What is Psoriasis?

Psoriasis is a chronic skin condition that causes skin cells to grow too quickly, resulting in thick, white, or red patches of skin. The patches range in size from small to large and typically occur on the knees, elbows, scalp, hands, feet, or lower back. Psoriasis is most common in adults, although children and teens may be affected.
Normally, skin cells mature gradually and are shed about every 28 days. New skin cells replace outer layers of the skin surface that are shed or sloughed off during normal daily activity. In psoriasis, skin cells do not mature but instead move rapidly up to the surface of the skin over 3 to 6 days and build up, forming the characteristic patches (plaques).

Psoriasis Facts

Psoriasis is a chronic skin condition affecting approximately 4.5 million people in the United States.
New skin cells grow too rapidly, resulting in inflamed, swollen, scaly patches of skin in areas where the old skin has not shed quickly enough.
Psoriasis can be limited to a few spots or can involve more extensive areas of the body, appearing most commonly on the scalp, knees, elbows and trunk.
Psoriasis is not a contagious disease.
The cause of psoriasis is unknown, and there currently is no cure.Psoriasis can strike people at any age, but the average age of onset is approximately 28 years. Likewise, it affects both men and women, with a slightly higher prevalence in women than in men.
Approximately 30 percent of people with psoriasis are estimated to have moderate-to-severe forms of the disease.Psoriasis can be a physically and emotionally painful condition.
It often results in physical limitations, disfiguration and a significant burden in managing the daily care of the disease.
Psoriasis sufferers may feel embarrassed, angry, frustrated, fearful, depressed and, in some cases, even suicidal.

Psoriasis Treatment

Treatment of psoriasis is determined by the location, severity and history of psoriasis in each individual. There is no one method of treatment, for each person with psoriasis may respond differently. One main objective of treatment is to slow down the more rapid than usual growth rate of the skin cells. The rapid growth rate of skin cells causes the red, scaly psoriasis patches. The underlying cause of this increased skin growth is not yet known. For patients with minimal psoriasis, therapy is limited to topical medications that are drugs applied to the skin. For patients with moderate to widespread psoriasis, topical treatments are often combined with ultraviolet light therapy. Either sunlight or artificial ultraviolet light therapy can be used. If topical and ultraviolet light therapy are not effective, or are not practical, systemic or oral medications can be used. These may be combined with ultraviolet light therapy, the so-called photo-chemotherapy or PUVA therapy. In severe cases and unresponsive cases of psoriasis, there are oral medications that slow down the growth rate of skin which are helpful. These drugs can have significant side effects and have to be used with the proper safeguard and caution. Even these strong drugs do not cure psoriasis but only help to control the disease.

Treating Guttate Psoriasis

Usually Guttate psoriasis spontaneously disappears in a few weeks without treatment. Simple reassurance and emollients may be sufficient care. As in other conditions, the choice of treatment should be tailored to the individual. For example, applying topical steroids, although effective, could be cumbersome, especially when the eruption is extensive as in most cases of guttate psoriasis.
Antimicrobials: Because of the clear association between guttate psoriasis and streptococcal infection in most cases, obtaining a throat culture for each bout of pharyngitis in patients with a known history of psoriasis and immediately starting the proper antibiotic treatment depending on the culture results are imperative. See Medication below for specific drugs.
Phototherapy: The clearance of guttate lesions can be accelerated by judicious exposure to sunlight or by a short course of either broadband UV-B or narrowband UV-B phototherapy. More resistant cases may benefit from oral psoralen plus exposure to ultraviolet A radiation (PUVA). Aside from the usual mechanisms by which UV light is believed to exert its beneficial effects in psoriasis, a specific fibrosing response to PUVA via increased mast cell activation has been observed in guttate psoriasis and might underlie the mechanism of action behind UV-induced resolution of the lesions. Considering the developments in photomedicine over the last several years, particularly regarding the clinical efficacy of narrowband UV-B phototherapy, treatment with narrowband UV-B might show equally satisfying results.

Understanding Guttate Psoriasis

Guttate psoriasis refers to a distinctive, acute clinical presentation of an eruption characterized by small, droplike, 1-10 mm in diameter, salmon-pink papules, usually with a fine scale. The word guttate comes from the Latin word gutta, meaning drop. This type of psoriasis primarily occurs on the trunk and the proximal extremities, but it may have a generalized distribution.
It is most common in individuals younger than 30 years with a history of upper respiratory infection secondary to group A beta-hemolytic streptococci (eg, Streptococcus pyogenes) often precedes the eruption by 2-3 weeks. Although recurrent episodes may occur, especially those due to pharyngeal carriage of streptococci, isolated bouts are known to occur.
The sudden appearance of the papular lesions may be either the first manifestation of psoriasis in a previously unaffected individual or an acute exacerbation of long-standing plaque psoriasis. On the other hand, guttate psoriasis may be chronic and unrelated to a streptococcal infection.
The exact pathophysiologic mechanism is undetermined. The disease is believed to result from an immune reaction triggered by a previous streptococcal infection. T lymphocytes and cytokines are believed to cause the characteristic inflammatory changes appreciated on histopathologic examination of lesional skin samples. An autoimmune phenomenon has also been postulated because some streptococcal products and components have been found to cross-react with normal human epidermis. Electron microscopic studies have shown that mast cell degranulation is an early and constant feature in the evolution of guttate psoriatic lesions.

Treating Erythrodermic Psoriasis

Topical agents are useful in treating erythrodermic psoriasis as adjunctive agents:
Emollients
Coal Tar and Anthralin
Topical Steroids
Calcipotriene Systemic modalities (internal treatments) are often required for erythrodermic psoriasis. These may be used on a rotational basis or in combination:
Phototherapy
Methotrexate
Acitretin
Systemic Corticosteroids
Cyclosporine A

Defining Erthrodermic Psoriasis

Erythrodermic psoriasis is described as a widespread reddening and scaling of the skin, often accompanied by itching or pain. Psoriasis characterized by severe redness and shedding of the body surface.

Erythrodermic Psoriasis is a generalized form of the disease, which covers 85% or more of the body, with which patients can be systemically ill. Erythrodermic psoriasis can appear suddenly or evolve from chronic Plaque Psoriasis, occasionally following initiation of exacerbating medications (such as Lithium or beta-blocking agents), or rapid systemic corticosteroid tapering.

Erythrodermic Psoriasis most commonly appears on people who have unstable Plaque Psoriasis, where the lesions are not clearly defined. The skin has large, red and fiery patches. Severe itching, swelling and pain may accompany the skin as it reddens and sheds.

Erythrodermic psoriasis can disrupt the body's ability to control its temperature, protein loss, and can lead to severe illness. In severe cases, people with this type of psoriasis may need to be hospitalized if they have lost a lot of fluid, have an infection or have poor blood flow (circulation). This can be life threatening.

A View of Psoriatic Arthritis

Psoriatic arthritis is a genetically driven autoimmune disease that occurs in less than 10% of persons with psoriasis. Large and small joints are affected. Psoriatic arthritis is often associated with psoriasis in fingernails and toenails.

About 95% of those with psoriatic arthritis have swelling in joints outside the spine, and more than 80% of people with psoriatic arthritis have nail lesions. The course of psoriatic arthritis varies, with most doing reasonably well.

Symptoms include:
Silver or grey scaly spots on the scalp, elbows, knees and/or lower end of the spine.
Pitting of fingernails/toenails
Pain and swelling in one or more joints
Swelling of fingers/toes that gives them a "sausage" appearance.

The Language of Psoriasis

Understanding psoriasis and its treatment must begin with an understanding of the terms and phrases associated with psoriasis and its treatment. This glossary of terms is a good place to begin the journey of psoriasis discovery and learning.

Living With Palmoplantar Psoriasis

Palmoplantar psoriasis is a chronic, recurring condition that affects the palms of hands and soles of feet. It looks similar to other types of skin conditions, such as hand dermatitis, but the appearance of psoriasis lesions elsewhere on the body is an indicator of psoriasis. It varies in severity, and may limit a person’s ability to complete their daily activities. It most often affects adults, and is sometimes hereditary.
Palmoplantar psoriasis is characterized by a few different symptoms:
The appearance of red patches of skin topped with scales typical of psoriasis on the palms and elsewhere on the body
Thickening and scaling of the skin accompanied with the formation of deep, painful fissures on the palms and soles
Palmoplantar pustulosis - the appearance of deep, yellowish pustules

Although rare, Pustular Psoriasis is a very serious condition which affects the body both internally and externally. Palmoplantar psoriasis is a type of Localized pustular psoriasis that affects the palms of hands and soles of feet. There are two types of Localized Pustular Psoriasis: Acropustulosis, which occurs only on the tips of the fingers, and Palmo-plantar pustulosis, which only occurs on the palms of hands and/or the soles of feet.
In general, Palmo-Plantar Pustulosis occurs in people between 20 and 60 years old, and may be triggered by infection and/or stress. It has also been found to affect females more than males. As with Generalized Pustular Psoriasis, Palmo-Plantar Pustulosis occurs in a cyclical pattern, with new pustules occurring after a period of low-to-no activity.

The "fleshy" areas of the hands and feet (base of thumb and/or sides of heels) develop large, yellowish pustules - about the size of a pencil eraser, or .5 centimeters. These Pustules have a studded pattern over reddened patches of skin, and contain non-infectious pus (white blood cells). Throughout the next 7 to 14 days, the Pustule will become smaller, lose it's yellowish color, and become topped with a brown scale of skin. Usually, the disease becomes much less active for a time after peeling.
Palmoplantar pustulosis had been found to occur more frequently in people who smoke or used to some tobacco. The causes of flare-ups are not known, but pressure and rubbing will make it worse. The effects on overall health are small, but it can be very uncomfortable and painful.

Palmo-Plantar Pustulosis is stubborn to treat, but the symptoms can be controlled. Although it often affects smokers, quitting smoking does not always help clear the disease. Topical treatments, such as corticosteroids, are usually prescribed first. PUVA, acitretin (Soriatane), methotrexate or cyclosporine (Neoral) sometimes must be used to clear this form. Combination treatment with PUVA and Soriatane (called RePUVA) may also be effective. No one treatment will work for everyone and most people will have to try several types of treatment in order to find one that works.

Acrodermatitis is a form of Palmo-Plantar Pustulosis which is characterized by painful, potentially disabling, skin lesions on the tips of fingers and sometimes the tips of the toes. The nails may become deformed, and this type of Palmo-Plantar Pustulosis can change and damage the bone in the affected area.

Acropustulosis occasionally starts after the skin is injured or infected. This form has traditionally been hard to treat. Tar preparations under occlusion help some patients. Oral retinoid drugs, such as acitretin (Soriatane), may help clear the lesions and restore the nails. PUVA may also be used.