Psoriasis

Psoriasis is a chronic autoimmune disease that can cause rashes on your skin and arthritis. It is similar to eczema in that it causes itchy red patches, but it also can cause silvery scales. Sometimes Psoriasis is misdiagnosed because it can look very similar to eczema, especially early on. Depending on the type of psoriasis, the skin may thicken and harden, form pustules, or develop in the skin fold areas of your body.

Distribution is commonly seen:

• Scalp
• Elbows and knees
• Palms and soles of feet

We don’t know why people get psoriasis, but there is a genetic component- it is very common to see multiple members of a family with psoriasis. People with psoriasis are also at risk for developing other health conditions, like diabetes and heart disease. People usually develop psoriasis between the ages of 15 and 35 years old, but some develop it earlier or later than that.

Flare-ups are generally triggered by things like:

• Stress
• Certain Medications
• Cold, dry weather
• Infections (especially strep throat)

Types of Psoriasis:

Plaque Psoriasis

• The most common type of psoriasis, it appears as thick, red/silvery scaly patches of built up dead skin on the scalp, elbows, knees and/or lower back. Often these plaques are itchy or painful and can crack and bleed when irritated.

Guttate Psoriasis

• This type usually starts in childhood or young adulthood after a strep infection or other illness. Guttate means “raindrop” and these red scaly patches are smaller lesions than typically seen in plaque psoriasis. This is the second most common form of psoriasis.

Inverse Psoriasis

• Also known as flexural psoriasis, this type tends to not be as thick as other types and it is found as very red, shiny, smooth patches in body folds such as the armpits, behind the knees, under breasts or in the groin. It is not uncommon to have this type and another type simultaneously.

Pustular Psoriasis

• The whitish pustules surrounded by red skin of pustular psoriasis is not caused by an infection and it is not contagious, but many people fear it is because of how it looks. This type of psoriasis can occur anywhere on the body, but occurs most frequently on the palms and soles of the feet.

Erythrodermic Psoriasis

• This is a very severe and rare form of life-threatening psoriasis that requires immediate medical attention. It causes an extensive bright red rash over most of the body and can cause severe pain and itching and the skin can flake off in big sheets.

Nail Psoriasis

• Can be seen with any of the above-mentioned types of psoriasis, and rarely it is the first or only presenting sign of psoriasis on the body. Nails can have pitting or “oil marks,” yellow, greasy looking spots on the nails. Pustules from pustular psoriasis can also form under the nails. This is a very difficult form of psoriasis to treat and nail psoriasis is more commonly seen in those who develop psoriatic arthritis.

Treatment Options

There are many treatments for psoriasis and which treatment you need depends upon many factors. The location of your rashes as well as the total Body Surface Area (BSA) are two things to consider. Your medical history and skin type are also important; some treatments can increase your risk for skin cancer or other types of cancer. Your quality of daily life is also important to consider. If you only have minimal skin involvement, but it is on highly visible areas of your body and causing you significant stress to the point that it is keeping you from doing activities you love due to being self-conscious, then you may qualify for more aggressive treatments than simple BSA would dictate.

Topical steroids are first-line treatment for psoriasis and they come in many strengths and formulations- people with psoriasis tend to prefer the ointments over the creams for most body parts, but lotions, foams and liquids are also available. Depending on which areas of the body you are applying the medications, you may need a few different strengths or types of steroid to treat your psoriasis. It is important to note that you cannot use a topical steroid multiple times a day for many weeks at a time- this could lead to something called atrophy, or thinning of the skin. You will be given proper instructions on how to use these topicals at your appointment. There are also non-steroid anti-inflammatory creams to use for sensitive areas like the face or groin and they can help maintain the clearance achieved from the topical steroids. Topical Vitamin D3 can also help to maintain clearance.

Phototherapy, also considered a first-line treatment, can be helpful for treating psoriasis too. There are lasers that target specific smaller body areas or light boxes that treat the whole body at once. They both involve ultraviolet radiation though, and will increase your risk for developing skin cancer, so phototherapy is not recommended for everyone, such as people with very fair skin types or those who already have a history of skin cancer. Phototherapy also does not help to treat arthritis.

Oral medications can be used to treat both psoriasis and psoriatic arthritis. Methotrexate was one of the first drugs to be used and is still commonly used by rheumatologists to treat psoriasis. Sometimes dermatologists use it too, but there are much more effective drugs with fewer side effects now available. Sometimes people try to use oral steroids, like prednisone to treat psoriasis, but this is often not helpful because most people will experience a flare of their psoriasis when they stop the steroids. Prednisone also causes increased blood sugar levels and is not recommended for diabetics because of this. A very useful oral drug called Otezla has been on the market for several years now and does not have the same risk of liver damage that methotrexate has. It does have other potential side effects though, so it is important to discuss this medication with your dermatologist to see if you are a candidate.

Biologic injections are another systemic way to treat psoriasis and psoriatic arthritis. They are approved for use in moderate to severe psoriasis. If your body surface area is between 5-10 percent, then that is considered a moderate amount of psoriasis. 10 percent or higher is considered severe psoriasis. In the last ten years, the amount of available biologic drug treatment options for psoriasis has jumped from only two to eleven with more coming in the next year or two. Biologics target specific proteins in your body that are associated with causing psoriasis. These medications are used long term to keep your psoriasis and arthritis under control. Some people will still need to use topicals or phototherapy in addition to their biologics from time to time to treat the occasional flare-ups. If you believe you have moderate to severe psoriasis, then you should consult with your dermatology provider to determine if you are a candidate for these medications.