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Paris Fears
Medical English 101
06/28/2011
Psoriasis: A Closer Look at the Other Skin
Introduction.
‘Scaly skin’ a term used to define most skin diseases since ancient Greek times. Today we use
that common characteristic of any skin disease to describe Psoriasis, a chronic non-infectious immunemediated skin condition that causes thick red and flaky patches of skin. For many years this skin
condition was not able to be differentiated from other common skin diseases including eczema, leprosy,
impetigo, and tubular lupus. Viennese dermatologist Ferdinand von Hebra, was able to assign the name
psoriasis and studies about the phenomenon known as ‘scaly skin’ began to arise.
With over 5 types of psoriasis, the disease is thought to affect about 7.5 to 8.5 million people in
the United States, and about 125 million worldwide. Recent studies have worked to access how Psoriasis
affects the quality of life of those affected. Common signs and symptoms are normally limited to surface
skin however; they can go as deep as joint pains. The median age of people affected is about 25 or 55,
and there is an increased prevalence in Caucasian and Hispanic races compared to African Americans.
Data has been shown that family history or genetics are thought to play a significant role in development
of psoriasis, and even more so other risk factors include alcohol, stress, and weight (obesity). Another
interesting contributor to psoriasis is the immune system. Over the last two decades studies for new
treatments have been explored however, very few are making significant breakthroughs and
organizations such as the National Psoriasis Foundation are still progressing. Through this review,
readers will gain an understanding of the prevalence, pathogenic aspects, clinical and physiological
factors, as well as new and developing treatments.
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Clinical Classification.
In Greek the word ‘Psora’ means to itch. Psoriasis is described as silver white scales on raised
red patches of skin. While one of the most common diseases is also very hard to treat because the
disease can be controlled not cured. There are 7 types of Psoriasis, including plague, guttate, inverse,
pustular, and erythrodermic. Other less diagnoses types include nail psoriasis and psoriasis arthritis.
Plaque is the most common of the 7 which is the basic dry, itchy red skin patches in certain sites.
Erythrodermic is a more aggressive type of plague psoriasis involving more pain and patches throughout
the whole body. Pustular psoriasis occurs as it is irritated and small pus filled bumps can cover either the
whole body or just hands and feet. Guttate proceeds after a strep throat infection, and manifest itself into
numerous red, scaly bumps. Inverse psoriasis occurs in excess skin folds (i.e. genitals, armpits, fat folds,
under breast) this type is susceptible to fungal infection. The other less diagnosed types including
psoriasis arthritis and nail psoriasis can manifest in severe cases of psoriasis. The natural course of
Psoriasis involves periods of outbreaks where your psoriasis is obvious and there are times of remission
meaning the rash clears for a period of time. With continuous use of medication the disease can be
treated however, if stopped or withdrawn from skin, the condition can worsen. Although Psoriasis can
begin at any age, its common onset is between the ages of 20 to 30 and later between the ages of 50 to
60.
Background.
The History of Psoriasis goes back to the ages of the bible, and up until 150 years ago people
mistook the common disease for leprosy. During the late 1700’s to early 1800’s two dermatologist,
Robert Willan and Joseph Jacob Plenck were writing of a condition similar to psoriasis but still could
not differentiate it as its own entity from leprosy. Joseph Jacob Plenck did not take the time to
differentiate the condition from other skin diseases. Robert Willan however had recognized the disease
and decided it was another category or phase of leprosy. His two phases were Leporasa Graecorum
which was when the skin had scales and Psora Leprosa which was when the condition became eruptive
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(Babu). In 1841 Ferdinand von Hebra a Viennese dermatologist, using Robert Willans notes, was able to
coin the name Psoriasis and describe the clinical picture of the condition as we see it today. Throughout
the 19th century many dermatologist worked to make connections to pathology of internal organs,
metabolism, and the nervous system. The prevalence of race and gender has been known to fluctuate
globally for years however; it is present in races from African American to Middle Eastern, to Asian and
Pacific Islanders. [Table 1] The New England Journal of Medicine suggests,
“Ethnic factors also
appear to influence the prevalence of psoriasis, which ranges from no cases in the Samoan population to
12 percent in Arctic Kasach'ye. The influence of ethnic factors is particularly evident when one
compares prevalence rates within the United States. The prevalence among blacks (0.45 to 0.7 percent)
is far lower than that in the remainder of the U.S. population (1.4 to 4.6 percent).”
Other studies show Caucasian and Hispanic infection rates are more prevalent than those of
African American. Psoriasis is less common in Asian populations than in the European population and
was rarely seen in Africa until the human immunodeficiency virus (HIV) pandemic. At the time the
connection was made between HIV and psoriasis many people were still uncertain as of why. However
in recent studies, dermatologists have identified similarities between the disease manifestations on the
body’s immune system. Within genetic studies the markers for psoriasis have been found in
chromosomes (1,3,4,6,8,10,16,17,18,19,20). [Table 2]. Table 2 shows the effected cytokines of psoriasis
and identifies which loci and chromosomal location they are found. Studies have found that if the
parents have psoriasis there is a 25% chance that the child may suffer from the skin disease. About 40%
of patients with psoriasis have a family history of the disorder among first-degree (i.e. parents, offspring,
siblings). Today around 7.5 to 8.5 million people in the United States and 125 million worldwide have
Psoriasis. 150,000 new cases of psoriasis are reported annually. It has been found that around four
hundred people die annually from psoriasis-related causes in the US. Throughout the 20th century the
advances of genetic and environmental influences on the disease are increasing in significance. The
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most beneficial connection made was between life style factors influencing the body’s immune system
speeding up growth of skin cells.
Physiology.
As stated psoriasis is an chronic “long term” inflammatory disorder of the immune system. The
most important thing to understand is psoriasis is not contagious or infectious; you cannot contract this
disease from touching, having sex, or swimming with someone who has psoriasis. Psoriasis Triggers are
normally anything that can cause a deficiency in the immune system functions include but not limited to
stressful events, different medications, cold/dry weather changes, alcohol use and/or withdrawal, to little
sun, injury to skin (including cuts, burns, and insect bites), and Bacteria or viral infections (strep throat
and upper respiratory infections). Drugs that have been known to worsen the symptoms of psoriasis
include anti-malaria drugs, beta-blockers, lithium, as well as ACE inhibitors. A normal immune system
protects the body against invaders and destroys bacteria and foreign protein. With a psoriasis patient the
immune system sends faulty signals for rapid skin cell reproduction and growth causing the red and
silvery white scaly skin. Normally, skin cells grow, mature, and are sloughed off over a period of about
a month. The body eventually sheds these cells, revealing new skin cells. In people with psoriasis,
however, the immune system is overactive and the skin cells reproduce in only 3 to 4 days. The body
has no way to shed the skin cells fast enough, and they accumulate on the surface, forming raised, red
patches or plaques (National Psoriasis Foundation). The accumulation of inflammatory cells in the
epidermis and altered dermal vessels are major characteristics, and these changes are driven by release
of cytokines and growth factors. Cytokines are signaling protein molecules that are mainly for
intercellular communication, with more of these in the cell signaling for their cell surface receptor the
skin thinks it’s time to grow skin cells when it hasn’t gone through is full cycle. Many investigations
have shown that the process of epidermal differentiation in the lesion is aberrant or very abnormal from
the regular process of the outer layer of skin. [Figure 1] Figure 1 proceeds to show the difference
between the epidermis and the keratin layer of skin in normal skin cells and psoriasis skin cells.
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Other ideas of the immune system importance relate to the T cells. T cells or lymphocytes also
known as white blood cells one of the key types of immune system cells. As mentioned T cells are
supposed to circulate through the body and fight invaders also known as antigens in body. Antigens
activate the T cells, which causes initiation of the immune system to neutralize them. In Psoriasis the
activated T cells with the virus/bacteria antigens rise to the skin surface and cause rapid skin cell growth
that makes red skin and itchy silvery scales. Theories as to the immune systems role in diseases include
its inability to rebuild itself. Once the skin T-cells begin depleting in psoriasis, just as in HIV form, the
body has to work overtime to fight it which many times is not enough to return the skin back to
normal.[Figure 2] Figure 2 demonstrates the antigens coming to activate the lymphocytes which reach
the surface and release cytokines to fight the psoriasis plaque. Alongside this process macrophages are
coming to aid the lymphocytes in the epidermis to kill the psoriasis effects from reaching the lymph
nodes.
Throughout the history it has been said psoriasis wasn’t detected in the African populations until
the epidemic of HIV an immunosuppressive disease. Studies show that psoriasis often has its initial
presentation in advanced HIV infection, and it may even be the initial clinical manifestation of HIV
infection. Psoriasis tends to become more severe as the HIV infection progresses, and there is even some
correlation between low CD4 counts and the severity of psoriasis. CD4 is the glycoprotein that the HIV
virus coat can bind to. Understanding the importance of CD4 and T4 cell counts affect the immune
system help display the correlation as to why patients with HIV may contract psoriasis. While many
authors and dermatologist try to make other connections aside from the CD4 count between psoriasis
and HIV there are very few that aren’t contradictory or speculation. Unfortunately scientist and
dermatologist have not been able to trace the antigens that cause psoriasis. Since normal symptoms of
psoriasis include dry itchy crackling skin, it is not uncommon for people to mistake psoriasis as dry skin
from the naked eye. They often to this and try different topical lotions for dry skin that later end up
worsening the condition. Other symptoms are pink or reddish dot patches, nail discoloration and
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disfiguration, along with swollen or stiff joints. These spots are seen in soft tissue areas for example the
mouth, genitals, under the breast, armpits. Also other common places all over the body include the
knees, elbows, back, and stomach.
Psoriasis can usually be recognized with ease, but atypical or non-classic forms are more
difficult to identify and treat. Diagnoses come from doctors doing basic skin observations. Most
diagnostics of Psoriasis can be confirmed through family history and physical examination. Studies
show that if joint pains are the only symptoms present it is common to have a skin biopsy performed.
Skin biopsy is a procedure where a skin tissue sample is removed and examined. This is normally done
for the very rare cases related to psoriasis however; it can be performed to find skin cancers.
Quality of Life.
Psoriasis is a serious condition strongly affecting the way a person sees him or herself and the
way he is seen by others. It has tremendous economic and financial ramifications. According to the
author of “The Burden of Skin Diseases”, the total annual cost for treating psoriasis is estimated to be in
the range of $1.6 billion to $4.3 billion dollars. As stated earlier there are about 250,000 new cases
observed annually of this non-curable disease, psoriasis. This disease was accounted for nearly 2.25
million visits to ambulatory care centers during 1996 in the US.
Since early diagnosis of psoriasis the quality of life has been very poor. In a survey by the
National Psoriasis Foundation almost 75% of patients believed that psoriasis had moderate to large
negative impact on their quality of life, with alterations in their daily activities. Many patients with
psoriasis often have many psychosocial issues such as poor self image, low self esteem, and shame and
embarrassment regarding their disease. Aside from the psychosocial quality of life traits there are many
health related alterations to a person with psoriasis. [Table 3]
Studies have shown an increase in the comorbidity connections to psoriasis from other diseases.
Some of the many comormidities include hypertension, obesity, cardiovascular disease, metabolic
syndrome, inflammatory bowel disease, cancer and malignancy, and/or other immune-related diseases.
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A study in the UK worked to show that patients ages 18 years or older, with psoriasis have an increasing
risk factor in having ischemic heart disease, myocardial infarcts, and cardiovascular disease. The study
showed that patients with severe psoriasis have an increased risk of CV mortality. It showed that males
with psoriasis were more likely to die of cardiovascular disease and contract CV risk, such as type 2
diabetes and hypertension, than other psoriasis patients and non-psoriasis patients. In a case-control
study, patients with new onset psoriasis were more likely to be obese compared with patients visiting a
dermatologist for a skin problem other than psoriasis. Some studies show correlation to body mass index
(BMI) while others have conflicting factors.
The direct link between psoriasis and many of the possibly associated diseases is the presence of chronic
inflammation and, in particular, elevated levels of the multifunctional cytokine tumor necrosis factor-α.
Conversely, obesity and smoking may increase the risk of developing psoriasis, suggesting that these
may be primary risk factors for several comorbidities and that psoriasis is no more than an innocent
bystander. Most importantly, psoriasis patients are more likely to visit physicians because of their
disease than ‘healthy’ people from the general population, which puts them at risk for being screened for
and diagnosed with other diseases (Bhosle, Kulkarni, Feldman, and Balkrishnan).
Due to the fact that some psoriasis patients had a 30% increased risk of cancer compared to the
general population malignancy, also known as cancerous cells spreading throughout the body to other
sites, is seen more often in psoriasis patients. Many of the connections are unclear if they are due to the
pathophysiology of psoriasis, related to the treatment of psoriasis, or simply psoriasis associated
behavior such as drinking and smoking. Above all, Smoking, obesity, and alcohol consumption have
been associated with psoriasis and/or the severity of psoriasis; however it is uncertain whether the
association is causal. While physicians are not sure exactly how these diseases are connected it is still
important to see correlation and connection to other diseases that are better understood so hopefully
dermatologist and scientist can further their treatment regiments.
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Treatments.
The treatments of psoriasis have been progressing over the years, as the knowledge of disease
and its causes increase. The normal methods of treatment include but are not limited to topical
treatments such as ointments and creams, systematic medications such as pills and oral anticoagulants,
and/or light therapy. Over the past decade, the topical treatment of psoriasis has evolved from the ageold applications, such as coal tar, to the more acceptable and efficacious options containing topical
corticosteroids, vitamin D analogues, and combined agents. The aim of the treatment is to interrupt or
stop the rapid growth of skin cells and clear and smooth the skin scales. According to The British
Journal of Dermatology studies show that some patients take anywhere from 2 to 5 medications daily to
treat their psoriasis disease. Table 4 expresses the co-medications involved in a study of 1203 patients
showed that of all patients 60·1% received regular systemic medication. In female patients 71·2% were
taking medications on a regular basis. Of all patients 18·5% took only one drug, 11·6% took two
different and 30% took three or more different systemic medications. Every seventh patient with
psoriasis (14·8%) in this survey had a recorded intake of five or more different drugs. [Table 4] The
medications listed in table 4 include but are not limited to diuretics, thyroid medication, angiotensin II
receptors, antidepressants, and gastritis medication.
Along with systematic drugs it is not uncommon for people to try home remedies or traditional
ways of curing skin diseases. Discovery Health recently released about 28 different ways to assist the
treatment of psoriasis. Natural home remedies include vinegar dips, the apple cider vinegar works as a
natural smoother for burns and skin inflammation, as well as a disinfectant. According to Psoriasis
Foundation people have also found success in covering psoriasis lesions with plastic wrap after applying
topical medications to make sure it sets into skin, moisturizing skin with olive oil before sun exposure,
capsaicin a substance from cayenne pepper also found in some medications can stop itching and pain of
plaque psoriasis. Other good psoriasis treatment ideas include homemade oatmeal rub with aloe and
other vitamins the body needs to be healthy smooth.
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Consequently because psoriasis is still a mystery in many laboratories and doctors offices, many
dermatologists find themselves trying different therapies. Acupuncture having a wide purpose of
treatment for not only the illness but the ‘whole body’ has been used for years in traditional Chinese
medicine especially for skin conditions. Acupuncture involves contact with the skin, so it is not
surprising that has been used for many years for the treatment of skin conditions in China. The evidence
of acupuncture are displayed in an open study of 61 psoriatic patients, all of whom had failed to respond
to conventional western medical management, 30 had complete or almost complete clearance of the skin
lesions, 14 patients experienced two-thirds clearance, and 8 had a third clearance. Nine patients had
minimal or no improvement. While acupuncture is not very common in western medicine many people
are beginning to turn to this alternate form of therapy.
Moreover heliotherapy has proven to be a good source of therapy as well. Many people assume
that sun is bad for the skin however, when used the correct way it can be very beneficial to both patients
with healthy skin or psoriasis. A study done in Spain recently stated, “Exposure to UV radiation
induces immunosuppressant and has beneficial effects on psoriasis as well as other inflammatory skin
disorders.” It has been recorded that sun light significantly reduces redness of psoriasis lesions and
reduces psoriasis causing cells. Heliotherapy is one of the many therapies that are being furthered for
psoriasis treatment however, ever little bit helps.
Discussion.
Although psoriasis is a very complex and still well underdeveloped skin condition there is still a
substantial amount of information known that could be ground breaking too many treatments. With
correspondence to the information already known about psoriasis it is interesting to think that
researchers haven’t taken a further look into regenerating and reproducing healthy cells for the people
affected. Studies have made it clear that because of linkage between psoriasis-susceptibility gene
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PSORS2 with a gene involved in the regulation of interleukin-2, psoriasis may not recur after bone
marrow transplantation from healthy donors (Schonan). Furthermore why can’t healthy T-cells be
injected into people so that more diseases are fought? Or even on a general level due to the fact psoriasis
is an auto-immune disease why can’t drugs solely used to build the immune system be given in efforts to
reverse the symptoms. Another good thought for treatment is removing the lesions just as people do for
warts and etc... Discovery health’s article on natural home remedies noted that mixture of acids (like
salicylic acid) can be used on psoriasis skin lesions just as they are used to remove warts.
In conclusion the globally known skin condition that has been present in history for more than 3
decades, psoriasis, is alive and prevalent in both genders and ranging in age groups from 3 to 95 but
primarily in ages 20 to 30 or 50 to 60. Psoriasis is even present in many different cultures from
Caucasian and Europeans to Hispanics and Chinese. While the condition is a complex immune-mediated
disease in which T-lymphocytes and dendrite cells play a central role, many people are still holding
confusion as to exact triggers and causes of this disease aside from stress, and genetics which play a key
factor in a little under 50% of people with the skin disease. The common chronic skin disorder typically
characterized by erythematous papules and plaques with a silver scale and other presentations is still
progressing both in its severity and quality of life in patients as well as in laboratory research and
treatment development.
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Table 1.
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Table 2
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Figure 1.
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Figure 2.
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Table 3.
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Table 4.
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