Very comprehensive guide to psoriasis treatment options.

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Very comprehensive guide to psoriasis treatment options.

Postby Nick Balgowan » Thu Oct 26, 2006 3:19 pm

Psoriasis

Introduction

We've all had itchy skin, but have you ever had itchy patches of raised, red, skin covered by a flaky, white buildup? This is the hallmark sign of a chronic skin condition known as psoriasis ("sore-I-ah-sis"), which affects more than 4.5 million adults in the United States. Psoriasis can be mild to debilitating, depending on what parts of the skin are affected and the severity of the disease. Read on to learn more about the causes, symptoms, and treatment of this skin condition.

What is it?


Psoriasis is a chronic skin condition that is most commonly distinguished by thickened, raised, red, patches of skin that are covered with silver-white scales or flakes. Psoriasis is most frequently found on the knees, elbows, scalp, hands, feet, or lower back. Typically, intense itching and burning accompany this skin condition. While bouts of psoriasis come and go, this condition is chronic in nature. Once a person is diagnosed with psoriasis, they are at risk for experiencing future outbreaks. Treatment is partly aimed at reducing the frequency of these outbreaks.

Most researchers now believe that psoriasis is related to the body's immune system (the system that helps the body fight off diseases and infections). Psoriasis is not contagious, but there is a definite genetic link to the disease. Several different types of psoriasis exist, with each type having certain appearances or symptoms. The various types of psoriasis are discussed below:

Plaque psoriasis is the most common form of psoriasis, accounting for 80% of all occurrences of the skin condition. Plaques can appear on any skin area of the body but most commonly appears on the knees, elbows, scalp, trunk, and nails. This type of psoriasis is identified by well-defined patches of red, raised, skin that is covered with silver-white scales or flakes.

Guttate psoriasis often begins in childhood or young adulthood. It can occur suddenly, over the course of a few days and is most often brought on by infections caused by bacteria or viruses. Guttate psoriasis is identified by small, red, individual bumps on the skin, usually on the trunk of the body and the limbs, but it is occasionally found on the head.

Inverse psoriasis is more common and troublesome in overweight people. This is because of increased rubbing (from skin on skin or skin on clothes) and sweating, which can lead to irritation of the affected areas. Inverse psoriasis is identified by red, swollen plaques that do not have scaling. These plaques are typically found on smooth areas of the skin, often in folds or creases.

Erythrodermic psoriasis is the least common form of psoriasis. It often involves flare-ups and a burning redness and swelling of the majority of skin on all locations of the body. Erythrodermic psoriasis can disrupt the body's ability to control its temperature and can lead to severe illness. In severe cases, people with this type of psoriasis may need to be hospitalized if they become dehydrated, have an infection, or have poor blood circulation.

Pustular psoriasis is identified by a general reddening of the skin that appears quickly and is tender. This redness then progresses, within as little as a few hours, to pus-filled blisters or lesions. Fever, chills, severe itching, a rapid pulse rate, exhaustion, anemia (a condition where there are not enough healthy red blood cells to carry oxygen to your body's tissues), weight loss, and muscle weakness may also accompany this form of psoriasis. Pustular psoriasis can cover the trunk of the body, arms, and legs (the most severe form of this type of psoriasis) or can be confined to the palms of the hands or soles of the feet.

Psoriatic ("sore-ee-AA-tic") arthritis is diagnosed in about 23% of the individuals who have any of the other types of psoriasis. Rarely will an individual develop psoriatic arthritis without having another form of psoriasis. Psoriatic arthritis typically occurs about 10 years after the first signs of psoriasis and most commonly affects the ends of the fingers, toes, and the spine. Early diagnosis is important for preventing long-term damage to joints and tissues. Some symptoms include stiffness, pain, swelling, and tenderness of the joints and surrounding tissues and a decrease in range of motion of the arms or legs.
Typically, individuals have only one type of psoriasis at a time (excluding psoriatic arthritis). Occasionally, two different types can occur together or one type may change to another type. Psoriasis can be mild to debilitating, depending on which body areas are affected and how much of the body is affected. For instance, many people get psoriasis on their scalp, which may be annoying but not as debilitating as developing psoriasis on the palms of the hands or the soles of the feet (which may hinder the ability to use the hands or to walk).

It is important for your doctor to differentiate between the various types of psoriasis because each type may require different treatments. It is very important that you talk with your physician about what treatment is best for your specific type of psoriasis.

What causes it?


Currently, researchers believe that the body's own defense system (the immune system) may send out false signals that cause the overgrowth of skin cells in individuals with psoriasis. In individuals without psoriasis, skin cells mature and are shed about every 28 days. In individuals with psoriasis, the skin cells move rapidly to the skin's surface in 3 to 6 days. This rapid production of skin cells does not allow time for the body to shed the cells, resulting in the formation of patches on the skin's surface. Certain individuals may have inherited genes that make them more likely to develop psoriasis, but not all individuals who have these genes will develop psoriasis. Often, certain triggers set these genes in motion.

Potential triggers may include:

Emotional stress caused by a job or event at home or school

Injury to the skin, such as cuts, burns or sunburns, rashes, insect bites

Certain infections (upper respiratory infections like strep throat)

Various prescription drugs (lithium, propranolol, quinidine, and indomethacin)

Alcohol

Smoking

Weather (cold temperatures often worsen psoriasis)

Who has it?

More than 4.5 million adults in the United States have a form of psoriasis. Between 10% and 30% of people with psoriasis also develop a related form of arthritis, called psoriatic arthritis. Approximately 150,000 new cases of psoriasis are diagnosed each year. Psoriasis most frequently occurs between the ages of 15 to 35 years, but can develop at any age. About 10% to 15% of individuals with psoriasis develop it before the age of 10. Psoriasis is thought to have a genetic component, with a family association existing in one of every three cases. Some studies have indicated a higher occurrence of psoriasis in men than in women.

What are the risk factors?


"Risk factors" are characteristics that can predispose you to developing a condition. The risks associated with developing psoriasis are similar to the triggers of the disease. Risk factors for psoriasis may include the following:

Family history of psoriasis

Physical trauma to skin, such as cuts, burns, or insect bites

Infections, such as strep throat, chicken pox, or the common cold, may increase the risk for the guttate form of psoriasis

Stressful situations caused by a job or event at home or school

Age (between 15 and 35 years)

Gender (some studies show a higher occurrence in males)

Race (occurs more frequently in Caucasians)

Weather (cold, dry air)

What are the symptoms?


Symptoms depend on the type of psoriasis the individual has and may include the following:

Raised, deep, pink-skin lesions, with red borders and silver-white surface scales; the affected area may be cracked and painful.

Blisters oozing with pus (pustular psoriasis)

Pitted, discolored, and possibly thickened fingernails or toenails

Itchy skin

Joint pain (psoriatic arthritis)

How is it treated?


While there is no cure for psoriasis, many treatments are available to help reduce or eliminate the symptoms and rash associated with the disease. Because various forms of psoriasis exist and the disease affects everyone differently, no single treatment works best for everyone. Doctors who specialize in treating skin conditions, known as dermatologists, may need to be consulted to help decide the best treatment.

Goals of treatment for psoriasis include clearing up the present psoriatic rash and preventing new flare-ups of the rash. Finding the most effective therapy with the fewest side effects is paramount. To accomplish these goals, treatments for psoriasis include topical medications, sunlight or artificial UV light therapy (also called phototherapy), and oral or injectable medications. Sometimes a combination of these treatments may be used. Topical medications and sunlight therapy have the least occurrence of side effects and are generally useful for mild forms of psoriasis. Artificial UV light therapy and oral or injectable medications are reserved for more moderate to severe cases of psoriasis and may have a higher occurrence of side effects. The type of psoriasis and the severity of the psoriasis will help the doctor determine the best treatment approach.

To learn more about how each type of psoriasis is treated, click on the treatment links below. To learn more about the specific medications used to treat psoriasis, click on the Drug Class links below.

Treatment of Plaque Psoriasis


Many safe and effective treatments are available for improving the condition of the skin by reducing the swelling, redness, flaking, and itching associated with plaque psoriasis. However, since psoriasis is a chronic (long-lasting) disease, it may be a challenge to treat. Generally, treatment is started with the least powerful treatment option. If this option fails, a stronger medication may be used. This cycle will continue until an acceptable combination is found.

Psoriasis Treatment Steps:

Step 1

Topical treatments are used first in treating plaque psoriasis because they tend to have the fewest side effects. These medications are commonly used in combination with phototherapy for the more severe cases of psoriasis. The following are the most common topical medications:

Anthralin: may slow down the rapid growth of skin cells.

Coal Tar: works by slowing skin cell growth.

Calcipotriene (Dovonex): helps to regulate skin cell production and may be used in combination with topical steroids. This product should not be used in combination with products containing salicylic acid because this combination will make the medication ineffective.

Moisturizers/Emollients: help keep the skin moist and prevent the cracking and itching associated with psoriasis.

Salicylic acid: helps to loosen and remove the build-up of skin cells or scales.

Steroids: may slow down the rapid growth of skin cells and decrease the swelling associated with the rashes.

Tazarotene (Tazorac): is available as a cream or gel and is applied once a day. This medication is thought to inhibit increased skin cell growth.
Step 2

Phototherapy (UV light therapy) is used for individuals with moderate to severe psoriasis who do not respond to topical treatments or whose condition is too severe for topical therapy.

Many people with psoriasis use sunlight to help heal lesions. Short, multiple sunbathing sessions can prove helpful in treating psoriasis. However, caution must be exercised because sunburn could actually worsen psoriasis.

PUVA (psoralen plus ultraviolet light A) is also called "photochemotherapy." Psoralen is a medication that can be taken orally or applied topically to increase sensitivity to ultraviolet light A. PUVA therapy slows the growth of psoriasis.

Ultraviolet Light B (UVB) is used to reduce the number of skin cells that grow at a faster rate in people with psoriasis and can reduce inflammation in the skin lesions.

Lasers represent the newest type of phototherapy for psoriasis. They work by destroying the tiny blood vessels in the skin that contribute to the formation of psoriasis lesions.
Natural sunlight and artificial ultraviolet light slow the rapid growth of skin cells. Although ultraviolet light or sunlight can cause skin wrinkling, eye damage, and skin cancer, light treatment is safe and effective under a doctor's supervision. People with psoriasis all over their entire body may require treatment in a medically approved center, equipped with special light boxes for full body exposure. Psoriasis patients who live in warm climates may be directed to carefully sunbathe. Seek the advice of a doctor before self-treating with natural or artificial sunlight.

Step 3

Systemic drugs (oral or injectable medications) are usually reserved for individuals with moderate to severe psoriasis or disabling psoriatic arthritis. The following systemic medications are the most commonly used:

Alefacept (Amevive) or efalizumab (Raptiva) works by blocking certain cells in the body's defense system (immune system) believed to trigger the start of increased skin cell growth.

Methotrexate works by halting the production of skin cells.

Cyclosporine (Neoral, Sandimmune) is believed to slow down the production of skin cells.

Acitretin (Soriatane) is thought to inhibit skin cell growth.
Other medications are sometimes used to treat psoriasis, although they do not have FDA-approval for treating psoriasis. These medications include hydroxyurea (Hydrea), mycophenolate (CellCept), sulfasalazine (Azulfidine), isotretinoin (Accutane), and 6-thioguanine (6-TG).

Treatment of Guttate Psoriasis


Because guttate psoriasis may be triggered by a bacterial infection, antibiotics may help prevent additional outbreaks by stopping the infection from recurring. Antibiotics work in various ways. They will either halt the growth and reproduction of bacteria or directly damage the bacteria, thereby causing the bacteria's death.

Topical medications may help mild to moderate cases of guttate therapy, but phototherapy may be needed to help relieve an outbreak. In severe cases when relief is needed quickly, a physician may need to prescribe oral medications.

Treatment of Erythrodermic Psoriasis

The initial treatment typically includes a combination of topical steroids, moisturizers and oatmeal baths, along with bed rest. However, if the disease worsens, oral medications and even hospitalization may be needed.

Treatment of Scalp Psoriasis


Topical medications in the form of shampoos, lotions, creams, foams, and oils are the standard of treatment for psoriasis on the scalp. The following medications have been used for scalp psoriasis:

Medicated shampoos containing salicylic acid help to loosen and remove scales from the scalp. Shampoos containing coal tar work by slowing skin cell growth.

Topical steroids, such as cortisone creams, may slow down the rapid growth of skin cells and decrease the swelling associated with the rashes.

Calcipotriene (Dovonex) helps regulate skin cell production and may be used in combination with topical steroids. This product should not be used in combination with products containing salicylic acid because this combination will make Dovonex ineffective.

Tazarotene (Tazorac) is available as a cream or gel and is applied once a day. This medication is thought to inhibit accelerated skin cell growth.

Phototherapy may be helpful if topical treatments stop working.

Systemic (oral) medications may be used, but the benefits of treatment must be weighed against the potential side effects.
A few things to keep in mind when treating scalp psoriasis:

Be gentle when treating the scalp. Picking or scratching the areas of psoriasis should be avoided. Breaking of the skin can make psoriasis worse.

Covering the treatment medication with a shower cap may be helpful, but this should only be done only under your doctor's guidance.

Be sure to use medicated shampoos as directed. It is important to rub the shampoo into the scalp and not just the hair.

Treatment of Inverse Psoriasis


Treatment of inverse psoriasis may be difficult due to the sensitivity of the skin affected.

Topical steroids, usually a cortisone cream, are most commonly used but should not be covered by plastic dressings because this can lead to increased absorption of the medication into the body and may increase the risk for side effects. Overusing or misusing steroids may result in the thinning of the skin and stretch marks.

Oral fluconazole (Diflucan) may help control the growth of yeast within the skin-folds, if topical treatments fail.

Other topical agents such as tazarotene (Tazorac) and anthralin may be used, but these agents may cause skin irritation.

Systemic (oral) medications should only be used if all other treatments fail.

Treatment of Pustular Psoriasis


Pustular psoriasis is often difficult to treat. Topical treatments, such as steroids, are usually prescribed first. These may be followed by phototherapy or systemic (oral) medications.

In severe cases, if an individual becomes exhausted from recurring outbreaks or becomes severely dehydrated as a result of fluid loss from the breaks in the skin barrier, hospitalization may be required. Hospitalization may consist of bed rest, topical therapy, rehydration with intravenous fluids, and avoidance of excessive heat loss. Also, if an infection is present, antibiotics may be necessary.

Treatment of Psoriatic Arthritis

The goals of treating psoriatic arthritis include providing pain relief and swelling reduction, maintaining proper joint function, and possibly preventing further tissue damage. Treatments are based on the type of psoriatic arthritis, its severity, and an individual's reaction to treatment. Treatments may include non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen, disease-modifying antirheumatic drugs (DMARDs) such as methotrexate or sulfasalazine, biologics such as etanercept, surgery, physical therapy and rehabilitation, or alternative therapies such as glucosamine and chondroitin or magnetic therapy.

Helping Yourself


Since psoriasis has been linked to certain "triggers," it is important to try and avoid these triggers. Listed below are some things to keep in mind.

Scratching affected skin will worsen your psoriasis and can even cause new lesions to form. Therefore, it is important not to scratch, pick, or rub psoriasis lesions.

During the winter months, the humidity is generally lower, especially in homes with forced air heating. This tends to cause dry, itchy skin. It's important to increase your use of moisturizing creams and ointments during the winter, applying heavy layers, especially over the skin affected by psoriasis. It is helpful to apply the moisturizing cream while your skin is damp. Also, be sure to pat yourself dry after bathing - don't rub yourself with the towel.

Natural sunlight can have a healing effect on psoriasis. The long-known benefits of sunlight provided the basis for the development of ultraviolet light therapy for treating psoriasis. However, you should be careful not to get too much sun exposure as this may cause sunburn, which can actually cause psoriasis to flare-up and worsen. Talk to your doctor to determine the appropriate amount of sunlight for you. Use sunscreen on body parts that are not affected by psoriasis.

What is on the horizon?


Research in the past few decades has increased our understanding of psoriasis; however, there is still a long way to go. While it is known that psoriasis is an immune system related condition, it is not completely understood how the immune system becomes activated to cause psoriasis. Researchers continue to learn more about this process. It is also known that psoriasis is a hereditary condition; however, some people who carry the gene for psoriasis do not actually develop the skin condition. Research to learn more about the genetic link to psoriasis continues.

Current treatments for psoriasis focus on alleviating the unpleasant symptoms of this skin disease. A study taking place throughout Canada will evaluate the effectiveness of Enbrel (etanercept) in patients with moderate-to-severe plaque psoriasis. Similar studies with Enbrel (etanercept) are taking place across the United States. Many different drug companies are researching new treatments for psoriasis that focus on the immune system. Many experts agree that the future of psoriasis treatment lies in getting to the root of the problem in the body's own defense system (immune system). This means significant resources will continue to be dedicated to research and development of new drugs for psoriasis.

References

American Academy of Dermatology Home Page. Accessed February 21, 2003 and May 30, 2006.

National Institute of Arthritis and Musculoskeletal and Skin Diseases Home Page. Accessed February 21, 2003 and May 30, 2006.

National Psoriasis Foundation Home Page. Accessed February 20, 2003 and May 30, 2006.

West DP West LE, Scuderi L, Micali G. Psoriasis. In: Pharmacotherapy A Pathophysiologic Approach. 6th ed. Dipiro JT, Talbert RL eds. Stamford, CT; Appleton and Lange: 2005: 1769-83.

Psoriasis Net Home Page. Accessed February 21, 2003 and May 30, 2006.

Swerlick RA, Lawley TJ. Eczema, Psoriasis, Cutaneous Infections, Acne, and Other Common Skin Disorders. In: Harrison's Principles of Internal Medicine. 14th ed. Fauci AS, Kasper DL, Hauser SL eds. St. Louis;McGraw-Hill;1998:300-1.
Nick Balgowan.
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