Psoriasis

Psoriasis is an autoimmune skin disorder characterized by the rapid buildup of skin cells, leading to red, scaly patches. While its exact cause remains unclear, genetic factors and immune system dysfunction play key roles in its development. This condition can affect any part of the body, causing discomfort, itching, and sometimes joint pain. The immune system’s misfire in psoriasis prompts skin cells to multiply at an accelerated rate, forming thick, silvery scales. Various factors, such as stress, infections, and certain medications, can trigger or exacerbate flare-ups. Despite its non-contagious nature, psoriasis can significantly impact individuals’ quality of life, affecting their physical and emotional well-being. It can flare up unexpectedly and there’s no cure.

Symptoms of psoriasis include thick areas of discolored skin covered with scales. In addition to skin plaques or a rash, you might have symptoms like Itchy skin, Cracked, dry skin, Skin pain, Nails that are pitted, cracked or crumbly, Joint pain.

Psoriasis can appear on any part of the body. Psoriasis is common on:

• Elbows and knees.
• Face and inside of your mouth.
• Scalp
• Fingernails and toenails.
• Genitals
• Lower back.
• Palms and feet

In most people, psoriasis covers a small area of their skin. In severe cases, the plaques connect and cover a large area of your body.

 Psoriasis is multifactorial. It is classified as an immune-mediated genetic skin disease. This involves a complex interaction between the innate and adaptive immune systems. 

Other Triggers for psoriasis include:

• Bacterial and viral infections
• Stress: Emotional or frictional on the skin surface inducing new areas of psoriasis and aggravating existing plaques

Medications

• Injury to the skin: Intentional such as with surgery, or unintentional such as a cut or scrape
• Dry skin: May lead to scratching of the skin
• Too little sunlight and even too much sunlight causing sunburn
• Alcohol
• Nicotine: Smoking and smokeless tobacco products

There are several types of psoriasis:

Plaque psoriasis:  

Plaque psoriasis is the most common type of psoriasis. About 80% to 90% of people with psoriasis have plaque psoriasis. On Caucasian skin, plaques typically appear as raised, red patches covered with a silvery white buildup of dead skin cells or scale. On skin of color, the plaques may appear darker and thicker and more of a purple or grayish color or darker brown.

Inverse psoriasis: 

This type appears in your skin folds areas like the axillae, groin and buttock creases and the folds under the breasts. It causes thin plaques without scales. Because of the heat and skin-on-skin friction at these sites, the scales tend to be rubbed off and all that remains is shiny, red smooth areas that look like scalded skin.

Guttate psoriasis: 

Guttate psoriasis may appear after a sore throat caused by a streptococcal infection. It looks like small, red, drop-shaped scaly spots and often affects children and young adults. This type may come and go and does not necessarily mean that a patient will develop ongoing, chronic plaque-type psoriasis.

Pustular psoriasis: 

 Pustular psoriasis is a type of psoriasis that causes pus-filled blisters on plaques, which are patches of scaly, flaky skin. Pustular psoriasis is common on your hands and feet but can form anywhere on your body. Pustular psoriasis isn’t rare, but a type of pustular psoriasis called generalized pustular psoriasis is the rarest form of psoriasis. Generalized pustular psoriasis causes symptoms of psoriasis that affect a large area of your body. Additionally, you may have symptoms like a fever and muscle weakness accompanying the quickly spreading psoriasis plaques on your skin.

Palmoplantar pustulosis, which is also known as palmoplantar pustular psoriasis, is pustular psoriasis that affects only your hands and feet.

Erythrodermic psoriasis:

This is a severe type of psoriasis that affects a large area (more than 90%) of your skin. It causes widespread skin discoloration and skin shedding. It very often occurs after a stressful event in the body as a whole, such as an infection, fever, or other significant illness.

Sebopsoriasis: 

Sebopsoriasis is a disease that has symptoms of two different skin conditions: psoriasis and seborrheic dermatitis. It presents as a red rash with yellow, greasy scales in areas of the body where seborrheic dermatitis typically appears (scalp, face, chest, and within skin folds). Although anyone at any age can be diagnosed with sebopsoriasis, the condition is more prevalent in children, adolescents, and people 50 years of age or older.  

Nail psoriasis: 

Nail psoriasis causes skin discoloration, pitting, and changes to your fingernails and toenails. Pitting, onycholysis, yellowing, and ridging are effects of Psoriasis. Fingernail shows three signs of nail psoriasis: Crumbling, roughness, and blood under the nail (arrow).

Psoriatic arthritis (PsA) is a chronic inflammatory musculoskeletal and skin disease, associated with psoriasis (PsO). PsA can affect peripheral joints, entheses, and the axial skeleton, and it is characterized by different clinical manifestations and a variable clinical course. It affects 10–40% of PsO patients. In most cases, skin manifestations precede arthritis, in 15% of the cases the onset is simultaneous, and in 10–15% of the cases, arthritis precedes PsO. Moreover, beyond musculoskeletal and skin manifestations, patients of PsA have a higher prevalence of comorbidities compared to the general population, with more than half of PsA patients reporting at least one comorbidity and up to 40% of patients having more than three comorbidities.

 PsA patients exhibit a high prevalence of cardiovascular (CV) risk factors, including metabolic syndrome (MetS)

The elevated MetS may account for the elevated CV risk observed in PsA. In fact, patients with PsA have a 55% higher probability of developing CV diseases such as ischemic heart disease, cerebrovascular events or congestive heart failure (17). Moreover, a recent meta-analysis found that PsA patients exhibit increased mortality [relative risk (RR): 1.74, 95% CI: 1.32–2.30], particularly arising from CV disease (RR: 1.84, 95% CI: 1.11–3.06).

Patients with psoriasis are more likely than others to have associated health conditions such as:

• Inflammatory “psoriatic arthritis” (an autoimmune disease) and spondyloarthropathy (seen in up to 40% of patients with early-onset chronic plaque psoriasis).
• Inflammatory bowel disease (Crohn’s disease and ulcerative colitis).
• Uveitis (a form of inflammation of the eye).
• Coeliac disease.
• Localized palmoplantar pustulosis, generalized pustulosis, and acute generalized exanthematous pustulosis.
• Non-alcoholic fatty liver disease

Psoriasis is diagnosed by its clinical features. If necessary, diagnosis is supported by typical skin biopsy findings. Patients with psoriasis should be well-informed about their skin condition and its treatment. Recommendations include:

• Smoking cessation
• Safe limits for alcohol consumption
• Maintaining optimal weight.
• Topical therapy
• Mild psoriasis is generally treated with topical agents alone. The selected treatment depends on the body site and the extent and severity of psoriasis.

Treatments fall into 3 categories:

• Topical – creams and ointments applied to your skin
• Phototherapy – your skin is exposed to certain types of ultraviolet light
• Systemic – oral and injected medications that work throughout the entire body

Different types of treatment are often used in combination: 

Emollients: Emollients are moisturizing treatments applied directly to the skin to reduce water loss and cover it with a protective film. The main benefit of emollients is to moisturize the skin and reduce itching and scaling. Some other topical treatments are thought to work better on moisturized skin. Wait at least 30 minutes before applying another topical treatment after an emollient.

Steroid creams or ointments: Steroid creams or ointments (topical corticosteroids) are commonly used to treat mild to moderate psoriasis in most areas of the body. The treatment works by reducing inflammation. This slows the production of skin cells and reduces itching.

Topical corticosteroids range in strength from mild to very strong. Only use them when recommended by your doctor.

Vitamin D analogues: Vitamin D analogue creams are commonly used along with or instead of steroid creams for mild to moderate psoriasis affecting areas such as the limbs, trunk or scalp. They work by slowing the production of skin cells. They also have an anti-inflammatory effect. Examples of vitamin D analogues are calcipotriol, calcitriol and tacalcitol. 

Calcineurin inhibitors: Calcineurin inhibitors, such as tacrolimus and pimecrolimus, are ointments or creams that reduce the activity of the immune system and help to reduce inflammation. They’re sometimes used to treat psoriasis affecting sensitive areas, such as the face, the genitals and folds in the skin, if steroid creams are not effective.

These medications can cause skin irritation or a burning and itching sensation when they’re started, but this usually improves within a week.

Coal tar: Coal tar is a thick, heavy oil and is probably the oldest treatment for psoriasis. How it works is not exactly known, but it can reduce scales, inflammation and itchiness.
It may be used to treat psoriasis affecting the limbs, trunk or scalp if other topical treatments are not effective. 

Dithranol: Dithranol has been used for more than 50 years to treat psoriasis. It has been shown to be effective in suppressing the production of skin cells and has few side effects. However, it can burn if it’s too concentrated. It’s typically used as a short-term treatment, under hospital supervision, for psoriasis affecting the limbs or trunk, as it stains everything it comes into contact with, including skin, clothes and bathroom fittings. It’s applied to your skin (by someone wearing gloves) and left for 10 to 60 minutes before being washed off. Dithranol can be used in combination with phototherapy.

Phototherapy: Most psoriasis centers offer phototherapy (light therapy) with ultraviolet (UV) radiation, often in combination with topical or systemic agents.

UVB phototherapy uses a wavelength of light invisible to human eyes. The light slows down the production of skin cells and is an effective treatment for some types of psoriasis that have not responded to topical treatments. Each session only takes a few minutes, but you may need to go to the hospital 2 or 3 times a week for 6 to 8 weeks.

Psoralen plus ultraviolet A (PUVA): For this treatment, you’ll first be given a tablet containing compounds called psoralens, or psoralen may be applied directly to the skin. This makes your skin more sensitive to light. Your skin is then exposed to a wavelength of light called ultraviolet A (UVA). This light penetrates your skin more deeply than UVB light. This treatment may be used if you have severe psoriasis that has not responded to other treatment.

Side effects include nausea, headaches, burning and itchiness. You may need to wear special glasses for 24 hours after taking the tablet to prevent the development of cataracts.

Combination light therapy: You may be offered creams or ointments (topical treatments) alongside light therapy if:

• your psoriasis is not responding to light therapy alone
• you cannot, or do not want to, take medicines for your psoriasis

Retinoids: These vitamin A-related drugs can help your psoriasis symptoms but may cause side effects, including birth defects.

Immune therapies: Newer immune therapy medications (biologics and small molecule inhibitors) work by blocking your body’s immune system so it can’t cause an autoimmune reaction.

Non-biological medications

Methotrexate: Methotrexate can help control psoriasis by slowing down the production of skin cells and suppressing inflammation. It’s usually taken once a week. Methotrexate can cause nausea and may affect the production of blood cells. Long-term use can cause liver damage. People who have liver disease should not take methotrexate, and you should not drink alcohol when taking it. Methotrexate can be very harmful to a developing baby, so it’s important that women use contraception and do not become pregnant while they take this drug and for at least 6 months after they stop. Men are advised to delay trying for a baby until at least 6 months since their last dose of methotrexate.

Ciclosporin: Ciclosporin is a medicine that suppresses your immune system (immunosuppressant). It was originally used to prevent transplant rejection but has proved effective in treating all types of psoriasis. It’s usually taken daily. Ciclosporin increases your chances of kidney disease and high blood pressure, which will need to be monitored.

Combination light therapy: You may be offered creams or ointments (topical treatments) alongside light therapy if:
your psoriasis is not responding to light therapy alone you cannot, or do not want to, take medicines for your psoriasis

Biological DMARDs

TNF Inhibitors The effectiveness of TNF in patients with MetS is still a subject of debate. Several studies highlight the reduced efficacy of TNF in obese patients. A recent study based on the US CORONA PsA/SpA registry found that the presence of obesity was a strong predictor of failure to achieve remission in PsA. Although the efficacy of TNFi may be lower in obese patients than in their non-obese counterparts, some studies have shown a lower risk of developing DM in TNFi-treated patients compared to other non-biological systemic treatments. Interestingly, the impact of TNFi seems to be associated with a beneficial effect on several MetS components, including, waist circumference, levels of triglycerides and HDLc as well as blood glucose levels

Other Biological Drugs: IL-17 and IL-12/23 Inhibitors Unfortunately, there is a lack of robust clinical evidence on the role of drugs targeting IL-17 and IL-12/23 on MetS and CV outcomes in PsA. Interestingly, this axis is expected to contribute to the cardiometabolic alterations, at least in PsO. A recent prospective study has demonstrated that overweight and obese patients had a better Disease Activity in Psoriatic Arthritis score compared with their normo-weight counterparts, and serum IL-17 seem to correlate BMI, pointing to an association between obesity and IL-17 and thus, a potential better clinical benefit in patients with obesity. This finding was also supported by the fact that obesity was related to a Th17 expansion in adipose and peripheral tissues. However, due to the paradoxical association between IL-17 and CV disease, whether IL-17 blockade leads to a more favorable profile and MetS mitigation requires further research.

Small Molecules

Apremilast: Apremilast is a phosphodiesterase 4 (PDE4) inhibitor belonging to the class of oral small molecules. It is indicated for the treatment of PsA and moderate/severe PsO . It acts at the intracellular level by modulating the production of pro-inflammatory and anti-inflammatory mediators by PDE4. In addition to fueling inflammatory processes, PDE4 seems to be also involved in lipid and glucose metabolism disorders, liver steatosis, altered lipolysis, and neuroendocrine alterations. Therefore, its inhibition may bring benefits on both the inflammatory component at the base of PsO/PsA, as well as on the MetS components. Inhibition of PDE4 improves liver steatosis, reduces lipid deposition in the liver and consequently improves insulin resistance.

Tofacitinib: Tofacitinib is an oral Janus kinase inhibitor (JAKi) that works interfering with the intracellular signaling pathway of s number of cytokines and inflammatory mediators. It is indicated for the treatment of PsA. Tofacitinib treatment has been observed to increase LDL levels. Hypercholesterolemia is an important CV risk factor, and for this reason tests have been carried out aimed at assessing the efficacy and safety of tofacitinib in patients with MetS, and in general in those with increased CV risk. A post-hoc analysis of phase III tofacitinib studies analyzed the efficacy and safety profile of this drug in patients with MetS.

Moderate to severe psoriasis warrants treatment with a systemic agent and/or phototherapy. Systemic corticosteroids are best avoided due to the risk of severe withdrawal flare of psoriasis and adverse effects.

Though psoriasis has no permanent cure but treatments provide relief and one feels better.
Preventive measures like following healthcare provider’s treatment, living a healthy lifestyle, taking good care of your skin and avoiding triggers that can cause an outbreak of symptoms help in comforting skin.