What is Psoriasis?
Psoriasis is a long-term (chronic) skin condition which causes the skin cells to grow rapidly, leading to formation of thick, white, silvery, or red patches on the skin.
Psoriatic patches on the hands
General Overview:
Psoriasis; Being a chronic and inflammatory skin condition, falls under the category of commonest of the skin disorders. The medical terminology ‘Psoriasis’ is extracted from Greek, referring to ‘an itchy condition’. Psoriasis is demonstrated by red, scaly patches, papules and plaques that usually are not itchy. These psoriatic lesions are observed in varied areas of the skin ranging from minor localized regions to covering almost the entire body. The lesions thus may differ in intensity depending on the area of the skin in which they are found. The term Psoriasis may also be referred to as “Psoriasis vulgaris”.
Predisposing factors:
What are the probable causes of acquiring Psoriasis?
- The actual cause for Psoriasis is not yet understood clearly.
- This is not just a skin condition and may influence many organ systems negatively.
- Psoriasis has been found to be associated with a raised risk of some cancers, cardiovascular disease and certain other immune-mediated disorders such as Crohn’s disease and Ulcerative Colitis.
- Psoriasis is believed to be a genetic disorder which is considered to be triggered or evoked by environmental factors.
- When the immune system misreads a normal skin cell for a pathogen, and sends out wrong signals leading to excessive production of new skin cells, Psoriasis develops.
- Psoriasis is not spread by contact, but it may be inherited.
- Triggering factors for Psoriasis may involve stress, oxidative stress and abrupt withdrawal of a systemic corticosteroid.
- An injury to the skin may result into local psoriatic skin changes which are termed as “Koebner phenomenon”.
Classification:
Psoriasis can be classified into 5 different types as following:
- Plaque
- Guttate
- Inverse
- Pustular
- Erythrodermic
Clinical Features:
- The Plaque variety of Psoriasis is observed in majority of patients. It typically presents itself as red and white scaly patches over the top layer of the skin. The skin cells come together at these site of Plaque and the skin appears silvery-white in that region. The skin areas that are most likely to get affected are the elbows and knees. Other areas of occurence may also comprise of the scalp, palms of hands and soles of feet, back and the genitals. Plaque Psoriasis being the most common variety, affects about 85-90% of the population. The lesions classically manifest as elevated regions of inflamed skin covered with silvery-white scales. These regions are termed as ‘plaques’.
- Guttate Psoriasis also known as “Eruptive Psoriasis” is a variety of psoriasis that clinically manifests as small lesions of about 0.5-1.5cm diameter. The lesions are most likely to be found over the upper trunk and the proximal extremities. Generally, a bacterial infection such as an Upper Respiratory Tract Infection (URTI), may be a probable triggering factor for Guttate Psoriasis.
For some individuals, it may begin as a throat infection (Streptococcal). After the infection has been subsided, the affected individual may feel fine for a few weeks before the red spots start appearing. These spots are dry and slightly itchy and appear tiny at the beginning. After being scratched or the dry layer of skin being picked, white flaky areas begin to show up. The spots may grow larger in size as the weeks go by. Some of these dry white larger lesions may give rise to a pale area in the centre which appears slightly yellow. The common sites of occurrence include torso, legs, arms, back, eyelids, bikini-line and neck.
- Inverse Psoriasis also referred to as ‘flexural psoriasis’ is a variety of psoriasis that usually affects the folds, recesses and flexor surfaces viz. the ears, groins, axillae, navel, folds beneath the mammary glands, intragluteal crease, lips, penis etc.
- Pustular type of psoriasis is manifested as elevated protruberances loaded with non-infectious pus (pustules). The skin which is beneath and adjacent to the pustules, appears red and tender. Pustular variety may be localized, generally to the hands and feet (palmoplantar psoriasis) or it may be occurring on any part of the body as widespread lesions.
Generalized Pustular Psoriasis, is a rare and severe form occurring at the time of pregnancy, which may need hospitalization. The predisposing factors may be sudden withdrawal of topical corticosteroid treatment, pregnancy, hypocalcemia or after an infection, or subsequent to an irritant topical treatment for plaque psoriasis. The lesions represent as multiple pustules above the tender red skin and are acute in onset. The eruption is followed by a fever, nausea, body ache, and raised WBC count.
Annular Pustular Psoriasis (APP) is a rare variant of Psoriasis observed during childhood. This variant is most likely to affect females as compared to males. The lesions are manifested as ring-shaped plaques with pustules around the corner and yellow crusts. APP is most likely to affect the neck, torso, arms and legs.
- Erythrodermic Psoriasis or Erythrodermic Psoriasis presents as widespread inflammation and flaking off of the skin over almost entire body surface. This may be followed by swelling, severe itching and pain. It may be as a result after a plaque psoriasis is worsened, especially subsequent to sudden withdrawal of systemic glucocorticoids. This variant can be lethal as the extreme inflammation and flaking off leads to derangement of body’s ability to modulate temperature and perform barrier functions.
- Psoriatic arthritis is a chronic inflammatory variant which usually takes place in combination with skin and nail psoriasis. The joints appear inflamed along with the adjacent connective tissue. It may affect any joint, but most likely affects the finger and toe joints. The lesions appear as sausage-shaped swelling of the fingers and toes which is termed as ‘dactylitis’. Psoriatic arthritis can also have an impact on the knees, hips, spine (spondylitis) and sacroiliac joint (sacroiliitis). Around 30% of sufferers with psoriasis are likely to develop psoriatic arthritis.
- Nail changes in Psoriasis include – whitening of nail, small bleeding areas from capillaries beneath the nail, yellowish-red discoloration of the nail (oil drop or salmon spot), thickening of the skin beneath the nail (subungual hyperkeratosis), crumbling of the nail, loosening and eventually separation of the nail (oncholysis).
Medical signs:
- Auspitz’s sign: Pinpoint bleeding of the skin after the scales have been removed.
- Koebner’s phenomenon: Psoriatic skin lesion as a result of injury to the skin.
- Itching and pain
Diagnosis:
The diagnosis may be made depending upon the appearance of the skin. Classical skin manifestations are red, scaly plaques, papules or skin patches which may be rarely itchy and painful.
How to treat Psoriasis?
Psoriasis is not a curable condition but can be treated. It may disappear completely never to recur again or can go into relapse anytime even after having subsided completely with treatment.
The treatment for Psoriasis can be divided into three ways:
- Topical agents – Topical corticosteroids are the first choice of treatment. Their efficacy is enhanced when used over a period of 8 weeks constantly. Along with these, moisturizers and emollients should also be supplemented such as mineral oil, Vaseline etc.
- Phototherapy – Phototherapy in the form of sunlight had shown good results in the past. Nowadays, special UV lamps are developed to administer Phototherapy. It has been found that wavelengths of 311-313 (narrow band UVB) nanometers show best results.
Also, Psoralen and Ultraviolet A phototherapy (PUVA) which is a combination of oral or topical therapy and phototherapy, has shown promising outcomes.
- Systemic agents – Systemic agents are used when topical and phototherapy fail to show any results. These include – oral medication and/or injectables viz. methotrexate, ciclosporin, hydroxycarbamide, fumarates, retinoids etc. Patients who are administered Systemic agents are advised to get regular blood and liver function tests done.
- Newer therapies – Injectables called biologicals are powerful immunomodulators which are now used for severe and resistant psoriasis.
- The Eximer Laser is a state-of-the-art laser which can be used very effectively to treat localized psoriasis with excellent results and free of any side effects.
In summary, psoriasis is a difficult skin disease to treat. Recurrences are common and this skin condition can harm the psyche, as much as it harms the skin. Treatment must be by a good dermatologist, especially trained in treating immunologically related inflammatory skin conditions.
Dr. Rinky Kapoor is a top/ Best dermatologist, Cosmetic Dermatologist, Laser Skin Expert Doctor, currently based in Mumbai, India. She has won many awards as the Best Dermatologist in India, Top 10 Skin Doctor in India, etc. She specializes in all skin diseases & conditions and given her training as a dermato-surgeon, provides non surgical liposuction surgery, laser lipo & lipoplasty etc for weight reduction & cellulite reduction. Dr. Rinky Kapoor is trained at the iconic National Skin Centre, Singapore and completed her Fellowship in Cosmetic Dermatology & Lasers at the world renowned Stanford University, USA.
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Dr. Rinky Kapoor- Top Skin Dermatologist in India 