Psoriasis

Table of Contents

Introduction
Types of Psoriasis
Causes
Triggers
Complications
Diagnosis
Treatments
Conclusion

Introduction

Psoriasis (suh-rye-uh-sis) is a chronic (long lasting) skin condition characterized by a buildup of cells on the surface of the skin. Skin cells grow and die at approximately 80%-100% faster with psoriasis. This leads to red patches of thick skin that can form scales. Typically psoriasis is itchy and painful.

There are several different types of psoriasis. They have unique symptoms and visual appearances, but 80% of psoriasis is plaque psoriasis.

While the exact cause of psoriasis is not fully understood, it is believed to be related to:

Genetics
The immune system
Environmental triggers

Symptoms can develop at any age, but are most commonly diagnosed in adults. Psoriasis is non-contagious, and can range from mild, to severe.
Common symptoms include:

Red patches of skin
Thick, silvery scales
Dry or cracked skin
Bleeding
Itching
Burning
Soreness
Thickened or ridged nails

Symptoms can come and go throughout a person’s life, and the disease is characterized by mild-to-severe flare-ups.

These can be triggered by a variety of external materials. There are also complications that can occur with psoriasis.

Psoriasis affects around 2-3% of the global population. The prevalence of psoriasis can be difficult to determine accurately due to variations in reporting and healthcare access in different regions of the globe.

Often, in the literature, patches of psoriasis (or other skin problems) are described as lesions. A lesion is a broad term that describes any abnormalities or damage to the skin.

There are many different treatments for psoriasis; and they range from non-steroidal topical creams, to steroidal topicals, light therapy (also known as phototherapy) that you put on your skin, to biologics that control the immune system itself. It can be difficult choosing and finding the best treatment. It may take many tries to get it right, but thankfully a high percentage of psoriasis can be effectively treated with the help of a dermatologist.

PASI: Measuring Psoriasis Severity.

Psoriasis symptoms are rated or measured using a scale called The Psoriasis Area and Severity Index (PASI)

PASI scores the redness, thickness, and scaling of lesions in four body regions: head, upper extremities, trunk, and lower extremities.

Each region is also scored based on the percentage of area affected, and these scores are combined to give a total PASI score ranging from 0 to 72.

This score helps doctors assess how severe psoriasis is and track treatment effectiveness.

Types of Psoriasis

Plaque Psoriasis

Plaque psoriasis is the most common form of psoriasis consisting of approximately 80% of all cases. It leads to thick, scaly skin patches, typically found on the elbows, back, knees, and scalp. In severe cases, it can spread to the face, feet, genitals, hands, and legs.

You’re more likely to develop it if you:

Drink alcohol, smoke cigarettes, or are overweight
Have family with psoriasis
Have stress or depression

Nail Psoriasis

Nail psoriasis causes discoloration, pain, and other changes in the nail. It may cause small dents (known as nail pitting) to form. It can also cause a build up underneath the nail, and the nail may become weak and crumble. As buildup occurs underneath the nail it can even separate and fall off.

Usually, nail psoriasis follows another psoriasis diagnosis; however – it can happen without any other signs of psoriasis.

Nail psoriasis has been shown to be more prevalent in:

Men
People over 40
Those with family psoriasis
Those with psoriatic arthritis

Guttate Psoriasis

Guttate psoriasis is a less common form of psoriasis making up about 2% of all cases. This psoriasis shows in the form of red drop-shaped lesions that appear on the skin. Usually the scales are thin, and red or pink in color.
Guttate psoriasis often affects the trunk, arms, and legs, but can sometimes cover a large portion of the body.
Known for developing suddenly, often in children or young adults, guttate psoriasis is commonly triggered by bacterial infections such as strep throat.

Guttate psoriasis is more likely if you:

Have recently had a bacterial infection, particularly streptococcal infections
Have a family history of psoriasis
Are under significant stress, or use alcohol.
Sunburnt
Have a history of viral infections
Are young (typically under 30 years old)

Each type of psoriasis has a unique appearance and shows up in different places. Their triggers are different, and so too are the severity and complications that come with each form of psoriasis.

Inverse Psoriasis

Pustular Psoriasis

Inverse psoriasis, also known as intertriginous psoriasis, is a form of psoriasis that appears in the skin folds. Around 20-30% of people with psoriasis will deal with inverse psoriasis.

Often developing in areas where skin touches skin, such as the armpits, groin, under the breasts, and around the genitals and buttocks. Inverse psoriasis symptoms are smooth, red, and inflamed patches that lack the typical scaly appearance. Inverse psoriasis can be particularly uncomfortable due to its location in sensitive areas that are prone to friction and sweating.

You are more likely to develop inverse psoriasis if you:

Are overweight or obese
Have a family history of psoriasis
Experience frequent friction and sweating
Suffer from other types of psoriasis
Have a weakened immune system

Pustular psoriasis is a rare form of psoriasis characterized by the presence of pus-filled blisters, or pustules, on the skin. It affects approximately 3% of all people with psoriasis. The pustules are usually surrounded by red, inflamed skin patches that are painful to touch. Pustular psoriasis may occur in localized areas of the body or it can cover large areas. Symptoms may be accompanied by fever, chills, or fatigue. It commonly affects the palms, soles, and fingers and toes, but can show up anywhere on the body.

The exact cause of pustular psoriasis is not fully understood, but it is believed to be related to an overactive immune system. Certain triggers, such as stress, infections, medications, and exposure to certain chemicals, can exacerbate symptoms. Steroid withdrawal can also trigger symptoms. 

Causes of Psoriasis

Psoriasis is an auto-immune disorder. Normally our immune system attacks things that are bad for us when they enter our body. Things like: viruses, bacteria, or even parasites. An auto-immune disorder causes the immune system to attack normal cells within the body. In psoriasis our skin cells become the target.

While the exact cause of psoriasis is not fully understood, it is believed to be related to:

Genetics
The immune system
Environmental triggers

Skin cell production increases rapidly. The skin cell growth cycle, which normally takes a month, can take only 3-4 days. This is how we get plaques and scales that form.

Triggers

Each type of psoriasis has individual triggers and causes. There are quite a few. This list does not cover all possible triggers, but helps reference some of the more common ones.

Cold, dry weather
Sudden changes in weather
Emotional stress
Physical stress (e.g., surgery, illness)
Cuts, scrapes, or scratches
Sunburns
Bug bites
Vaccinations, tattoos, or piercings (Koebner phenomenon)
Alcohol consumption
Smoking
Certain foods (e.g., gluten, dairy, red meat, processed foods)
Streptococcal throat infection (strep throat)
Skin infections
Respiratory infections (e.g., colds, flu)
HIV infection
Fungal infections (e.g., Candida)
Beta-blockers (e.g., propranolol)
Lithium (used for bipolar disorder)
Antimalarial drugs (e.g., chloroquine, hydroxychloroquine)
NSAIDs (e.g., ibuprofen, naproxen)
Tetracyclines (antibiotics)
Excessive bathing or showering (especially with hot water)
Climate (humidity levels)

Interferons (used to treat certain viral infections and cancers)
Puberty
Pregnancy
Menopause
Menstrual cycle
Pollen
Pet dander
Dust mites
Certain soaps and detergents
Perfumes and fragrances
Chemicals in cleaning products
Obesity
Diabetes
Cardiovascular disease
Lack of sleep
Sedentary lifestyle
Poor diet
Autoimmune diseases (e.g., rheumatoid arthritis, Crohn’s disease)
Anxiety
Depression
Dry skin
Excessive sun exposure

As you can see the potential triggers for psoriasis flare-ups are many. It’s typically recommended that people keep a trigger journal so they can keep track of what makes their symptoms flare up.

Complications with Psoriasis

Psoriatic Arthritis (PsA)

This condition is relatively common in those with Psoriasis (about 30%). It causes pain, stiffness, and potentially permanent joint damage where bones are connected to tendons and ligaments. There is currently no cure for PsA, but there are treatments that can slow its progression.

Eye Health

Psoriasis is also associated with several eye problems. Up to one fifth of people with psoriasis can get uveitis, and there is an association between psoriasis and dry-eye and conjunctivitis.

Cancer

Research has shown a small increase in the development of certain cancers for people with psoriasis. More studies are required to develop a greater understanding of the links between cancer and psoriasis.

Gastrointestinal

There is an increased risk of developing gut problems such as crohn’s disease, or ulcerative colitis when one has psoriasis.

Metabolic Syndrome

Metabolic syndrome involves a collection of risk factors that increase the likelihood of cardiovascular disease. Research shows this is one of the most common complications of having psoriasis. The causes are complex, and not fully understood.

In a 2019 study review, researchers proposed the involvement of preventative medicine and nutritionists early in a person’s psoriasis diagnosis to help control for the dangers of metabolic syndrome as early as possible. 

Oral Health

Though infrequent, people with psoriasis may be more susceptible to mouth problems, including fissures in the tongue and lesions on the gums and cheeks. The underlying cause of this association remains elusive.

Research suggests that both psoriasis and oral health problems might originate from similar genetic factors, or they could be triggered by common influences such as stress and alcohol consumption.

Kidney Disease

It has been found that having psoriasis increases a person’s risk of developing Chronic Kidney Disease (CKD). It may be due to the increased levels of constant inflammation in the body and the toxicity of psoriasis medications. The risk of complication increases as the severity of psoriasis does.

Mental Health

Depression and feelings of hopelessness are fairly common for those with psoriasis. It is a painful burden to bear. Having physical symptoms that people can see can lead to feelings of embarrassment and shame; hiding skin, avoiding activities. There might be bullying, or shocked reactions, or stares.

Beyond social discomfort, the disease itself requires excessive time to manage and is very uncomfortable to have. It is not hard to see why results from one study showed that up to one fifth of people with psoriasis also have feelings of depression.

Diagnosis

Diagnosis of psoriasis involves a physical exam for symptoms. The doctor may look over your skin for characteristic psoriasis inflammation and plaques.

They will ask you questions to determine the likelihood of psoriasis.

Family history,
Current or past symptoms
Presence of other diseases

In some cases a doctor might want to take a biopsy. This is when they numb your skin and cut off a small piece for testing.

A biopsy being preformed on a mole

Treatments

Topical Treatments

Emollients

Commonly found as ingredients in moisturizers, emollients are essential for soothing and softening the skin.

While they do not directly add moisture to the skin, they play a crucial role in restoring the skin barrier. By filling in gaps on the skin’s surface, they help prevent water loss.

Additionally, emollients often contain ingredients that promote the health of lipids, which are vital for maintaining the skin barrier.

Dry skin leads to greater irritation and more hydrated skin tends to be more receptive to other treatments.

Steroid Creams or Ointments

Available as lotions, gels, shampoos, or creams, corticosteroids work by reducing inflammation, excessive cell growth, and immune system responses. Typically applied directly to affected areas, they are highly effective against psoriasis. Steroids can work against most cases of psoriasis. 

Withdrawal Risk: Prolonged use can lead to cortisone dependency. Use of, and gradual tapering under dermatological guidance is crucial to avoid withdrawal complications.

Vitamin D creams

By contributing to slower skin growth and the reduction of inflammation vitamin D creams work well for mild cases of psoriasis. They are sometimes prescribed with steroid creams as a mixed therapy. These are a popular option for treating sensitive areas such as the face.

Calcineurin Inhibitors

Calcineurin inhibitors work by blocking the activity of calcineurin, dampening the immune response and reducing inflammation in the skin. By targeting this underlying immune dysfunction, calcineurin inhibitors help to alleviate the symptoms of psoriasis and promote healing of the affected skin.
These medications are typically available in topical form, such as creams or ointments, which can be applied directly to the affected areas of the skin.

Coal Tar

Coal tar can effectively treat itching and scaling in psoriasis. It is a staple in psoriasis treatment and has been prescribed for over 100 years. Coal tar is not a good option for everyone however. Pregnant or breastfeeding women are advised not to use it.  

Retinoids

Retinoids are a topical ointment that can cause skin irritation, but have been shown to effectively treat psoriasis symptoms. They are at times prescribed with topical steroids. The American Academy of Dermatology states that most patients see around a 50% reduction in their psoriasis.

Phototherapy

Phototherapy is an effective treatment for psoriasis symptoms. It can reduce swelling, itching, slow down cell growth, and suppress the immune system response that causes psoriasis symptoms.

There are some potential side effects however.

Red or tender skin, sunburn
Mild stinging or burning
Dark spots, particularly in people with medium to dark skin tones
Itching
Rarely, blisters or burns
Freckles
Premature skin aging, such as age spots, wrinkles, and loose skin
Increased risk of skin cancer

Biologics

Biologics are the most scientifically advanced treatments, and are highly effective for moderate to severe psoriasis. This class of medication is created from the biological process of a living organism, and its main goal is often to modify the dysfunctional immune response. For many people, they represent the most exciting developments in medical science.

Currently there is a wide variety of biologics available for treating psoriasis and several in the research stage of development.

It’s important to know that finding the right treatment may take several or more tries.
 

Systemic Treatments

Systemic treatments impact the entire body because they are typically swallowed in a pill. Compared to a cream, or a localized injection, the medication is spread out through the body. This is beneficial when psoriasis is severe and covers a large area; but the drawback is that most medicines for psoriasis have side effects. Doctors prefer topical medications because it reduces the amount of medicine the body has to tolerate, and potential for side effects.

Conclusion

Despite increasing investment in psoriasis treatment research, and the approval of new and unique treatments that open doors for many psoriasis patients, it is still a very difficult disease to deal with, and causes significant harm.

Over the next decade, it is likely that psoriasis care will see great improvements. The industry is poised to leverage new technology for faster, more accurate, safe, and lower cost trials.

There is a lot of psoriasis research going on right now. Researchers are currently studying the causes of psoriasis, and have been testing many different therapies in recent years. New treatments are frequently truly innovative and offer an entirely new benefit to those with psoriasis.

SimcoDerm is a full service, comprehensive dermatology clinic located in Barrie. We provide our services to all the patients in Simcoe County and beyond.

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