Psoriasis: forms and methods of treatment

Psoriasis in a nutshell: what is it?

Psoriasis is an inflammatory skin disease that affects both men and women. And although the onset of the disease generally occurs at age 33, psoriasis can affect infants, children, adolescents, and the elderly.

Psoriasis is characterized by a genetic predisposition. Psoriasis is also susceptible to other factors, such as environmental triggers. The first reaction is a skin inflammatory response, which causes, among other things, a rapid and abnormal turnover of keratinocytes (the cells that make up the epidermis). Thus, renewal of the epidermis, which usually takes 28 days, occurs within 5–7 days. This recurrent phenomenon leads to the appearance of red plates (spots) that flake off with white scales, which can be called dandruff. These plaques can appear in various parts of the body, most commonly on the elbows, knees and scalp. It is important to remember that psoriasis is not contagious: it is based on a genetic and immunological component, which, under the influence of environmental factors, contributes to the onset of the disease.

Forms of psoriasis

Plaque psoriasis: the most common form of the disease, accounting for about 80% of cases. Its characteristic clinical manifestation is the presence of reddish spots that rise above the rest of the skin surface and are covered on top with a large number of silvery-white scales.

Localization: scalp, elbows, knees and lower back.

Guttate psoriasis: It occurs in 10% of cases and usually affects children and adolescents. The skin elements in appearance resemble small drops of red or purple color, which usually appear after or as a result of a streptococcal infection.

Localization: limbs and torso.

Pustular psoriasis: manifests itself as a generalized and local rash on the palms and soles. There are no microorganisms in the contents of the pustules. First, erythema appears on the skin, and then small superficial painful and itchy pustules. As the disease progresses, the lesions merge, the epidermis peels off, creating erosions covered with pus. This type of disease occurs in less than 1% of cases.

Localization: palms and soles; much less commonly, pustular psoriasis can be generalized, with a wide distribution of pustules over the entire surface of the body.

Psoriasis of the folds (intertriginous) is more common in children or elderly people with diabetes mellitus. The rashes are red, clearly defined, have a smooth, moist surface, with cracks deep in the folds.

Localization: armpits, submammary folds, perineum, navel and other natural folds of the human body.

Psoriatic erythroderma: characterized by the appearance of red patches on the skin and increased local and systemic temperature. Initially, areas of erythema are localized independently of papules and plaques, but subsequently they merge, covering the entire skin. In this case, there is dryness, peeling and itching of the skin, as well as an enlargement of all lymph nodes (lymphadenopathy). This form of the disease is usually accompanied by fever, chills and requires immediate hospitalization.

Treatment methods

Psoriasis is a disease from which it is currently impossible to completely recover, just like, for example, diabetes. But it is a disease whose outbreaks can be successfully controlled.

The procedures are aimed at combating inflammation and accelerated renewal of keratinocytes, and at “whitening” the plates. Meanwhile, the patient receives “beautiful” skin, itching, pain and persistent peeling of the plates are eliminated. There are different types of treatment, which are often related to each other as complementary.

Local treatment

In addition to good skin hydration, the local treatment acts directly on the plates. These so-called "attacks" in treatment can relieve itching as well as support ongoing exfoliation of the plates.

Topical corticosteroids are available in several dosage forms: not only ointments and creams, but also lotions, gels, shampoos and foams suitable for each affected area. They act quickly, especially on inflammation and itching. However, such treatment should be limited in time. The treated area of skin should not be too wide. Abruptly stopping essential steroids may be accompanied by a “rebound effect” (it is important not to cause a relapse), which implies a gradual reduction in the frequency of use of the drug.

Vitamin D derivatives are useful in maintenance therapy already started by topical corticosteroids - this way the therapeutic effect is prolonged. They sometimes irritate delicate areas of the skin.

Topical retinoids are little used because they often cause irritation.

Phototherapy and PUVA therapy

It is known that adequately dosed sunbathing can reduce the manifestations of psoriasis in almost 90% of cases. To imitate this effect, phototherapy and photochemotherapy (PUVA therapy: the use of UVA radiation in combination with psoralen) are used. The number of PUVA therapy sessions is calculated individually for each patient. This treatment provides significant improvement in the affected areas in just two months, provided the therapy is completed 2-3 times a week.

The advantage of narrowband phototherapy (UVB) is that it does not require taking psoralen. This treatment lasts 1.5–2 months, 2–3 sessions per week, and allows the plates to whiten after 4–6 weeks of use. It is currently the most widely used therapy.

Regardless of therapy, sessions should be limited to 150 to 200 over a lifetime to prevent skin cancer in the long term.

Systemic treatment (oral or injection)

Systemic treatment is prescribed for moderate to severe degrees of psoriasis. Systemic drugs fight inflammation, which underlies psoriasis and causes proliferation of keratinocytes.

Retinoids (acitretin) are more effective for treating psoriatic erythroderma or pustular psoriasis than plaque psoriasis. Acitretin has been used successfully in combination with other treatments, especially phototherapy.

Oral cyclosporine is a powerful immunosuppressant that has a pronounced effect on the immune system. Immunosuppressants are traditionally prescribed to patients who have undergone organ transplantation. In much smaller doses, this drug is an effective treatment for psoriasis. But its use must be controlled and limited in time due to its toxicity to the kidneys and many medical contraindications.

Methotrexate is the basic drug for the systemic treatment of psoriasis. This drug has been used for a long time, is inexpensive and is very useful for moderate to severe forms of psoriasis with or without joint damage. It is taken weekly either orally or by subcutaneous injection. It is a cytostatic, a derivative of folic acid, which inhibits cell division. The main problem with long-term treatment with methotrexate is that after accumulation in the body, this drug can cause irreversible changes in the liver, so it is necessary to regularly conduct blood tests and examine the patient. Another common side effect of methotrexate is gastrointestinal disturbances, which are alleviated by concomitant administration of folic acid.

Immunobiological therapy: anti-TNF or anti-IL-12/IL-23 are innovations in the treatment of psoriasis. This new class of drugs, administered by infusion or subcutaneous injection, is a big step forward for patients with psoriasis refractory to systemic therapy. These drugs have a special feature: their goal is to treat the inflammatory molecule. The release of new biological products is expected in the near future.

Balneotherapy: water-based treatment that includes natural thermal springs, mineral or sea waters. It is recommended to prescribe a course of balneotherapy: for three weeks, annually for three years. Away from the stress and bustle of everyday life, the disease recedes.

Stop, myths!

Now let's go through the most common statements about psoriasis and see how true they are.

Psoriasis is associated with tension and psychological problems. Myth. Psoriasis is not a psychological disease. It usually appears after strong emotions (positive or negative), but they are not the cause of its appearance.

Psoriasis is contagious . Myth. The disease cannot be transmitted through touch, clothing or physical contact. Its origin is multifactorial (genetic component, immunology...).

Psoriasis can be inherited. Fact. In 40% of cases, several family members suffer from psoriasis. If one parent is sick, the child's risk of getting the disease ranges from 5-10%.

A person can suffer from psoriatic arthritis without skin psoriasis. Fact. This occurs in rare cases; psoriatic arthritis precedes the appearance of skin psoriasis.

Sun (in moderation) is effective against the disease. Fact. 90% of patients who receive short but regular sun exposure (with sunscreen) notice a reduction in the psoriasis crisis. But you need to keep an eye on your tan because overexposure to the sun can worsen symptoms.

Psoriasis affects only the outer areas of the skin. Myth. Current research shows that advanced psoriasis is associated with cardiovascular risk factors such as obesity, dyslipidemia, diabetes mellitus...

Therefore, comprehensive patient support is necessary, and it should not be limited to skin care!

First published: Les Nouvelles Esthetiques Ukraine, No. 5 (87), 2014, pp. 98-102