Psoriasis is a systemic inflammatory disease driven by T-lymphocytes, arising from a complex interaction between numerous genetic factors and environmental influences. A genetic predisposition, combined with triggering factors, initiates an abnormal immune response that leads to the development of initial psoriatic skin lesions. Additionally, it is an immune-mediated disease in which the skin inflammatory changes are dependent on immune cells and their cytokines, the interaction of dermal dendritic cells with activated TH-1 and TH-17 T cells, along with various cytokines and growth factors, leads to the epidermal hyperplasia and dermal inflammation observed in psoriasis patients. There are several types of psoriasis such as plaque (psoriasis vulgaris), flexural and/or intertriginous (inverse psoriasis), seborrheic, scalp, acrodermatitis of hallopeau, palm and/or soles, generalized pustular psoriasis, guttate, and erythrodermic. Plaque psoriasis is the most prevalent form, about 8 in 10 people with psoriasis have this kind.
The diagnosis of psoriasis is based on the characteristic psoriatic lesions and not on laboratory tests. Psoriasis is traditionally classified into mild, moderate, or severe disease. Assessment typically includes measures of symptoms and involvement such as body surface area (BSA), Psoriasis Area and Severity Index (PASI), or Physician’s Global Assessment (static PGA). Additionally quality-of-life measures, such as the Dermatology Life Quality Index (DLQI) or Short Form (SF-36) Health Survey. To roughly estimate the extent of body surface area (BSA) involvement in psoriasis, consider the following approximations: the size of your palm is about 1% BSA, involvement on the head and neck is around 10% BSA, both upper limbs account for roughly 20% BSA, the trunk (front and back combined) is about 30% BSA, and both lower limbs constitute approximately 40% BSA.
Treatment Overview:
The treatment approach for psoriasis involves addressing its underlying pathophysiology. Key strategies include utilizing agents that modulate the abnormal immune response, such as topical corticosteroids and biologic agents. Furthermore, therapies targeting cell turnover, like retinoids, are effective in managing psoriasis. Moreover, the treatment of psoriasis depends on the type, location, and extent of disease. All patients should be educated to avoid excess drying or irritation of their skin and to maintain adequate cutaneous hydration. A topical vitamin D analogue such as calcipotriene and a retinoid (tazarotene) are also effective in the treatment of mild psoriasis and have mainly replaced other topical agents such as coal tar, salicylic acid, and anthralin.
Ultraviolet (UV) light, whether from natural sources or artificial sources, presents an effective therapeutic option for several psoriasis patients with widespread symptoms. Clinical practice commonly utilizes Ultraviolet B (UVB), narrowband UVB, and Ultraviolet A (UVA) light alongside oral or topical psoralens (PUVA). The therapeutic efficacy of UV light in psoriasis is due to its immunosuppressive properties, however, it is significant to recognize that UV light is also mutagenic and may increase the risk of both nonmelanoma and melanoma skin cancers.
Methotrexate demonstrates effectiveness, particularly in those individuals with Psoriatic Arthritis. Acitretin, a synthetic retinoid can be used in those cases where immunosuppression needs to be avoided. Apremilast functions by inhibiting phosphodiesterase type 4 and is approved for treating both psoriasis and PsA. However, caution is advised when administering it in individuals with renal failure or depression.
Psoriasis presents as a chronic condition with no known cure. It's crucial to recognize the potential for significant comorbidities to accompany this condition. Tailoring treatment approaches to individual patients is key, accounting for factors such as disease severity, patient risk profiles, age, and concurrent health conditions. Goals of treatment for the patient should include control of psoriasis (skin normalization and increase pliability of skin), decrease or clearing of erythema, papules, plaques, and scales, and improving quality of life. The expanding array of treatment options, including the introduction of several biologic therapies, enhances the tools available for managing psoriasis. Looking ahead, the ongoing research and advancements in therapeutic approaches hold promise for enhancing the well-being of those navigating this dermatological condition.
According to current studies, more than 8 million Americans have psoriasis. In a 2021 cross sectional study, the prevalence of psoriasis in the U.S. was 3% for individuals over 20 years of age. An immune-mediated disease, psoriasis affects nearly 125 million individuals worldwide. This chronic condition causes inflammation in the body resulting in raised plaques, redness, itchiness, burning, and stinging. The plaques are formed due to an overactive immune system resulting in a scaly pile-up of skin cells, often found on the elbows, knees, and scalp. Although the pathogenesis in unclear, several concepts have been hypothesized. The most common hypothesis being the “activation of T cells, inflammatory cells, and keratinocytes leading to the release of cytokines. The plaque formation is due to the hyper-proliferation of the keratinoctytes.” It has been reported that this chronic disorder may have predispositions and triggering environmental factors such as bacterial infections, trauma, and even drug-induced, although none have been confirmed. Other forms of psoriasis include guttate psoriasis, inverse psoriasis, pustular psoriasis, and erythrodermic psoriasis, and psoriatic arthritis.
Psoriasis negatively impacts the quality of life, as commonly seen among young children and women. As there is no cure for psoriasis, it is the healthcare team’s goal to increase pliabliity of the skin and decrease or clear any erythema, papules, plaques, and scales, to improve the quality of life. With the ongoing expanding market of psoriasis treatments, topical agents are the first-line drugs of choice before the introduction of phototherapy or a systemic agent. These topical agents range from corticosteroids, emollients, tar, typical retinoids, anthralin, to topical calcineurin inhibitors, although results may take a few months. More advanced treatments include methotrexate, cyclosporine, and newly-discovered biologics. The variability of treatment options is so vast, topical corticosteroids can be further divided in potency categories. Psoriasis treatment, unfortunately, becomes a game of trail and error for many individuals.
With biologics being the revolutionary drugs of the decade, these immunomodulators come with their fair share of cons. Although less toxicity is observed towards the kidneys and liver with quicker and efficient results, patients leave themselves susceptible to infections, exacerbation of existing cardiovascular diseases, demyelinating diseases, and even blood dyscrasias.
One of the most commonly administered biologics for psoriasis is infliximab (Remicade). A TNFA-alpha blocker, infliximab is only available through an infusion. In spite of the fact that a single, reconstituted-vial of the drug costs rougly $1,000, a single treatment session ranges between $3,000 and $5,000. Completing the entire regimen can cost well over $50,000 for the year as patients must return at weeks 0, 2, and 6 and every 8 weeks thereafter. Infliximab has FDA-approved biosimilars, however, costs range between $500 and $1,000. Biologic usage has promising results but is reserved as a last-line treatment for refractory patients.
Psoriasis is a common and chronic immune-mediated disease which causes inflammation in the body. The inflammation can be visibly seen on the skin through raised plaques and scales. These plaques can be seen anywhere on the body, but are most common on the elbows, knees and scalp. The reason for the plaques and scales and skin cell overgrowth. Typically skin cells completely grow and shed off within a month. For those who suffer from psoriasis, the skin grows every 3 or 4 days without shedding. This leads to a skin cell pile up on the surface of the skin. Not only is the inflammation visible, but many report feeling the plaques itch, burn and sting.
There are many types of psoriasis. Plaque psoriasis is the most common. This is the subtype which is expressed through build up skin cells resulting in pruritic plaques and scales. It can be present in almost any part of the body including the scalp. Another subtype is guttate psoriasis. The name guttate is to describe the drop-like appearance of the skin lesions. Guttate psoriasis is presented as small lesions over the upper trunk and throughout the proximal extremities. Pustular psoriasis is a much more severe case. The plaque and itchiness is substituted with blisters and can be much more painful. These blisters can be limited to one area of the body or in multiple areas at once. Once the blisters are treated, the skin is left scaly and uncomfortable.
Psoriasis can leave many patients vulnerable as it destroys one of our most protective layers. The skin is a big part of our immune system, and when damaged can leave the body vulnerable to many infections and illnesses. One illness which is commonly found when patients have psoriasis is streptococcus infection or strep throat. Many times in children, strep throat is what triggers the first onset of guttate psoriasis. Some common triggers of psoriasis include stress. Unfortunately in this case, many times psoriasis flare ups can cause stress, resulting in a loop of stress induced flare ups. Another big trigger is injury to the skin. These injuries can be minor, yet still result in a psoriasis flare up. This is a result of the KEB-ner phenomenon. Basically it means scratches, sunburns, bug bites and even vaccinations can all be common skin injuries that lead to a psoriasis flare up. The weather is another common trigger. Often times it is colder weather which is triggering. The decrease in humidity and sunlight leads to drier skin. There are some who suspect allergies, certain foods, alcohol and tobacco may be a trigger. This theory is much more patient based. For instance one may have a flare up from her food allergy, while another wouldn't be affected at all.
Genetics plays a large role in the likelihood of developing plaque psoriasis. It is also seen that around 2% of the population has plaque psoriasis, with women generally having an earlier onset of the symptoms. The pathogenesis of psoriasis is based around the innate and adaptive immune response. A disturbance is stimulated somewhere around the innate system, leading to an inflammatory response. When activated the innate system stimulates T cells. T cells release proinflammatory cytokines. Activated T cells of the TH-1 and the TH-17 as well as the cytokines are what lead to the inflammatory response seen in the skin in people with psoriasis.
The main treatment for psoriasis is topical corticosteroids. Corticosteroids have anti-inflammatory and immunosuppressive properties. The goal of therapy is to eliminate the visible signs of psoriasis, the plaques and scales. It is also to reduce the frequency of flare ups as well as the discomfort of the person. The overuse of topical corticosteroids can cause multiple side effects including; stretch marks, thinning skin, increased bruising, dilated blood vessels and in some cases an increase in hair growth.
Although psoriasis is most visible through the skin, the skin is not the only target. There are many comorbidities associated with psoriasis. Some of the comorbidities associated; PsA or psoriatic arthritis, depression, diabetes, metabolic syndrome, inflammatory bowel disease and cardiovascular disease. Psoriatic arthritis is connected to the severity of the psoriasis. Early diagnosis of PsA is vital for proper treatment. If the psoriasis is severe the patient should be checked for PsA. Unfortunately 1 in 10 people with PsA go undiagnosed. The pain can be subtle at first, but with the proper patient education, patients can help catch an earlier diagnosis and receive the treatment needed for them. Another common disease seen in psoriasis is cardiovascular disease. Chronic inflammation is the main issue of psoriasis, and inflammation is a large factor in causing cardiovascular disease. Chronic inflammation also increases the risk of stroke. Treating psoriasis is linked with a decreased risk of stroke and/or heart attack. Chronic inflammation also affects how sugar is absorbed in the body. This greatly increases the risk of type II diabetes. Type II diabetes also leads to other comorbidities such as heart disease and obesity. The inflammation in psoriasis is due to certain genes and some of these genes are the same ones which cause inflammatory bowel syndrome. If psoriasis flare ups and associated with inflammatory bowel disease symptoms, it should be reported to the doctor. Symptoms include abdominal pain, diarrhea, constipation and bloody stool.
Unlike the previous morbidities discussed previously, depression is not physical. The National Psoriasis Foundation found depression to be at the top of the comorbidity list of psoriasis. Depression is the persistent feeling of sadness or loss of interest. Behavioral changes can be seen when depressed such as changes in sleep, appetite, self-esteem and energy-level. Antidepressants can be given to patients to help, but it has been shown that treating the psoriasis also helps. Depression in many times can be linked to one's health. Psoriasis puts a person in pain and a constantly uncomfortable state. Other than that it also affects a person's appearance. This can greatly damage one's self esteem. Together, the effects of psoriasis eventually will decrease a person's quality of life. By treating the condition, the person will in turn feel better, and increase the quality of life, decreasing the risk of depression.
References:
National Psoriasis Foundation. (n.d.). Psoriasis: Causes, triggers and treatments. The National Psoriasis Foundation: National Psoriasis Foundation. https://www.psoriasis.org/about-psoriasis/
Psoriasis is a chronic inflammatory disease mediated by the immune system. Psoriasis is also likely an autoimmune disease. The buildup of skin cells causes itchy, white scales or plaques to form on the skin. It is mostly located on the elbows, knees, or scalp, but can occur on other parts of the body as well. It is often associated with other comorbidities like psoriatic arthritis, mood disorders, cardiovascular disease, and metabolic syndrome. Psoriasis is the result of sustained inflammation leading to uncontrolled proliferation of keratinocytes and dysfunctional differentiation (Rendon, A., & Schäkel, K.). Sustained inflammation is due to changes in the innate and adaptive immune responses in the skin. The innate immune system is activated and there is also an autoinflammatory or autoimmune reaction. Dendritic cells are activated in the initial stages of psoriasis. There is activation of T cells during the maintenance phase of psoriasis. Dysregulation of the IL-23/Th-17 signaling pathway also drives the disease.
Treatment for psoriasis has evolved over time. In the 19th century and first half of the 20th century, arsenic was used for psoriasis before it was determined that there was toxicity associated with it. X-rays were also used in the 20th century, but it was determined that there were carcinogenic side effects associated with it. In the 1950s, corticosteroids were discovered. Oral prednisolone and triamcinolone were effective. Topical steroids like betamethasone and fluocinolone were used in the 1960s and showed significant effects. Topical steroids are only able to treat psoriasis temporarily and are not a permanent solution. Steroids are anti-inflammatory, immunosuppressive, and anti-proliferative. Methotrexate was first used in the 1950s and is currently the first line treatment for patients that can be treated systemically and also for psoriatic arthritis (Reid, C., & Griffiths, C. E. M.). Another treatment is the use of psoralens (photosensitizers) with UVA. This treatment can increase risk of cutaneous squamous cell carcinoma so its use has declined. Ciclosporin is an immunosuppressive drug that is used for psoriasis. The success of ciclosporin helped determine that psoriasis is mediated by T cells. Furthermore, ciclosporin can cause nephrotoxicity so it is dosed in short courses of therapy. Vitamin D analogues like calcipotriol can be used in combination with the topical steroid betamethasone valerate as an effective treatment. Biologics have become a growing focus in the modern century. They are indicated in moderate-severe psoriasis after failure of first line therapies. T cell targeted biologics included alafacept and efalizumab which were both withdrawn from the market. Tumor necrosis factor (TNF)-α is the target of etanercept, infliximab, and adalimumab. Adalimumab is the biologic that is the first line recommended treatment for psoriasis with psoriatic arthritis. Currently, the focus is on targeting cytokines IL-23 or IL-17 and disrupting their signaling. Three biologics against IL-17 include secukinumab, ixekizumab, and brodalumab ((Reid, C., & Griffiths, C. E. M.).
Psoriasis is associated with comorbidities like metabolic syndrome. They are both associated with Il-23/Th-17 signaling pathways. About 20-50% of patients with psoriasis have metabolic syndrome (Wu, J. J. et al.). There has not been a definitive link between psoriasis and metabolic syndrome, but genetics, the overlapping signaling pathways, and the environment can contribute. Family members of patients with psoriasis have an increased risk of developing psoriasis. Treating one condition may help improve the other. When treating patients for psoriasis, they should be screened for comorbidities before creating a treatment plan because systemic treatment may be warranted to treat multiple conditions.
Resources:
Reid, C., & Griffiths, C. E. M. (2020). Psoriasis and Treatment: Past, Present and Future Aspects. Acta dermato-venereologica, 100(3), adv00032. https://doi.org/10.2340/00015555-3386
Rendon, A., & Schäkel, K. (2019). Psoriasis Pathogenesis and Treatment. International journal of molecular sciences, 20(6), 1475. https://doi.org/10.3390/ijms20061475
Wu, J. J., Kavanaugh, A., Lebwohl, M. G., Gniadecki, R., & Merola, J. F. (2022). Psoriasis and metabolic syndrome: implications for the management and treatment of psoriasis. Journal of the European Academy of Dermatology and Venereology : JEADV, 36(6), 797–806. https://doi.org/10.1111/jdv.18044
Psoriasis is a chronic inflammatory skin disease which affects around 2% of the world. It is characterized by chronic inflammation that leads to uncontrolled keratinocyte proliferation and dysfunctional differentiation. It is an immune-mediated disease in which T lymphocytes, dendritic cells, and cytokines (interleukin 23, interleukin 17, and tumor necrosis factor) play a central role.
There are several different subtypes of psoriasis. The most common is plaque psoriasis which presents as sharply demarcated, erythematous, pruritic plaques covered in silvery scales usually present on the trunk, extensor surfaces of the limbs, and the scalp. The next type is guttate psoriasis which is characterized by acute onset of small erythematous papules and plaques. The trunk and proximal extremities are the main areas affected by the guttate type. Pustular psoriasis is a severe form of psoriasis with multiple, coalescing sterile pustules. It is associated with malaise, fever, diarrhea, leukocytosis, and hypocalcemia. Erythrodermic psoriasis is uncommon but is characterized by generalized erythema and scaling on all or most of the body surface. Patients with this type are at high risk for infection and electrolyte abnormalities.
Psoriasis was originally thought to be just a disease of the skin but was found that it affects the body as a whole with related comorbidities in other organ systems. The most common comorbidity is psoriatic arthritis, occurring in about 40% of patients with psoriasis. Symptoms of psoriatic arthritis include joint pain, joint stiffness, and back pain. Dactylitis and enthesitis present in oligoarticular or polyarticular patterns.
In addition to the psoriatic arthritis risk, patients with psoriasis also have increased hyperlipidemia, hypertension, coronary artery disease, type 2 diabetes, and increased body mass index as compared to patients without psoriasis. Psoriasis can also cause patients to experience depression or low self-esteem due to the appearance of their condition.
Treatment of psoriasis may be topical or systemic depending on the severity of disease. Topical medications are most commonly used for mild to moderate psoriasis. Topical corticosteroids demonstrate high efficacy and safety. They have anti-inflammatory, antiproliferative, immunosuppressive, and vasoconstrictive effects. They are available in seven different classes of potency and several different vehicles which are chosen based on the disease location, severity and patient preference. As a general rule, lower potency steroids should be used on the face, intertriginous areas, and areas susceptible to atrophy such as the forearms. Areas with thick, stubborn plaques should be treated with ultrahigh-potency corticosteroids. Some adverse effects of topical corticosteroids include skin atrophy, folliculitis, and purpura however they are effective in treating mild to moderate disease.
Calcineurin inhibitors are another class of topical therapy for psoriasis. They work by binding to calcineurin, blocking phosphorylation which inhibits T-cell activation and the synthesis of proinflammatory cytokines which have a role in the development of psoriasis. Tacrolimus and pimecrolimus are effective on thinner skin on the face and intertriginous areas which is helpful if patients do not want to use steroids on these delicate areas. Vitamin D analogues such as calcipotriene inhibit keratinocyte proliferation and enhance keratinocyte differentiation. Calcipotriene is used mostly in patients with mild to moderate psoriasis. While these topical therapies may be effective for mild to moderate psoriasis, systemic treatments have higher efficacy and may be necessary to see improvement of severe psoriasis.
Systemic treatments for psoriasis include methotrexate, apremilast, cyclosporine, acitretin, and tofacitinib. Methotrexate is a dihydrofolate reductase competitive inhibitor. It has a potent effect on rapidly dividing cells in psoriasis. Patients being treated with methotrexate must be supplemented with folic acid to decrease the occurrence of adverse effects of methotrexate. Adverse effects include fatigue, anorexia and nausea. Apremilast is another systemic treatment approved for psoriasis in 2014. It is a phosphodiesterase 4 inhibitor which causes decreased inflammatory mediators like TNF-alpha, interleukin-23, and interleukin-10. It has a better side effect profile compared with methotrexate. Side effects include diarrhea, nausea, upper respiratory tract infection, and headache.
The therapies listed are only some of the treatments available for psoriasis. The wide variety of treatment options for psoriasis gives hope to patients with the disease but these treatments come with their own side effects. Patients may need to use topical and systemic treatment intermittently throughout their whole lifetime in order to keep the disease controlled.
Resources:
Elmets CA, Korman NJ, Prater EF, et al. Joint AAD–NPF guidelines of care for the management and treatment of psoriasis with topical therapy and alternative medicine modalities for psoriasis severity measures. Journal of the American Academy of Dermatology. 2021;84(2):432-470. doi:10.1016/j.jaad.2020.07.087
Menter A, Gelfand JM, Connor C, et al. Joint American Academy of Dermatology–National Psoriasis Foundation guidelines of care for the management of psoriasis with systemic nonbiologic therapies. Journal of the American Academy of Dermatology. 2020;82(6):1445-1486. doi:10.1016/j.jaad.2020.02.044
Rendon A, Schäkel K. Psoriasis Pathogenesis and Treatment. Int J Mol Sci. 2019;20(6):1475. Published 2019 Mar 23. doi:10.3390/ijms20061475
Psoriasis is a skin disorder concerning the hyperproliferation of the epidermis. There is an increased numbers of cells undergoing DNA synthesis and a faster turnover rate of the epidermis. It is an immune-mediated disease where T lymphocytes, dendritic cells, cytokines, and tumor necrosis factor are heavily involved. Psoriasis can be visibly characterized by plaques of red or pink color, covered by white or silvery scales. The plaques are most active around the edges and rapidly progressing. They are found commonly at the elbows, knees, scalp and lower back in a symmetric pattern. However, new lesions can form at atypical spots such as sites of trauma or pressure known as the Koebner phenomenon. There are four major subtypes of psoriasis: chronic plaque, guttate, pustular and erthyrodermic psoriasis. Chronic plaque psoriasis is the most common subtype. It can be described as having erythematous plaques with defined margins ranging from localized sites to the majority of the body surface area. Guttate psoriasis consists of the sudden appearance of small papules and plaques that are usually less than 1 cm in diameter, referring to a "drop-like" shape. The plaques primarily form at the trunk and proximal extremities. Pustular psoriasis can be life-threatening presenting with widespread erythema and sheets of superficial pustules. Other symptoms include fever, diarrhea, leukocytosis with possible renal and hepatic complications. Erythrodermic psoriasis encompasses erythema and scaling involving all of the body with a loss of barrier protection resulting in infections and electrolyte abnormalities.
There are a variety of treatments available. For mild psoriasis, one can utilize topical corticosteroids. They can be divided based off their potency with class I corticosteroids having the strongest potency and class VII having the weakest. For moderate psoriasis, phototherapy may be useful including UV-B, and UV-A. Narrowband UV-B is the preferred treatment due to its efficacy. It decreases DNA synthesis causing keratinocyte apoptosis and reduced the number of inflammatory cytokines. Lastly, there are TNF-α inhibitors which are biologics approved for psoriasis treatment. They inhibit TNF- α, interfering with the inflammatory cascade responsible for psoriasis.
References:
Armstrong AW, Read C. Pathophysiology, Clinical Presentation, and Treatment of
Psoriasis: A Review. JAMA.2020;323(19):1945–1960.
Feldman, Steven. “Psoriasis: Epidemiology, Clinical Manifestations, and Diagnosis.”
Psoriasis. What is it? How serious can it be? Does it affect the day-to-day life? Psoriasis is known as an immune-mediated disease. This means that the body’s own immune system (aka the body’s defense mechanism against any foreign substances) is attacking itself leading to inflammation of the body. Normal skin cells take about 30 days to regrow and fall off; this process is called skin cell turnover. With psoriasis, the skin cell turnover time takes only three to four days. As opposed to the skin shedding, it piles up instead. Psoriasis can occur at any part of the body and the build-up appears as plaques and scales; it can be described as felling itchy, burning, and stinging. Psoriasis is most commonly seen on elbows, knees and scalp. Although it seems superficial, psoriasis can affect other organs as well. The inflammation caused by the immune system leads to certain comorbidities.
Psoriasis is not very common as a disease and its cause is unknown. Contrary to one’s belief, psoriasis is not contagious. If the causes are unknown then who is at risk? Psoriasis may occur due to an incident or a trigger that changes the immune system. A person with no family history may develop psoriasis. Triggers are different from each person but a few triggers that can initiate psoriasis are stress, injury to the skin, illness, weather, and although less common but allergies can also be a trigger. It is important to track triggers over time in order to be able to acknowledge what causes the flares as well as to be able to treat them.
There are different types of psoriasis, five to be exact. They are Guttate, Pustular, Plaque, Inverse, and Erythrodermic Psoriasis. Guttate Psoriasis appears as small, round, red spots. Pustular Psoriasis include pustules which are pus-filled painful bumps and may be inflamed on the surrounding area. Plaque Psoriasis is one of the most common types and it appears as raised patched of inflamed, itchy and painful skin with scales. Inverse Psoriasis is shown as inflamed deep-red skin that is smooth and it can cause itching and pain. Erythrodermic Psoriasis is the rarest out of all types and it can cause intense redness and shedding of skin layers in large sheets. Erythrodermic affects the whole body and it can be life-threatening by changing heart rate, temperature, causing dehydration and changes in the nail.
Psoriasis is linked to other health conditions as well. Psoriatic arthritis (PsA) is one of the more common health conditions that may occur when having psoriasis. It is a chronic disease that leads to inflammation of the joints as well as areas where the tendons and ligaments connect to the bone. A few symptoms that people with PsA experience include stiffness, pain and swelling, nail changes, redness and pain of the eye. There is no cure for PsA but there are treatments that are available to slow the disease progression. Treatments include topical, phototherapy, oral treatments, as well natural medicine approaches. There are other health conditions linked to psoriasis as well such as cardiovascular diseases and obesity. It is important to understand what aggravates a person’s psoriasis in order to manage the flares better.
“Causes, Triggers and Treatments.” Psoriasis, National Psoriasis Foundation, www.psoriasis.org/about-psoriasis/.
“Locations & Types of Psoriasis.” Locations & Types of Psoriasis: National Psoriasis Foundation, National Psoriasis Foundation, www.psoriasis.org/locations-and-types/.
“What Is Psoriatic Arthritis?” What Is Psoriatic Arthritis?: National Psoriasis Foundation, National Psoriasis Foundation, www.psoriasis.org/about-psoriatic-arthritis/.
See Source 1: Psoriasis is a chronic, systemic immune-mediated disease characterized by development of erythematous, indurated, scaly, pruritic and often painful skin plaques. Psoriasis pathogenesis is driven by proinflammatory cytokines and psoriasis is associated with increased risk for comorbidities, including, but not limited to, psoriatic arthritis, cardiovascular disease, diabetes mellitus, obesity, inflammatory bowel disease and nonalcoholic fatty liver disease compared with the general population.
Like many skin conditions, psoriasis can be treated to lessen the severity and frequency of occurrence, but cannot be cured. Because of this, it is a chronic condition which can last for years or the rest of the patient’s life. Topical steroids and Vitamin A derivatives are first line treatment. It is important to educate the patient on proper skin cleansing and moisturization techniques as well. Fatty, oil-based products such as petroleum jelly used once daily along with stress management and other lifestyle modifications can make psoriasis manageable.
If the patient prefers more hydrophilic products which may be less sticky in comparison, other vehicles noted by source 4 are the following -
· Ointments - administered for thick hyper-keratotic lesions; the most potent vehicle since they are the most occlusive and should not be administered on hair-bearing regions because it may result in folliculitis
· Creams - less potent than ointment but cosmetically more appealing since they leave no residue; the drying, non-occlusive nature leads to their administration for acute exudative inflammation and dermatitis within the intertriginous areas.
· Lotions - less occlusive and greasy; work well in hair-bearing regions
· Gels - like lotions, less occlusive and greasy; work well in hair-bearing regions; more beneficial for the scalp as they do not cause matting of thleast occlusive and greasye hair
· Foams - highly effective for steroid delivery to the scalp but are costly
The American Academy of Dermatology (AAD) Association defines psoriasis as “an inflammatory, immunologically mediated condition stemming from inappropriate activation of cutaneous T cells and dendritic cells with subsequent release of a variety of cytokines and other soluble mediators” (1). The resulting keratinocyte proliferation, skin cell buildup, and chronic inflammation can contribute to comorbidities such as arthritis, dyslipidemia, metabolic syndrome, and cardiovascular disease. Generally, psoriasis manifests as thick, dry, scaly patches of skin that may be itchy, but there are several types of psoriasis with various symptoms. Plaque psoriasis is the most common and it appears as dry, silver scales on the skin, usually on the elbows, scalp, knees, or lower back (but can be anywhere on the body). Scalp psoriasis is when the psoriatic patches are isolated in the scalp area. Nail psoriasis appears as yellow-brown spots on the nails, pitted nails, and weak nails that easily crumble or fall off. Guttate psoriasis appears as small, scaly spots that usually occur in children after an infection. Inverse psoriasis is located where skin frequently rubs against itself, like the armpit or groin area, and appears as shiny, smooth, red patches instead of scaly ones. Pustular psoriasis causes painful pus-filled blisters and thick scales on the hands and feet. It can progress to generalized pustular psoriasis when it spreads to the rest of the body, which is a medical emergency. Finally, there is erythrodermic psoriasis which makes large areas of the skin appear bright red and burnt. When psoriasis affects the joints, it is called psoriatic arthritis and the joints tend to become swollen and tender, the heels may hurt, there may be swelling on the back of the legs, and there may be morning stiffness. Psoriasis is typically a lifelong skin condition that can never be fully cured, only acutely treated and managed using topical and systemic medications and/or phototherapy. The cycle of inflammation that drives psoriasis increases the risk of cardiovascular disease and other comorbidities, which makes regular checkups with their health care providers even more important for patients with psoriasis.
Works Cited:
Elmets CA, Leonardi CL, Davis DMR, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities. J Am Acad Dermatol. 2019;80(4):1073-1113. doi:10.1016/j.jaad.2018.11.058
Menter A, Gottlieb A, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis Section 1. Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics. J Am Acad Dermatol 2008;58:826-50.
Psoriasis
Psoriasis is a systemic inflammatory disease driven by T-lymphocytes, arising from a complex interaction between numerous genetic factors and environmental influences. A genetic predisposition, combined with triggering factors, initiates an abnormal immune response that leads to the development of initial psoriatic skin lesions. Additionally, it is an immune-mediated disease in which the skin inflammatory changes are dependent on immune cells and their cytokines, the interaction of dermal dendritic cells with activated TH-1 and TH-17 T cells, along with various cytokines and growth factors, leads to the epidermal hyperplasia and dermal inflammation observed in psoriasis patients. There are several types of psoriasis such as plaque (psoriasis vulgaris), flexural and/or intertriginous (inverse psoriasis), seborrheic, scalp, acrodermatitis of hallopeau, palm and/or soles, generalized pustular psoriasis, guttate, and erythrodermic. Plaque psoriasis is the most prevalent form, about 8 in 10 people with psoriasis have this kind.
The diagnosis of psoriasis is based on the characteristic psoriatic lesions and not on laboratory tests. Psoriasis is traditionally classified into mild, moderate, or severe disease. Assessment typically includes measures of symptoms and involvement such as body surface area (BSA), Psoriasis Area and Severity Index (PASI), or Physician’s Global Assessment (static PGA). Additionally quality-of-life measures, such as the Dermatology Life Quality Index (DLQI) or Short Form (SF-36) Health Survey. To roughly estimate the extent of body surface area (BSA) involvement in psoriasis, consider the following approximations: the size of your palm is about 1% BSA, involvement on the head and neck is around 10% BSA, both upper limbs account for roughly 20% BSA, the trunk (front and back combined) is about 30% BSA, and both lower limbs constitute approximately 40% BSA.
Treatment Overview:
The treatment approach for psoriasis involves addressing its underlying pathophysiology. Key strategies include utilizing agents that modulate the abnormal immune response, such as topical corticosteroids and biologic agents. Furthermore, therapies targeting cell turnover, like retinoids, are effective in managing psoriasis. Moreover, the treatment of psoriasis depends on the type, location, and extent of disease. All patients should be educated to avoid excess drying or irritation of their skin and to maintain adequate cutaneous hydration. A topical vitamin D analogue such as calcipotriene and a retinoid (tazarotene) are also effective in the treatment of mild psoriasis and have mainly replaced other topical agents such as coal tar, salicylic acid, and anthralin.
Ultraviolet (UV) light, whether from natural sources or artificial sources, presents an effective therapeutic option for several psoriasis patients with widespread symptoms. Clinical practice commonly utilizes Ultraviolet B (UVB), narrowband UVB, and Ultraviolet A (UVA) light alongside oral or topical psoralens (PUVA). The therapeutic efficacy of UV light in psoriasis is due to its immunosuppressive properties, however, it is significant to recognize that UV light is also mutagenic and may increase the risk of both nonmelanoma and melanoma skin cancers.
Methotrexate demonstrates effectiveness, particularly in those individuals with Psoriatic Arthritis. Acitretin, a synthetic retinoid can be used in those cases where immunosuppression needs to be avoided. Apremilast functions by inhibiting phosphodiesterase type 4 and is approved for treating both psoriasis and PsA. However, caution is advised when administering it in individuals with renal failure or depression.
Psoriasis presents as a chronic condition with no known cure. It's crucial to recognize the potential for significant comorbidities to accompany this condition. Tailoring treatment approaches to individual patients is key, accounting for factors such as disease severity, patient risk profiles, age, and concurrent health conditions. Goals of treatment for the patient should include control of psoriasis (skin normalization and increase pliability of skin), decrease or clearing of erythema, papules, plaques, and scales, and improving quality of life. The expanding array of treatment options, including the introduction of several biologic therapies, enhances the tools available for managing psoriasis. Looking ahead, the ongoing research and advancements in therapeutic approaches hold promise for enhancing the well-being of those navigating this dermatological condition.
References:
Law, R. M., & Gulliver, W. (n.d.-b). accesspharmacy-mhmedical-com.j. https://accesspharmacy-mhmedical-com.jerome.stjohns.edu/content.aspx?sectionid=271955913&bookid=3097#1205349588
Mayo Foundation for Medical Education and Research. (2024b, May 17). Psoriasis. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/psoriasis/diagnosis-treatment/drc-20355845
Lawley, L. P., Cheeley, J. T., & Swerlick, R. A. (n.d.). https://accesspharmacy-mhmedical-com. https://accesspharmacy-mhmedical-com.jerome.stjohns.edu/content.aspx?sectionid=262791247&bookid=3095#274787244
According to current studies, more than 8 million Americans have psoriasis. In a 2021 cross sectional study, the prevalence of psoriasis in the U.S. was 3% for individuals over 20 years of age. An immune-mediated disease, psoriasis affects nearly 125 million individuals worldwide. This chronic condition causes inflammation in the body resulting in raised plaques, redness, itchiness, burning, and stinging. The plaques are formed due to an overactive immune system resulting in a scaly pile-up of skin cells, often found on the elbows, knees, and scalp. Although the pathogenesis in unclear, several concepts have been hypothesized. The most common hypothesis being the “activation of T cells, inflammatory cells, and keratinocytes leading to the release of cytokines. The plaque formation is due to the hyper-proliferation of the keratinoctytes.” It has been reported that this chronic disorder may have predispositions and triggering environmental factors such as bacterial infections, trauma, and even drug-induced, although none have been confirmed. Other forms of psoriasis include guttate psoriasis, inverse psoriasis, pustular psoriasis, and erythrodermic psoriasis, and psoriatic arthritis.
Psoriasis negatively impacts the quality of life, as commonly seen among young children and women. As there is no cure for psoriasis, it is the healthcare team’s goal to increase pliabliity of the skin and decrease or clear any erythema, papules, plaques, and scales, to improve the quality of life. With the ongoing expanding market of psoriasis treatments, topical agents are the first-line drugs of choice before the introduction of phototherapy or a systemic agent. These topical agents range from corticosteroids, emollients, tar, typical retinoids, anthralin, to topical calcineurin inhibitors, although results may take a few months. More advanced treatments include methotrexate, cyclosporine, and newly-discovered biologics. The variability of treatment options is so vast, topical corticosteroids can be further divided in potency categories. Psoriasis treatment, unfortunately, becomes a game of trail and error for many individuals.
With biologics being the revolutionary drugs of the decade, these immunomodulators come with their fair share of cons. Although less toxicity is observed towards the kidneys and liver with quicker and efficient results, patients leave themselves susceptible to infections, exacerbation of existing cardiovascular diseases, demyelinating diseases, and even blood dyscrasias.
One of the most commonly administered biologics for psoriasis is infliximab (Remicade). A TNFA-alpha blocker, infliximab is only available through an infusion. In spite of the fact that a single, reconstituted-vial of the drug costs rougly $1,000, a single treatment session ranges between $3,000 and $5,000. Completing the entire regimen can cost well over $50,000 for the year as patients must return at weeks 0, 2, and 6 and every 8 weeks thereafter. Infliximab has FDA-approved biosimilars, however, costs range between $500 and $1,000. Biologic usage has promising results but is reserved as a last-line treatment for refractory patients.
References
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8246333/
https://pubmed.ncbi.nlm.nih.gov/23565631/
https://pubmed.ncbi.nlm.nih.gov/32121574/
Yu Feng Lin & Fawziya Twam
Psoriasis is a common and chronic immune-mediated disease which causes inflammation in the body. The inflammation can be visibly seen on the skin through raised plaques and scales. These plaques can be seen anywhere on the body, but are most common on the elbows, knees and scalp. The reason for the plaques and scales and skin cell overgrowth. Typically skin cells completely grow and shed off within a month. For those who suffer from psoriasis, the skin grows every 3 or 4 days without shedding. This leads to a skin cell pile up on the surface of the skin. Not only is the inflammation visible, but many report feeling the plaques itch, burn and sting.
There are many types of psoriasis. Plaque psoriasis is the most common. This is the subtype which is expressed through build up skin cells resulting in pruritic plaques and scales. It can be present in almost any part of the body including the scalp. Another subtype is guttate psoriasis. The name guttate is to describe the drop-like appearance of the skin lesions. Guttate psoriasis is presented as small lesions over the upper trunk and throughout the proximal extremities. Pustular psoriasis is a much more severe case. The plaque and itchiness is substituted with blisters and can be much more painful. These blisters can be limited to one area of the body or in multiple areas at once. Once the blisters are treated, the skin is left scaly and uncomfortable.
Psoriasis can leave many patients vulnerable as it destroys one of our most protective layers. The skin is a big part of our immune system, and when damaged can leave the body vulnerable to many infections and illnesses. One illness which is commonly found when patients have psoriasis is streptococcus infection or strep throat. Many times in children, strep throat is what triggers the first onset of guttate psoriasis. Some common triggers of psoriasis include stress. Unfortunately in this case, many times psoriasis flare ups can cause stress, resulting in a loop of stress induced flare ups. Another big trigger is injury to the skin. These injuries can be minor, yet still result in a psoriasis flare up. This is a result of the KEB-ner phenomenon. Basically it means scratches, sunburns, bug bites and even vaccinations can all be common skin injuries that lead to a psoriasis flare up. The weather is another common trigger. Often times it is colder weather which is triggering. The decrease in humidity and sunlight leads to drier skin. There are some who suspect allergies, certain foods, alcohol and tobacco may be a trigger. This theory is much more patient based. For instance one may have a flare up from her food allergy, while another wouldn't be affected at all.
Genetics plays a large role in the likelihood of developing plaque psoriasis. It is also seen that around 2% of the population has plaque psoriasis, with women generally having an earlier onset of the symptoms. The pathogenesis of psoriasis is based around the innate and adaptive immune response. A disturbance is stimulated somewhere around the innate system, leading to an inflammatory response. When activated the innate system stimulates T cells. T cells release proinflammatory cytokines. Activated T cells of the TH-1 and the TH-17 as well as the cytokines are what lead to the inflammatory response seen in the skin in people with psoriasis.
The main treatment for psoriasis is topical corticosteroids. Corticosteroids have anti-inflammatory and immunosuppressive properties. The goal of therapy is to eliminate the visible signs of psoriasis, the plaques and scales. It is also to reduce the frequency of flare ups as well as the discomfort of the person. The overuse of topical corticosteroids can cause multiple side effects including; stretch marks, thinning skin, increased bruising, dilated blood vessels and in some cases an increase in hair growth.
Although psoriasis is most visible through the skin, the skin is not the only target. There are many comorbidities associated with psoriasis. Some of the comorbidities associated; PsA or psoriatic arthritis, depression, diabetes, metabolic syndrome, inflammatory bowel disease and cardiovascular disease. Psoriatic arthritis is connected to the severity of the psoriasis. Early diagnosis of PsA is vital for proper treatment. If the psoriasis is severe the patient should be checked for PsA. Unfortunately 1 in 10 people with PsA go undiagnosed. The pain can be subtle at first, but with the proper patient education, patients can help catch an earlier diagnosis and receive the treatment needed for them. Another common disease seen in psoriasis is cardiovascular disease. Chronic inflammation is the main issue of psoriasis, and inflammation is a large factor in causing cardiovascular disease. Chronic inflammation also increases the risk of stroke. Treating psoriasis is linked with a decreased risk of stroke and/or heart attack. Chronic inflammation also affects how sugar is absorbed in the body. This greatly increases the risk of type II diabetes. Type II diabetes also leads to other comorbidities such as heart disease and obesity. The inflammation in psoriasis is due to certain genes and some of these genes are the same ones which cause inflammatory bowel syndrome. If psoriasis flare ups and associated with inflammatory bowel disease symptoms, it should be reported to the doctor. Symptoms include abdominal pain, diarrhea, constipation and bloody stool.
Unlike the previous morbidities discussed previously, depression is not physical. The National Psoriasis Foundation found depression to be at the top of the comorbidity list of psoriasis. Depression is the persistent feeling of sadness or loss of interest. Behavioral changes can be seen when depressed such as changes in sleep, appetite, self-esteem and energy-level. Antidepressants can be given to patients to help, but it has been shown that treating the psoriasis also helps. Depression in many times can be linked to one's health. Psoriasis puts a person in pain and a constantly uncomfortable state. Other than that it also affects a person's appearance. This can greatly damage one's self esteem. Together, the effects of psoriasis eventually will decrease a person's quality of life. By treating the condition, the person will in turn feel better, and increase the quality of life, decreasing the risk of depression.
References:
National Psoriasis Foundation. (n.d.). Psoriasis: Causes, triggers and treatments. The National Psoriasis Foundation: National Psoriasis Foundation. https://www.psoriasis.org/about-psoriasis/
Shibboleth authentication request. (n.d.). https://accesspharmacy-mhmedical-com.jerome.stjohns.edu/content.aspx?bookid=2577§ionid=239761543#1182453916
National Psoriasis Foundation. (n.d.-a). Psoriasis: Causes & triggers. The National Psoriasis Foundation: National Psoriasis Foundation. https://www.psoriasis.org/causes/#:~:text=There%20is%20a%20connection%20between,strep%20throat%20without%20showing%20symptoms.
Barhum, L. (2022, July 28). Common comorbidities in psoriasis. Verywell Health. https://www.verywellhealth.com/psoriasis-comorbidities-4777652#:~:text=Comorbidities%20associated%20with%20psoriasis%20include,%2C%20cardiovascular%20disease%2C%20and%20more.
Psoriasis
Psoriasis is a chronic inflammatory disease mediated by the immune system. Psoriasis is also likely an autoimmune disease. The buildup of skin cells causes itchy, white scales or plaques to form on the skin. It is mostly located on the elbows, knees, or scalp, but can occur on other parts of the body as well. It is often associated with other comorbidities like psoriatic arthritis, mood disorders, cardiovascular disease, and metabolic syndrome. Psoriasis is the result of sustained inflammation leading to uncontrolled proliferation of keratinocytes and dysfunctional differentiation (Rendon, A., & Schäkel, K.). Sustained inflammation is due to changes in the innate and adaptive immune responses in the skin. The innate immune system is activated and there is also an autoinflammatory or autoimmune reaction. Dendritic cells are activated in the initial stages of psoriasis. There is activation of T cells during the maintenance phase of psoriasis. Dysregulation of the IL-23/Th-17 signaling pathway also drives the disease.
Treatment for psoriasis has evolved over time. In the 19th century and first half of the 20th century, arsenic was used for psoriasis before it was determined that there was toxicity associated with it. X-rays were also used in the 20th century, but it was determined that there were carcinogenic side effects associated with it. In the 1950s, corticosteroids were discovered. Oral prednisolone and triamcinolone were effective. Topical steroids like betamethasone and fluocinolone were used in the 1960s and showed significant effects. Topical steroids are only able to treat psoriasis temporarily and are not a permanent solution. Steroids are anti-inflammatory, immunosuppressive, and anti-proliferative. Methotrexate was first used in the 1950s and is currently the first line treatment for patients that can be treated systemically and also for psoriatic arthritis (Reid, C., & Griffiths, C. E. M.). Another treatment is the use of psoralens (photosensitizers) with UVA. This treatment can increase risk of cutaneous squamous cell carcinoma so its use has declined. Ciclosporin is an immunosuppressive drug that is used for psoriasis. The success of ciclosporin helped determine that psoriasis is mediated by T cells. Furthermore, ciclosporin can cause nephrotoxicity so it is dosed in short courses of therapy. Vitamin D analogues like calcipotriol can be used in combination with the topical steroid betamethasone valerate as an effective treatment. Biologics have become a growing focus in the modern century. They are indicated in moderate-severe psoriasis after failure of first line therapies. T cell targeted biologics included alafacept and efalizumab which were both withdrawn from the market. Tumor necrosis factor (TNF)-α is the target of etanercept, infliximab, and adalimumab. Adalimumab is the biologic that is the first line recommended treatment for psoriasis with psoriatic arthritis. Currently, the focus is on targeting cytokines IL-23 or IL-17 and disrupting their signaling. Three biologics against IL-17 include secukinumab, ixekizumab, and brodalumab ((Reid, C., & Griffiths, C. E. M.).
Psoriasis is associated with comorbidities like metabolic syndrome. They are both associated with Il-23/Th-17 signaling pathways. About 20-50% of patients with psoriasis have metabolic syndrome (Wu, J. J. et al.). There has not been a definitive link between psoriasis and metabolic syndrome, but genetics, the overlapping signaling pathways, and the environment can contribute. Family members of patients with psoriasis have an increased risk of developing psoriasis. Treating one condition may help improve the other. When treating patients for psoriasis, they should be screened for comorbidities before creating a treatment plan because systemic treatment may be warranted to treat multiple conditions.
Resources:
Reid, C., & Griffiths, C. E. M. (2020). Psoriasis and Treatment: Past, Present and Future Aspects. Acta dermato-venereologica, 100(3), adv00032. https://doi.org/10.2340/00015555-3386
Rendon, A., & Schäkel, K. (2019). Psoriasis Pathogenesis and Treatment. International journal of molecular sciences, 20(6), 1475. https://doi.org/10.3390/ijms20061475
Wu, J. J., Kavanaugh, A., Lebwohl, M. G., Gniadecki, R., & Merola, J. F. (2022). Psoriasis and metabolic syndrome: implications for the management and treatment of psoriasis. Journal of the European Academy of Dermatology and Venereology : JEADV, 36(6), 797–806. https://doi.org/10.1111/jdv.18044
Psoriasis: Overview
Psoriasis is a chronic inflammatory skin disease which affects around 2% of the world. It is characterized by chronic inflammation that leads to uncontrolled keratinocyte proliferation and dysfunctional differentiation. It is an immune-mediated disease in which T lymphocytes, dendritic cells, and cytokines (interleukin 23, interleukin 17, and tumor necrosis factor) play a central role.
There are several different subtypes of psoriasis. The most common is plaque psoriasis which presents as sharply demarcated, erythematous, pruritic plaques covered in silvery scales usually present on the trunk, extensor surfaces of the limbs, and the scalp. The next type is guttate psoriasis which is characterized by acute onset of small erythematous papules and plaques. The trunk and proximal extremities are the main areas affected by the guttate type. Pustular psoriasis is a severe form of psoriasis with multiple, coalescing sterile pustules. It is associated with malaise, fever, diarrhea, leukocytosis, and hypocalcemia. Erythrodermic psoriasis is uncommon but is characterized by generalized erythema and scaling on all or most of the body surface. Patients with this type are at high risk for infection and electrolyte abnormalities.
Psoriasis was originally thought to be just a disease of the skin but was found that it affects the body as a whole with related comorbidities in other organ systems. The most common comorbidity is psoriatic arthritis, occurring in about 40% of patients with psoriasis. Symptoms of psoriatic arthritis include joint pain, joint stiffness, and back pain. Dactylitis and enthesitis present in oligoarticular or polyarticular patterns.
In addition to the psoriatic arthritis risk, patients with psoriasis also have increased hyperlipidemia, hypertension, coronary artery disease, type 2 diabetes, and increased body mass index as compared to patients without psoriasis. Psoriasis can also cause patients to experience depression or low self-esteem due to the appearance of their condition.
Treatment of psoriasis may be topical or systemic depending on the severity of disease. Topical medications are most commonly used for mild to moderate psoriasis. Topical corticosteroids demonstrate high efficacy and safety. They have anti-inflammatory, antiproliferative, immunosuppressive, and vasoconstrictive effects. They are available in seven different classes of potency and several different vehicles which are chosen based on the disease location, severity and patient preference. As a general rule, lower potency steroids should be used on the face, intertriginous areas, and areas susceptible to atrophy such as the forearms. Areas with thick, stubborn plaques should be treated with ultrahigh-potency corticosteroids. Some adverse effects of topical corticosteroids include skin atrophy, folliculitis, and purpura however they are effective in treating mild to moderate disease.
Calcineurin inhibitors are another class of topical therapy for psoriasis. They work by binding to calcineurin, blocking phosphorylation which inhibits T-cell activation and the synthesis of proinflammatory cytokines which have a role in the development of psoriasis. Tacrolimus and pimecrolimus are effective on thinner skin on the face and intertriginous areas which is helpful if patients do not want to use steroids on these delicate areas. Vitamin D analogues such as calcipotriene inhibit keratinocyte proliferation and enhance keratinocyte differentiation. Calcipotriene is used mostly in patients with mild to moderate psoriasis. While these topical therapies may be effective for mild to moderate psoriasis, systemic treatments have higher efficacy and may be necessary to see improvement of severe psoriasis.
Systemic treatments for psoriasis include methotrexate, apremilast, cyclosporine, acitretin, and tofacitinib. Methotrexate is a dihydrofolate reductase competitive inhibitor. It has a potent effect on rapidly dividing cells in psoriasis. Patients being treated with methotrexate must be supplemented with folic acid to decrease the occurrence of adverse effects of methotrexate. Adverse effects include fatigue, anorexia and nausea. Apremilast is another systemic treatment approved for psoriasis in 2014. It is a phosphodiesterase 4 inhibitor which causes decreased inflammatory mediators like TNF-alpha, interleukin-23, and interleukin-10. It has a better side effect profile compared with methotrexate. Side effects include diarrhea, nausea, upper respiratory tract infection, and headache.
The therapies listed are only some of the treatments available for psoriasis. The wide variety of treatment options for psoriasis gives hope to patients with the disease but these treatments come with their own side effects. Patients may need to use topical and systemic treatment intermittently throughout their whole lifetime in order to keep the disease controlled.
Resources:
Elmets CA, Korman NJ, Prater EF, et al. Joint AAD–NPF guidelines of care for the management and treatment of psoriasis with topical therapy and alternative medicine modalities for psoriasis severity measures. Journal of the American Academy of Dermatology. 2021;84(2):432-470. doi:10.1016/j.jaad.2020.07.087
Menter A, Gelfand JM, Connor C, et al. Joint American Academy of Dermatology–National Psoriasis Foundation guidelines of care for the management of psoriasis with systemic nonbiologic therapies. Journal of the American Academy of Dermatology. 2020;82(6):1445-1486. doi:10.1016/j.jaad.2020.02.044
Rendon A, Schäkel K. Psoriasis Pathogenesis and Treatment. Int J Mol Sci. 2019;20(6):1475. Published 2019 Mar 23. doi:10.3390/ijms20061475
Psoriasis
Psoriasis is a skin disorder concerning the hyperproliferation of the epidermis. There is an increased numbers of cells undergoing DNA synthesis and a faster turnover rate of the epidermis. It is an immune-mediated disease where T lymphocytes, dendritic cells, cytokines, and tumor necrosis factor are heavily involved. Psoriasis can be visibly characterized by plaques of red or pink color, covered by white or silvery scales. The plaques are most active around the edges and rapidly progressing. They are found commonly at the elbows, knees, scalp and lower back in a symmetric pattern. However, new lesions can form at atypical spots such as sites of trauma or pressure known as the Koebner phenomenon. There are four major subtypes of psoriasis: chronic plaque, guttate, pustular and erthyrodermic psoriasis. Chronic plaque psoriasis is the most common subtype. It can be described as having erythematous plaques with defined margins ranging from localized sites to the majority of the body surface area. Guttate psoriasis consists of the sudden appearance of small papules and plaques that are usually less than 1 cm in diameter, referring to a "drop-like" shape. The plaques primarily form at the trunk and proximal extremities. Pustular psoriasis can be life-threatening presenting with widespread erythema and sheets of superficial pustules. Other symptoms include fever, diarrhea, leukocytosis with possible renal and hepatic complications. Erythrodermic psoriasis encompasses erythema and scaling involving all of the body with a loss of barrier protection resulting in infections and electrolyte abnormalities.
There are a variety of treatments available. For mild psoriasis, one can utilize topical corticosteroids. They can be divided based off their potency with class I corticosteroids having the strongest potency and class VII having the weakest. For moderate psoriasis, phototherapy may be useful including UV-B, and UV-A. Narrowband UV-B is the preferred treatment due to its efficacy. It decreases DNA synthesis causing keratinocyte apoptosis and reduced the number of inflammatory cytokines. Lastly, there are TNF-α inhibitors which are biologics approved for psoriasis treatment. They inhibit TNF- α, interfering with the inflammatory cascade responsible for psoriasis.
References:
Armstrong AW, Read C. Pathophysiology, Clinical Presentation, and Treatment of
Psoriasis: A Review. JAMA.2020;323(19):1945–1960.
Feldman, Steven. “Psoriasis: Epidemiology, Clinical Manifestations, and Diagnosis.”
UpToDate, UpToDate, Dec. 2019.
Psoriasis. What is it? How serious can it be? Does it affect the day-to-day life? Psoriasis is known as an immune-mediated disease. This means that the body’s own immune system (aka the body’s defense mechanism against any foreign substances) is attacking itself leading to inflammation of the body. Normal skin cells take about 30 days to regrow and fall off; this process is called skin cell turnover. With psoriasis, the skin cell turnover time takes only three to four days. As opposed to the skin shedding, it piles up instead. Psoriasis can occur at any part of the body and the build-up appears as plaques and scales; it can be described as felling itchy, burning, and stinging. Psoriasis is most commonly seen on elbows, knees and scalp. Although it seems superficial, psoriasis can affect other organs as well. The inflammation caused by the immune system leads to certain comorbidities.
Psoriasis is not very common as a disease and its cause is unknown. Contrary to one’s belief, psoriasis is not contagious. If the causes are unknown then who is at risk? Psoriasis may occur due to an incident or a trigger that changes the immune system. A person with no family history may develop psoriasis. Triggers are different from each person but a few triggers that can initiate psoriasis are stress, injury to the skin, illness, weather, and although less common but allergies can also be a trigger. It is important to track triggers over time in order to be able to acknowledge what causes the flares as well as to be able to treat them.
There are different types of psoriasis, five to be exact. They are Guttate, Pustular, Plaque, Inverse, and Erythrodermic Psoriasis. Guttate Psoriasis appears as small, round, red spots. Pustular Psoriasis include pustules which are pus-filled painful bumps and may be inflamed on the surrounding area. Plaque Psoriasis is one of the most common types and it appears as raised patched of inflamed, itchy and painful skin with scales. Inverse Psoriasis is shown as inflamed deep-red skin that is smooth and it can cause itching and pain. Erythrodermic Psoriasis is the rarest out of all types and it can cause intense redness and shedding of skin layers in large sheets. Erythrodermic affects the whole body and it can be life-threatening by changing heart rate, temperature, causing dehydration and changes in the nail.
Psoriasis is linked to other health conditions as well. Psoriatic arthritis (PsA) is one of the more common health conditions that may occur when having psoriasis. It is a chronic disease that leads to inflammation of the joints as well as areas where the tendons and ligaments connect to the bone. A few symptoms that people with PsA experience include stiffness, pain and swelling, nail changes, redness and pain of the eye. There is no cure for PsA but there are treatments that are available to slow the disease progression. Treatments include topical, phototherapy, oral treatments, as well natural medicine approaches. There are other health conditions linked to psoriasis as well such as cardiovascular diseases and obesity. It is important to understand what aggravates a person’s psoriasis in order to manage the flares better.
“Causes, Triggers and Treatments.” Psoriasis, National Psoriasis Foundation, www.psoriasis.org/about-psoriasis/.
“Locations & Types of Psoriasis.” Locations & Types of Psoriasis: National Psoriasis Foundation, National Psoriasis Foundation, www.psoriasis.org/locations-and-types/.
“What Is Psoriatic Arthritis?” What Is Psoriatic Arthritis?: National Psoriasis Foundation, National Psoriasis Foundation, www.psoriasis.org/about-psoriatic-arthritis/.
See Source 1: Psoriasis is a chronic, systemic immune-mediated disease characterized by development of erythematous, indurated, scaly, pruritic and often painful skin plaques. Psoriasis pathogenesis is driven by proinflammatory cytokines and psoriasis is associated with increased risk for comorbidities, including, but not limited to, psoriatic arthritis, cardiovascular disease, diabetes mellitus, obesity, inflammatory bowel disease and nonalcoholic fatty liver disease compared with the general population.
Like many skin conditions, psoriasis can be treated to lessen the severity and frequency of occurrence, but cannot be cured. Because of this, it is a chronic condition which can last for years or the rest of the patient’s life. Topical steroids and Vitamin A derivatives are first line treatment. It is important to educate the patient on proper skin cleansing and moisturization techniques as well. Fatty, oil-based products such as petroleum jelly used once daily along with stress management and other lifestyle modifications can make psoriasis manageable.
If the patient prefers more hydrophilic products which may be less sticky in comparison, other vehicles noted by source 4 are the following -
· Ointments - administered for thick hyper-keratotic lesions; the most potent vehicle since they are the most occlusive and should not be administered on hair-bearing regions because it may result in folliculitis
· Creams - less potent than ointment but cosmetically more appealing since they leave no residue; the drying, non-occlusive nature leads to their administration for acute exudative inflammation and dermatitis within the intertriginous areas.
· Lotions - less occlusive and greasy; work well in hair-bearing regions
· Gels - like lotions, less occlusive and greasy; work well in hair-bearing regions; more beneficial for the scalp as they do not cause matting of thleast occlusive and greasye hair
· Foams - highly effective for steroid delivery to the scalp but are costly
1. Management of psoriasis as a systemic disease: what is the evidence? https://pubmed.ncbi.nlm.nih.gov/31225638/
2. Psoriasis Pathogenesis and Treatment, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6471628/
3. Diagnosis and management of psoriasis, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5389757/
4. Topical corticosteroids, https://www.ncbi.nlm.nih.gov/books/NBK532940/
The American Academy of Dermatology (AAD) Association defines psoriasis as “an inflammatory, immunologically mediated condition stemming from inappropriate activation of cutaneous T cells and dendritic cells with subsequent release of a variety of cytokines and other soluble mediators” (1). The resulting keratinocyte proliferation, skin cell buildup, and chronic inflammation can contribute to comorbidities such as arthritis, dyslipidemia, metabolic syndrome, and cardiovascular disease. Generally, psoriasis manifests as thick, dry, scaly patches of skin that may be itchy, but there are several types of psoriasis with various symptoms. Plaque psoriasis is the most common and it appears as dry, silver scales on the skin, usually on the elbows, scalp, knees, or lower back (but can be anywhere on the body). Scalp psoriasis is when the psoriatic patches are isolated in the scalp area. Nail psoriasis appears as yellow-brown spots on the nails, pitted nails, and weak nails that easily crumble or fall off. Guttate psoriasis appears as small, scaly spots that usually occur in children after an infection. Inverse psoriasis is located where skin frequently rubs against itself, like the armpit or groin area, and appears as shiny, smooth, red patches instead of scaly ones. Pustular psoriasis causes painful pus-filled blisters and thick scales on the hands and feet. It can progress to generalized pustular psoriasis when it spreads to the rest of the body, which is a medical emergency. Finally, there is erythrodermic psoriasis which makes large areas of the skin appear bright red and burnt. When psoriasis affects the joints, it is called psoriatic arthritis and the joints tend to become swollen and tender, the heels may hurt, there may be swelling on the back of the legs, and there may be morning stiffness. Psoriasis is typically a lifelong skin condition that can never be fully cured, only acutely treated and managed using topical and systemic medications and/or phototherapy. The cycle of inflammation that drives psoriasis increases the risk of cardiovascular disease and other comorbidities, which makes regular checkups with their health care providers even more important for patients with psoriasis.
Works Cited:
Elmets CA, Leonardi CL, Davis DMR, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities. J Am Acad Dermatol. 2019;80(4):1073-1113. doi:10.1016/j.jaad.2018.11.058
Menter A, Gottlieb A, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis Section 1. Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics. J Am Acad Dermatol 2008;58:826-50.