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Specific Forms of Psoriasis
The National Psoriasis Foundation (NPF) welcomes your requests for more information and looks forward to providing you with support. We offer an extensive selection of educational booklets, two newsletters, individualized assistance and an interactive Web site. We are capable of putting you in touch with others who share your concerns through our Web site and Pen Pal Club. Please contact us when we can be of assistance. 6600 SW 92nd Avenue, Suite 300 Portland, OR 97223-7195 USA Tel: 503-244-7404 or (800) 723-9166 Fax: 503-245-0626 E-Mail: email@example.com Web Site: www.psoriasis.org The NPF was founded and continues to be directed by people who have psoriasis and their family and friends. The NPF works to improve the quality of life for people who have psoriasis and psoriatic arthritis. The NPF depends on donations from the public to advance its mission of educating the public about psoriasis and advancing psoriasis research. Membership is a yearly donation of any amount. NATIONAL PSORIASIS FOUNDATION® Psoriasis Research is published as an educational service and is not intended to replace the counsel of a physician. The NPF advises you to consult a physician before initiating any treatment. The NPF does not endorse any medications, products or treatment of psoriasis. Mission Statement Our mission is to improve the quality of life of people who have psoriasis and psoriatic arthritis.Through education and advocacy, we promote awareness and understanding, ensure access to treatment, and support research that will lead to effective management and, ultimately, a cure.
soriasis is a chronic, noncontagious skin disease that can occur on any part of the body, including the face. Psoriasis sometimes appears on the eyelids, ears, mouth and lips, as well as on skin folds, the hands and feet, and nails. The type of skin at each of these sites is different and requires different treatments. For example, the skin on the face is very different from the thicker, rougher skin of the elbow. In addition, psoriasis can vary widely among individuals and in its response to treatment. Effective treatments are available, however. This booklet discusses the complexities associated with psoriasis when it occurs on specific skin sites, the range of available treatments, and any risks or side effects that may be involved.
Psoriasis on the face
In diagnosing facial psoriasis, your physician will examine your lesions and take a personal and family history. Facial psoriasis most often affects the eyebrows, the skin between the nose and upper lip, the upper forehead and the hairline. A biopsy may be warranted to differentiate psoriasis from other skin diseases, but its diagnosis can usually be made without biopsy. Facial psoriasis may respond initially to non-irritating moisturizers and petroleum jelly. Intermittent use of mild topical steroids may also be effective. Other treatments include calcipotriene (a topical vitamin D3 derivative, sold under the brand name Dovonex), tazarotene (a topical vitamin A derivative, sold as Tazorac®), keratolytic products (scale removers) and ultraviolet light. Dovonex and Tazorac can be irritating, so their use should be guided by a physician. In December 2000, the FDA approved a new drug called tacrolimus (brand name Protopic) for eczema, but many dermatologists have also found it works well for treating psoriasis on the face or other sensitive areas. Medication used to treat facial psoriasis should be applied carefully and thinly; creams and ointments can irritate the eyes, and large amounts offer no additional benefits. Because facial skin is delicate, prolonged use of steroids may cause it to become thin, shiny and/or prone to enlarged capillaries (“spider veins”). Treatment with stronger steroids can be safe if a careful treatment schedule is followed. In a study of 20 patients with moderate to severe psoriasis on the face and intertriginous areas (under the breasts, the groin, skin folds), limited application of fluticasone propionate ointment 0.005% twice per week proved effective for patients without damaging the skin.
Psoriasis on the eyelids
When psoriasis affects the eyelids, lashes may become covered with scales, and lid margins may be red and crusty. If inflamed for long periods, the rims of the lids may turn up or down. If the Psoriasis on the eyelids rim turns down, lashes can rub against the eyeball and cause irritation. Treating eyelid inflammation involves a regimen of washing the lid margins and eyelashes with a solution of water and baby shampoo. Cotton tip applicators or washcloths are
2003 National Psoriasis Foundation
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blisters and swelling. In some cases. is also effective for some people. Psoriasis of the eye Psoriasis of the eye is extremely rare. secrete a discharge. Removing local irritants. Over time. with an antifungal agent. Whether ultraviolet light is appropriate is based on an assessment by your physician. The eardrum is easily damaged. Topical steroids or. can occur in the armpits. mild soaps and soap substitutes. improving hygiene and rinsing frequently with a saline solution can relieve oral discomfort. Also. alternating a moderate-strength steroid. This type of psoriasis first shows up as smooth. Tiny bumps may develop and. the tongue. However. psoriasis lesions appear on the gums. Psoriasis in skin folds Flexural psoriasis. your doctor will carefully supervise the treatment because eyelid skin can be easily damaged. a product originally produced to soften cows’ udders. A small 1992 study published in the Journal of the American Academy of Dermatology suggests that it is possible to deliver incremental ultraviolet light treatments. impaction of scale already present from psoriasis can occur if medication prescribed for the skin on the ear gets inside the ear canal. which is the reason doctors suggest having your intraocular pressure checked regularly by an ophthalmologist.org Psoriasis on Specific Skin Sites . or covered with any type of dressing. inside the cheek. Dovonex or Tazorac may cause irritation when used alone and may be best used in combination with a topical steroid. flares are accompanied by fissures. inside the nose or on the lips. under the breasts and in other skin folds around the genitals and buttocks. such as Nizoral. dry lesions that are very red. however. Emollients without corticosteroids may then be applied. Psoriasis on the hands and feet Acute flares of psoriasis on the hands and feet need to be treated promptly and carefully. such as betamethasone. Low-potency steroids 2 National Psoriasis Foundation® www. These may provide temporary relief. Pustular psoriasis on palm of hand General treatments include the use of emol. Because of the sensitivity of skin folds. Steroid creams and ointments are considered very effective in treating inverse psoriasis. Dovonex. The most common type of interior eye involvement is conjunctivitis. For the most part. we suggest consulting an ophthalmologist. it can cause inflammation. preferably by a physician. The lesions are usually white to gray. Inverse psoInverse psoriasis in the armpit riasis is particularly subject to irritation from rubbing and sweating due to its location in skin folds and tender areas. glaucoma and/or cataracts may develop. overthe-counter ear-cleaning kits that involve squirting small amounts of fluid into the ear and letting it drain may be used. For a severe episode of inverse psoriasis. in rare instances. the efficacy as well as the irritation of these agents may increase. can help soften skin. When it does occur. Conjunctivitis also can result in eye dryness. Topical antibiotics are used to treat infection. Prescription steroid solutions can be dripped into the ear canal or applied to the outside portion of the ear canal. such as 1% to 2% hydrocortisone with anti-yeast or antifungal agents. a condition in which the mucous membrane lining of the eyelids—the conjunctiva—becomes irritated and the vessels become dilated. if steroids get in your eyes. Eyelids must be kept closed during phototherapy. Prescription examples of these are Vioform-Hydrocortisone cream or a combination of one of the broad spectrum of imidazol creams (clotrimazole or miconazole) with 1% to 2% hydrocortisone. potent steroids may be used to treat your eyelids. if infected. They also should not be occluded. Tazorac and Protopic may also be used in these areas. In some cases. If so. Protopic ointment does not cause glaucoma and is effective on eyelids. Because these areas are prone to fungal infections. in combination with soothing baths may be helpful. psoriasis treatments for the mouth and nose involve the use of topical steroids that have been designed to treat moist areas. groin. followed by a thin layer of mineral oil applied with a cotton swab. and may impair vision. Psoriasis in the ears Scale buildup that blocks the ear canal and is bothersome should be removed. dryness and discomfort. Care should be taken when inserting anything rigid into the ear. to eyelid skin to achieve clearing of psoriasis. superficial skin fissures In and around the mouth and nose For a very small number of people.The use of Protopic for eyelid psoriasis helps avoid the potential side effects of topical steroids. Because conjunctivitis may or may not be due to psoriasis. or inverse psoriasis. but can sting the first few days of use. a special ophthalmic steroid medication may be used to treat scaling. physicians sometimes use diluted topical steroids in combination with other medications. such as hydrocortisone 1% ointment may be useful in treating psoriasis on the lips. Some people have reported in the “It Works for Me” column in the NPF Bulletin that Bag Balm.(above) and foot (below) lients. Topical steroids should be used with caution because skin folds are more susceptible to thinning of the skin.useful for scrubbing the lids. Plain warm water. Others have helped non-bleeding.psoriasis. or phototherapy.
thinning of nail plates. it is difficult to treat. Plaque psoriasis can appear elsewhere on the body.separation of the nail from the nail bed • discoloration . alternating the use of Tazorac and a topical steroid may be effective. Dovonex may be prescribed. methotrexate. steroid impregnated tape (Cordran). Antibiotics are occasionally prescribed with varying results. Soriatane may make the psoriasis less resistant to topical therapy. In some places.methotrexate.shallow or deep holes in the nail • deformation . oral retinoids. such as Soriatane. the pustules are dried to a brownish crust.alterations in the normal shape of the nail • onycholysis . The nail problems most commonly experienced by Nail pitting due to psoriasis psoriasis patients are: • pitting . cyclosporine (Neoral) or acitretin (Soriatane). The major treatments for nails are: • topical treatment . Systemic therapies taken by mouth or injection for palm and sole psoriasis can be very beneficial but have potential side effects. Cyclosporine is similarly effective for palm and sole psoriasis but is limited by kidney side effects. where the nail is formed. such as hair loss. can be helpful. The combination of retinoids with PUVA.Dovonex. The matrix.injection of steroids such as triamcinolone acetonide into each affected nail. the lesions are painful and disabling. headaches. are dramatically helpful for pustular psoriasis. combined with exposure to ultraviolet light (UVA). your physician may recommend PUVA. The pain of the injections must be weighed along with the possibility of the relief being only temporary. Occlusion with Tazorac is not normally recommended but could be tried for palm/sole lesions. Methotrexate can clear most cases of palm and sole psoriasis within four weeks. But oral retinoids have numerous potential side effects. or wrapping the affected area in plastic wrap or cloth. Because of the latter side effect. Warm water soaks with oilated oatmeal powder or bath oil for 20 to 30 minutes. corticosteroids. Tazorac. at the same time. some topical medications may be used with occlusion. By thinning out the thick scale build up on the palm or sole. dry. This intensifies the effect of the cream or ointment. The lesions are most prominent on the palm toward the base of the thumb. • photochemotherapy . a product by Zila Pharmaceuticals.org Psoriasis on Specific Skin Sites . 5-fluorouracil. PUVA. or special occlusive foot covers can be used on the feet. Injections of steroids into the nail bed or matrix area have been used with varying results. Soaking the hands or feet in warm water can reduce swelling. the fleshy part of the palm toward the ring and little fingers and on the soles and sides of the heels. Cotton or plastic gloves can be worn over creams or moisturizers on the hands and socks. These drugs have dried lesions on the palms and soles within days Psoriasis of the nails Nail changes in psoriasis occur in up to 50 percent of people with psoriasis and at least 80 percent of people with psoriatic arthritis. A regimen combining Dovonex and superpotent topical steroids may be beneficial. nausea. However. retinoids and methotrexate may have to be used in order to clear this form. such as the face or body folds. but should be followed by an application of medications or emollients. is one of the most effective treatments available for palm and sole psoriasis. such as Soriatane. It may be necessary to find additional ways to reduce the thickness of the built-up layers of skin in order for medications and phototherapy to be effective. which can be taken orally or appplied topically. Normally. PUVA involves the use of a light-sensitizing drug called psoralen. When directed by a physician. is difficult to penetrate with topical medications. followed by a gentle scraping of the affected skin with a sponge or Buf Puf.” Elmer’s Wonder Bond Glue or Dermaflex.unusual nail coloration. Soriatane should not be taken by women planning a pregnancy within three years. Traditional topical therapy of palm and sole psoriasis includes tars. cyclosporine (injected or taken by mouth) and other systemic medications rarely are used solely for nail psoriasis. will result in thinning of the plaques over a period of days or weeks. Many medical schools and a number of private dermatologists’ offices have them. as well.PUVA (applied as “paint” or taken by mouth to increase sensitivity to light). topical treatments such as steroids and coal tar are tried first. If topical medications do not work. Often. called RePUVA. For people with scaling plaques of the palms and soles. Special palm/sole units have been designed to treat psoriasis on the hands and feet. salicylic acid and steroids. cracked lips and birth defects. • intralesional . Oral retinoids. Pustular psoriasis of the palms and soles This form of psoriasis is characterized by red plaques with scaling and pustules up to a quarter inch in size. • systemic treatment .heal by closing them up with “super glue. The risk of side effects can be reduced by combining low doses of retinoids with UVB or PUVA. such as yellowbrown Nail treatments Because psoriasis affects the nail in the formative stage.psoriasis. cotton gloves should be worn to prevent transfer of the medication to sensitive skin sites. Try occlusion while you sleep or for an hour or two before going to bed. Combinations of these three agents may be superior to each of the individual components. 3 National Psoriasis Foundation® www. however.
Long. Loose nails continue to be subjected to strain as they rub against surfaces.• cosmetic repair . Rule out any sensitivity reactions before using artifi- 4 National Psoriasis Foundation® www. and using good clippers to cut off a small piece at a time. Be gentle when using instruments for cleaning under the nails. a fungal infection that causes thickening of the nails.nails deformed by psoriasis may be removed surgically or with a strong urea compound. gently filing the thickened part of the toenail with an emery board. About one-third of people who have nail psoriasis also have a fungal infection that could actually be triggering psoriasis or making the psoriasis worse. such as cyclosporine. some patients’ nails were wrapped (occluded) with a plastic film after the medication was applied. If your nails are substantially intact. application of a nail hardener or artificial nails can improve their appearance. and pitted nails can be buffed and polished. Be aware that a manicurist may be reluctant to apply the nails to badly eroded fingernails. Systemic medications for psoriasis also may improve nail psoriasis. generalized psoriasis.Vigorous cleaning and scraping under the nails may break the skin where the nail is attached. When it does. One way to do this is to wear gloves while you are working with your hands. the nail improvement may lag behind clearance of psoriatic plaques on the body by several months. When people have severe. In the study. Color changes can be covered with nail polish. for example. Soaking your nails can help. In some instances. but usually result in the formation of very thin nails that are not normal in appearance. A variety of tar bath oils and moisturizers are available at local pharmacies. cial nails. However. Onychomycosis. It is important to protect your nails from damage because trauma will often trigger or worsen nail psoriasis. it usually accompanies an improvement in skin lesions. Toenails can be improved by soaking the feet for 10 minutes in a tub of warm water. Occasionally.psoriasis. It can be treated with systemic antifungal agents. nail psoriasis improves by itself. sensitivity reactions to glues and chemicals may be a problem. The nail changes caused by retinoids resolve several months after retinoids are discontinued. the nails should be trimmed back to the point of firm attachment with manicure scissors. If a person’s condition requires methotrexate. may be present with nail psoriasis. artificial nails may be warranted. Nail care In most cases. Similar results may be expected from other systemic psoriasis therapies that are dramatically effective. Try three capfuls of tar bath oil in a bowl of warm water. Soak your fingers for 20 minutes and then rub moisturizer into each nail. randomized study of Tazorac gel in the treatment of nail psoriasis found that once daily applications of the medication can significantly reduce separation of the nail from the nail bed (in occluded and non-occluded nails) and pitting (in occluded nails). The aim is to cut straight across the toenail to help keep it from becoming ingrown. nails may improve. Wearing roomy shoes leaves room for the toes and helps avoid the friction that can cause toenails to thicken.org Psoriasis on Specific Skin Sites . further loosening the base of attachment. thick nails can be scraped and filed down. As with systemic therapy. the nail treatment is determined by the treatments they are already receiving for other parts of the body. nails are likely to improve. A double-blind. In people whose psoriasis is sufficiently severe that treatment with PUVA is warranted. Systemic retinoids such as Soriatane can be beneficial for skin lesions of psoriasis.
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