All About Psoriasis | Diagnosis | Causes | Risk Factors | Prevention and Treatment

All About Psoriasis | Diagnosis | Causes | Risk Factors | Prevention and Treatment


Psoriasis | Diagnosis | Causes | Risk Factors
| Prevention and Treatment Tests and Diagnosis for Psoriasis Since other inflammatory diseases of the skin
(like eczema) can be confused with psoriasis, it is important that a board-certified dermatologist
makes the diagnosis. Physical Examination The dermatologist will examine the outer arms,
legs and scalp. The nails need to be examined because there may be visible pits in the nails
that appear much like hammered brass when the disease is flared or active. In addition, the tongue may manifest as a
geographic tongue, which has white scale in a ring-like pattern. Typically, a thorough physical examination
of the scalp, skin and nails is enough to make an accurate diagnosis. Although the size of an individual lesion
may vary from pinpoint to over 20 centimeters in diameter, the outline of the lesion is
usually circular, oval or polycyclic (derived from several smaller units or with many sides). Psoriasis lesions characteristically have
a very sharp border and do not fade into normal skin like other inflammatory skin rashes.
In addition, psoriatic lesions are sometimes surrounded by a pale blanching ring, which
is commonly referred to as a Woronoff ring. The surface of psoriasis plaques at times
can be removed. When this happens, a characteristic Auspitz sign is observed, which refers to
a collection of pinpoint bleeding. Skin Biopsy A skin biopsy may be necessary if the dermatologist
is considering other similar inflammatory skin rashes, such as eczema, seborrheic dermatitis,
dermatomyositis, lichen planus, pityriasis rosea or tinea corporis (ringworm). After a local anesthesia injection with lidocaine
(to numb the skin) and epinephrine (to control bleeding), a plastic device is used to remove
three to four millimeters of skin. Many times a simple stitch or two is necessary,
which will need to be removed in two weeks. The tissue is then examined under a microscope
by a dermatopathologist to confirm the diagnosis. The Psoriasis Area and Severity Index Because the percentage of body surface area
is important in regards to deciding which treatment would be appropriate for each individual
patient, a scale for measuring the number and thickness of psoriasis plaques was developed. The most widely used measuring scale is called
the PASI score. This stands for Psoriasis Area and Severity Index. These scores can
be used in both clinical and research settings. Other Tests Radiographs assessing for joint disease may
be useful in patients also suffering from psoriatic arthritis. Blood testing for inflammatory
markers, such as a CRP or ESR level, may also be helpful. A rheumatologist typically makes this diagnosis
because he or she studies autoimmune diseases that affect the joints. It will then be necessary to determine a treatment
regimen, which many times involves both topical creams, lifestyle and diet changes and possibly
systemic oral or injectable medication, depending upon the severity of the condition. Many times collaboration with both the dermatologist
and rheumatologist is necessary for optimal patient outcome. Causes, Risk Factors and Prevention of Psoriasis With normal, unaffected skin, the body takes
28 to 30 days to create new skin cells and shed dead ones. But when you have plaque psoriasis,
your immune system is overactive, causing skin cells to be pushed to the skin’s surface
in approximately three to four days. However, your body can’t keep up with this
rate of production. So while new skin cells are being produced, dead skin cells pile up
on top of each other. This creates thick, red, itchy, flaky patches known as plaques. The Role of Genetics Psoriasis occurs in increased frequency in
some families. When it comes to children developing psoriasis, a large German survey found that
if both parents were affected with psoriasis, the risk for the child developing the disorder
was up to 50 percent. But if only one parent was affected, the risk
was 16 percent. Likewise, if one sibling was affected, the risk was 8 percent. Based upon the analysis of family pedigrees,
a polygenic (or one that involves many genes) inheritance provides the best model for the
complex genetics of psoriasis. There’s also evidence that genetic factors
play a role in the clinical course or psoriasis. The PSOR1 gene is considered a major gene
that’s involved in up to 50 percent of patients with psoriasis. Psoriasis as an Autoimmune Disease Autoimmune diseases occur when the body’s
immune system accidentally attacks and destroys healthy body tissue. There are more than 80
types of autoimmune diseases, including plaque psoriasis. In psoriasis patients, the T cells attack
healthy skin cells. They trigger an immune response that leads to blood vessel dilation
in the skin around the plaques and an increase in white blood cells in the outer layer of
skin. This results in an increased production of
healthy skin cells, T cells and white blood cells. The ongoing cascade of new skin cells
moves to the outermost layer in days rather than weeks. Dead skin and white blood cells do not slough
off quickly enough and therefore build up into thick, scaly patches on the skin’s
surface. Potential Triggers Triggering factors can be both external (those
that directly interact with the skin) and internal or systemic, which can elicit psoriasis
in genetically predisposed patients. Here are a few of the most common: 1. Stress Additionally, environmental factors, including
infection, drugs, trauma, weather changes, obesity and stress, play an important role
in the development of psoriasis. Severe emotional stress tends to aggravate
psoriasis in almost half of those patients studied. Exacerbations of psoriasis typically occur
a few weeks to months after a stressful life event. Additionally, in pregnancy, psoriasis
symptoms can improve. However, after childbirth, there’s a tendency for it to get worse. 2. Alcohol Consumption, Smoking and Obesity Obesity, alcohol consumption and smoking have
also been associated with psoriasis. Smoking plays a role in the onset of psoriasis, while
obesity appears to be a result of psoriasis. The relationship between alcoholism and psoriasis
is likely due to the psychological effects of the patient and psoriasis. And excess weight
increases the risk of psoriasis, as plaques often develop in skin folds. 3. Infections Infections, particularly bacterial, may induce
or flare psoriasis. This has been observed in approximately 45 percent of psoriatic patients. Beta-hemolytic strep, especially manifesting
as strep throat, is the most common offender. Additionally, dental abscesses, perianal cellulitis
and impetigo can flare psoriasis. These types of infections typically manifest themselves
in the form of “gumdrop” psoriasis. This type of psoriasis is common in childhood and
teenagers. Similarly, patients with HIV have higher rates
of psoriasis. Less commonly, sinus, respiratory, gastrointestinal or genitourinary tracts may
be responsible for disease flare. 4. Skin Trauma Trauma to the skin like a scrape, bite or
sunburn can trigger psoriasis. This is called the Koebner phenomenon. It is observed in
approximately 25 percent of patients with psoriasis. Other forms of skin injuries, such as sunburn,
drug eruptions or viral rashes, can also induce psoriasis. The lag time between the trauma
and the appearance of the skin lesion is usually two to six weeks. 5. Certain Drugs There are several drugs that induce psoriasis,
including: lithium (used to treat bipolar disease), interferon (used for immune system
regulation), beta blockers and calcium channel blockers (used for hypertension), terbinafine
(used for fungal infections) and anti-malarials (used to treat infection and for autoimmune
diseases). Rapid tapers of oral steroids (prednisone)
may induce pustular psoriasis as well as flares of plaque psoriasis. That is why it is very
important to be aware of the affects of these medications on one’s psoriasis before starting
any of them. Drugs and Treatment for Psoriasis There are a variety of topical treatments
and systemic therapies available to help treat psoriasis. Long-term management of psoriasis
requires individualization of therapy, taking into account the extent of the disease, the
patient’s perception of the severity and the potential side effects of the treatments. The chronic nature of the disease necessitates
adoption of a long-term approach while avoiding dramatic short-term fixes that may produce
a more reactive disease state. It is often necessary to combine treatments for psoriasis
patients. There is a need for new therapies, and these
will eventually come with recent and future medical advances. Approximately 40 percent of patients reported
frustration with the ineffectiveness of their current treatment. Topical Treatments While there is no cure, current treatments
may offer significant relief. The primary goal of treatment is to regulate or stop the
skin cells from growing and exfoliating too quickly while reducing inflammation. Topical treatments — medications applied
to the skin — are usually the first method used to help relieve skin symptoms. There
are several topical treatments for psoriasis that have been shown to be effective. While many can be purchased at your local
drugstore, others require a prescription. Topical prescription steroid creams work well
for mild, limited cases. As anti-inflammatory agents, they reduce the swelling and redness
of skin lesions. Secondly, vitamin D-3 analogs, or calcipotriene,
affect skin-cell differentiation through the regulation of epidermal responsiveness to
calcium. Crude coal tar, antralin, tazarotene or retinoic
acid (topical vitamin A preparations) and salicylic acid are all anti-inflammatory topical
treatments that regulate cell turnover and can also be beneficial in the treatment of
psoriasis. Over-the-counter topicals come in many forms.
Salicylic acid and coal tar are the two active ingredients approved by the FDA for the treatment
of psoriasis. Products that contain aloe vera, jojoba, zinc
pyrithione and capsaicin are used to moisturize and soothe irritated skin and potentially
remove scales or relieve itching. Sunlight Therapy Sunlight therapy involves exposing your skin
to small amounts of natural sunlight for approximately 20 minutes per day, depending upon time of
year and distance from the equator. And it may help improve psoriasis symptoms, as UV
light is anti-inflammatory in small doses. There are also many indoor sources, including
monitored phototherapy units, which emit a specific type of UV light that has been shown
to be more effective. These sessions can occur in the home or at the dermatologist’s office. It is important to note that these wavelengths
of light are not found in your local tanning-bed facility. The lights in tanning beds are not
regulated and may result in sunburn, which can trigger a psoriasis outbreak. It is very
important not to sunburn if you have psoriasis. Ultraviolet light A (UVA) — also in sunlight
— is another option for sunlight therapy. But unlike UVB, UVA needs to be used with
a light-sensitizing medication (psoralen), given either topically or orally. This process, called PUVA, slows down excessive
skin-cell growth and can clear psoriasis symptoms for varying periods of time. PUVA is most
beneficial for those with stable plaque psoriasis, guttate psoriasis and psoriasis of the palms
and soles. The treatment is not without side effects,
though, and can cause nausea, itching and redness of the skin. Ginger can help with
the nausea, and antihistamines, oatmeal baths or topical capsaicin products may relieve
itching. Try compression hose for swollen legs caused
by standing during PUVA treatment. Photochemotherapy with ultraviolent light
and the ingestion of psoralen or topical psoralen for moderate to severe psoriasis is highly
effective. This can be performed with different wavelengths
of light, such as narrow-band UVB. Finally, the excimer laser can be used to
target smaller or a limited number of psoriatic plaques. This laser is found at your local
dermatologist’s office and may be covered by insurance in many cases. Systemic Medications Systemic treatments affect the entire body,
not just the skin. Biologic agents for moderate to severe psoriasis include: etanercept (Enbrel),
adalimumab (Humira) and ustekinumab (Stelara). These have dramatic responses to both psoriasis
and psoriatic arthritis. These are expensive agents, but are quite
good for cases with significant skin involvement or for patients with comorbidities like psoriatic
arthritis. Tuberculosis skin testing and hepatitis B
titers are required prior to initiation of therapy. During the course of therapy labs are typically
monitored, which include complete blood counts and liver-function tests until the medication
is well tolerated and the lab values are stable. These medications lower one’s immune system
and slightly increase the risk of developing lymphoma. These agents are injected into the
subcutaneous tissue either at home or at the dermatologist’s office. Methotrexate, which blocks DNA synthesis,
still remains a viable option for patients. This medication is either taken by mouth or
injected into the skin by the patient. However, it is important to rule out liver or kidney
disease prior to initiation. In addition, methotrexate increases one’s
risk of developing skin cancer. Thus, patients with a strong personal or familial risk of
skin cancers should reconsider this treatment option. New oral “small molecule” treatments have
emerged that can selectively target molecules inside immune cells. These treatments slow overactive immune responses
and target inflammation within the cell. This lessens the redness and scaliness of plaques
and relieves joint tenderness and swelling. Apremilast (Otezla) is the newest prescription
oral medicine approved for the treatment of adult patients with moderate to severe plaque
psoriasis/arthritis. Apremilast treats psoriatic arthritis by inhibiting an enzyme that controls
much of the inflammation within cells. Visit the website. Click below

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