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Psoriasis
Psoriasis is a chronic (ongoing) skin condition involving itchy red patches that appear and fade
gradually at various sites on the body. These patches are often covered with thick, silvery scales called
plaques, caused by a rapid build-up of skin cells.
Psoriasis is common, affecting approximately 2 percent of Americans; about 10 percent of sufferers are
children under the age of 10. Children usually have more severe psoriasis than adults, with large areas of
skin affected.
The cause of psoriasis is unknown, but research has demonstrated that about one-third of all sufferers
have a family history of the disease. Non-genetic factors, such as climate, stress and certain medications
can trigger an attack or affect the severity of symptoms.
Note your symptoms
Thickened patches of itchy red skin are the hallmark of psoriasis. These patches are well-defined and
frequently covered with silvery scales ( plaques ). Patches can vary greatly in size and shape, sometimes
forming giant lesions. Psoriasis can appear anywhere on the body, but occurs most often on the elbows,
knees, buttocks and scalp. Other commonly affected areas are the genital and anal regions, ear canals,
shins, and the backs of the hands.
Psoriasis can be symmetrical, with identical patches appearing on both sides of the body. If it affects the
nails, they become discolored, thickened and deformed, which makes the condition hard to distinguish
from a fungal infection. Minor scratches or burns can trigger psoriasis, a condition called the Koebner
phenomenon.
What causes it?
Psoriasis is caused by a problem with the immune system. This faulty immune response causes
inflammation and stimulates the rapid growth of skin cells. New skin cells normally take 28 days to
travel from the base of the skin to the top layer. If psoriasis is present, new skin cells take only four days
to emerge at the top layer. This rapid cell build-up creates the silvery plaques characteristic of psoriasis.
The skin beneath the plaque is inflamed; blood vessels are dilated (swollen) and circulation is increased.
Why rapid cell growth occurs is still unknown.
Who gets it?
An estimated 2 percent of those who live in the United States have psoriasis, although the actual
numbers are probably under reported. A family history of the disease is a strong indicator of risk. Most
sufferers are between the ages of 10 and 40, with equal numbers occurring in men and women. Psoriasis
is also fairly common in older adults between 57 to 60 years of age. Older people usually experience a
milder, more stable form of the disease. About 10 percent of cases involve children younger than 10.
Children usually have a more severe form of the condition, involving a larger area of skin. Teaching
them proper treatment methods is important, as they have a tendency to scratch affected areas. It's also
important to reassure children, whose self-esteem can be severely damaged by the condition.
How is a diagnosis made?
There are no screening tests for psoriasis. A healthcare provider makes a diagnosis based on a person's
medical history, family history of psoriasis and a physical exam. Sometimes a skin biopsy is performed
to confirm a diagnosis. Because the disease has many forms and can be confused with other skin
disorders, diagnosis is often made by a dermatologist (skin specialist) experienced with the disease.
Psoriasis is classified as mild, moderate or severe based on the percentage of body area affected by the
condition. In mild disease less than 2 percent of the skin is affected, while in moderate disease 2 to 10
percent of the body is affected. If 10 percent or more of the body affected, the condition is considered
severe.
What your doctor may do
Because the disease varies so much from person to person, finding the right treatment may require
experimentation and possibly a combination of therapies. Treatment is based on the type of psoriasis
involved and the severity of the condition, as well as the patient's individual and family health history.
The treatment ladder
The National Psoriasis Foundation recommends treating psoriasis according to a "ladder" approach that
begins with mild therapies and progresses to more aggressive treatment approaches, as necessary. Step 1
is topical (application to the surface of the skin) treatment; Step 2 involves phototherapy (light
exposure); Step 3 is systemic therapy and involves the use of oral medication. A combination of these
approaches is often necessary to control the condition.
Children are usually treated at the Step 1 level, with topical treatments sometimes mixed with
sunbathing. More aggressive therapies may be used short-term in crisis situations. No systemic therapies
are approved for long-term use in infants and children.
Step 1: Topical treatments
Corticosteroids Corticosteroids applied to the skin are the most commonly used treatment for psoriasis.
These medications are inexpensive and effective and short-term side effects are rare, although resistance
to corticosteroids may reduce their effectiveness over time. Examples include Ultravate and Lidex.
Luxiq, an easy-to-apply foam, is used for scalp psoriasis.
Coal tar An old but effective remedy, coal tar is available in both prescription and over-the-counter
(OTC) form. It is often used in combination with other psoriasis medications or ultraviolet B (UVB)
phototherapy. Some people resist using coal tar because of its unappealing odor and tendency to stain
clothing. More refined preparations of coal tar may be found in shampoo, bath oil, gel, cream and
solution forms.
Anthralin (Dithranol, Anthra-Derm) Anthralin is available in a variety of forms and strengths and is
often part of the traditional Ingram regimen, which includes a daily coal-tar bath, phototherapy, and the
application of anthralin paste.
Dovonex Dovonex is an ointment containing a form of vitamin D that is applied for eight weeks at a
time. Dovonex may be combined with corticosteroid ointment.
Tazorac This water-based gel contains a medication related to Vitamin A that produces rapid and
sustained improvement in many patients.
Emollients These thick creams hydrate and soften the scales and are usually applied twice daily.
Keratolytic agents Keratolytic agents are usually ointments that contain salicylic acid to soften the
scales and ease their removal. They also enhance the effect of topical corticosteroids or coal tar. The
area may be wrapped in plastic or covered with clothing to help speed the healing process.
Step 2: Phototherapy
UVB Ultraviolet B radiation (UVB) is provided by both sunlight and artificial lights. UVB treatment in
combination with coal-tar therapy (Goeckerman treatment) is considered one of the safest therapies
available. The treatment is used daily for two to three weeks, then as needed to maintain results. UVB
equipment is available for home use by prescription.
PUVA (psoralen with UVA) Psoralen (Oxsoralen) is an oral medication that increases the skin's
sensitivity to UVA light. It is also available in a topical cream or lotion base that can be painted on
localized lesions. Soak PUVA is a topical product that allows immersion of selected areas such as the
hands or feet. Bath PUVA involves immersion of the whole body.
All topical PUVA paint or soak regimens are closely followed by UVA exposure from a special
ultraviolet lamp. PUVA is highly effective; remissions can last from six to 12 months after two to three
months of therapy.
Step 3: Internal medication
Step 3 is a high-risk therapy involving oral or injected medication. It is reserved for those with severe
disease who have not responded to topical treatment. Careful monitoring by a doctor is required.
Methotrexate (MTX) Methotrexate is one of the most commonly prescribed oral medications. It slows
skin cell growth and reproduction. Methotrexate can cause both short and long-term side effects.
Soriatane, Tegison Soriatane and Tegison are vitamin A derivatives normally used in conjunction with
another therapy such as PUVA, UVB or anthralin therapy. They affect cell division.
Systemic corticosteroids Systemic corticosteroids are used only in people who are severely ill. They
are prescribed in the shortest courses possible because of potential side effects with long-term use.
Cyclosporine (Neoral) Cyclosporine suppresses the immune system. The disease recurs quickly once
treatment is discontinued, so maintenance therapy is required. Cyclosporine is a last-resort therapy.
alefacept ( Amevive ), a protein that reduces specific immune responses involved in psoriasis. Alefacept
may be used to treat moderate to severe chronic plaque psoriasis in people who are candidates for
systemic therapy or phototherapy. It is injected into a vein or muscle and usually administered once a
week for a 12-week period.
CAUTION: Never abruptly stop or change a prescribed medication without first consulting your
doctor or dermatologist. Some must be tapered off slowly; others may need to be adjusted when
one is stopped. Inform the dermatologist if medications for other conditions have changed.
What you can do
Follow your treatment regimen carefully and with patience. It may take a long while to see any
improvement. In addition:
Treat all skin gently, as trauma may lead to the development of lesions in the area of the injury
(Koebner phenomenon). Avoid drying the skin by limiting baths and showers and the use of
soap.
Wear rubber gloves for dishwashing and other household chores.
Use an unscented moisturizer over the entire body to prevent drying.
Avoid scented products and use only hypoallergenic make-up or wear none at all.
If plaques crack and become sore and itchy, trim the nails to minimize the effects of scratching.
Avoid anesthetic lotions or antihistamine creams. They can actually increase irritation.
Avoid the triggers that cause outbreaks, such as high-stress situations, infection, skin trauma and
certain medications.
To relieve itching
Use ice packs to keep the skin cool and relieve itching and skin irritation:
Apply crushed ice, a bag of frozen vegetables, or a commercial ice pack, which will conform to
the shape of the body. (To protect your skin, place a dry cloth between the ice and your skin and
change the cloth if it becomes wet.)
Apply ice for 15 to 20 minutes at a time, more frequently initially, and then 3 to 4 times daily.
Leave ice off for at least 20 minutes between applications.
Sunlight may help
Psoriasis responds well to sunlight on areas of skin that are free of plaques. However, sun exposure must
be limited and a sun screen should be used. Because of the risk of skin cancer, a yearly medical checkup
is recommended.
Other treatments
Over-the-counter bath water additives include coal tar or oatmeal solutions, bath oil, Epsom salts and
sea salts. Soothing treatments for lesions include aloe vera topical, jojoba topical and anti-scaling
ingredients such as coal tar.
What can you expect?
Periods of active disease and remission are typical with psoriasis. Although it is an incurable disease
most people experience lengthy remissions. With treatment, the disease can be controlled.
The severity of future bouts with psoriasis is usually related to the severity and extent of the first
outbreak. In general, the younger the age at onset of the disease, the more severe and unpredictable is its
course. Severe forms of psoriasis may affect the joints, causing a rheumatoid-like arthritis. It can be
distinguished from rheumatoid arthritis with a blood test. In rare cases, arthritis mutilans, a severe
disease that destroys bone, can develop.
Final note
Medical therapies for skin conditions such as psoriasis are advancing rapidly, but so far there is no
"cure." Your healthcare provider can probably suggest a good skin specialist who may be able to help
you. Emotional support is also important, especially for children; consider joining a support group. For
further information, contact the National Psoriasis Foundation, 6600 SW 92nd Ave., Suite 300, Portland,
OR 97223; 1-800-723-9166.
Last Update: 12/11/07
Copyright © SHPS, Inc 2007