INTRODUCTION:

Psoriasis is a long-lasting autoimmune disease characterized by patches of abnormal skin.¹ These skin patches are typically red, itchy, and scaly.² Psoriasis varies in severity from small, localized patches to complete body coverage.² Injury to the skin can trigger psoriatic skin changes at that spot, which is known as the Koebner phenomenon.³

The word psoriasis is from Greek, meaning "itching condition" or "being itchy"³from psora, "itch" and -iasis, "action, condition"⁴

Psoriasis is generally thought to be a genetic disease that is triggered by environmental factors.² In twin studies, identical twins are three times more likely to be affected compared to non-identical twins. This suggests that genetic factors predispose to psoriasis.⁵ Symptoms often worsen during winter and with certain medications, such as beta blockers or NSAIDs.⁵ Infections and psychological stress can also play a role.² Psoriasis is non contagious.⁵ The underlying mechanism involves the immune system reacting to skin cells.⁵ Diagnosis is typically based on the signs and symptoms.⁵

TYPES:

There are five main types of psoriasis:

plaque, guttate, inverse, pustular, and erythrodermic.¹

Plaque psoriasis:

also known as psoriasis vulgaris, makes up about 90 percent of cases.⁵ It typically presents as red patches with white scales on top.⁵ Areas of the body most commonly affected are the back of the forearms, shins, navel area, and scalp.⁵

Guttate psoriasis:

has drop-shaped lesions.¹

Pustular psoriasis:

presents as small non-infectious pus-filled blisters.⁶

Inverse psoriasis:

forms red patches in skin folds.¹

Erythrodermic psoriasis:

occurs when the rash becomes very widespread, and can develop from any of the other types.⁵ Fingernails and toenails are affected in most people with psoriasis at some point in time.⁵ This may include pits in the nails or changes in nail color.⁵

EPIDEMIOLOGY:

Psoriasis is estimated to affect 2–4% of the population of the western world.⁷ The rate of psoriasis varies according to age, region and ethnicity; a combination of environmental and genetic factors is thought to be responsible for these differences.⁷ It can occur at any age, although it most commonly appears for the first time between the ages of 15 and 25 years. Approximately one third of people with psoriasis report being diagnosed before age 20.⁸ Psoriasis affects both sexes equally.⁹

Psoriasis affects about 6.7 million Americans and occurs more frequently in adults.¹⁰

People with inflammatory bowel disease such as Crohn's disease or ulcerative colitis are at an increased risk of developing psoriasis.¹¹ Psoriasis is more common in countries farther from the equator.¹¹ Persons of white European ancestry are more likely to have psoriasis and the condition is relatively uncommon in African Americans and extremely uncommon in Native Americans.¹²

HISTORY:

Psoriasis is thought to have first been described in Ancient Rome by Cornelius Celsus. The disease was first classified by English physician Thomas Willan. The British dermatologist Bateman described a possible link between psoriasis and arthritic symptoms in 1813.¹³

The history of psoriasis is littered with treatments of dubious effectiveness and high toxicity. In the 18th and 19th centuries, Fowler's solution, which contains a poisonous and carcinogenic arsenic compound, was used by dermatologists as a treatment for psoriasis.¹⁴ Mercury was also used for psoriasis treatment during this time period.¹⁴ Sulfur, iodine, and phenol were also commonly used treatments for psoriasis during this era when it was incorrectly believed that psoriasis was an infectious disease.¹⁴ Coal tars were widely used with ultraviolet light irradiation as a topical treatment approach in the early 1900s.¹⁴ During the same time period, psoriatic arthritis cases were treated with intravenously administered gold preparations in the same manner as rheumatoid arthritis.¹³ All of these treatments have been replaced with modern topical and systemic therapies.

ETYMOLOGY:

The word psoriasis is from Greek, meaning "itching condition" or "being itchy"⁴from psora, "itch" and -iasis, "action, condition"

SIGNS AND SYMPTOMS:

Plaque psoriasis:

Psoriatic plaque, showing a silvery center surrounded by a reddened border. Psoriasis vulgaris (also known as chronic stationary psoriasis or plaque-like psoriasis) is the most common form and affects 85%–90% of people with psoriasis.¹⁵ Plaque psoriasis typically appears as raised areas of inflamed skin covered with silvery-white scaly skin. These areas are called plaques and are most commonly found on the elbows, knees, scalp, and back.¹⁵

Figure 1: Signs and symptoms of psoriasis

Psoriatic erythroderma (erythrodermic psoriasis) involves widespread inflammation and exfoliation of the skin over most of the body surface. It may be accompanied by severe itching, swelling, and pain. It is often the result of an exacerbation of unstable plaque psoriasis, particularly following the abrupt withdrawal of systemic glucocorticoids.¹⁶ This form of psoriasis can be fatal as the extreme inflammation and exfoliation disrupt the body's ability to regulate temperature and perform barrier functions.¹⁶

Other forms:

Additional types of psoriasis comprise approximately 10% of cases. They include pustular, inverse, napkin, guttate, oral, and seborrheic-like forms.¹⁷

Pustular psoriasis appears as raised bumps filled with noninfectious pus (pustules).¹⁸ The skin under and surrounding the pustules is red and tender.¹⁹

Inverse psoriasis:

Inverse psoriasis (also known as flexural psoriasis) appears as smooth, inflamed patches of skin. The patches frequently affect skin folds, particularly around the genitals (between the thigh and groin), the armpits, in the skin folds of an overweight abdomen (known as panniculus), between the buttocks in the intergluteal cleft, and under the breasts in the inframammary fold. Heat, trauma, and infection are thought to play a role in the development of this atypical form of psoriasis.²¹

Guttate psoriasis:

Guttate psoriasis is characterized by numerous small, scaly, red or pink, droplet-like lesions (papules). These numerous spots of psoriasis appear over large areas of the body, primarily the trunk, but also the limbs and scalp. Guttate psoriasis is often triggered by a streptococcal infection, typically streptococcal pharyngitis.21 The reverse is not true.

Napkin psoriasis:

Napkin psoriasis is a subtype of psoriasis common in infants characterized by red papules with silver scale in the diaper area that may extend to the torso or limbs.²² Napkin psoriasis is often misdiagnosed as napkin dermatitis (diaper rash).²³

Oral (Mouth) psoriasis:

Psoriasis in the mouth is very rare,²³ in contrast to lichen planus, another common papulosquamous disorder that commonly involves both the skin and mouth. When psoriasis involves the oral mucosa (the lining of the mouth), it may be asymptomatic,²³but it may appear as white or grey-yellow plaques.²³ Fissured tongue is the most common finding in those with oral psoriasis and has been reported to occur in 6.5–20% of people with psoriasis affecting the skin. The microscopic appearance of oral mucosa affected by geographic tongue (migratory stomatitis) is very similar to the appearance of psoriasis.²⁴ However, modern studies have failed to demonstrate any link between the two conditions.²⁵

Seborrheic-like psoriasis:

Seborrheic-like psoriasis is a common form of psoriasis with clinical aspects of psoriasis and seborrheic dermatitis, and it may be difficult to distinguish from the latter. This form of psoriasis typically manifests as red plaques with greasy scales in areas of higher sebum production such as the scalp, forehead, skin folds next to the nose, skin surrounding the mouth, skin on the chest above the sternum, and in skin folds.²¹

Psoriatic arthritis:

Psoriatic arthritis is a form of chronic inflammatory arthritis that has a highly variable clinical presentation and frequently occurs in association with skin and nail psoriasis.²⁶ It typically involves painful inflammation of the joints and surrounding connective tissue and can occur in any joint, but most commonly affects the joints of the fingers and toes. This can result in a sausage-shaped swelling of the fingers and toes known as dactylitis.²⁶ Psoriatic arthritis can also affect the hips, knees, spine (spondylitis), and sacroiliac joint (sacroiliitis). About 30% of individuals with psoriasis will develop psoriatic arthritis. Skin manifestations of psoriasis tend to occur before arthritic manifestations in about 75% of cases.

The most common symptoms are:

· Painful, stiff joints that are worse in the morning and after rest

· Sausage-like swelling of the fingers and toes

· Warm joints that may be discolored

Nail Psoriasis:

Psoriasis can affect the nails and produces a variety of changes in the appearance of finger and toe nails. Nail psoriasis occurs in 40–45% of people with psoriasis affecting the skin and has a lifetime incidence of 80–90% in those with psoriatic arthritis.²⁷ These changes include pitting of the nails (pinhead-sized depressions in the nail is seen in 70% with nail psoriasis), whitening of the nail, small areas of bleeding from capillaries under the nail, yellow-reddish discoloration of the nails known as the oil drop or salmon spot, thickening of the skin under the nail (subungual hyperkeratosis), loosening and separation of the nail (onycholysis), and crumbling of the nail.²⁷

Medical signs:

In addition to the appearance and distribution of the rash, specific medical signs may be used by medical practitioners to assist with diagnosis. These may include Auspitz's sign (pinpoint bleeding when scale is removed), Koebner phenomenon (psoriatic skin lesions induced by trauma to the skin),²¹ and itching and pain localized to papules and plaques.

The symptoms of psoriasis include:

· Areas of itchy, scaly skin on the scalp, knees, elbows, and upper body; these deep-pink, raised plaques of skin have white scales.

· Psoriasis on fingernails and toenails can make the nails become thick, pitted, and discolored; nails may separate from underlying nail bed.

· Red, scaly, cracked skin with tiny pustules on the palms of the hands and/or feet; you may have pustular psoriasis.

CAUSES:

The cause of psoriasis is not fully understood, but a number of theories exist.

Genetics:

Some people inherit genes that make them more likely to develop psoriasis. Around one-third of people with psoriasis report a family history of the disease, and researchers have identified genetic loci associated with the condition. However, the percentage of people who have psoriasis and a genetic predisposition is small. Approximately 2 to 3 percent of people with the gene develop the condition, according to the National Psoriasis Foundation.

Identical twin studies suggest a 70% chance of a twin developing psoriasis if the other twin has the disorder. The risk is around 20% for non-identical twins. These findings suggest both a genetic susceptibility and an environmental response in developing psoriasis.²⁸

Lifestyle:

Conditions reported as worsening the disease include chronic infections, stress, and changes in season and climate.²⁹ Others that might worsen the condition include hot water, scratching psoriasis skin lesions, skin dryness, excessive alcohol consumption, cigarette smoking, and obesity.²⁹

Skin injury:

A cut, scrape, bug bite, infection, bad sunburn, or even too much scratching can trigger the condition

HIV:

Psoriasis tends to be more severe in people infected with HIV.³⁰ A much higher rate of psoriatic arthritis occurs in HIV-positive individuals with psoriasis than in those without the infection.

Microbes:

Psoriasis has been described as occurring after strep throat, and may be worsened by skin or gut colonization with Staphylococcus aureus, Malassezia, and Candida albicans.³¹

Strep infections, in particular, are linked with guttate psoriasis, which looks like small, red drops. Kids will often have strep throat before their first flare. Earaches, bronchitis, tonsillitis, or a respiratory infection such as a cold, the flu, or pneumonia can also set off your skin problems.

Medications:

Drug-induced psoriasis may occur with

· Lithium, which treats bipolar disorder and other mental illnesses.

· High blood pressure and heart medicines, including propranolol (Inderal) and other beta blockers, ACE inhibitors, and quinidine.

· Antimalarial, including chloroquine, and hydroxychloroquine (Plaquenil), and quinacrine.

· Indomethacin (Indocin), which treats inflammation.

Withdrawal of corticosteroids (topical steroid cream) can aggravate psoriasis due to the rebound effect.¹²

Stress:

Scientists think our immune system may respond to emotional and mental pressures the same way it does to physical problems like injuries and infections.

Weight:

People who are obese tend to get plaques in their skin creases and folds.

Smoking:

Lighting up can double the risk of getting psoriasis. If an individual has a family history of the disease, then chances of acquiring the disease is nine times greater. And smoking makes it harder to get rid of symptoms. It's closely linked with a kind of pustular psoriasis on the palms and soles that's difficult to treat.

Alcohol:

Heavy drinkers have a higher risk, especially younger men. Alcohol can make treatments less effective, too.

Hormone changes:

The disease often shows up or flares during puberty. Menopause can also trigger it. A pregnant woman's symptoms may get better or even disappear during pregnancy. But after the baby is born, many women have a flare.

MECHANISM:

Psoriasis is characterized by an abnormally excessive and rapid growth of the epidermal layer of the skin.³²Abnormal production of skin cells (especially during wound repair) and an overabundance of skin cells result from the sequence of pathological events in psoriasis.¹⁹ Skin cells are replaced every 3–5 days in psoriasis rather than the usual 28–30 days. These changes are believed to stem from the premature maturation of keratinocytes induced by an inflammatory cascade in the dermis involving dendritic cells, macrophages, and T cells (three subtypes of white blood cells). These immune cells move from the dermis to the epidermis and secrete inflammatory chemical signals (cytokines) such as interleukin-36γ, tumor necrosis factor-α, interleukin-1β, interleukin-6, and interleukin-22.³³ These secreted inflammatory signals are believed to stimulate keratinocytes to proliferate.³³ One hypothesis is that psoriasis involves a defect in regulatory T cells, and in the regulatory cytokine interleukin-10.³³

Gene mutations of proteins involved in the skin's ability to function as a barrier have been identified as markers of susceptibility for the development of psoriasis.³⁴

DNA released from dying cells acts as an inflammatory stimulus in psoriasis³⁵and stimulates the receptors on certain dendritic cells, which in turn produce the cytokine interferon-α.³⁵ In response to these chemical messages from dendritic cells and T cells, keratinocytes also secrete cytokines such as interleukin-1, interleukin-6, and tumor necrosis factor-α, which signal downstream inflammatory cells to arrive and stimulate additional inflammation.

Dendritic cells bridge the innate immune system and adaptive immune system. They are increased in psoriatic lesions³² and induce the proliferation of T cells and type 1 helper T cells (Th1). Targeted immunotherapy as well as psoralen and ultraviolet A (PUVA) therapy can reduce the number of dendritic cells and favors a Th2 cell cytokine secretion pattern over a Th1/Th17 cell cytokine profile.³³Psoriatic T cells move from the dermis into the epidermis and secrete interferon-γ and interleukin-17. Interleukin-23 is known to induce the production of interleukin-17 and interleukin-22.³² Interleukin-22 works in combination with interleukin-17 to induce keratinocytes to secrete neutrophil-attracting cytokines.

Figure 2 : Mechanism

DIAGNOSING PSORIASIS:

Two tests or examinations may be necessary to diagnose psoriasis.

Physical examination:

A diagnosis of psoriasis is usually based on the appearance of the skin. Symptoms of psoriasis are typically evident and easy to distinguish from other conditions that may cause similar symptoms. Skin characteristics typical for psoriasis are scaly, erythematous plaques, papules, or patches of skin that may be painful and itch. No special blood tests or diagnostic procedures are usually required to make the diagnosis.¹⁹

The differential diagnosis of psoriasis includes dermatological conditions similar in appearance such as discoid eczema, seborrhoeic eczema, pityriasis rosea (may be confused with guttate psoriasis), nail fungus (may be confused with nail psoriasis) or cutaneous T cell lymphoma (50% of individuals with this cancer are initially misdiagnosed with psoriasis).¹² Dermatologic manifestations of systemic illnesses such as the rash of secondary syphilis may also be confused with psoriasis.¹²

Biopsy:

If the clinical diagnosis is uncertain, a skin biopsy or scraping may be performed to rule out other disorders and to confirm the diagnosis.

· Skin from a biopsy will show clubbed epidermal projections that interdigitate with dermis on microscopy.

· Epidermal thickening is another characteristic histologic finding of psoriasis lesions.¹⁹

· The stratum granulosum layer of the epidermis is often missing or significantly decreased in psoriatic lesions; the skin cells from the most superficial layer of skin are also abnormal as they never fully mature. Unlike their mature counterparts, these superficial cells keep their nucleus.¹⁹

Inflammatory infiltrates can typically be visualized on microscopy when examining skin tissue or joint tissue affected by psoriasis. Epidermal skin tissue affected by psoriatic inflammation often has many CD8+T cells while a predominance of CD4+T cells makes up the inflammatory infiltrates of the dermal layer of skin and the joints.¹⁹

TREATMENT:

There is no cure for psoriasis; however, various treatments can help control the symptoms.⁵ These treatments include steroid creams, vitamin D3 cream, ultraviolet light and immune system suppressing medications, such as methotrexate.¹ About 75 percent of cases can be managed with creams alone.⁵ The disease affects two to four percent of the population. Men and women are affected with equal frequency.¹ The disease may begin at any age, but typically starts in adulthood.⁶ Psoriasis is associated with an increased risk of psoriatic arthritis, lymphomas, cardiovascular disease, Crohn's disease and depression.⁵ Psoriatic arthritis affects up to 30 percent of individuals with psoriasis.⁶

Topical treatments:

When used alone, creams and ointments applied on to the skin can effectively treat mild to moderate psoriasis. When the disease is more severe, creams are likely to be combined with oral medications or light therapy. Topical psoriasis treatments include:

Topical corticosteroids:

These drugs are the most frequently prescribed medications for treating mild to moderate psoriasis. They reduce inflammation and relieve itching and may be used with other treatments.

Mild corticosteroid ointments are usually recommended for sensitive areas, such as face or skin folds, and for treating widespread patches of damaged skin.

Doctor may prescribe stronger corticosteroid ointment for smaller, less sensitive or tougher-to-treat areas.Long-term use or overuse of strong corticosteroids can cause thinning of the skin. Topical corticosteroids may stop working over time. It's usually best to use topical corticosteroids as a short-term treatment during flares.

Vitamin D analogues:

These synthetic forms of vitamin D slow skin cell growth. Calcipotriene (Dovonex) is a prescription cream or solution containing a vitamin D analogue that treats mild to moderate psoriasis along with other treatments. Calcipotriene might irritate your skin. Calcitriol (Vectical) is expensive but may be equally effective and possibly less irritating than calcipotriene.

· Anthralin:

This medication helps slow skin cell growth. Anthralin (Dritho-Scalp) can also remove scales and make skin smoother. But anthralin can irritate skin, and it stains almost anything it touches. It's usually applied for a short time and then washed off.

· Topical retinoids:

These are vitamin A derivatives that may decrease inflammation. The most common side effect is skin irritation. These medications may also increase sensitivity to sunlight, so while using the medication sunscreen must be applied before going outdoors.

The risk of birth defects is far lower for topical retinoids than for oral retinoids. But tazarotene (Tazorac, Avage) isn't recommended when for pregnant or breast-feeding or women planning pregnancy.

· Calcineurin inhibitors:

Calcineurin inhibitors — tacrolimus (Prograf) and pimecrolimus (Elidel) — reduce inflammation and plaque buildup.

Calcineurin inhibitors are not recommended for long-term or continuous use because of a potential increased risk of skin cancer and lymphoma. They may be especially helpful in areas of thin skin, such as around the eyes, where steroid creams or retinoids are too irritating or may cause harmful effects.

· Salicylic acid:

Available over-the-counter (nonprescription) and by prescription, salicylic acid promotes sloughing of dead skin cells and reduces scaling. Sometimes it's combined with other medications, such as topical corticosteroids or coal tar, to increase its effectiveness. Salicylic acid is available in medicated shampoos and scalp solutions to treat scalp psoriasis.

· Coal tar:

Derived from coal, coal tar reduces scaling, itching and inflammation. Coal tar can irritate the skin. It's also messy, stains clothing and bedding, and has a strong odor.

Coal tar is available in over-the-counter shampoos, creams and oils. It's also available in higher concentrations by prescription. This treatment isn't recommended for women who are pregnant or breast-feeding.

· Moisturizers:

Moisturizing creams alone won't heal psoriasis, but they can reduce itching, scaling and dryness. Moisturizers in an ointment base are usually more effective than are lighter creams and lotions. Apply immediately after a bath or shower to lock in moisture.

Light therapy (phototherapy):

This treatment uses natural or artificial ultraviolet light. The simplest and easiest form of phototherapy involves exposing the skin to controlled amounts of natural sunlight. Other forms of light therapy include the use of artificial ultraviolet A (UVA) or ultraviolet B (UVB) light, either alone or in combination with medications.

· Sunlight:

Exposure to ultraviolet (UV) rays in sunlight or artificial light slows skin cell turnover and reduces scaling and inflammation. Brief, daily exposures to small amounts of sunlight may improve psoriasis, but intense sun exposure can worsen symptoms and cause skin damage. Before beginning a sunlight regimen, doctor advice must be taken to know the safest way to use natural sunlight for psoriasis treatment.

· UVB phototherapy:

Controlled doses of UVB light from an artificial light source may improve mild to moderate psoriasis symptoms. UVB phototherapy, also called broadband UVB, can be used to treat single patches, widespread psoriasis and psoriasis that resists topical treatments. Short-term side effects may include redness, itching and dry skin. Using a moisturizer may help decrease these side effects.

· Narrow band UVB phototherapy:

A newer type of psoriasis treatment, narrow band UVB phototherapy may be more effective than broadband UVB treatment. It's usually administered two or three times a week until the skin improves, and then maintenance may require only weekly sessions. Narrow band UVB phototherapy may cause more-severe and longer lasting burns, however.

· Goeckerman therapy:

Some doctors combine UVB treatment and coal tar treatment, which is known as Goeckerman treatment. The two therapies together are more effective than either alone because coal tar makes skin more receptive to UVB light.

· Psoralen plus ultraviolet A (PUVA):

This form of photochemotherapy involves taking a light-sensitizing medication (psoralen) before exposure to UVA light. UVA light penetrates deeper into the skin than does UVB light, and psoralen makes the skin more responsive to UVA exposure.

This more aggressive treatment consistently improves skin and is often used for more-severe cases of psoriasis. Short-term side effects include nausea, headache, burning and itching. Long-term side effects include dry and wrinkled skin, freckles, increased sun sensitivity, and increased risk of skin cancer, including melanoma.

· Excimer laser:

This form of light therapy, used for mild to moderate psoriasis, treats only the involved skin without harming healthy skin. A controlled beam of UVB light is directed to the psoriasis plaques to control scaling and inflammation. Excimer laser therapy requires fewer sessions than does traditional phototherapy because more powerful UVB light is used. Side effects can include redness and blistering.

Oral or injected medications:

In case of severe psoriasis or if it is resistant to other types of treatment, oral or injected drugs are prescribed. This is known as systemic treatment. Because of severe side effects, some of these medications are used for only brief periods and may be alternated with other forms of treatment.

· Retinoids:

Related to vitamin A, this group of drugs may help in case of severe psoriasis. Side effects may include lip inflammation and hair loss. And because retinoids such as acitretin (Soriatane) can cause severe birth defects, women must avoid pregnancy for at least three years after taking the medication.

· Methotrexate:

Taken orally, methotrexate (Rheumatrex) helps psoriasis by decreasing the production of skin cells and suppressing inflammation. It may also slow the progression of psoriatic arthritis in some people. Methotrexate is generally well-tolerated in low doses but may cause upset stomach, loss of appetite and fatigue. When used for long periods, it can cause a number of serious side effects, including severe liver damage and decreased production of red and white blood cells and platelets.

· Cyclosporine:

Cyclosporine (Gengraf, Neoral) suppresses the immune system and is similar to methotrexate in effectiveness, but can only be taken short-term. Like other immunosuppressant drugs, cyclosporine increases your risk of infection and other health problems, including cancer. Cyclosporine also makes you more susceptible to kidney problems and high blood pressure — the risk increases with higher dosages and long-term therapy.

· Drugs that alter the immune system (biologics):

Several of these drugs are approved for the treatment of moderate to severe psoriasis. They include etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), ustekinumab (Stelara), golimumab (Simponi), apremilast (Otezla), secukinumab (Cosentyx) and ixekizumab (Taltz). Most of these drugs are given by injection (apremilast is oral) and are usually used for people who have failed to respond to traditional therapy or who have associated psoriatic arthritis. Biologics must be used with caution because they have strong effects on the immune system and may permit life-threatening infections. In particular, people taking these treatments must be screened for tuberculosis.

· Other medications:

Thioguanine (Tabloid) and hydroxyurea (Droxia, Hydrea) are medications that can be used when other drugs can't be given.

TREATMENT CONSIDERATIONS:

Although doctors choose treatments based on the type and severity of psoriasis and the areas of skin affected, the traditional approach is to start with the mildest treatments — topical creams and ultraviolet light therapy (phototherapy) — in those patients with typical skin lesions (plaques) and then progress to stronger ones only if necessary. Patients with pustular or erythrodermic psoriasis or associated arthritis usually need systemic therapy from the beginning of treatment. The goal is to find the most effective way to slow cell turnover with the fewest possible side effects.

POTENTIAL FUTURE TREATMENTS:

There are a number of new medications currently being researched that have the potential to improve psoriasis treatment. These treatments target different proteins that work with the immune system.

ALTERNATIVE MEDICINE:

A number of alternative therapies claim to ease the symptoms of psoriasis, including special diets, creams, dietary supplements and herbs. None have definitively been proved effective. But some alternative therapies are deemed generally safe, and they may be helpful to some people in reducing signs and symptoms, such as itching and scaling. These treatments would be most appropriate for those with milder, plaque disease and not for those with pustules, erythroderma or arthritis.

· Aloe vera:

Taken from the leaves of the aloe vera plant, aloe extract cream may reduce redness, scaling, itching and inflammation.

· Fish oil:

Omega-3 fatty acids found in fish oil supplements may reduce inflammation associated with psoriasis, although results from studies are mixed. Taking 3 grams or less of fish oil daily is generally recognized as safe, and you may find it beneficial.

· Oregon grape:

Also known as barberry, topical applications of Oregon grape may reduce inflammation and ease psoriasis symptoms.

LIFESTYLE AND HOME REMEDIES:

Although self-help measures won't cure psoriasis, they may help improve the appearance and feel of damaged skin. These measures may benefit you:

· Take daily baths:

Bathing daily helps remove scales and calm inflamed skin. Add bath oil, colloidal oatmeal, Epsom salts or Dead Sea salts to the water and soak. Avoid hot water and harsh soaps, which can worsen symptoms; use lukewarm water and mild soaps that have added oils and fats. Soak about 10 minutes then gently pat dry skin.

· Use moisturizer:

After bathing, apply a heavy, ointment-based moisturizer while your skin is still moist. For very dry skin, oils may be preferable — they have more staying power than creams or lotions do and are more effective at preventing water from evaporating from your skin. During cold, dry weather, you may need to apply a moisturizer several times a day.

· Expose your skin to small amounts of sunlight:

A controlled amount of sunlight can improve psoriasis, but too much sun can trigger or worsen outbreaks and increase the risk of skin cancer. First ask your doctor about the best way to use natural sunlight to treat your skin. Log your time in the sun, and protect skin that isn't affected by psoriasis with sunscreen.

· Avoid psoriasis triggers, if possible:

Find out what triggers, if any, worsen your psoriasis and take steps to prevent or avoid them. Infections, injuries to your skin, stress, smoking and intense sun exposure can all worsen psoriasis.

· Avoid drinking alcohol:

Alcohol consumption may decrease the effectiveness of some psoriasis treatments. If you have psoriasis, avoid alcohol. If you do drink, keep it moderate.

DIET:

Uncontrolled studies have suggested that individuals with psoriasis or psoriatic arthritis may benefit from a diet supplemented with fish oil rich in eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA).³⁶ Diet recommendations include consumption of cold water fish (preferably wild fish, not farmed) such as salmon, herring, and mackerel; extra virgin olive oil; legumes; vegetables; fruits; and whole grains, and avoid consumption of alcohol, red meat, and dairy products. The effect of consumption of caffeine (including coffee, black tea, mate, and dark chocolate) remains to be determined.³⁷

There is a higher rate of celiac disease among people with psoriasis.^[88][89] When adopting a gluten-free diet, disease severity generally decreases in people with celiac disease and those with anti-gliadin antibodies.³⁶

PROGNOSIS:

Most people with psoriasis experience nothing more than mild skin lesions that can be treated effectively with topical therapies.³⁸

Psoriasis is known to have a negative impact on the quality of life of both the affected person and the individual's family members.^[31] Depending on the severity and location of outbreaks, individuals may experience significant physical discomfort and some disability. Itching and pain can interfere with basic functions, such as self-care and sleep.³⁹ Participation in sporting activities, certain occupations, and caring for family members can become difficult activities for those with plaques located on their hands and feet.³⁹ Plaques on the scalp can be particularly embarrassing, as flaky plaque in the hair can be mistaken for dandruff.⁴⁰

Individuals with psoriasis may feel self-conscious about their appearance and have a poor self-image that stems from fear of public rejection and psychosexual concerns. Psoriasis has been associated with low self-esteem and depression is more common among those with the condition.² People with psoriasis often feel prejudiced against due to the commonly held incorrect belief that psoriasis is contagious.³⁹ Psychological distress can lead to significant depression and social isolation; a high rate of thoughts about suicide has been associated with psoriasis.²² Many tools exist to measure the quality of life of patients with psoriasis and other dermatological disorders. Clinical research has indicated individuals often experience a diminished quality of life.⁴⁰ Children with psoriasis may encounter bullying.⁴¹

Cardiovascular disease:

Psoriasis has been associated with obesity² and several other cardiovascular and metabolic disturbances. The incidence of diabetes is 27% higher in people affected by psoriasis than in those without the condition.⁴² Severe psoriasis may be even more strongly associated with the development of diabetes than mild psoriasis.⁴² Younger people with psoriasis may also be at increased risk for developing diabetes. Individuals with psoriasis or psoriatic arthritis have a slightly higher risk of heart disease and heart attacks when compared to the general population. Cardiovascular disease risk appeared to be correlated with the severity of psoriasis and its duration. There is no strong evidence to suggest that psoriasis is associated with an increased risk of death from cardiovascular events. Methotrexate may provide a degree of protection for the heart.⁴³

Other diseases:

The rates of Crohn's disease and ulcerative colitis are increased when compared with the general population, by a factor of 3.8 and 7.5 respectively.² People with psoriasis also have a higher risk of celiac disease.³⁷ Few studies have evaluated the association of multiple sclerosis with psoriasis, and the relationship has been questioned.² Psoriasis has been associated with a 16% increase in overall relative risk for non-skin cancer.⁴³ People with psoriasis have a 52% increased risk cancers of the lung and bronchus.

ORGANIZATIONS ASSOCIATED:

The International Federation of Psoriasis Associations (IFPA) is the global umbrella organization for national and regional psoriasis patient associations and also gathers the leading experts in psoriasis and psoriatic arthritis research for scientific conferences every three years.⁴⁴ The Psoriasis International Network, a program of the Foundation René Touraine, gathers dermatologists, rheumatologists and other caregivers involved in the management of psoriasis. Non-profit organizations the National Psoriasis Foundation in the United States, the Psoriasis Association in the United Kingdom and Psoriasis Australia offer advocacy and education about psoriasis in their respective countries.

RESEARCH:

The role of insulin resistance in the pathogenesis of psoriasis is currently under investigation. Preliminary research has suggested that antioxidants such as polyphenols may have beneficial effects on the inflammation characteristic of psoriasis.⁴⁵

Many novel medications being researched target the Th17/IL-23 axis,⁴⁵ particularly IL-23p19 inhibitors, as IL-23p19 is present in increased concentrations in psoriasis skin lesions while contributing less to protection against opportunistic infections.⁴⁶ Other cytokines such as IL-17 and IL-22 also have been targets for inhibition as they play important roles in the pathogenesis of psoriasis.⁴⁶

Another avenue of research has focused on the use of vascular endothelial growth factor inhibitors to treat psoriasis. Oral agents being investigated as alternatives to medications administered by injection include Janus kinase inhibitors, protein kinase C inhibitors, mitogen-activated protein kinase inhibitors, and phosphodiesterase 4 inhibitors, all of which have proven effective in various phase 2 and 3 clinical trials.⁴⁶ However, these agents have potentially severe side-effects due to their immunosuppressive mechanisms.

Important points:

· Get educated:

Find out as much as you can about the disease and research your treatment options. Understand possible triggers of the disease, so you can better prevent flare-ups. Educate those around you — including family and friends — so they can recognize, acknowledge and support your efforts in dealing with the disease.

· Follow your doctor's recommendations:

If your doctor recommends certain treatments and lifestyle changes, be sure to follow them. Ask questions if anything is unclear.

· Find a support group:

Consider joining a support group with other members who have the disease and know what you're going through. You may find comfort in sharing your experience and struggles and meeting people who face similar challenges. Ask your doctor for information on psoriasis support groups in your area or online.

· Use cover-ups when you feel it necessary:

On those days when you feel particularly self-conscious, cover the psoriasis with clothing or use cosmetic cover-up products, such as body makeup or a concealer. These products can mask redness and psoriasis plaques. They can irritate the skin, however, and shouldn't be used on open sores, cuts or unhealed lesions.

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Received on 20.10.2018 Modified on 24.11.2018

Asian J. Res. Pharm. Sci. 2019; 9(1):29-38.

DOI: 10.5958/2231-5659.2019.00005.5