Psoriasis

Psoriasis is of the following types:

• Plaque Psoriasis
  It is one of the most common types of psoriasis. About 80% of cases of psoriasis belong to this category. It results in the formation of plaque-like skin lesions. The skin lesions are dry, red and raised and often covered with silvery scales or plaques. These lesions can occur anywhere on the body. The most common sites are knees, elbows and scalp.
• Nail Psoriasis
  This form of psoriasis affects fingernails and toenails. It causes abnormal nail growth, along with colouring and pitting of nails. Nails affected by psoriasis may loosen up and even fall off (onycholysis). In severe cases, nails become crumbled.
• Guttate Psoriasis
  This variant of psoriasis affects children and young adults. It causes skin lesions that are small, water-drop like which scale off eventually. This type of psoriasis affects trunk, legs or scalp. These lesions are also covered by fine scales (but not too thick). Usually, this type of psoriasis is triggered by a bacterial throat infection (like streptococcal infection) and it fades away on its own, rarely showing any recurrence.
• Inverse Psoriasis
  It is usually triggered by a fungal infection and is also known to mimic a fungal infection. It is common in areas of the skin which are usually sweat easily such as armpits, areas under the breast, groins and around genitals. Skin lesions appear fiery red; they are inflamed and worsen due to sweat or friction.
• Pustular Psoriasis
  This is another rare variant of psoriasis, which affects a larger skin area (generalized pustular psoriasis) or may affect smaller areas like fingertips, toe tips or hands and legs. It causes pus-filled tiny blisters that appear quickly (even less than an hour) causing redness, tenderness followed by intense itching, which may appear and disappear frequently. It is occasionally accompanied by diarrhoea, fever and chills.
• Erythrodermic Psoriasis
  It is the rarest and the most severe form of the disease, which affects the entire body and causes a fiery red rash. This rash causes intense itching and burning. This can be a life-threatening disease and requires immediate therapy.
• Psoriatic Arthritis
  It is one of the most prevalent complications of long-standing psoriasis. Apart from having red, itchy and flaky patches on the body, it causes painful and swollen joints (mimicking arthritis). Rarely, it is the joints which get affected first and then a rash develops. Commonly affected joints are smaller joints of wrist, fingers, ankles or toes and it rarely affects larger joints like knees or elbows. It causes pain and stiffness of the affected joint. If left untreated or in severe cases, it can cause permanent joint deformities.

Psoriasis is rarely staged and is more commonly classified on the basis of the severity of the condition. The severity of psoriasis is determined by the total body surface area affected. Certain factors like redness, scaling and thickness of the skin are also considered to categorize it.

• Mild Psoriasis
  Psoriasis is categorized as mild if it affects less than 3% of the total body surface area.
• Moderate Psoriasis
  Moderate psoriasis is the one in which 3 – 10% of the total body surface area is affected.
• Severe Psoriasis
  In severe psoriasis, more than 10% of the total body surface is involved.

The symptoms of psoriasis vary from person to person and with the type of psoriasis. These patches vary from a few spots to large lesions. Most commonly affected areas are the scalp, elbows, knees, hands, and feet.

Symptoms of psoriasis include:

• Appearance of red patches on the skin, which are covered by silvery thick scales.
• These spots become itchy, cause a burning sensation and soreness.
• Sometimes skin may bleed due to excessive dryness or due to scratching.
• Areas affected are that of scalp, elbows, knees or upper body.
• Nail psoriasis causes thickness, pitting and discolouration of the nails. Sometimes nails separate out from the nail bed.
• Pustular psoriasis causes scaly-red, cracked skin with pus-filled eruptions over the hands and feet.

Usually, these symptoms show periodicity or cycles of waxing and waning. The symptoms may be severe for a few days or weeks and then settle down or sometimes they even clear off and become unnoticeable. And then again, the symptoms reappear due to any of the triggering factors.

Symptoms of psoriatic arthritis include:

• Involvement of joints on one or both sides of the body.
• Affected joints are painful and swollen, and may feel warm on touching.
• Joints of the fingers and toes appear sausage-like due to swelling and these can cause deformities.
• Sometimes, the joints between the vertebrae are affected and cause symptoms of lower back pain (resembling lumbar spondylitis).
• Affected Achilles tendon and plantar fascia cause severe pain in the heel or back of the foot. (Read more - Heel pain causes and treatment)

Causes

In psoriasis, the skin cells grow much faster than normal skin cells. This results in piling up and sloughing off of these cells, causing thick-scaly patches. The exact mechanism or the reason behind these skin cells to go haywire is not known, but it is believed that this happens due to some factors related to the immunity and genetics.

• Genetics
  Psoriasis is believed to be related to a person's genes. Any of the immediate family members having psoriasis puts you at a high risk of developing the disease. However, about 2-3 % of people having such a genetic background suffer from psoriasis.
• Immune System
  Psoriasis is a disease, in which your body’s defence cells start attacking your skin cells. These defence cells are called T-lymphocytes (a sub-type of white blood cells or immune cells), which attack healthy skin cells mistakenly to heal a wound or kill bacteria. These T-cells also promote the production of healthy skin cells. Along with these T-cells, neutrophils (another variant of the defence cell) collect in the skin and cause redness or pus-filled eruptions.
  This abnormal increase in the speed of skin cell cycle pushes the inner skin cells outwards too quickly, resulting in thickening and scaling over the skin surface.
  The exact reasons behind T-cell mutation or malfunction remain unclear, but it is believed that genetics play some role along with the environmental factors (triggering factors).

Triggering factors

Psoriasis shows periodicity and has phases of waxing and waning. There are certain triggering factors, which worsen or trigger these psoriatic patches. It is better to identify these factors so that they can be avoided as much as possible.  

These triggering factors include:

• Bacterial infections (throat or skin infection) commonly caused by Streptococci.
• Skin injury due to a bug bite, cut or sunburns.
• Smoking.
• Alcohol.
• Stress.
• Vitamin D deficiency. (Read more - Vitamin D benefits and sources)
• Medications like anti-malarial drugs, iodides, beta blockers or lithium compounds.

Risk Factors

Although psoriasis could affect anyone, there are certain risk factors that increase the chances of triggering the immune cells. These risk factors include:

• Family history
  This is one of the most important risk factors for developing psoriasis. A family history of psoriasis in one or both the parents increases the risk of psoriasis in the children.
• Bacterial infections
  Recurrent bacterial infections such as streptococcal skin infection or throat infections increase the risk of psoriasis.
• Viral infections
  People affected with HIV are more prone to developing psoriasis, as compared to other non-infected people.
• Obesity
  People who are overweight or have obesity are prone to develop multiple skin folds. These skin folds increase the risk of developing psoriasis.
• Smoking
  Smoking tobacco not only increases the risk of developing psoriasis but also increases the severity of the disease.
• Stress
  Stress has a direct impact on the immune system. Thus, high-stress levels have a strong relation with psoriasis.

Psoriasis cannot be prevented, as it has multi-factorial causes. But, once developed, the flare-ups can be prevented well. There are many ways to prevent further episodes and flare-ups. These include the following:

• Use moisturisers regularly. They will protect your skin from drying.
• Abstain from picking at psoriatic patches or scales as this can worsen the disease.
• Avoid staying in dry weather, as dry weather can flare up psoriasis. You can use a humidifier to keep the air moist and warm.
• Use medications like lithium compounds, beta blockers or anti-malarial drugs with caution.
• Use a sunscreen if you are going to be in the sun for a longer duration.
• Avoid getting injuries on the skin.
• Wear long sleeves shirt and gloves while gardening.
• Avoid getting infections by following healthy habits such as washing hands with soap and water, avoiding food that is kept out for long, reducing exposure to people who are sick.
• Avoid alcohol and smoking.
• Reduce stress by practising meditation and yoga.
• Maintain an ideal BMI by following a healthy diet and staying active. This will help prevent obesity, which is a triggering factor. (Read more - Diet chart for weight loss)
  
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Diagnosis of psoriasis includes two components- physical examination and skin biopsy. Usually, a thorough medical history and physical examination hint at the diagnosis of psoriasis, but sometimes it can be confused with eczema, so biopsy serves as a confirmatory test.

• Physical Examination
  Proper medical history along with a thorough examination of the skin (of the affected area) almost confirms the diagnosis. It also helps in determining the severity of the disease by helping in finding out the affected total body surface area.
• Skin Biopsy
  A small sample of the skin, taken under local anaesthesia, helps in confirming the diagnosis of psoriasis. It also participates in determining the type of psoriasis, when examined well under the microscope.
• X-ray
  In the case of psoriatic arthritis, several blood tests like RA factor, vitamin D3 levels, CRP levels and others are evaluated along with an X-ray of the affected joint to rule out other causes of arthritis.

There is no permanent cure for psoriasis. Treatment is aimed at improving the person’s quality of life and in relieving symptoms. Treatment of psoriasis is divided into 3 categories- topical treatment, systemic medications and phototherapy (light therapy)

• Topical Treatment
  In mild psoriasis, topical medicines alone may suffice. In moderate or severe psoriasis, topical application is combined with oral medication or phototherapy. The topical applications include:
  • Corticosteroids
  • Vitamin D analogues
  • Topical retinoids
  • Salicylic acid
  • Coal tar
  • Calcineurin inhibitors
  • Anthralin
  • Moisturisers
• Systemic medications
  Oral or injectable medications are prescribed when psoriasis is severe or is resistant to the topical therapy. Usually, these medications have severe side effects, thus they are used for a shorter period of time and alternated with other forms of therapies. Drugs used for treating psoriasis are:
  • Methotrexate
  • Cyclosporine
  • Retinoids
  • Immunomodulators
  • Hydroxyureas
  • Light therapy
    The ideal phototherapy includes exposure of these scaly lesions to the ultra-violet rays (natural or artificial). Usually moderate of severe psoriasis is managed with phototherapy in combination with topical applications or systemic medications. Various light therapy modalities include
    • Sunlight exposure
    • UVB Phototherapy
    • Goeckerman therapy
    • Laser therapy
    • Psoralen plus ultraviolet A therapy

Lifestyle management

Psoriasis can impact a person’s lifestyle as well as his/her quality of life. Awareness about psoriasis can help a person cope with psoriasis more efficiently. It is helpful in adjusting with the disease as well as finding solutions to the challenges that the disease poses. These coping techniques include:

• Managing the itch
  Usually, itching is like a vicious cycle i.e., the more you itch, the more you feel itchy. So, avoiding itching works well, especially for scaly forms of psoriasis. Use of moisturisers helps in reducing itching.
• Weight management
  Losing weight or achieving the target BMI works well for reducing the intensity of the symptoms of psoriasis. Apart from that, having a diet rich in fruits, vegetables, whole grain, lean meat and fish has a positive impact on psoriasis. On the other hand, consuming a high amount of red meat, high-fat dairy products, refined food and alcohol tends to worsen psoriasis.
• Stress management
  Stress is one of the most common triggering factors of psoriasis. Managing your stress with yoga, breathing techniques and meditation helps in reducing the flare-ups of psoriasis.

Prognosis

Though psoriasis is an incurable condition, with proper treatment and life-style changes its symptoms can be kept under control and the quality of life can be improved. Only issues are with people who have severe psoriasis, as the condition can have a huge negative impact on his/her quality of life. There are several factors which affect the prognosis of psoriasis and they include:

• Remissions and flare-ups
  Smallest of exposure to triggering factor can flare up the disease and its duration can vary a great length as well, while most patients experience variable phases of remission.
• Morbidity
  Several researchers suggest that physical and mental agony associated with severe psoriasis is as bad as that associated with cancer or heart disease, which is the major concern. Many people with psoriasis may develop depression due to psoriasis. Rarely, suicidal tendencies and thoughts may be observed in some people with psoriasis.
• Mortality
  Mild to moderate form has low mortality rates. But severe cases have an impact on the life expectancy which can get reduced by 3-5 years.
• Effects of therapy
  In the majority of the cases, adequate therapy takes you to the period of clinical remission, where you can be asymptomatic, and this period of remission is variable. It can be for days, weeks, months or even years together.

Complication

Having psoriasis may predispose a person to several other disease conditions, which include:

• Psoriatic arthritis
  It is the most common complication of a long-standing and poorly treated psoriasis. It results in painful swelling of small joints.
• Eye problems
  People having psoriasis are at high risk of developing conjunctivitis, uveitis or blepharitis.
• Type 2 diabetes
  The severity of psoriasis is in direct relation to diabetes. More severe the psoriasis, greater are the risk of developing type 2 diabetes.
• Obesity
  Obesity is a predisposing factor for psoriasis and a complication of psoriasis too. Obese people are at risk of developing psoriasis and vice versa, psoriatic people are at risk of being obese.
• Parkinson’s disease
  Parkinson's disease is a chronic neurological disease and people having psoriasis are prone to develop this neurodegenerative disorder.
• Other autoimmune diseases
  Other autoimmune diseases such as Crohn’s disease, ulcerative colitis, sclerosis or celiac disease are quite common with people having psoriasis.
• Kidney disease
  Severe psoriasis is usually associated with chronic kidney disease.

There are more than hundreds of skin diseases that affect humans. Most of these conditions have similar symptoms. These conditions may differ based on their symptoms which could be temporary or permanent, painful or painless, itchy or without the itch. The causes are diverse and may include allergy, infection, defects in the immune system and genes. The symptoms vary in their severity. Some symptoms are minor and disappear on their own while some tend to be more severe and need hospitalization. Psoriasis is one of the most common skin conditions which affects about 5% of the world population.

What is Psoriasis?

Psoriasis is a skin condition that speeds up the skin growth by increasing multiplication of skin cells. This results in building up of skin cells. These clusters of cells accumulate in patches which are itchy and turn red and sometimes get even painful. It is a long-term (chronic) condition that appears in a periodic pattern. It is incurable and hence the primary goal of the therapy is to keep the symptoms under control.