Psoriasis is a dermatological disease that has been mismanaged for centuries before its mechanism was well understood and effective medications were introduced. There are 5 main subtypes of psoriasis depending on how they look which are: guttate, plaque, pustular, inverse and erythrodermic psoriasis. The mechanism responsible for the formation of psoriasis has been proven to be autoimmune with a significant genetic component, and this is why it commonly runs in families. This genetic defect causes an increased rate of division of skin cells called keratinocytes which aren’t given enough time to mature resulting in the characteristic appearance of silver scales over red areas. The red is the inflammation and the scales are the shed immature skin cells.
Psoriasis is a chronic condition that has no ultimate cure with most modern therapies aiming at causing a remission and abating symptoms. Psoriasis clinical research is advancing rapidly, however, and I won’t be surprised if we could find an ultimate cure within our lifetimes.
How to treat psoriasis?
Since psoriasis is an autoimmune mediated skin condition, most medications given tend to suppress that autoimmune reaction, decrease inflammation as well as reduce the complications known to occur. Psoriasis can be managed by a combination of different classes of medications in some cases to achieve optimal results.
Psoriasis treatment also depends on the morphological type of the disease which can require different classes of drugs in some cases. The loss of the skin function can be severe since the skin is an important barrier between our internal and external environment and many complications can result from such disruption especially in case of pustular, generalized and guttate psoriasis. Plaque and scalp psoriasis are usually mild and most patients don’t present with the lesions but can be discovered accidently.
Home and natural remedies
Although most natural remedies for skin conditions advertised nowadays aren’t effective, in some cases they can provide optimal results especially in less severe cases. In mild psoriasis, many natural compounds or even sun exposure can be effective. Most of those treatments center around preventing the most annoying itchiness and irritation associated with psoriasis. Among the commonly used therapies are:
- Petrolatum jelly: Known for its anti-irritant properties, it can be useful to decrease the itchiness of psoriasis.
- Sun exposure: Sun exposure is arguable considered the best natural remedy for psoriasis. The ultraviolet radiation found in sunlight slows the rate of division of the immature skin cells. Excessive exposure to sunlight should, however, be avoided especially in people with complexions liable to sunburn since sunburn can aggravate psoriasis.
- Tar: Many tar preparations are present for individual use. Tar acts on psoriasis by different mechanisms such as reducing irritation, moisturizing the skin with removal of scales and slowing the rate of division of skin cells. The effect of tar is also magnified when used in conjunction with other treatments especially topical ones.
- Sea salt: You might have heard about people visiting Egypt or Jordan for natural remedies for psoriasis. This is done through bathing in seas with high salt content such as the dead sea. Salt can reduce itchiness and limit the inflammatory process of psoriasis. The salts of the Dead Sea can also penetrate deep into the skin offering long term relief for itchiness and dryness of the skin felt in psoriasis.
- Omega-3 fatty acids: Omega 3 fatty acids are unsaturated fats that are prescribed for many ailments including cardiovascular ones. They don’t cause atherosclerosis and can reduce triglyceride levels. They also boast anti-inflammatory properties that can benefit patients with psoriasis reduce itchiness and inflammation. They also provide lubrication for the skin.
- Losing weight: Some studies have suggested that patients who lose weight have experienced improved symptoms and less plaques.
- Mediterranean diet: Although specific dietary changes didn’t show satisfactory results in clinical trials, patients who shifted to Mediterranean diets have shown improved symptoms. This can be due to the increased content of unsaturated fats or vitamin D.
- Oatmeal baths: Oatmeal baths are a natural remedy that helps with itchiness and irritation.
- Avoiding skin trauma: Psoriasis may exhibit a phenomenon called Kobner’s which means that lesions tend to appear in sites which are damaged either physically or chemically, so patients are instructed to avoid activities which can cause skin damage.
Medications used in psoriasis
Although natural remedies show significant improvement in a large number of cases and that they are used almost always with any other treatment, they are not enough in advanced cases and further medical therapy is needed. Common medical therapy used includes:
1) PUVA therapy:
PUVA stands for Psoralen therapy with ultraviolet B radiation. Psoralen is a chemical substance ingested by the patient before ultraviolet therapy to concentrate ultraviolet radiation at the site of skin lesions. Ultraviolet therapy is considered as one of the most effective methods of controlling skin manifestations. It induces remission of the disease through acting on the cells that directly cause the mechanism of it. It does come with side effects though and excessive exposure to ultraviolet radiation especially in people with fair skin increases the risk of developing skin cancer. Narrow band ultraviolet radiation can also be used without psoralen.
2) Topical steroids:
Topical corticosteroid therapy is considered the gold standard for most psoriasis cases. Steroids have many immunosuppressive properties and being applied topically makes its side effects fewer.
3) Methotrexate:
Methotrexate is perhaps the most potent medication in the management of psoriasis. It is also an immunosuppressant drug that is used in many autoimmune diseases like rheumatoid arthritis. It acts through decreasing the rate of division of skin cells as well as white blood cells responsible for the condition. It can be given as injections -preferably- or orally. It is, however, only used in patients with severe psoriasis whose condition can’t be controlled by other medications since it comes with its fair share of side effects including severe nausea and vomiting if it is administered orally. It also has a profound effect on the liver, and therefore, alcohol should be restricted during the duration of therapy and regular liver function tests are done.
Methotrexate can also cause fetal damage, so women should be instructed to use effective contraception during the duration of therapy and 6 months afterwards. It can also affect sperms and males and they should also use effective contraception methods for at least 3 months after terminating therapy as well.
4) Vitamin D:
Vitamin D analogues like calcitriol and calcipotriene are used in some cases which show resistance to topical therapies and are usually used with other medications. Vitamin D controls the rate of division of skin cells.
5) Retinoids:
Retinoids are a class of drugs that include tazarotene. They are used in the management of conditions like acne, some types of skin cancers and some inflammatory conditions like psoriasis. It helps reduce the rate of division of skin cells, reduce inflammation and decreases skin thickness. Retinoids in general can be given topically in the form of a cream or systemically as pills or injections.
Topical medications are the ones usually used in psoriasis and they tend to have fewer side effects than those given systemically. They are, however, also contraindicated in pregnancy and effective contraception is a must during therapy. The most common side effects with retinoids include skin reactions in the form of redness and scaling.
6) Cyclosporine:
Cyclosporine is a potent immunosuppressant which acts on a receptor called calcineurin and causes immunosuppression of both types of immunity. As can be expected such dramatic response in psoriasis is also coupled with profound immunosuppression which puts the body at the mercy of countless bacteria and viruses. This is why cyclosporine is not used continuously but rather as pulse therapy to achieve quick response in some cases that fail to respond to other medications. It can be used in combination with other therapies and withdrawn later.
7) Infliximab:
Infliximab is considered from a class of drug called biologic agents and is an antibody that targets an inflammatory molecule called tumor necrosis factor alpha. Infliximab is used in severe conditions when traditional therapy proves ineffective. It is also especially effective in patients with psoriatic arthritis.
Treatment of ocular psoriasis
Psoriasis can also target the eye especially the conjunctiva, but many other parts may be affected like the cornea and the eyelids. The management of ocular psoriasis is challenging and despite the clear understanding of the disease, ocular involvement can still cause complications even with therapy. Common therapies available include local corticosteroids and artificial tears for the associated eye dryness. Systemic therapy can also be effective to a limit.
Nail psoriasis
Nail psoriasis can occur in up to half the cases of diagnosed systemic psoriasis, but it can still occur in patients with no other sites of affection on the skin. It is, however, mostly seen in patients with psoriatic arthritis and it usually indicates severe arthritis. Manifestations vary in severity, but most cases present with one of the following:
- Pitting of the nails
- Nail destruction
- White nail
- Transverse ridges of the nail
- Thickening of the nail bed
Nail psoriasis has to be differentiated from other dermatological conditions that cause a similar picture. They include lichen planus, fungal infection of the nail and alopecia. If the doctor can’t be certain, then they might order a nail biopsy to confirm the diagnosis.
The treatment of nail psoriasis can be medical, surgical or more frequently a combination of both depending on the condition and the number of nails affected. Common medications used in nail psoriasis are:
- Topical corticosteroids
- PUVA therapy, which is as effective in nail psoriasis as in skin lesions.
- 5-fluorouracil: Despite being a primarily anti-cancer medication, it proves effective in many cases of nail psoriasis not responding to topical steroids especially those with nail bed thickening.
Surgical therapy is not always needed but can be resorted to as a last attempt when other methods prove ineffective and the discomfort is unbearable. The nail can be removed physically under local anesthesia or by using chemical compounds like urea. Surgical removal carries the risk of nongrowth of the nail again or the growth of a deformed nail.
Scalp psoriasis
The scalp is formed of skin just like the one covering our entire body surface and therefore can be affected by psoriasis. It shows the same shape of reddish plaques with silver scales, but being in the scalp, they can be mistaken for other similar conditions like dandruff and seborrheic dermatitis, and can also be concealed by the thick hair.
The management of scalp psoriasis is quite similar to other skin lesions and includes the use of shampoos and lotions containing tar and salicylic acid, topical steroids, retinoids and vitamin D preparations. Unlike many other scalp conditions, scalp psoriasis does not cause permanent hair loss and any hair loss associated with it can result from other conditions like stress which may have triggered psoriasis in the first place.