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Psoriasis

Psoriasis is a common disorder of the skin that can dramatically reduce a person’s quality of life. It is characterized by skin inflammation that causes peeling, redness, itching, swelling and in the most severe cases, pain.

“Today, psoriasis vulgaris is recognized as the most prevalent autoimmune disease caused by inappropriate activation of the cellular immune system. Psoriasis affects people of all ages, but there is a strong tendency for disease onset in early adulthood in patients who develop psoriasis due to genetic transmission. There has been a major international effort to characterize psoriasis susceptibility genes, but until recently, virtually nothing learned from linkage analysis has advanced the understanding of disease pathophysiology. Unlike other common tissue specific autoimmune diseases, psoriasis vulgaris does not have a generally accepted animal model, and thus our understanding of pathogenesis is derived mainly from clinical studies and translational science done in patients with this disease. That work initially pointed towards a major role of T lymphocytes as inducers of the disease phenotype and the pathogenic contribution of this cell type has now been tested through clinical studies of more than a dozen immune modifying biological agents in patients with psoriasis.”1

The World Health Organization (WHO) has estimated that more than 100 million people in the world suffer from this annoying condition. This number is increasing due to factors common in modern life, such as stress, environmental pollution, chemical substances that surround us and even some medications.

“Psoriasis is a common, chronic, noncommunicable skin disease, with no clear cause or cure. The negative impact of this condition on people’s lives can be immense. Psoriasis affects people of all ages, and in all countries. The reported prevalence of psoriasis in countries ranges between 0.09% and 11.43%, making psoriasis a serious global problem with at least 100 million individuals affected worldwide. Psoriasis has an unpredictable course of symptoms, a number of external triggers and significant comorbidities, including arthritis, cardiovascular diseases, metabolic syndrome, inflammatory bowel disease and depression.”2

This pathology mainly affects people between 15 and 35 years of age, although it can also appear in children and the elderly.

The origin of psoriasis is idiopathic. However, it is known to have a genetic and hereditary component. In fact, if both parents suffer from psoriasis, there is a possibility that one in four children will suffer from this disease. Some other causes that we can mention are:

  • The consumption of some medications, which may contribute to the appearance or proliferation of psoriatic outbreaks. For this reason, it is important that we inform our doctor of any medication we are taking when seeking counsel.
  • Stressful situations
  • Frequent climate changes
  • Many types of trauma, for example, sunburns

The main symptom of psoriasis is the appearance of reddish spots on the skin. These usually result in peeling and itching, which can be very painful. The most common areas where the symptoms of psoriasis appear are the back, scalp and extremities. However, there are also cases where it proliferates on the genitals, underarms or even under the nails.

Psoriasis can manifest itself very differently in each individual, so its classification is based on the severity of the injury, the shape and pattern of the scales. In general, this diagnosis is made by a specialist (dermatologist), who will proceed to evaluate the lesions and prescribe treatment.

In its initial stage, psoriasis can go unnoticed and confused with an allergic reaction. In some instances, a skin biopsy may be done in order to analyze the sample and rule out other possible pathologies.

Clinical Features

“Psoriasis is a papulosquamous disease with variable morphology, distribution, severity, and course. Papulosquamous diseases are characterized by scaling papules (raised lesions, 1 cm in diameter) and plaques (raised lesions .1 cm in diameter). Other papulosquamous diseases that may be considered in the differential diagnosis include tinea infections, pityriasis rosea, and lichen planus. The lesions of psoriasis are distinct from these other entities and are classically very well circumscribed, circular, red papules or plaques with a grey or silvery-white, dry scale. In addition, the lesions are typically distributed symmetrically on the scalp, elbows, knees, lumbosacral area, and in the body folds. Psoriasis may also develop at the site of trauma or injury, known as Koebner’s phenomenon. If psoriasis is progressive or uncontrolled, it can result in a generalized exfoliative erythroderma. Nail involvement may be present, particularly if psoriatic arthritis (PsA) is present.

Occasionally psoriasis may involve the oral mucosa or the tongue. When the tongue is involved, the dorsal surface may have sharply circumscribed gyrate red patches with a white-yellow border. The patches may evolve and spread, changing on a daily basis, can assume distinct annular patterns and may resemble a map, hence the term geographic tongue.

Psoriasis can be highly variable in morphology, distribution, and severity. Despite the classic presentation described above, the morphology can range from small tear shaped papules (guttate psoriasis) to pustules (pustular psoriasis) and generalized erythema and scale (erythrodermic psoriasis). In addition, these different forms of psoriasis may be localized or widespread and disabling. Further, psoriasis may have a variable course presenting as chronic, stable plaques or may present acutely, with a rapid progression and widespread involvement. Psoriasis may be symptomatic with patients complaining of intense pruritus or burning.3

“Psoriasis is also associated with considerable morbidity and comorbid conditions. Psoriasis and Crohn’s disease share common genetic susceptibility factor(s), with the incidence of Crohn’s disease among psoriatics being 3.8 to 7.5 times that of the general population.10 In addition, there may be a link of psoriasis with multiple sclerosis. Patients with psoriasis also have an increased incidence of lymphoma, heart disease, obesity, type 2 diabetes, and the metabolic syndrome. Depression and suicide, smoking, and alcohol consumption are also more common in patients with psoriasis. Patients with severe psoriasis have an increased risk for mortality, largely attributable to cardiovascular death, and die on average about 5 years younger than patients without psoriasis. The basis for the relationship between these associations is complex, with the effects of chronic systemic inflammation, psychosocial issues, and potential adverse effects of therapies likely to be important. Both genetic and environmental factors contribute to the development of psoriasis. In the skin, scaling, thickened plaques, and erythema can be attributed to hyperproliferation of epidermal keratinocytes and to a dysregulated interplay among the epidermis and dermis, the cutaneous microvasculature, and the immune system.4

There are three types of treatment for psoriasis

  • Phototherapy: consists of controlled exposure to ultraviolet light. In this manner, it is possible to reduce inflammation and stop the excessive production of skin cells that form psoriasis. It is a very effective treatment, although quite long since it requires a minimum of 20 sessions.

“Solar ultraviolet (UV) radiation has been used since ancient times to treat various diseases. This has a scientific background in the fact that a large number of molecules (chromophores) in different layers of the skin interact with and absorb UV. These interactions may have both positive and negative biological implications. Most of the positive effects of solar radiation are mediated via ultraviolet-B (UVB) induced production of vitamin D in skin. In our day’s phototherapy is a valuable option in the treatment of many psoriatic and nonpsoriatic conditions, including atopic dermatitis, sclerosing skin conditions such as morphea, sclero‐ derma, vitiligo, and mycosis fungoides. UVB radiation reaches the epidermis and the upper dermis where it is absorbed by DNA, trans-urocanic acid (trans-UCA), and cell membranes. Absorption of UVB by nucleotides leads to the formation of DNA photo‐ products, primarily pyrimidine dimers. UVB exposure reduces the rate of DNA synthesis. In addition, UVB radiation causes photoisomerization of trans-UCA to cis-UCA which has immunosuppressive effects. Furthermore, UV radiation can affect extranuclear molecular targets (cell surface receptors, kinases, phosphatases, and transcription factors) located in the cytoplasm and in the cell membanes. Keratinocytes, circulating and cutaneous T lymphocytes, monocytes, Langerhans cell, mast cells and fibroblasts are all targeted by narrowband UVB. Narrowband UVB induces also local and systemic immunosuppressive effects which may particularly contribute to the beneficial effects of this light source. UVA radiation penetrates more deeply into the skin than UVB, and reaches not only epidermis, but also dermis with blood vessels affecting dermal dendritic cells, dermal fibroblasts, endothelial cells, mast cells, and granulocytes. UVA radiation is absorbed by pyridine nucleotides (NAD and NADP), riboflavins, porphyrins, pteridines, cobalamins and bilirubin Porphyrins and riboflavins are photosensitizers. UVA effects are dominated by indirect DNA damage caused by reactive oxygen species such as singlet oxygen. The ability of UVA radiation to cause skin erythema is approximately 103 to 104 times lower than that of UVB. As UVA-1 is even less erythematogenic than broadband UVA much higher doses of UVA-1 can be tolerated by the patients. UVA-1 phototherapy works mainly through induction of apoptosis of skin infiltrating T cells, T-cell depletion and induction of collagenase-1 expression in human dermal fibroblast.5

  • Drugs: are administered orally and fight outbreaks from within the body.

“Patients with moderate to severe psoriasis benefit most from systemic therapies.1 Traditional oral therapies used for psoriasis include methotrexate, cyclosporine, and acitretin. A newer oral therapy for psoriasis is apremilast.

Methotrexate. The oral and injectable antimetabolite methotrexate increases extra-cellular adenosine with its anti-inflammatory properties. Methotrexate is the mainstay of systemic treatment for psoriasis in the US and Europe, despite its significant adverse effects on major organs—liver function enzyme elevation, bone marrow suppression, and pulmonary fibrosis—which limit its long-term use. Methotrexate is contraindicated in women who are actively conceiving, pregnant, or lactating. […]

Cyclosporine. Although the calcineurin inhibitor cyclosporine is effective, it is reserved for short-term interventional use in patients with psoriasis who are experiencing flares. Because long-term use of cyclosporine is associated with hypertension and irreversible renal damage, it is typically used for no more than 3 to 6 months and then discontinued.

Acitretin. The oral retinoid acitretin has been used with variable success for pustular psoriasis and palmoplantar psoriasis. It has a synergistic effect when combined with UV therapy. Patients using a combination of acitretin and UV therapy can reduce the UV dose. Acitretin has modest efficacy in patients with moderate to severe psoriasis. Significant potential adverse effects include dyslipidemia and less frequently liver function test abnormalities.

Apremilast, an oral PDE-4 inhibitor approved in 2014, is modestly effective in patients with psoriasis and PsA. Its short-term, ie, initial first month of therapy, effect on the immune system is not well understood. Common adverse effects include diarrhea, nausea, and rare cases of upper respiratory tract infection, and headache.1 Warnings for apremilast include rare cases (1%) of depression.”6

  • Topical ointments and creams: the majority of cases are treated with creams, lotions and shampoos, which are applied directly on the skin. “Although there is no cure for psoriasis, there are multiple effective treatment options. Topical therapy is the standard of care for treatment of mild to moderate disease. A large proportion of patients would benefit from topical therapy, which can be initiated at the primary care level. If topical agents do not elicit an adequate response or if they are not practical owing to the affected body surface area, these patients can be referred for assessment by a dermatologist, at which point systemic therapy with topical adjuncts might be more suitable. Presence of psoriatic arthritis might also call for systemic therapies in collaboration with a rheumatologist.”7

“Biologics developed for psoriasis are for the indication of patients with moderate to severe psoriatic disease that are candidates for systemic treatment or phototherapy. Some of the biologics have also received approval for PsA. Most results on the latest biologics developed for psoriasis are based on randomized studies with placebo as the control arm, whereas only a few head-to-head studies have been completed. Also, there is a need for data on long-term efficacy and safety that cannot be generated from the relative short-term clinical trials required for drug approval. Therefore, it is not possible, at this point, to draw conclusions on the most favorable drug within the group of the newest, highly targeted biologics. One approach is indeed to identify the best drug over others on average. However, another future approach may be to focus research on the link between psoriasis, genetics and co-morbidities in context with the mechanism of new biologics. This valuable knowledge may generate the possibility of an individualized treatment according to a mapped, personal ‘psoriasis-profile’ for each patient.”8

Prevention and Treatment

Here are some tips to prevent and treat psoriasis in a simple and natural way:

  • Reduce the consumption of dairy products, sugars, fats and refined flours
  • Avoid toxic habits such as tobacco and alcohol, thus improving the function of the liver, kidneys and intestine to facilitate the elimination of toxins.
  • Drink plenty of water throughout the day
  • Enjoy the sun in moderation.
  • Hydrate your skin with natural creams. Aloe Vera is an excellent ingredient with soothing and regenerating effects.

References:

(1) Krueger, J. G., & Bowcock, A. (2005). Psoriasis pathophysiology: current concepts of pathogenesis. Annals of the rheumatic diseases, 64(suppl 2), ii30-ii36. Available online at https://ard.bmj.com/content/annrheumdis/64/suppl_2/ii30.full.pdf

(2) World Health Organization. (2016). Global report on psoriasis. Available online at World Health Organization. (2016). Global report on psoriasis. Available online at https://apps.who.int/iris/bitstream/handle/10665/204417/9789241565189_eng.pdf.psoriasis?sequence=1

(3) Langley, R. G. B., Krueger, G. G., & Griffiths, C. E. M. (2005). Psoriasis: epidemiology, clinical features, and quality of life. Annals of the rheumatic diseases, 64(suppl 2), ii18-ii23. Available online at https://ard.bmj.com/content/annrheumdis/64/suppl_2/ii18.full.pdf

(4) Menter, A., Korman, N. J., Elmets, C. A., Feldman, S. R., Gelfand, J. M., Gordon, K. B., … & Lim, H. W. (2011). Guidelines of care for the management of psoriasis and psoriatic arthritis: section 6. Guidelines of care for the treatment of psoriasis and psoriatic arthritis: case-based presentations and evidence-based conclusions. Journal of the American Academy of Dermatology, 65(1), 137-174. Available online at https://www.sciencedirect.com/science/article/pii/S0190962210021730

(5) Zangeneh, F. Z., & Shooshtary, F. S. (2013). Psoriasis—types, causes and medication. In Psoriasis-Types, Causes and Medication. IntechOpen. Available online at http://cdn.intechopen.com/pdfs/44173/InTech-Psoriasis_types_causes_and_medication.pdf

(6) Armstrong, A. W., Gordon, K. B., & Wu, J. J. (2018). New Treatment Paradigms in Psoriasis: Understanding and Incorporating Recent and Emerging Trends. A. Menter (Ed.). Frontline Medical Communications Incorporated. Available online at https://www.globalacademycme.com/sites/default/files/scms_psoriasissuppl_v37-2s_march_2018.pdf

(7) Kim, W. B., Jerome, D., & Yeung, J. (2017). Diagnosis and management of psoriasis. Canadian Family Physician, 63(4), 278-285. Available online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5389757/

(8) Rønholt, K., & Iversen, L. (2017). Old and new biological therapies for psoriasis. International journal of molecular sciences18(11), 2297. Available online at https://www.mdpi.com/1422-0067/18/11/2297

Robert Velasquez
14 December, 2018

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Hello everyone, my name is Robert Velazquez. I am a content marketer currently focused on the medical supply industry. I studied Medicine for 5 years. I have interacted with many patients and learned a lot...read more:

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