Psoriasis

Psoriasis is a long-lasting autoimmune disease that primarily affects the skin. It is characterised by the rapid build-up of skin cells, leading to the formation of thick, red, flaky, and often itchy patches covered with silvery-white scales. These patches, commonly referred to as plaques, can appear anywhere on the body, but are most frequently found on the scalp, elbows, knees, and lower back. While psoriasis is primarily a skin condition, it can also affect the nails and joints (a condition known as psoriatic arthritis).

Psoriasis is not contagious, meaning it cannot be spread from person to person through skin contact. It is a chronic condition, and while there is currently no cure, various treatments can effectively manage the symptoms and improve the quality of life for those affected. 

At its core, psoriasis is an immune-mediated disease. This means that the body's own immune system mistakenly attacks healthy skin cells. Normally, skin cells grow and are shed over a period of about a month. In psoriasis, this process is dramatically accelerated, with new skin cells being produced and pushed to the surface in just a few days. This rapid overproduction leads to the accumulation of skin cells on the surface, forming the characteristic thick, scaly plaques.

The inflammation associated with this overactive immune response also contributes to the redness and itching often experienced with psoriasis. The exact triggers for this immune system malfunction are not fully understood, but genetic predisposition and environmental factors are believed to play significant roles. Psoriasis typically follows a relapsing-remitting course, meaning individuals may experience periods of more severe symptoms (flare-ups) followed by periods of improvement or even remission, where symptoms lessen or disappear temporarily.

The global prevalence of psoriasis is estimated to be around 2-3% of the population. However, prevalence rates can vary significantly across different geographical regions and ethnic groups.

In India, some regions report higher prevalence rates than others. Factors such as genetic background and environmental influences are thought to contribute to these regional differences.

Worldwide, prevalence rates are generally higher in populations further away from the equator. For instance, Scandinavian countries and Russia tend to have higher prevalence rates compared to those in Southeast Asia or Africa. It is believed that environmental factors like sunlight exposure might play a role in these variations.

Psoriasis manifests in several distinct forms, each with its own characteristic appearance and distribution on the body:

Plaque Psoriasis (Psoriasis Vulgaris): This is the most common type, accounting for around 80-90% of cases. It is characterised by raised, red patches (plaques) covered with a silvery-white build-up of dead skin cells (scales). These plaques most often appear on the elbows, knees, scalp, and lower back, but can occur anywhere on the skin. They can be itchy, painful, and may crack and bleed.
 

Guttate Psoriasis: This type often appears suddenly as small, drop-shaped spots on the skin. It is frequently triggered by a streptococcal throat infection. Guttate psoriasis is more common in children and young adults and may resolve on its own within a few weeks or months, or it can develop into plaque psoriasis.
 

Inverse Psoriasis: This type affects the skin folds, such as under the arms, in the groin, under the breasts, and around the genitals. Instead of scaly plaques, inverse psoriasis presents as smooth, red, inflamed patches that can be very sore and are often worsened by friction and sweating.
 

Pustular Psoriasis: This is a less common form characterised by widespread or localised areas of red, inflamed skin with small, pus-filled bumps (pustules). There are several subtypes of pustular psoriasis, including generalised pustular psoriasis (Von Zumbusch psoriasis), which can be severe and may be accompanied by fever, chills, and fatigue, and palmoplantar pustulosis, which affects the palms of the hands and soles of the feet.
 

Erythrodermic Psoriasis: This is a rare and severe form of psoriasis where the skin becomes extensively red and inflamed over most of the body surface. It can cause intense itching, pain, and changes in body temperature and heart rate. Erythrodermic psoriasis can be life-threatening and requires immediate medical attention.
 

Nail Psoriasis: Psoriasis can affect the fingernails and toenails, causing pitting (small dents), thickening, discolouration (yellow-brown), separation from the nail bed (onycholysis), and crumbling. Nail changes can occur in any type of psoriasis and can be the only manifestation in some individuals.
 

Psoriatic Arthritis: This is a related condition where individuals with psoriasis also develop inflammation of the joints, causing pain, stiffness, and swelling. It can affect any joint in the body and often occurs alongside nail changes.

The exact cause of psoriasis is not fully understood, but it is considered to be a complex interplay of genetic, immunological, and environmental factors. It is not caused by an infection and is not contagious. Key factors believed to contribute to the development of psoriasis include:

• Genetics: Psoriasis has a strong genetic component. Individuals with a family history of psoriasis are at a significantly higher risk of developing the condition. Multiple genes have been identified that are associated with an increased susceptibility to psoriasis, but no single "psoriasis gene" exists.
• Immune System Dysfunction: Psoriasis is an autoimmune disease where the immune system mistakenly attacks healthy skin cells. Specifically, T cells, a type of white blood cell, become overactive and trigger inflammation and the rapid production of skin cells. Cytokines, such as tumour necrosis factor-alpha (TNF-alpha) and interleukins, play a crucial role in this inflammatory process.
• Environmental Triggers: While genetics and the immune system are central to psoriasis, various environmental factors can trigger or worsen flare-ups in susceptible individuals. 

The symptoms of psoriasis vary depending on the type of psoriasis a person has and the severity of their condition. However, common symptoms include:

• Red, raised patches of skin (plaques): Often the most visible symptom, ranging from small spots to large areas.
• Silvery-white scales: Dead skin build-up on plaques that flakes off easily.
• Itching: Intense itchiness that may lead to scratching and irritation.
• Burning or soreness: Affected skin may feel hot, painful, or tender.
• Thickened, pitted, or ridged nails: Nails may show dents, ridges, or lift from the nail bed.
• Swollen and stiff joints: Painful joint inflammation seen in psoriatic arthritis.
• Dry, cracked skin that may bleed: Severely dry skin can split open, causing bleeding.
• Small red spots (papules): Drop-shaped red spots typical of guttate psoriasis.
• Smooth, red patches in skin folds: Inflamed, shiny skin in areas like the armpits or groin (inverse psoriasis).

Psoriasis is typically diagnosed based on a physical examination of the skin, scalp, and nails by a dermatologist (a doctor specialising in skin conditions). The characteristic appearance and distribution of the plaques are usually sufficient for diagnosis. The doctor will also take a thorough medical history, asking about family history of psoriasis, any recent illnesses (like a sore throat), medications being taken, and any known triggers.

In some cases, especially if the diagnosis is uncertain or to rule out other skin conditions like eczema or fungal infections, a skin biopsy may be performed. This involves taking a small sample of the affected skin and examining it under a microscope in a laboratory. The microscopic features of psoriatic skin are distinct and can help confirm the diagnosis.

There are no specific blood tests to diagnose psoriasis itself. However, blood tests may be ordered to assess for signs of inflammation or to monitor for associated conditions like psoriatic arthritis. 

While there is currently no cure for psoriasis, a wide range of effective treatments are available to manage the symptoms, reduce inflammation, slow down the rapid skin cell turnover, clear the skin, and improve the patient's quality of life. Treatment options are tailored to the type and severity of psoriasis, the areas of the body affected, and the individual's overall health and preferences. Common treatment approaches include:

Topical Treatments: These are medications applied directly to the skin and are often the first-line treatment for mild to moderate psoriasis.(Brands available: Betnovate N, Betnovate C, Derobin) Examples include:

• Topical Corticosteroids: These are potent anti-inflammatory drugs that can reduce redness, itching, and scaling. They come in various strengths, and the potency used depends on the location and severity of the psoriasis. 
• Vitamin D Analogues: These synthetic forms of vitamin D help to slow down skin cell growth. Examples include calcipotriol and calcitriol.
• Topical Retinoids: These vitamin A derivatives can help to reduce inflammation and skin cell turnover. Tazarotene is a common topical retinoid used for psoriasis.
• Calcineurin Inhibitors: These medications, such as tacrolimus and pimecrolimus, are typically used for inverse psoriasis and sensitive skin areas. They work by suppressing the immune response.
• Salicylic Acid: This helps to remove scales and soften thick plaques, making other topical treatments more effective.
• Coal Tar: This older treatment can help to reduce scaling, itching, and inflammation. It can be messy and have a strong odour.

Phototherapy (Light Therapy): This involves exposing the skin to specific types of ultraviolet (UV) light under medical supervision. Common types of phototherapy for psoriasis include:

• Ultraviolet B (UVB) Therapy: Narrowband UVB is often the most effective form of phototherapy for psoriasis.
• Broadband UVB Therapy: This uses a wider spectrum of UVB light.
• Psoralen plus Ultraviolet A (PUVA): This involves taking a medication called psoralen, which makes the skin more sensitive to UVA light, followed by exposure to UVA.

Systemic Medications: These are oral or injectable drugs that work throughout the body to suppress the overactive immune system and slow down skin cell production. Systemic treatments are typically used for moderate to severe psoriasis or when topical treatments and phototherapy are not effective. Examples include:

• Traditional Systemic Drugs: Methotrexate, ciclosporin, and acitretin are older systemic medications that have been used effectively for psoriasis for many years. They require regular monitoring due to potential side effects.
• Biologics: These are newer, more targeted systemic drugs that block specific proteins in the immune system that contribute to psoriasis. They are usually administered by injection or infusion and include TNF-alpha inhibitors (e.g., adalimumab, etanercept, infliximab), interleukin inhibitors (e.g., secukinumab, ixekizumab, ustekinumab), and other biologics.
• Small Molecule Inhibitors: These are oral medications that target specific intracellular pathways involved in inflammation. Apremilast is an example of a small molecule inhibitor used for psoriasis and psoriatic arthritis.

Combination Therapy: Often, a combination of different treatments, such as topical medications with phototherapy or systemic drugs, is used to achieve the best results.

Several factors can increase a person's risk of developing psoriasis:

• Family History: Having a parent or sibling with psoriasis significantly increases the risk of developing the condition.
• Age: While psoriasis can develop at any age, it most commonly appears between the ages of 15 and 35.
• Smoking: Smoking is a significant risk factor for developing psoriasis and can also make the condition more severe and harder to treat.
• Obesity: Being overweight or obese is associated with an increased risk of psoriasis and may also make treatment less effective.
• Stress: High levels of stress can trigger or worsen psoriasis flare-ups.
• Certain Infections: Streptococcal throat infections are a known trigger for guttate psoriasis.
• Certain Medications: As mentioned earlier, some medications can trigger or worsen psoriasis.

Psoriasis is not just a skin condition; it can be associated with several other health issues and complications:

• Psoriatic Arthritis: As discussed earlier, this inflammatory joint condition affects up to 30% of people with psoriasis, causing pain, stiffness, and swelling in the joints.
• Eye Conditions: People with psoriasis have a higher risk of developing certain eye conditions, such as uveitis (inflammation of the middle layer of the eye), conjunctivitis (inflammation of the conjunctiva), and blepharitis (inflammation of the eyelids).
• Metabolic Syndrome: Psoriasis is linked to an increased risk of metabolic syndrome, a cluster of conditions that increase the risk of heart disease, stroke, and type 2 diabetes. These conditions include high blood pressure, high blood sugar, unhealthy cholesterol levels, and excess abdominal fat.
• Cardiovascular Disease: Individuals with psoriasis, especially severe psoriasis, have an increased risk of heart attack, stroke, and other cardiovascular problems. The chronic inflammation associated with psoriasis is thought to contribute to this increased risk.
• Mental Health Issues: The visible nature of psoriasis, along with the itching, pain, and impact on quality of life, can lead to mental health issues such as depression, anxiety, and low self-esteem.
• Other Autoimmune Diseases: People with psoriasis have a slightly higher risk of developing other autoimmune diseases, such as Crohn's disease and ulcerative colitis.
• Kidney Disease: Some studies have suggested a potential link between psoriasis and an increased risk of kidney disease.

Here are some tips to help manage the condition and improve quality of life:

• Follow Your Treatment Plan: Adhere to the treatment regimen prescribed by your dermatologist consistently.
• Moisturise Regularly: Keeping the skin well-moisturised can help to reduce dryness, itching, and scaling. Use thick, fragrance-free emollients.
• Avoid Harsh Soaps and Products: Use mild, gentle cleansers and avoid products with harsh chemicals or fragrances that can irritate the skin.
• Take Lukewarm Baths or Showers: Hot water can dry out the skin and worsen itching. Opt for lukewarm water.
• Use Topical Treatments Correctly: Apply topical medications as directed by your doctor, usually after bathing or showering when the skin is slightly damp.
• Manage Stress: Find healthy ways to cope with stress, such as exercise, yoga, meditation, or spending time on hobbies.
• Seek Support: Connect with support groups or online communities for people with psoriasis. Sharing experiences and tips can be helpful.
• Protect Your Skin from Sunburn: While controlled sun exposure can be beneficial for some, sunburn can trigger flare-ups. Use sunscreen and protective clothing when outdoors.
• Maintain a Healthy Diet: While diet may not directly cure psoriasis, a balanced diet can contribute to overall health.
• Communicate with Your Healthcare Team: Maintain regular contact with your dermatologist to discuss your treatment, any concerns, and any changes in your condition.
• Be Patient and Persistent: Finding the right treatment or combination of treatments can take time and effort. Be patient and work closely with your doctor.
• Take Care of Your Mental Health: If you are experiencing depression, anxiety, or low self-esteem related to your psoriasis, seek help from a mental health professional.

It is important to see a doctor, preferably a dermatologist, if you suspect you have psoriasis or if you experience any of the following:

• New patches of red, scaly skin.
• Persistent itching, burning, or soreness of the skin.
• Changes in your nails, such as pitting, thickening, or discolouration.
• Joint pain, stiffness, or swelling, especially if you also have skin symptoms.
• Widespread redness or blistering of the skin (erythrodermic or pustular psoriasis), which requires immediate medical attention.
• If your psoriasis symptoms are not improving with over-the-counter treatments.
• If your psoriasis is significantly impacting your quality of life or mental health.

When you see your doctor about psoriasis, here are some questions you may want to ask:

• What type of psoriasis do I have?
• What are my treatment options?
• What are the potential benefits and risks of each treatment?
• How long will it take to see results from the treatment?
• Are there any lifestyle changes that might help my psoriasis?
• What should I do during a flare-up?
• How can I manage the itching?
• Are there any support groups or resources available for people with psoriasis?
• What is the long-term outlook for my psoriasis?
• Should I be concerned about psoriatic arthritis or other associated conditions?

• Encourage Them to Seek and Adhere to Treatment: Support their efforts to manage their condition by encouraging them to follow their treatment plan and attend medical appointments.
• Be a Good Listener: Provide a safe space for them to talk about their feelings and experiences without judgment.
• Challenge Stigma: Correct any misinformation or negative attitudes you encounter about psoriasis.
• Focus on Their Strengths: Remind them of their abilities and qualities beyond their skin condition.
• Include Them in Activities: Encourage them to participate in social activities and help them feel included and accepted.
• Be Patient: Understand that psoriasis is a chronic condition with ups and downs.

Psoriasis is a complex and chronic autoimmune skin condition that affects millions worldwide. While there is no cure, significant advancements in treatment have made it possible for most individuals to effectively manage their symptoms and lead fulfilling lives. 

By promoting awareness, challenging misconceptions, and providing comprehensive care and support, we can help individuals with psoriasis navigate their journey with greater confidence and well-being.