How to recognize and treat psoriasis

What is psoriasis, what symptoms it manifests, how to diagnose and treat this disease, as well as how to prevent it from worsening - read in our article.

Psoriasis is a chronic skin disease in which the body is covered with plaques with silvery scales. These can be localized on the elbows, abdomen, back, head and other areas. In mild cases, the symptoms are almost invisible, but in severe cases, even the joints may be affected, leading sooner or later to disability.

Psoriasis has been described as far back as Ancient Egypt and Ancient Greece, but at that time it was not considered a distinct skin disease. In the Middle Ages, it was often confused with leprosy because of the external similarities, and such people were often isolated even from their families.

In the late 18th century, the dermatologist Robert Willan first identified psoriasis as a separate pathology, although the disease was not always easy to distinguish from eczema and syphilis. It was not until 1841 that the Austrian dermatologist Ferdinand von Hebra introduced the term 'psoriasis', which is still used today.

Dermatologists identify the following types of psoriasis:

• Chronic psoriasis vulgaris - the most common form, accounting for about 80% of all cases. Usually the outer surfaces of the knees and elbows are affected, as well as the scalp - the skin is covered with red plaques with clear edges and scales;
• guttate psoriasis - is rarer and usually starts in children and young people as an acute eruption with papules (pimples) and small plaques (less than 1 cm in diameter). Warning. In most cases, guttate psoriasis occurs after streptococcal strep throat;
• pustular psoriasis - is a severe form of the disease whose complications can be life-threatening. It is manifested by general malaise, fever, increased leukocyte count in the blood and decreased calcium levels, diarrhea, and in severe cases - liver and/or kidney damage, respiratory disorders and even sepsis;
• erythrodermic psoriasis - a rare form in which all (or a large part of) the skin turns red and begins to flake. Because of this, the skin barrier is damaged - electrolyte disturbances, dehydration and secondary infections (sepsis) can occur.

Three forms of psoriasis are also identified according to the localization of the plaques:

• intertriginous psoriasis, or inverse - affects the areas between the buttocks, under the breasts, groin and armpits. A characteristic feature of this form is the almost complete absence of scales, which means that it is often mistaken for a fungal or bacterial skin infection;
• nail psoriasis - damage to the nail plates may be the only symptom of the disease, but is usually accompanied by psoriatic arthritis;
• palmo-plantar psoriasis - painful cracks often appear on the skin of the palms and soles; the nails may also be affected.

Main causes of psoriasis

There is no single cause of psoriasis. The disease is not caused by viruses, bacteria or fungi, so none of its forms are contagious.

So why does psoriasis occur? It is a chronic skin disease in which keratinocytes (epidermal cells) overgrow and the epidermis and dermis itself become inflamed.

Psoriasis is not considered a classic autoimmune disease, but the immune system plays an important role in its development. It is the cells of the immune system (T lymphocytes, dendritic cells and cytokines) that cause the skin changes that "poison" the patient's life.

Factors that can trigger the development of the disease include:

• hereditary predisposition - 40% of people with psoriasis also have family members affected by the same disease. Psoriasis is also more common in monozygotic twins than in dizygotic twins;
• Genetic factors - there are certain genes that are responsible for "psoriasis susceptibility" (for example, PSORS1 or HLA-Cw6);
• infections - group A beta-hemolytic streptococcus (the causative agent of bacterial tonsillitis) or HIV often cause guttate psoriasis;
• unhealthy habits (alcohol and smoking) - these not only increase the risk of developing psoriasis, but also worsen the course of the disease;
• obesity - overweight people are more prone to psoriasis;
• certain medications - medicines for high blood pressure (beta-blockers), lithium, antimalarials and tetracyclines can cause psoriatic flare-ups or worsen the skin manifestations of existing psoriasis;
• vitamin D deficiency - it is not known exactly whether lack of vitamin D contributes to the development of the disease, but vitamin D deficiency is very commonly seen in people with psoriasis;
• stress - according to studies, there is no clear evidence of a link between stress and the onset of psoriasis in adults. However, dermatologists say that the disease often begins after severe psychological trauma or in the context of chronic stress.

Triggers for psoriasis also include injuries and sunburn.

Symptoms of psoriasis

The characteristic signs of psoriasis are plaques, which are clearly defined, red, scaly, scaly, clearly defined eruptions. They can be itchy (sometimes extremely itchy) and scaly, although asymptomatic disease progression is not uncommon.

Most often, psoriatic plaques are localized on the scalp and hands (on elbows), knees, sacral area, buttocks. The genitals, navel, skin of the eyebrows and armpits may also be affected.

The color of the plaques depends on the color of the skin: in dark-skinned people they are usually purple, while in fair-skinned people they are pink or red. However, the way the plaques are distributed and desquamate is independent of race.

If the plaques become too numerous, they coalesce, covering entire anatomical regions, thus causing distress to the patient - not only because of unpleasant sensations but also because of their unsightly appearance.

Psoriasis can be easily recognized in its early stages by the characteristic appearance of the plaques and their location. Doctors also identify two specific signs:

• Auspitz sign - the appearance of blood drops after the scales are removed from the plaque surface;
• the Köbner phenomenon - the appearance of plaques in places where the skin has been traumatized.

Nail tags in psoriasis take on a characteristic appearance - they become punctate and may become crumbly, and red spots appear on the lunula. If the disease affects the nail bed, the nails take on a yellowish-brown color, similar to motor oil. These changes are called the 'oil drop mark'. The nails also thicken (hyperkeratosis), deteriorate (onycholysis) and subungual bleeding may occur.

Often, nail psoriasis (unless accompanied by plaques on the body) is confused with onychomycosis - a fungal nail infection.

Psoriasis in children

Approximately 30% of people experience the first signs of psoriasis in childhood (adolescents are more affected than young children). In children, the disease often begins after a streptococcal or staphylococcal infection, chickenpox, Kawasaki disease, trauma or severe stress.

As in adults, psoriasis in children usually manifests as chronic psoriasis vulgaris - round plaques covered with fine, mica-like scales appear. However, one third of children develop guttate psoriasis.

The plaques are usually localized on the elbows and knees, although in infants they may cover the entire diaper area (this form is called "diaper psoriasis"). In addition, 4-5% of children may have the only symptom of the disease - damage to the face - scaly patches on the eyebrows, in the nasolabial folds and around the mouth.

In 75-80% of children, the patches are localized on the scalp, and this form is more common in girls. Doctors explain this phenomenon by Köbner's phenomenon - girls' scalp is more often traumatized by combing or intensive shampooing.

In children, "paradoxical psoriasis " may also occur - the appearance of characteristic plaques during treatment with biological tumor necrosis factor inhibitors.

Diagnosis of psoriasis

The diagnosis of 'psoriasis' is usually established during a clinical examination. The skin changes are so characteristic that diagnosis of the disease is not difficult.

However, in some cases, dermatologists may perform a biopsy of an affected area of the skin with staining of the tissue sample, as other skin diseases may be hidden under the mask of psoriasis:

• eczema;
• seborrheic dermatitis;
• lichen lichen chronicus, lichen roseatum or lichen planus;
• contact dermatitis;
• dermatophytosis;
• cutaneous lupus erythematosus;
• secondary syphilis.

Nail psoriasis can often resemble onychomycosis, so the nails are specially stained and examined for the presence of fungal infection.

Self-assessment of skin condition in psoriasis

Although the diagnosis of psoriasis can only be established by a doctor, it is very useful to monitor the condition of the skin on your own - this will allow early detection of worsening disease or disease progression and assessment of the effectiveness of treatment.

It is important to pay attention to the following indicators:

• the affected area;
• redness of the plaques (an indicator of the intensity of inflammation);
• flaking;
• itching and other unpleasant sensations;
• nail changes.

If the plaques spread all over the body, become inflamed, intensely itchy and the nails are affected - you should consult your doctor for adjustment of therapy.

How is psoriasis treated?

Psoriasis cannot be cured completely, therefore the question of how to relieve the symptoms of psoriasis remains topical in dermatology. Since psoriatic changes have a complex mechanism of development, physicians try to intervene with various means.

Modern and effective treatment of psoriasis includes:

• topical medication;
• phototherapy;
• systemic therapy.

Topical medication

Topical treatment can be effective in mild to moderate psoriasis vulgaris. Medications for external use include:

• corticosteroids (hormones) - in the form of creams or ointments, usually applied twice daily under occlusive dressings. In severe cases, hormones may be injected directly into the affected lesions. Warning. Systemic glucocorticoids (in tablets or injections/infusions) are not used in the treatment of psoriasis, as they may worsen the course of the disease or even cause a severe pustular form;
• vitamin D3 analogs - for example, ointments containing calcipotriol. These reduce keratinocyte proliferation. Doctors may prescribe calcipotriol as monotherapy or in combination with topical corticosteroids - 5 days a week the vitamin D analog is applied, and 2 days - calcipotriol + hormones;
• calcineurin inhibitors (tacrolimus or pimecrolimus) - not as effective as hormones, but have a lower risk of side effects;
• tazarotene - a topical retinoid with pronounced keratolytic action, often applied to the face. It is mainly prescribed for large psoriatic plaques;
• roflumilast - a phosphodiesterase-4 inhibitor, used in the gentle treatment of the face, anogenital area and axillae;
• salicylic acid - it softens scales and accelerates their exfoliation, especially on the scalp where they are denser;
• coal tar and anthralin - reduce inflammation and excessive keratinocyte proliferation. Their mechanism of action is still unknown.

Phototherapy

Until recently, phototherapy was the main method of treatment for psoriasis, but it is now less commonly used due to the accessibility of systemic methods.

The mechanism of action of phototherapy is not fully understood, but it is known that UV rays slow down DNA synthesis and moderately inhibit the immune system. The most commonly used is PUVA therapy: ingestion of the photosensitizer psoralen + exposure to long-term UV-A light. This combination significantly reduces skin cell proliferation.

One of the most modern phototherapy treatments is the use of the 308 nm excimer laser.

Systemic therapy

Systemic therapy is used when topical medications and phototherapy are not enough. The most commonly used drugs include:

• Methotrexate - effective in severe (disabling) psoriasis, but toxic to the body, requiring regular monitoring of liver and kidney function and blood tests;
• cyclosporine - usually used for several months because of the risk of side effects;
• mycophenolate mofetil - an alternative drug in case of ineffectiveness or intolerance to methotrexate/cyclosporine;
• systemic retinoids - used to treat severe and resistant forms of psoriasis vulgaris and pustular psoriasis. These drugs are effective, but highly teratogenic (some retinoids can cause fetal malformations even if pregnancy occurs 2-3 years after the end of therapy).

The newest methods of psoriasis treatment include the use of biologic drugs - therapeutic monoclonal antibodies

• TNF inhibitors (etanercept, adalimumab);
• Interleukin-23 inhibitors (risankizumab, guselkumab);
• interleukin-17 inhibitors (secukinumab, brodalumab).

The efficacy and safety of biologic drugs for the treatment of psoriasis and psoriatic arthritis are intensively studied in modern research.

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Natural treatments for psoriasis

Although herbal treatments for psoriasis (decoctions of celeriac and burdock, infusions of horsetail, birch tar) are very popular, they cannot replace traditional therapy and are much less effective. Incorrect application of these remedies can even worsen the skin condition, causing irritation and exacerbating the disease.

Psoriasis and diet

A proper diet does not cure psoriasis, but can prevent the disease from worsening. Dermatologists recommend following the Pagano diet:

• avoiding semi-processed products, refined sugars, red meat, alcohol;
• eating more fish, healthy fats, vegetables, fruit and greens.

Skin care

Proper skin care influences the course of the disease and the frequency of relapses.

In psoriasis, moisturizers are extremely effective - emollients. These are creams and ointments containing vaseline, paraffin and hydrogenated vegetable oils.

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Applying emollients to the skin twice a day and after bathing (hand washing) significantly reduces flaking.

Emollients have almost no side-effects (allergic reactions can rarely occur) and are very effective in relieving the symptoms of mild to moderate psoriasis.

It is also important to follow a few simple rules:

• Moderate sun exposure is beneficial for psoriasis, as UV rays slow the proliferation of keratinocytes, but excessive sun exposure can cause skin cancer, so sunscreen creams are necessary;
• avoid soaps and shampoos, body gels high in colorants and perfumes;
• bathing should be in cool or lukewarm water - hot water dries the skin;
• although thick scales damage the appearance, they should be removed carefully - for example, after applying an emollient or salicylic acid product.

How to prevent psoriasis relapsing?

There are no effective ways to prevent psoriasis, but relapses can be avoided.

Firstly, it is important to avoid stress, and if this is impossible - learn how to cope with it. Relaxation methods such as yoga, meditation, deep breathing or even regular walks outdoors, watching your favorite movies and reading can help.

It is also important to watch out for triggers. It is known that a streptococcal infection can cause a recurrence of psoriasis, so in case of a sore throat, consult your GP or an ENT specialist.

It is very important to protect the skin from mechanical damage - any trauma can trigger the Köbner reaction, and so plaques can multiply considerably. Remember to protect your hands during sport or when working with sharp objects.

Psoriasis "loves" dry skin, so in addition to moisturizing creams, it's a good idea to buy room air humidifiers - they're particularly useful in winter.

The importance of a complex approach to treating psoriasis

Psoriasis is a disease with many causes; its development can be caused by many different factors. For this reason, it is important to adopt a complex approach to the treatment of this condition - only in this way can all the links in the pathological process be influenced. Also, the response to treatment is different for everyone: some people find emollients sufficient, while others need to use phototherapy and methotrexate.

Fortunately, modern methods of treating psoriasis are quite effective - if you follow your doctor's recommendations strictly, most patients manage to cope with the unpleasant symptoms of the disease.