Psoriasis
What is Psoriasis?
Psoriasis is a disorder of the joints and mainly the skin, which is characterized by red plaques or scaly patches on the skin due to excessive inflammation and more than usual skin production.
Symptoms of Psoriasis
Plaques occur on the skin of the scalp, elbows, genitals, knees, and the skin on the outer surface of joints. The skin rapidly accumulates at these sites and gives a silvery-white appearance. The disorder is a recurring condition over a long period of time. It can be in the form of a few patches in localized areas of the body or all over the body. Patients of psoriasis can also be afflicted by psoriatic arthritis (inflamed joints), thus adding to the discomfort.
Diagnosis of Psoriasis
Psoriasis is diagnosed by the appearance of the skin. A biopsy is undertaken merely to confirm or rule out suspected psoriasis.
General checkup: The severity of the disease is generally based on numerous factors like the proportion of body’s surface-area affected; degree of plaque redness, thickness and scaling; response to previous therapies; and the extent of adverse impact of the disease on the person’s life.
PASI test: Psoriasis Area Severity Index (PASI) test is the most widely used tool for the diagnosis of psoriasis. PASI combines the assessment of the severity of lesions and the area affected into a single score in the range 0 (no disease) to 72 (maximum severity). But, the PASI can be too unwieldy to use except for the purpose of clinical trials.
% Area infected: A simpler method that is usually used is of grading the severity by the percentage of area affected. For example, mild psoriasis would be where only 3% of the body is affected. Moderate would be where 10% of the body is affected. And a severe case would be where more than 10% of the body has lesions.
Causes of Psoriasis
As the cause of Psoriasis is not accurately known, the probable causes are a matter of hypothesis. But it is widely believed among medical circles that genetic framework is a major factor that increases the risk of psoriasis.
There are two schools of thought as to the cause of psoriasis. One school purports that psoriasis is disorder of excessive growth and reproduction of skin cells. In other words it is a skin disorder.
The second school of thought sees the disease as being an immune-mediated disorder, i.e. the excessive reproduction of skin cells is the immune system’s reaction to some unidentifiable skin disorder. T cells (which normally help protect the body against infection) become overactive, migrate to the dermis and trigger the release of cytokines which cause inflammation and the rapid reproduction of skin cells.
Also, studies have shown that some factors tend to aggravate the incidence of psoriasis. They are skin injuries, stress (both physical and mental) or bacterial infection (streptococcal infection), seasonal changes causing allergies, medicines like lithium salt or beta-blockers, alcohol, smoking, obesity, etc. Patients suffering from advanced AIDS symptoms can also get psoriasis, as their immune system is ineffective.
Types of Psoriasis
Plaque psoriasis: The common type of Psoriasis is plaque psoriasis or psoriasis vulgaris, which is nearly 85% of psoriasis cases. The plaques look like raised parts of swollen areas covered with whitish shining scales.
Guttate psoriasis: This is characterized by numerous small round spots or small oval shaped lesions. These spots appear over large areas on the skin like the torso, limbs and scalp. This type is associated with streptococcal throat infection.
Inverse psoriasis: In flexural psoriasis, the folds of skin around the genitals, armpits, under an overweight stomach or under large breasts. It is aggravated by movement which causes friction as well as perspiration, as the moist folds of skin are susceptible to fungal infections.
Erythrodermic psoriasis: This type involves the widespread inflammation and exfoliation of the skin over most of the body surface. Other accompanying symptoms are severe itching, swelling and pain. It is often the result of the abrupt withdrawal of systemic treatment. This form of psoriasis can be fatal, as the extreme inflammation and exfoliation disrupt the body’s ability to regulate temperature and for the skin to perform barrier functions.
Pustular psoriasis: In this type, pustules (pus-filled bumps) form on the skin. The surrounding skin is sore. Pustular psoriasis can form only on a particular area like on the hands and feet, but it can also be randomly widespread covering a lot of surface area.
Nail psoriasis: This affects finger and toe nails in particular. The affected
nail looks disfigured – the nail plate is discolored and ugly; the skin under the nail thickens abnormally; pitting of the nails occurs and sometimes the nail loosens and crumbles.
Psoriatic arthritis: This involves inflammation of the joints and cartilage. There are two subtypes in this: Dactylitis – when the joints of toes and fingers get painfully swollen like sausages; and Spondylitis – which affects the knees, hips and spine.
Treatment of Psoriasis
In the 18th and 19th centuries, Fowler’s solution containing a poisonous and carcinogenic arsenic compound was used by dermatologists as a treatment for psoriasis. Treatment with Grenz rays (or ultrasoft X-rays or Bucky rays) was a popular during the middle of the 20th century. Sulphur was popular as a treatment for psoriasis in the Victorian and Edwardian eras. All this is prior to ultraviolet therapy.
Today, dermatologists have to use a trial and error method for finding out the correct treatment of psoriasis. The treatment is undertaken in steps, increasing the toxicity of the medications if the previous one doesn’t work.
Topical medications: Ointments and creams for external use are prescribed initially for treatment of psoriasis. In some mild cases, this alone may work successfully. Ointments and creams containing coal tar, dithranol, corticosteroids, vitamin D3 analogues and retinoids are commonly used. Argan oil has also been used successfully. These help to normalize skin cell reproduction and reduce inflammation.
Phototherapy: Exposure to ultraviolet B (UVB) radiation several times per week over several weeks can help reduce inflammation and normalize skin cell reproduction. This is carried out along with topical treatment.
Photochemotherapy: This is a combination therapy of oral or topical administration of psoralen with exposure to ultraviolet A (UVA) light. But it is not used frequently because it induces side effects like nausea, headache, fatigue, burning, itching and sometimes skin cancers.
Systemic treatment: If creams/ointments as well as radiation do not cure the symptoms, oral or injectible medications, which do not potentially cause any adverse reactions, are used. This is called systemic treatment. If this does not cure the disease, then medications with suitable toxicity have to be used. When systemic treatment is going on, regular blood and liver function tests become necessary due to the toxicity of the medication. These medications cannot be used to treat psoriasis in pregnant women. Also, symptoms of psoriasis may recur after systemic treatment is discontinued.
Climatotherapy: Some schools of thought believe that a change in climate can relieve the symptoms of some diseases. Clinics for psoriasis are located all over the world but the Dead Sea (which has the highest density of mineral salt content) is considered the most popular location. A number of clinics are located in this area.
But, the decision on which type of treatment to use is depends on the geographical location; extent and severity of the disease; as well as the patient’s age, sex, quality of life, etc. Treatment rotation (switching treatment type) becomes necessary to prevent immunity of the disease to certain medications.
Living with Psoriasis
Psoriasis is not a cosmetic problem but a medical problem which requires treatment. The constant itching and pain has a great negative impact on the day-to-day life of the patient. It causes other health disorders/problems like myocardial infarction (heart attack), hypertension, depression or type-2 diabetes. Patients experience physical discomfort and some disability. Swelling on and thickness of hands and feet can hamper daily activities of the patient. The cost of medical treatment is prohibitive. Also, it can have an adverse effect on work or school schedules of the patient. Plaques on the scalp can be particularly embarrassing, causing low self-esteem and inferiority.
Prevention of Psoriasis 
As Psoriasis has genetic and environmental causes, it cannot really be prevented. But the symptoms can be alleviated by preventing dryness of skin.
1) Avoid using shower scrubs which could damage skin and also scrape off the essential natural skin oil, more so in fair-skinned races.
2) Change of environment and climate can be helpful if these factors adversely affect a person in any way. Cold, dry air aggravates psoriasis.
3) Avoid contracting any diseases of the upper respiratory tract as patients of such diseases are more susceptible to psoriasis.
4) HIV/AIDS paintients are also more vulnerable.
5) Use of beta-blockers and mood disorder drug like lithium should be kept to the minimum.
6) Diet control to prevent obesity can help.
7) Cessation of cigarettes and alcohol is a must.
Plenty of vegetables and fruits in the diet can be a great help.
9) Use of humidifiers and moisturizers can help too.
The World Psoriasis Day Consortium estimates show that about 3% of the world’s population is affected by psoriasis. The phrase “the heartbreak of psoriasis” is often used both seriously and ironically to describe the emotional impact of the disease and the adverse impact on the appearance of the patient.
