PSORASIS

Psoriasis is a long-lasting autoimmune disease characterized by patches of abnormal

skin. These skin patches are typically red, itchy, and scaly.Psoriasis varies in severity
from small, localized patches to complete body coverage. Injury to the skin can trigger
psoriatic skin changes at that spot, which is known as the Koebner phenomenon.

There are five main types of psoriasis: plaque, guttate, inverse, pustular, and
erythrodermic. Plaque psoriasis, also known as psoriasis vulgaris, makes up about 90
percent of cases. It typically presents as red patches with white scales on top.Areas of
the body most commonly affected are the back of the forearms, shins, navel area, and
scalp. Guttate psoriasis has drop-shaped lesions. Pustular psoriasis presents as small
non-infectious pus-filled blisters. Inverse psoriasis forms red patches in skin folds.
Erythrodermic psoriasis occurs when the rash becomes very widespread, and can
develop from any of the other types. Fingernails and toenails are affected in most
people with psoriasis at some point in time. This may include pits in the nails or changes
in nail color.

The symptoms of psoriasis include:

Areas of itchy, scaly skin on the scalp, knees, elbows, and upper body; these deep-
pink, raised plaques of skin have white scales.
Psoriasis on fingernails and toenails can make the nails become thick, pitted, and
discolored; nails may separate from underlying nail bed.
Red, scaly, cracked skin with tiny pustules on the palms of the hands and/or feet; you
may have pustular psoriasis.
Stiffness, pain, and tenderness of the joints
Reduced range of motion
Nail changes, such as pitting, which is found in up to 80% of people with psoriatic
arthritis
Causes
genetisc;
Around one-third of people with psoriasis report a family history of the diseasePsoriasis
has a strong hereditary component, and many genes are associated with it, but it is
unclear how those genes work together. Most of the identified genes relate to the
immune system, particularly the major histocompatibility complex (MHC) and T cells.
Lifestyle

Conditions reported as worsening the disease include chronic infections, stress, and
changes in season and climate. Others that might worsen the condition include hot
water, scratching psoriasis skin lesions, skin dryness, excessive alcohol consumption,
cigarette smoking, and obesity.
HIV

The rate of psoriasis in HIV-positive individuals is comparable to that of HIV-negative

individuals, however, psoriasis tends to be more severe in people infected with HIV. A
much higher rate of psoriatic arthritis occurs in HIV-positive individuals with psoriasis
than in those without the infection. The immune response in those infected with HIV is
typically characterized by cellular signals from Th2 subset of CD4+ helper T
cells,whereas the immune response in psoriasis vulgaris is characterized by a pattern of
cellular signals typical of Th1 subset of CD4+ helper T cells and Th17 helper T cells
Microbes

Psoriasis has been described as occurring after strep throat, and may be worsened by
skin or gut colonization with Staphylococcus aureus, Malassezia, and Candida albicans
Medications

Drug-induced psoriasis may occur with beta blockers,lithium, antimalarial medications,

non-steroidal anti-inflammatory drugs,terbinafine, calcium channel blockers, captopril,
glyburide, granulocyte colony-stimulating factor,interleukins, interferons,lipid-lowering
drugs, and paradoxically TNF inhibitors such as infliximab or adalimumab.Withdrawal of
corticosteroids (topical steroid cream) can aggravate psoriasis due to the rebound effect
The 5 Major Types of Psorias

Plaque Psoriasis
This is the most common type. About 8 in 10 people with psoriasis have this kind. You
may hear your doctor call it "psoriasis vulgaris."

Plaque psoriasis causes raised, inflamed, red skin covered with silvery, white scales.
These patches may itch and burn. It can appear anywhere on your body, but often pops
up in these areas:

Elbows
Knees
Scalp
Lower back

Guttate Psoriasis
This type often starts in children or young adults. It happens in less than 2% of cases.

Guttate psoriasis causes small, pink-red spots on your skin. They often appear on your:

Trunk
Upper arms
Thighs
Scalp

Triggers include:

Upper respiratory infection such as strep throat or tonsillitis

 Stress
Skin injury
Certain drugs such as beta-blockers
This type of psoriasis may go away within a few weeks, even without treatment. Some
cases, though, are more stubborn and require treatment .
Inverse Psoriasis
This type shows up as areas that are bright red, smooth, and shiny, but don't have
scales. It's usually found in these locations:

Armpits
Groin
Under the breasts
Skin folds around the genitals and buttocks

Inverse psoriasis may worsen with sweating and rubbing. A buildup of yeast may trigger
it.
Pustular Psoriasis

This kind of psoriasis is uncommon and mostly appears in adults. It causes pus-filled
bumps (pustules) surrounded by red skin. These may look infectious, but are not.

This type may show up on one area of your body, such as the hands and feet.
Sometimes it covers most of your body, which is called "generalized" pustular psoriasis.
When this happens it can be very serious, so get immediate medical attention.

Generalized pustular psoriasis can cause:

Fever
Chills
Nausea
Fast heart rate
Muscle weakness

Triggers include:

Topical medicine (ointments you put on your skin) or systemic medicine (drugs that
treat your whole body), especially steroids
Suddenly stopping systemic drugs or strong topical steroids that you used over a
large area of your body
Getting too much ultraviolet (UV) light without using sunscreen
Pregnancy
Infection
Stress
Exposure to certain chemicals
Erythrodermic Psoriasis
This type is the least common, but it's very serious. It affects most of your body and
causes widespread, fiery skin that appears burned. You might also have:

Severe itching, burning, or peeling

A faster heart rate
Changes in body temperature

If you have these symptoms, see your doctor right away. You may need to get treated in
a hospital. This type of psoriasis can cause severe illness from protein and fluid loss.
You may also develop an infection, pneumonia, or congestive heart failure.

Triggers include:

Suddenly stopping your systemic psoriasis treatment

An allergic drug reaction
Severe sunburn
Infection
Medications such as lithium, anti-malarial drugs, cortisone, or strong coal tar products

Erythrodermic psoriasis may also happen if your psoriasis is hard to control.

Nail Psoriasis
Up to half of those with psoriasis have nail changes. This is even more common in
people who have psoriatic arthritis, which affects your joints.

Common symptoms include:

Pitting of your nails

Tender, painful nails
Separation of the nail from the bed
Color changes (yellow-brown)
Chalk-like material under your nails

You're also more likely to also have a fungal infection .

Psoriatic Arthritis
This is a condition where you have both psoriasis and arthritis (joint inflammation). In
70% of cases, people have psoriasis for about 10 years before developing psoriatic
arthritis. About 90% of people with it also have nail changes. The most common
symptoms are:

Painful, stiff joints that are worse in the morning and after rest
Sausage-like swelling of the fingers and toes
Warm joints that may be discolored
Mechanism
Psoriasis is characterized by an abnormally excessive and rapid growth of the
epidermal layer of the skin.[44] Abnormal production of skin cells (especially during
wound repair) and an overabundance of skin cells result from the sequence of
pathological events in psoriasis.[17] Skin cells are replaced every 3–5 days in psoriasis
rather than the usual 28–30 days.[45] These changes are believed to stem from the
premature maturation of keratinocytes induced by an inflammatory cascade in the
dermis involving dendritic cells, macrophages, and T cells (three subtypes of white
blood cells).[11][36] These immune cells move from the dermis to the epidermis and
secrete inflammatory chemical signals (cytokines) such as interleukin-36γ, tumor
necrosis factor-α, interleukin-1β, interleukin-6, and interleukin-22.[29][46] These
secreted inflammatory signals are believed to stimulate keratinocytes to proliferate.[29]
One hypothesis is that psoriasis involves a defect in regulatory T cells, and in the
regulatory cytokine interleukin-10.[29]

Gene mutations of proteins involved in the skin's ability to function as a barrier have
been identified as markers of susceptibility for the development of psoriasis.[47][48]

DNA released from dying cells acts as an inflammatory stimulus in psoriasis[49] and
stimulates the receptors on certain dendritic cells, which in turn produce the cytokine
interferon-α.[49] In response to these chemical messages from dendritic cells and T
cells, keratinocytes also secrete cytokines such as interleukin-1, interleukin-6, and
tumor necrosis factor-α, which signal downstream inflammatory cells to arrive and
stimulate additional inflammation.[29]

Dendritic cells bridge the innate immune system and adaptive immune system. They
are increased in psoriatic lesions[44] and induce the proliferation of T cells and type 1
helper T cells (Th1). Targeted immunotherapy as well as psoralen and ultraviolet A
(PUVA) therapy can reduce the number of dendritic cells and favors a Th2 cell cytokine
secretion pattern over a Th1/Th17 cell cytokine profile.[29][38] Psoriatic T cells move
from the dermis into the epidermis and secrete interferon-γ and interleukin-17.
Interleukin-23 is known to induce the production of interleukin-17 and interleukin-22
Interleukin-22 works in combination with interleukin-17 to induce keratinocytes to
secrete neutrophil-attracting cytokines
diagnosis

A health care professional can usually diagnose psoriasis by carefully checking the skin
and asking the patient about signs and symptoms. There are no specific blood tests or
diagnostic procedures for psoriasis.
Physical exam and medical history. Your doctor usually can diagnose psoriasis by
taking your medical history and examining your skin, scalp and nails.
Skin biopsy. Rarely, your doctor may take a small sample of skin (biopsy). He or she will
likely first apply a local anesthetic. The sample is examined under a microscope to
determine the exact type of psoriasis and to rule out other disorders
inflammatory infiltrates can typically be visualized on microscopy when examining skin
tissue or joint tissue affected by psoriasis. Epidermal skin tissue affected by psoriatic
inflammation often has many CD8+ T cells while a predominance of CD4+ T cells
makes up the inflammatory infiltrates of the dermal layer of skin and the joints
Epidemiology

Psoriasis is estimated to affect 2–4% of the population of the western world.[8] The rate
of psoriasis varies according to age, region and ethnicity; a combination of
environmental and genetic factors is thought to be responsible for these differences.[8]
It can occur at any age, although it most commonly appears for the first time between
the ages of 15 and 25 years. Approximately one third of people with psoriasis report
being diagnosed before age 20.[103] Psoriasis affects both sexes equally.[55]
Psoriasis affects about 6.7 million Americans and occurs more frequently in adults
Management

While no cure is available for psoriasis,many treatment options exist. Topical agents are
typically used for mild disease, phototherapy for moderate disease, and systemic
agents for severe disease
Topical agents

Topical corticosteroid preparations are the most effective agents when used
continuously for 8 weeks; retinoids and coal tar were found to be of limited benefit and
may be no better than placebo
Vitamin D analogues such as paricalcitol were found to be superior to placebo.
Combination therapy with vitamin D and a corticosteroid was superior to either
treatment alone and vitamin D was found to be superior to coal tar for chronic plaque
psoriasis
moisturizers and emollients such as mineral oil, petroleum jelly, calcipotriol, and decubal
(an oil-in-water emollient) were found to increase the clearance of psoriatic plaques.
Emollients have been shown to be even more effective at clearing psoriatic plaques
when combined with phototherapy

The emollient salicylic acid is structurally similar to para-aminobenzoic acid (PABA),

commonly found in sunscreen, and is known to interfere with phototherapy in psoriasis.
Coconut oil, when used as an emollient in psoriasis, has been found to decrease plaque
clearance with phototherapy

Ointment and creams containing coal tar, dithranol, corticosteroids (i.e.

desoximetasone), fluocinonide, vitamin D3 analogs (for example, calcipotriol), and
retinoids are routinely used. The use of the finger tip unit may be helpful in guiding how
much topical treatment to use.

Vitamin D analogues may be useful with steroids; however, alone have a higher rate of
side effects.[69] They may allow less steroids to be used.[70]

Another topical therapy used to treat psoriasis is a form of balneotherapy, which

involves daily baths in the Dead Sea.
UV phototherapy

Phototherapy in the form of sunlight has long been used for psoriasis. UVB
Wavelengths of 311–313 nanometers are most effective, and special lamps have been
developed for this application. The exposure time should be controlled to avoid over
exposure and burning of the skin. The UVB lamps should have a timer that will turn off
the lamp when the time ends. The amount of light used is determined by a person's skin
type
Surgery

Limited evidence suggests removal of the tonsils may benefit people with chronic
plaque psoriasis, guttate psoriasis, and palmoplantar pustulosis
Diet

Uncontrolled studies have suggested that individuals with psoriasis or psoriatic arthritis
may benefit from a diet supplemented with fish oil rich in eicosapentaenoic acid (EPA)
and docosahexaenoic acid (DHA).[87] Diet recommendations include consumption of
cold water fish (preferably wild fish, not farmed) such as salmon, herring, and mackerel;
extra virgin olive oil; legumes; vegetables; fruits; and whole grains; and avoid
consumption of alcohol, red meat, and dairy products. The effect of consumption of
caffeine (including coffee, black tea, mate, and dark chocolate) remains to be
determined.
Treatment
Psoriasis treatments reduce inflammation and clear the skin. Treatments can be divided
into three main types: topical treatments, light therapy and systemic medications.
Topical treatments

Used alone, creams and ointments that you apply to your skin can effectively treat mild
to moderate psoriasis. When the disease is more severe, creams are likely to be
combined with oral medications or light therapy. Topical psoriasis treatments include:

Topical corticosteroids. These drugs are the most frequently prescribed medications
for treating mild to moderate psoriasis. They reduce inflammation and relieve itching
and may be used with other treatments.

Mild corticosteroid ointments are usually recommended for sensitive areas, such as
your face or skin folds, and for treating widespread patches of damaged skin.

Your doctor may prescribe stronger corticosteroid ointment for smaller, less sensitive
or tougher-to-treat areas.

Long-term use or overuse of strong corticosteroids can cause thinning of the skin.
Topical corticosteroids may stop working over time. It's usually best to use topical
corticosteroids as a short-term treatment during flares.
Vitamin D analogues. These synthetic forms of vitamin D slow skin cell growth.
Calcipotriene (Dovonex) is a prescription cream or solution containing a vitamin D
analogue that treats mild to moderate psoriasis along with other treatments.
Calcipotriene might irritate your skin. Calcitriol (Vectical) is expensive but may be
equally effective and possibly less irritating than calcipotriene.
Anthralin. This medication helps slow skin cell growth. Anthralin (Dritho-Scalp) can
also remove scales and make skin smoother. But anthralin can irritate skin, and it stains
almost anything it touches. It's usually applied for a short time and then washed off.

Topical retinoids. These are vitamin A derivatives that may decrease inflammation.
The most common side effect is skin irritation. These medications may also increase
sensitivity to sunlight, so while using the medication apply sunscreen before going
outdoors.

The risk of birth defects is far lower for topical retinoids than for oral retinoids. But
tazarotene (Tazorac, Avage) isn't recommended when you're pregnant or breast-
feeding or if you intend to become pregnant.

Calcineurin inhibitors. Calcineurin inhibitors — tacrolimus (Prograf) and pimecrolimus

(Elidel) — reduce inflammation and plaque buildup.

Calcineurin inhibitors are not recommended for long-term or continuous use because
of a potential increased risk of skin cancer and lymphoma. They may be especially
helpful in areas of thin skin, such as around the eyes, where steroid creams or retinoids
are too irritating or may cause harmful effects.
Salicylic acid. Available over-the-counter (nonprescription) and by prescription,
salicylic acid promotes sloughing of dead skin cells and reduces scaling. Sometimes it's
combined with other medications, such as topical corticosteroids or coal tar, to increase
its effectiveness. Salicylic acid is available in medicated shampoos and scalp solutions
to treat scalp psoriasis.

Coal tar. Derived from coal, coal tar reduces scaling, itching and inflammation. Coal
tar can irritate the skin. It's also messy, stains clothing and bedding, and has a strong
odor.

Coal tar is available in over-the-counter shampoos, creams and oils. It's also
available in higher concentrations by prescription. This treatment isn't recommended for
women who are pregnant or breast-feeding.
Moisturizers. Moisturizing creams alone won't heal psoriasis, but they can reduce
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.