Psoriasis

Psoriasis is a common chronic, relapsing, non-contagious skin disorder characterised by red patchy lesions, with grey or silvery-white, dry scales, which are frequently painful, itchy and may bleed. Lesions are typically distributed symmetrically on the scalp, elbows, knees and essentially any part of the body. It is a disease with an unpredictable course, prone to flare-ups and remissions, and which can affect the joints, nails and eyes [1, 2]. Psoriasis is found worldwide but the prevalence varies among different ethnic groups. It affects 1-5% of Europeans overall, with rates as high as 6% in France and Germany. In the UK, it is the 3rd most common dermatological disease, affecting approximately 1-2% of the population; this equates to approximately 1.2 million people and accounts for 10-20% of visits to a hospital dermatology unit [1, 3, 4]. It can afflict both men and women, and usually begins in early adulthood although it has been reported at birth. The mean age of onset for the first presentation of psoriasis can range from 15-20 years of age, with a second peak occurring between ages 55-60 years [5].

Psoriasis is generally categorised into one of three severities based on the extent of body surface covered. Where 2% of the body is affected, it is classified as mild, where 3-10% of the body is covered, it is classified as moderate and where more than 10% of the body is affected, the disease is classified as severe. Based on these criteria, approximately 25-30% of patients have psoriasis, which is considered moderate to severe [1].

Causes or Risk Factors
The exact cause of psoriasis is unknown; however, numerous studies have attempted to define the risk factors for developing psoriasis. The following have been named as risk factors for the development of psoriasis,

1. Family history (genetics)
This is the most well established risk factor for the development of psoriasis. Approximately 40% of patients with psoriasis have a family history amongst first-degree relatives. It has also been noted that psoriasis develops in as many as half of the siblings when both parents have psoriasis, this falls to 16% when only one parent is affected, and 8% when neither parent is affected but there is an affected sibling [6].

2. Infections
Bacterial and viral infections may be linked to psoriasis; however, beyond streptococcus, the role of other infections in precipitating psoriasis has not been studied [4, 6].

3. Alcohol and smoking
Some studies have suggested smoking or alcohol as a cause of psoriasis. Although a large proportion of these studies have been case-control studies, based on a typical group of patients admitted to hospital, in a population based study, alcohol was shown to be a significant risk factor for mortality among patients suffering from psoriasis. Not only that, alcohol has been associated with worsening of skin disease after drinking in men and women and treatment failures. Alcohol seems to affect dermatological diseases such as psoriasis by influencing metabolism, cutaneous vasculature (arrangement of blood vessel around the skin), and the immune response [7]. Alcohol intake can lead to liver dysfunction, when the liver cannot get rid of toxins as a result of this, the different systems in the body are affected, including the skin. The skin, trying to purge itself of toxins may result in an immune related disease, such as psoriasis. It is quite possible that alcohol may alter the expression of psoriasis and its clinical course. Abstinence from alcohol can induce remission [4, 6, 8].

The role of smoking as a risk factor for psoriasis remains elusive. According to Neimann et al (2006) in 1992, researchers in the UK evaluated 108 patients with new psoriasis and compared rates with matched controls in the community. They showed a significant association between smoking ¡§prior to onset¡¨ and psoriasis.

Although it has often been implicated in the pathogenesis and progression of the disease, conclusive data on the role of smoking is currently lacking. As indicated by some studies, whether or not smoking causes psoriasis, cessation probably does not alter the course of the disease [4, 6].

4. Trauma
Psoriasis may appear at the sites of trauma, including sites of sunburn, following surgery or biopsies, or even after simply scratching an area.

5. Stress
Recently, stress has been implicated in the acceleration or in accelerating the worsening of psoriasis, as can be found in many other diseases with complex natural history. Although this factor has not been robustly studied, the view that stress is a significant factor in the natural history of psoriasis is widespread, particularly among patient groups [4].

6. Drugs
Although drug exposure has not been well defined as a risk factor for new incidence of psoriasis, some drugs have been reported to worsen pre-existing cases of psoriasis. These drugs include lithium (mood stabilising drug) and antimalarials [4, 6].

Types of Psoriasis
1. Plaque psoriasis
This is the most common form of psoriasis characterised by sharply circumscribed (hemmed in or confined), round-oval or coin-sized plaques, with white blanching rings observed in the skin surrounding the plaques. Scales are typically present, characteristically silvery-white, and can vary in thickness. The amount of these scales can vary in size from patient to patient and at different sites on a particular patient. Removal of such scales may reveal tiny bleeding points. Plaque psoriasis affects the back of the elbows and the front of the knees as well as the back and scalp (scalp psoriasis) [4, 5].

2. Guttate psoriasis
From the Greek word gutta meaning droplet, Guttate psoriasis presents as small patches (2-10 mm diameter) of psoriasis all over the body. Accounting for about 2% of the total cases of psoriasis, it usually occurs shortly after a throat infection (streptococcal infection of the pharynx or tonsils) and can be the presenting episode of psoriasis in children or, occasionally, adults. The number of patches manifested in this type of psoriasis varies and can range from 5 or 10 to over 100 [5].

3. Flexural psoriasis
This affects the flexures (skin folds e.g. under breasts), and have lesions, which are devoid of scales and appear as red, shiny, well demarcated plaques [5].
4. Generalised pustular psoriasis
This is a rare type of psoriasis, which represents active, unstable disease. It is characterised by anti-inflammatory changes in the psoriatic sites and lesions are presented as small, red, circular patches, filled with pus. Patients often present with a fever and usually need to be admitted to the hospital for management as it can be a life-threatening condition with a variety of consequences, including hypothermia (dangerously low body temperature) [4, 5].

5. Erythrodermic psoriasis
This is a serious but rare complication of psoriasis. It may take one of two forms,
a) Chronic plaque psoriasis, which may gradually progress as plaques become confluent (run together) and extensive, or
b) A manifestation of unstable psoriasis brought about by infection, tar, drugs, or withdrawal from corticosteroids (a synthetic drug similar or identical to a natural corticosteroid, used to reduce inflammation and control allergic disorder).

It is one of the few emergencies involving skin conditions as it may impair the thermoregulation capacity of the skin, leading to hypothermia (dangerously low body temperature), high output cardiac failure and metabolic changes such as anaemia due to loss of iron and vitamin B12. Patients suffering from this rare disease are usually admitted to the hospital [4, 5].

6. Palmoplantar pustulosis
This presents as sterile, yellow pustules (small round raised area of inflamed skin filled with pus) on a background of abnormally red skin caused by local congestion (as in inflammation) and scaling, which affects the palms and/or soles of the feet. Pustules are tender and fade to form dark brown colouration with scales or crusts, which adhere to them. Palmoplantar pustulosis most commonly affects women, presents most commonly between the ages of 40 and 60 years and is associated with current or past smoking in up to 95% of subjects.

(It is now believed however that palmoplatar pustulosis may not be a form of psoriasis) [4, 5].

7. Psoriatic nail disease
This usually affects the fingernails much more than toenails. The most common finding is small pits (as of a thimble) in the nail plate, resulting from defective nail formation in the proximal portion (near to the point of attachment) of the nail matrix. Orange-yellow areas may also be present beneath the nail plate; these are referred to as ¡§oil spots¡¨. The nail plate may become thickened, opaque and discoloured [5].

Associated diseases
In addition to skin lesions, a number of serious health conditions have been associated with psoriasis [9]. These associations are important as they are part of the burden of psoriasis and can also be potentially important in managing and counselling patients [6].

1. Psoriatic arthritis (PsA)
The association of arthritis with psoriasis represents one of the very first examples of disease association in dermatology [10]. Psoriatic arthritis has been defined as ¡§a unique inflammatory arthritis associated with psoriasis and has emerged as a specific disease, independent from rheumatoid arthritis¡¨ [6, 11]. The exact incidence of PsA is unknown; however estimates vary from 0.3% to 1% of the population (occurring in equal frequencies in both sexes). Among patients with psoriasis, the incidence of inflammatory arthritis varies from 6% to 42% [10].
A number of clinical features help to distinguish PsA from rheumatoid arthritis (RA). In PsA, the specific clinical features include the common involvement of distal joints, this is such that all the joints of a single digit are more likely to be affected than the same joints on both sides, a feature which is typical of RA. In addition, rheumatoid nodules are absent in PsA; rheumatoid factor, which is detected in more than 80% of patients with RA may only be detected in about 13% of patients with PsA. According to Gladman et al (2005) the deformities, which result from PsA lead to shortening of digits due to severe joint or bone lysis (dissolution or degeneration of bone tissue due to disease). Several patterns of joint involvement have been identified including distal arthritis, asymmetric oligoarthritis, symmetric polyarthritis, spondyloarthropathy and arthritis mutilans. PsA usually presents in the asymmetric oligoarthritis pattern; however, with time, PsA becomes polyarticular (having a symmetric polyarthritis pattern). About 20% of patients develop a very destructive disabling form of arthritis. This is such that overtime, there is clinically active arthritis, whereby on following patients for more then 10 years, 55% have five or more deformed joints! The severity of PsA is also increased in mortality. Patients suffering from PsA are at an increased risk for death and the cause of death are similar to those noted in the general population, with cardiovascular disease being the most common [6, 11].

Nail lesions may help to identify patients with psoriasis who are at a higher risk of developing arthritis and to also distinguish between patients who have PsA and those with RA. Nail lesions occur in about 40-45% of patients with psoriasis uncomplicated with arthritis and around 87% of patients with PsA. Gladman et al (2005) mention that it appears that the presence of 20 nail pits distinguishes patients with PsA from those with RA and psoriasis. PsA generally tends to appear several years after the onset of skin lesions in a large proportion of patients. It can however precede the psoriasis by many years in approximately 13-17% of cases [6, 11].

2. Cardiovascular disease
Its association with psoriasis has been found by several studies; however, no details of the type of psoriasis are provided. Several observational studies have suggested that patients with psoriasis are at higher risk of cardiovascular disease, such as hypertension and heart failure, compared with individuals without psoriasis. This risk appears to be highest for those with more severe psoriasis. The exact way in which this association occurs is unknown; however proposed mechanisms include, the sharing of common risk factors such as smoking and alcohol consumption, and from the medications commonly used to treat psoriasis, which may contribute to the increased risk [10, 12-13].

3. Obesity
Several studies have also shown an association between obesity and psoriasis. These studies indicated that obesity was seen more often in psoriasis compared with patients suffering from skin problems other than psoriasis. There has also been a positive association between the onset of psoriasis and body mass index (BMI). According to Hamminga et al (2006), over the last decade, an abundance of evidence has shown that obesity is characterized by a state of chronic low-level inflammation, similar to that in psoriasis [6, 14]. However, a cohort study carried out in England and Scotland, which followed 17, 032 women for the pattern of referral to hospital for skin disorders, showed no association between BMI, obesity and psoriasis [6]. As such, this is an area where more studies need to be carried out to establish the association between obesity and psoriasis.

4. Crohn¡¦s disease
The strongest link so far of psoriasis with autoimmune diseases has been with inflammatory bowel disease, particularly Crohn¡¦s disease. Due to the immunological nature of psoriasis, patients may more than likely develop other immune-related diseases. Patients with Crohn¡¦s disease (CD) demonstrate psoriatic skin lesions seven times more often than those without CD do. Studies have shown that the incidence of psoriasis in patients with Crohn¡¦s disease is higher than chance would allow if they were mutually exclusive diseases [6, 15].

5. Other diseases
Other diseases associated with psoriasis include type-two diabetes and liver disease.

Quality of Life and Psychological Aspects
Psoriasis generally does not affect survival; however, it is important to view the disease as a serious one and to resist the tendency to underestimate its impact on the overall well being of sufferers. It is a common misconception that skin diseases are somehow less serious than other medical illnesses; however, the major negative effects psoriasis has on sufferers is substantial and severe, this is demonstrable by a significant detriment to quality of life. Patients with psoriasis have a reduction in their quality of life quite similar to or even worse than patients with other chronic diseases such as ischaemic heart disease (IHD) or diabetes [5, 16].

The disease not only complicates millions of lives, it also disrupts countless interpersonal relationships. Fouere et al (2005) made mention of the fact that previous research have confirmed that more than 80% of patients suffering from psoriasis expressed difficulties in establishing social contacts and relationships being the worse aspect of their psoriasis. Psoriasis sufferers often feel stigmatised by the condition and this in itself contributes to everyday disability leading to depression and sometimes suicidal ideation in more than 5% of patients. According to Langley et al (2005), recent work has identified that pathological worry and anxiety occur in at least a third of patients with psoriasis. Psychological interpersonal difficulties have also been found to severely affect all aspects of the patient¡¦s daily life. Engaging in avoidance behaviours and the belief that they are being evaluated on the basis of their skin disease, both contribute to stress in patients [3, 5].

Symptoms of Psoriasis
The symptoms of psoriasis vary depending on the type you have (see types of psoriasis). The most common symptoms mostly associated with plaque psoriasis include,
1. Patches of red skin covered with silvery white raised scales often on the knees, elbows trunk or scalp. These may become itchy, painful and can sometimes crack and bleed.
2. Fingernails and toenails can be affected, including discoloration and pitting of nails.
3. Small areas of bleeding where skin is scratched.
4. Patients can sometimes suffer with arthritis (see Psoriatic arthritis in associated diseases).
Treatment of Psoriasis
There is no cure for psoriasis; treatment is however aimed at providing symptomatic relief and improved quality of life for sufferers. Strategies for treatment depend greatly on the severity, location and extent of lesion coverage.1 Current treatments include;
1. Sun exposure, which improves the appearance of psoriasis, particularly mild psoriasis.
2. Prescribed creams and lotions, including topical steroids, dithranol, tar preparations, emollients, topical vitamin D3 analogues such as calcipotriol and tacalcitol, and salicylic acid.
3. For moderate to severe psoriasis, which are generally less responsive to the above, more intense treatment are required in the form of,
„« Prescribed medication including methotrexate, cyclosporin and acitretin.
„« Phototherapy (light therapy) such as PUVA (psoralen and Ultraviolet A), UVA, UVB and Narrowband UVB sun beds.
„« Herbal medicines, Chinese herbs, Homeopathic treatments
4. If triggered by throat infection, antibiotics will help.

Important!!
Stress in the form of pathological worry has a detrimental effect on response to the treatment of psoriasis. According to Langley et al (2005) patients undergoing PUVA therapy, who are regarded as being high or pathological worriers tend to clear significantly more slowly, if at all this happens, compared with patients who are low worriers. As such, psychological intervention, in the form of Cognitive Behavioural Stress Management, may perhaps play a role in the management of psoriasis. When used in addition to the regular treatment for psoriasis, the cognitive behavioural stress management is of immense benefit as it helps to provide a marked improvement in clinical severity of the disease [5].

Preventative measures
No preventative measures are known; however, it does help to note the following,
1. Keep skin well moisturised, to prevent the skin drying
2. Avoid soap and harsh detergents
3. Wear natural fibres, such as cotton, next to the skin
4. Enjoy the sunshine, don¡¦t hide your skin away

Recommended Products for Psoriasis

References
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2. National Institute for Health and Clinical Excellence. Infliximab for the treatment of adults with psoriasis (final scope). October 2006. 1-3.
3. Fouere S, Adjadj L, Pawin H. How patients experience psoriasis: results from a European survey. JEADV 2005; 19 (Suppl. 3): 2-6.
4. Naysmith L. and Rees JL. Psoriasis and its management. J R Coll Physicians Edinb 2003; 33: 104-113.
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12. Kremers HM, McEvoy MT, Dann FJ, Gabriel SE. Heart disease in psoriasis. J Am Acad Dermatol 2007; 10.1016/j.jaad.2007.02.007.
13. Henseler T, Christophers E. Disease concomitance in psoriasis. J Am Acad Dermatol 1995; 32: 982-986.
14. Hamminga EA, van der Lely AJ, Neumann HAM, Thio HB. Chronic inflammation in psoriasis and obesity: Implications for therapy. Medical Hypotheses 2006; 67: 768-773.
15. Christophers E. Comorbidities in psoriasis. JEADV 2006; 20 (Suppl. 2): 52-55.
16. Wolkenstein P. Living with psoriasis. JEADV 2006; 20 (Suppl. 2): 28-32.
17. Lebwohl M, Ali S. Treatment of psoriasis. Part 1. Topical therapy and phototherapy. Continuing Medical Education, Department of Dermatology Mount Sinai School of Medicine of New York University 2001.
18. Tse W-P, Che C-T, Liu K, Lin Z-X. Evaluation of the anti-proliferative properties of selected psoriasis-treating Chinese medicines on cultured HaCaT cells. J Eth Pharm 2006; 108: 133-141.

Disclaimer
This article is only for informative purposes. It is not intended to be a medical advice and is not a substitute for professional medical advice. Please consult your doctor for all your medical concerns. Kindly follow any information given in this article only after consulting your doctor or qualified medical professional. The author is not liable for any outcome or damage resulting from any information obtained from this article.