination. An experienced dermatologist can diagnose the condition while monitoring the skin changes. Skin biopsy (an examination of tissue removed from a living body to discover the presence, cause, or extent of a disease) confirms the diagnosis and excludes other similar-looking skin diseases.

Treatment

The disease has a chronic course, with periods of exacerbation and improvement (remission).

The treatment can be extremely prolonged, it may sometimes last for years. Psoriasis can be a tricky condition to manage, but the right skin care routine may help a lot to maintain healthy skin.

The most important things you should remember: to always keep your skin moisturized, especially after bathing; To avoid irritating cosmetics and soaps; you shouldn’t scratch your skin off; bathing with moisturizing oils can help relieve irritations; exposure to sunlight improves symptoms for most patients with psoriasis.

There are three basic types of treatment which are usually administered for psoriasis symptoms:

  • Local therapy (medications that are applied topically)
  • Phototherapy (light therapy)
  •  Systemic therapy (medications, which are taken internally)

These types of therapeutic activities may be administered separately or in combination.

Local therapy – the topical application of creams and lotions is the first treatment option for psoriasis.

Such medications slow down or normalize excessive cell reproduction and reduce psoriasis inflammation. Usually, corticosteroids are applied (in order to reduce the swelling and redness of lesions), as well as derivatives of vitamin D, anthralin, or retinoids. These drugs provide

Usually, corticosteroids are applied (in order to reduce the swelling and redness of lesions), as well as derivatives of vitamin D, anthralin, or retinoids.

These drugs provide a different effect in individual patients. Since each of these medications has its own side effects, their application should be alternated.

Phototherapy (Ultraviolet light therapy) – ultraviolet light slows down the production of skin cells and reduces the inflammation.

Sunlight improves the symptoms of psoriasis. Phototherapy is now one of the most common treatment options for psoriasis—with nbUVB and psoralen ultraviolet A (PUVA) as the most widely used applications.[9] Psoralen is drugs that make the skin more sensitive to sun radiation.

Systemic therapy [10] – such treatment may be applied in case local and phototherapy have no effect.

In generalized pustular psoriasis, this type of therapy can be administered at the very beginning of the disease. Systemic therapy is used in the active forms of psoriatic arthritis.

Herbal treatment

For the reduction of psoriasis symptoms can be applied herbs to relieve symptoms, primarily itching, as well as to purify the body internally.

One of the best remedies to relieve the itching is mint. Used in the form of peppermint oil. To it can be added to olive oil, which has moisturizing properties. Other tools that alleviate the symptoms of psoriasis are aloe juice, oatmeal, tea tree oil.

It is believed that milk thistle regulates the immune system, which may be useful in the treatment of psoriasis. Moreover, it supports liver function.

Evening primrose oil can also be taken in psoriasis. Then the interior, it may be applied to affected areas to relieve the symptoms.

Other herbs that can be used for psoriasis in the form of decoction are the curly dock, red clover, and burdock. They can be administered alone or can be combined.

References

  1. https://www.ncbi.nlm.nih.gov/pubmed/15462603
    Heredity of psoriasis
  2. http://apps.who.int/iris/bitstream/10665/204417/1/9789241565189_eng.pdf
    Global report on Psoriasis: The World Health Organisation
  3. https://www.ncbi.nlm.nih.gov/pubmed/7037041
    Response to injury of skin involved and uninvolved with psoriasis, and its relation to disease activity: Koebner and ‘reverse’ Koebner reactions.
  4. https://clinicaltrials.gov/ct2/show/NCT00129415
    Ultraviolet (UVA and UVB) Light Therapy in the Treatment of Inflammatory Skin Conditions
  5. https://www.ncbi.nlm.nih.gov/pubmed/7593594
    Evidence for a streptococcal superantigen-driven process in acute guttate psoriasis.
  6. https://www.ncbi.nlm.nih.gov/pubmed/26553732
    Psoriasis and Smoking: A Systematic Literature Review and Meta-Analysis With Qualitative Analysis of Effect of Smoking on Psoriasis Severity.
  7. https://www.ncbi.nlm.nih.gov/pubmed/10606066
    Alcohol and psoriasis: a double burden.
  8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4777452/
    The role of hormones in the pathogenesis of psoriasis vulgaris
  9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3736829/
    Phototherapy in Psoriasis: A Review of Mechanisms of Action
  10. https://www.ncbi.nlm.nih.gov/pubmed/24002153
    Effectiveness of systemic treatment agents on psoriatic nails: a comparative study.

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