Psoriasis: Symptoms and Treatments

Psoriasis is a common autoimmune disease that primarily affects the skin. The National Psoriasis Foundation reports that more than 8 million Americans and "125 million people worldwide -- 2 to 3 percent of the total population -- have psoriasis."

Dr. Vanessa Johnson, a dermatologist with Health First Medical Group in Viera, Florida, says that about 2 percent of adults in the U.S. are dealing with psoriasis. And although psoriasis can occur at any time, it tends to develop in people between the ages of 15 and 25. Older adults are not immune to developing the condition, and likewise, the Psoriasis Foundation reports that about 10 to 15 percent of patients are diagnosed prior to age 10. Your race may also impact your risk. Johnson says about 3.6 percent of Caucasians have psoriasis compared to about 2 percent of African Americans and 1.6 percent of Hispanics. It's believed that genetics are involved with the development of psoriasis, so if a close relative such as a parent, sibling or child has psoriasis, that makes you more likely to develop it, too.

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What Causes Psoriasis?

As with other autoimmune diseases, psoriasis begins as a misdirection of the immune system against your own healthy cells. The immune system is designed to protect the body from foreign invaders such as bacteria and viruses, but sometimes it gets confused and begins attacking your own cells.

In psoriasis, cytokines -- proteins generated by the immune system -- trigger excess inflammation in the skin and sometimes the joints. This causes skin cells to grow faster. In normal skin, it takes 23 to 30 days for skin cells growing deep in the skin to slowly rise to the surface. For individuals with psoriasis, the process happens in just a few days. "Elevated cytokines cause the skin to get red and the body to make new skin cells in days rather than weeks. This results in a build-up of thick, red and scaly skin," Johnson says. Those thick plaques can cause pain and itching, and may be unsightly and cause much embarrassment and discomfort.

What Are the Symptoms of Psoriasis?

Especially early on, the symptoms of psoriasis can be similar to those of other skin conditions, such as an allergy or eczema. Therefore, if you develop a rash or itchy patches of skin that persist for more than a few days, it's important to visit your doctor for evaluation. You'll likely be referred to a dermatologist for more specialized treatment.

Your doctor may be able to make a diagnosis based on a physical exam, because the red, scaly patches of skin called plaques that develop from an overgrowth of skin cells tend to be such a recognizable, hallmark symptom of psoriasis. These plaques may look like a rash in the beginning, and tend to develop around the elbows, knees, legs, scalp, lower back, face, palms and the soles of the feet. Symptoms usually worsen over time as more skin cells build up and plaques can develop most anywhere on the body. Other symptoms may include:

-- Very dry skin that cracks or bleeds.

-- Pain and itching or burning of the skin around the patches.

-- Fingernails or toenails that are thick and ridged, pitted, discolored or crumbly.

-- Warm, swollen and painful joints.

Severity of symptoms can vary from patient to patient, but in the most severe cases the plaques will cover more skin and may crack or bleed. Symptoms may worsen in the winter with drier air making skin itchier and more likely to crack or bleed.

How Is Psoriasis Treated?

Although psoriasis is an incurable, chronic disease, there are ways to manage and treat it, and the options have recently expanded as medical science advances in understanding how the disease works. "Because we have these new tools and treatments for psoriasis, the treatment can be tailored to the individual patient's needs, considering them as a whole person, with their other medical conditions in mind," Johnson says.

Depending on the type and severity of your psoriasis, there are now many effective treatments available to you. But any treatment choice depends on the type and severity of your individual case. About 80 to 90 percent of all cases of psoriasis are plaque psoriasis, but there are several other varieties of the skin condition that have somewhat different manifestations and appearances. Guttate psoriasis is the second most common type, accounting for about 10 percent of cases. Guttate means "drop" in Latin, and Dr. Jessica Kaffenberger, assistant professor of dermatology at The Ohio State University Wexner Medical Center in Columbus, says this type of psoriasis "looks as though you took the plaques from plaque psoriasis and shrank them down. They're tiny little spots of psoriasis," that can occur most anywhere on the body. This form of psoriasis is typically triggered by a bacterial infection such as strep.

Other types of psoriasis include:

-- Pustular psoriasis, which presents as pus-filled blisters on top of red, painful patches of skin.

-- Erythrodermic psoriasis, the least common but the most debilitating form of psoriasis that presents as a red, peeling painful rash over the entire body.

-- Palmoplantar psoriasis, which affects the hands and feet causing itchiness, pain and peeling on the palms and soles.

-- Inverse psoriasis, which features smooth, red patches of inflamed skin in folds of skin such as under the breasts, along the groin, behind the knees and in the armpits.

-- Scalp psoriasis, a form of plaque psoriasis that affects the scalp.

-- Nail psoriasis, which causes discoloration and abnormal nail growth in the fingernails and toenails.

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The National Psoriasis Foundation defines psoriasis severity by the percentage of skin affected. Mild psoriasis affects less than 3 percent of the skin. Moderate psoriasis affects 3 percent to 10 percent of the skin. Severe psoriasis involves more than 10 percent of the skin. For easy reference, a person's hand represents approximately 1 percent of the skin surface, so Kaffenberger notes that if your psoriasis covers "10 handprints worth of skin or more, that's 10 percent or more of the body," which would mean your case is severe. In those instances, "we think about more aggressive therapies," which may include a combination of medications or treatment approaches. These treatments may include:

-- Topical corticosteroids. These are used to reduce inflammation of the skin and are often administered as creams, sprays or ointments spread on the skin. For moderate or mild cases, "we usually start with topical steroids," Kaffenberger says.

-- Other topical medications. Such medications may include a synthetic form of vitamin D -- examples include calcipotriene (Dovonex) or calcitriol (Vectical) -- to slow cell growth. Salicylic acid, coal tar, calcineurin inhibitors and vitamin A derivatives can also decrease inflammation and encourage peeling to reduce the buildup of skin cells.

-- Phototherapy. Some forms of psoriasis may also be effectively treated using phototherapy, a form of light therapy that directs UVB rays to penetrate the skin and slow the growth of skin cells, Kaffenberger says. Phototherapy is not the same as visiting a tanning salon or simply sitting out in the sun. Dr. Howard Bruce Pride, a dermatologist with Geisinger in Danville, Pennsylvania, says "it's a really spectacularly safe treatment," because it uses only a very narrow spectrum of light that does not age the skin or elevate risk for skin cancer. "For many people it's very effective," particularly in treating large swaths of skin. The downside is that traditionally, patients have needed to go to the doctor's office a few times a week for these treatments, but in-home light therapy equipment is making it a more convenient option for some patients.

-- Systemic medications. Since the 1970s, systemic drugs like methotrexate, originally used to treat cancer, have been helpful in controlling symptoms of psoriasis. This drug is less expensive than some of the newer treatments, but may have worse side effects.

-- Biologics. This powerful new class of drugs is helping many patients live more comfortable lives with clearer skin and fewer psoriasis flare-ups. Examples of these drugs include adalimumab (Humira), etanercept (Enbrel) and infliximab (Remicade). They are often used to treat more severe cases of psoriasis, and may be delivered via injection or IV drip as infrequently as once every three months. These drugs "can completely clear people of a condition which can be such a burden for some patients," Johnson says. "It is amazing to see people who were once covered in psoriasis, embarrassed to put on a swimsuit or roll their sleeves up, now have completely clear skin with four injections per year."

-- Moisturizers. The Mayo Clinic reports that while moisturizing creams and lotions "won't heal psoriasis," they can be helpful in reducing "itching, scaling and dryness. Moisturizers in an ointment base are usually more effective than are lighter creams and lotions. Apply immediately after a bath or shower to lock in moisture."

In addition, if you're experiencing emotional or mental health consequences of psoriasis, you may also want to seek psychological support. A mental health provider may be able to use cognitive behavioral therapy (a form of talk therapy that helps patients change thought patterns and develop better coping strategies) or medications to alleviate depression and anxiety associated with psoriasis. You may also want to find a support group, as talking with other people dealing with the same condition can help you feel less alone.

Why Is It Important to Seek Treatment for Psoriasis?

Most cases of psoriasis are considered mild, but they can progress, and certain stressors and triggers can lead to worsening symptoms. Because psoriasis is linked with inflammation, it can affect much more than just the skin. "Patients with psoriasis are at much higher risk of heart disease," and other autoimmune and systemic conditions, Kaffenberger says. These conditions may include:

-- Metabolic syndrome, which includes heart disease, stroke and Type 2 diabetes. It often begins with elevated cholesterol levels and blood pressure.

-- Arthritis, which features pain, stiffness and swelling of the joints. About 30 percent of people with psoriasis go on the develop psoriatic arthritis.

-- Inflammatory bowel syndrome, which features inflammation and sores or ulcers in the digestive tract.

-- Depression, resulting from social stigmatization or body image issues related to the hallmark plaques on the skin.

-- Thyroid disease, or problems with the way the thyroid produces certain hormones.

-- Kidney disease from increased inflammation taking a toll on the kidneys.

While there is no cure for psoriasis, treatment focuses on managing, minimizing or eliminating symptoms. While symptoms may go away, they often reappear at a later time. These flare-ups may require additional treatment. Keeping a journal about when your symptoms worsen may help you better track your disease and understand which triggers are problematic for you.

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What Else Can I Do to Improve My Psoriasis?

Symptoms of psoriasis can be debilitating and disruptive to daily life. Therefore, it's important to follow your doctor's orders regarding management and treatment. Other things you can do to manage your disease include:

-- Improving your diet. Although evidence is limited, some patients have found that adding more turmeric -- a bright orange spice found in Indian cuisine -- can help reduce inflammation and symptoms. Fish oil supplements have also been found in some studies to reduce inflammation, but talk to your doctor before adding any drug or supplements to your diet, even those that are available over-the-counter.

-- Reducing your body weight. "Psoriasis can improve with weight loss," Kaffenberger says, and she counsels her overweight or obese patients to drop some pounds in order to better control the condition. Adipose, or fat tissue, is metabolically active and can elevate inflammation throughout the body, so dropping some weight can help tamp down inflammation in the body.

-- Avoiding tobacco products. Smoking plays a role in the onset of psoriasis and future flare-ups, Kaffenberger notes, and roughly 90 percent of patients with palmoplantar psoriasis are smokers, so it's believed that smoking cigarettes may trigger the development of psoriasis or worsen symptoms in some people.

-- Reducing your alcohol intake. Alcohol can have an inflammatory effect in the body and may increase flare-ups. It can also interfere with certain medications, causing them to become less effective.

-- Controlling other medical conditions. Because psoriasis can affect so many other body systems and organs, it's important to stay on top of routine health care. Particularly if you have diabetes, heart disease, high blood pressure or high cholesterol levels, you need to follow your doctor's advice for managing those conditions to prevent them from getting worse and making your psoriasis worse or leading to other health problems.

-- Knowing it's not just about clear skin. Lastly, it's important to remember that psoriasis is more than a cosmetic issue. If left untreated, it can lead to serious medical complications.