What is psoriasis?

Psoriasis is a chronic skin disorder that produces thick, pink to red, itchy areas of skin covered with white or silvery scales.

The rash usually occurs on the scalp, elbows, knees, lower back and genitals, but it can appear anywhere. It can also affect the fingernails.

Psoriasis usually begins in early adulthood, but it can start later in life. The rash can heal and come back throughout a person’s life.

Psoriasis is not contagious and does not spread from person to person. In most people, the rash is limited to a few patches of skin.

In severe cases, it can cover large areas of the body.

How does the rash start?

Psoriasis starts as small red bumps that grow in size, on top of which scale forms. These surface scales shed easily, but scales below them stick together.

When scratched, the lower scales may tear away from the skin, causing pinpoint bleeding. As the rash grows larger, “plaque” lesions can form.

What are the symptoms of psoriasis?

As well as the symptoms described above, the rash can be associated with:

Itching

Dry and cracked skin

Scaly scalp

Skin pain

Pitted, cracked, or crumbly nails

Joint pain

What are less common forms of psoriasis?

nverse psoriasis Psoriasis found in skin folds. This form may present as thin pink plaques without scale.

Guttate psoriasis Small, red, drop-shaped, scaly spots in children and young adults that often appear after a sore throat caused by a streptococcal infection.

Pustular psoriasis Small, pus-filled bumps appear on the usual red patches or plaques.

Sebopsoriasis Typically located on the face and scalp; this form is made of red bumps and plaques with a greasy yellow scale. This is an overlap between psoriasis and seborrheic dermatitis.

How can I know if I have psoriasis?

If you have a skin rash that does not go away, contact your healthcare provider. He or she can look at the rash to see if it is psoriasis or another skin condition.

A small sample of skin may be taken to view under a microscope.

What causes psoriasis?

The cause of psoriasis is unknown. The condition tends to run in families, so it may be passed on to children by parents.

Psoriasis is related to a problem of new skin cells developing too quickly. Normally, skin cells are replaced every 28 to 30 days.

In psoriasis, new cells grow and move to the surface of the skin every three to four days. The build-up of old cells being replaced by new cells creates the hallmark silvery scales of psoriasis.

What causes psoriasis outbreaks?

No one knows what causes psoriasis outbreaks. How serious and how often outbreaks happen with each person. Outbreaks may be triggered by:

Skin injury (for example, cuts, scrapes or surgery)

Emotional stress

Cold, cloudy weather

Streptococcal and other infections

Certain prescription medicines (for example, lithium and certain beta

blockers)

How is psoriasis treated?

Your healthcare provider will select a treatment plan depending on the seriousness of the rash, where it is on your body, your age, health, and other factors.

For a limited disease affecting only a few areas on the skin, topical creams or ointments may be all that is needed. When larger areas are involved or joint pain indicating arthritis is suspected, additional therapy may be needed.

Common treatments include:

Steroid creams

Moisturizers (to relieve dry skin)

Anthralin (a medicine that slows skin cell production)

Coal tar (common for scalp psoriasis; may also be used with light therapy for severe cases; available in lotions, shampoos and bath solutions)

Vitamin D3 ointment

Vitamin A or “retinoid” creams. Vitamin A in foods and vitamin pills has no effect on psoriasis.

Treatment for severe cases:

Light therapy (ultraviolet light at specific wavelengths decreases inflammation in the skin and helps to slow the production of skin cells)

PUVA (treatment that combines a medicine called “psoralen” with exposure to a special form of ultraviolet light)

Methotrexate (a medicine taken by the mouth; methotrexate can cause liver disease, so its use is limited to severe cases and is carefully watched with blood tests and sometimes liver biopsies)

Retinoids (a special form of Vitamin A-related drugs, retinoids can cause serious side effects, including birth defects)

Cyclosporine (a very effective capsule reserved for severe psoriasis because it can cause high blood pressure and damage to kidneys).

Newer drugs for treating psoriasis include injectable immune “biologic” therapies as well as small molecule immune-modulating pills. They work by blocking the body’s immune system from “kickstarting” an autoimmune disease such as psoriasis. These include anti-TNF agents like Enbrel, Humira and secukinumab (cosentyx) and ustekinumab.

Can psoriasis be cured?

Psoriasis cannot be cured, but treatment greatly reduces symptoms, even in severe cases. Tips for improving psoriasis in addition to prescription medicines:

Use moisturizer.

Avoid using harsh soaps.

Apply oil or moisturizer after bathing.

Use tar or salicylic acid shampoo for scale on the scalp.

What is psoriatic arthritis?

Psoriatic arthritis is a form of inflammatory arthritis.

Up to 30 per cent of people with psoriasis can develop psoriatic arthritis.

Both psoriasis and psoriatic arthritis are chronic autoimmune diseases – meaning conditions in which certain cells of the body attack other cells and tissues of the body.

Psoriasis is most commonly seen as raised red patches or skin lesions covered with a silvery white build-up of dead skin cells, called a scale.

Scales can occur on any part of the body. Psoriasis is not contagious – you cannot get psoriasis from being near someone with this condition or from touching psoriatic scales.

There are five different types of psoriatic arthritis. The types differ by the joints involved, ranging from only affecting the hands or spine areas to a severe deforming type called arthritis mutilans.

Like psoriasis, psoriatic arthritis symptoms flare and subside, vary from person to person, and even change locations in the same person over time.

How is psoriatic arthritis diagnosed?

There is no single test to diagnose psoriatic arthritis. Doctors make the diagnosis based on a patient’s medical history, physical exam, blood tests, laboratory tests and MRIs and/or Xrays of the affected joints.

X-rays are not usually helpful in making a diagnosis in the early stages of the disease.

In the later stages, X-rays may show changes that are more commonly seen only in psoriatic arthritis.

The diagnosis of psoriatic arthritis is easier for your doctor to confirm if psoriasis exists along with symptoms of arthritis.

However, in as many as 15% of patients, symptoms of psoriatic arthritis appear before symptoms of psoriasis.

Since the disease symptoms can vary from patient to patient, it is even more important to meet with your doctor when symptoms worsen, or new symptoms appear.

What are the symptoms of psoriatic arthritis?

The symptoms of psoriatic arthritis may be gradual and subtle in some patients; in others, they may be sudden and dramatic.

The most common symptoms – and you may not have all of these of psoriatic arthritis are:

Discomfort, stiffness, pain, throbbing, swelling, or tenderness in one or more joints

Reduced range of motion in joints

Joint stiffness and fatigue in the morning

Tenderness, pain, or swelling where tendons and ligaments attach to the bone (enthesitis); example: Achilles’Achilles’ tendonitis

Inflammation of the eye (such as iritis)

Silver or grey scaly spots on the scalp, elbows, knees, and/or the lower spine

Inflammation or stiffness in the lower back, wrists, knees or ankles

Swelling in the distal joints (small joints in the fingers and toes closest to the nail), giving these joints a sausage-like appearance

Pitting (small depressions) of the nails Detachment or lifting of fingernails or toenails

Other tests supportive for the diagnosis

Positive testing for elevated sedimentation rate (indicates the presence of inflammation)

Positive testing for elevated C reactive protein (indicates the presence of acute inflammation)

A negative test for rheumatoid factor and anti-CCP( performed to rule out rheumatoid arthritis)

Anaemia a state in which there is a decrease in haemoglobin

Who is at risk for psoriatic arthritis?

Psoriatic arthritis occurs most commonly in adults between the ages of 30 and 50; however, it can develop at any age.

Psoriatic arthritis affects men and women equally.

Up to 40% of people with psoriatic arthritis have a family history of skin or joint disease.

Children of parents with psoriasis are three times more likely to have psoriasis and are at greater risk for developing psoriatic arthritis than children born of parents without psoriasis.

If you do have psoriasis, let your doctor know if you are having joint pain. In as many as 85% of cases, skin disease occurs before the joint disease.

What causes psoriatic arthritis?

The cause of psoriatic arthritis is unknown. Researchers suspect that it develops from a combination of genetic (heredity) and environmental factors.

They also think that immune system problems, infection, and physical trauma play a role in determining who will develop the disorder.

Psoriasis itself is not an infectious condition.

Recent research has shown that people with psoriatic arthritis have an increased level of tumour necrosis factor (TNF) in their joints and affected skin areas. These increased levels can overwhelm the immune system, making it unable to control the inflammation associated with psoriatic arthritis.

The approach to treatment

Early diagnosis and treatment can relieve pain and inflammation and help prevent progressive joint involvement and damage.

Without treatment, psoriatic arthritis can potentially be disabling and crippling.

The type of treatment will depend on how severe your symptoms are at the time of diagnosis. Some early indicators of more severe disease include onset at a young age, multiple joint involvement, and spinal involvement.

Good control of the skin may be valuable in the management of psoriatic arthritis.

In many cases, you may be seen by two different types of doctors – a rheumatologist and a dermatologist.

What are the treatment options for psoriatic arthritis?

The aim of treatment for psoriatic arthritis is to relieve symptoms. Treatment may include any combination of the following:

Choice of medications depends on disease severity, the number of joints involved, and associated skin symptoms.

During the early stages of the disease, mild inflammation may respond to nonsteroidal anti-inflammatory drugs (NSAIDs).

Cortisone injections may be used to treat ongoing inflammation in a single joint.

However, oral steroids, if used to treat psoriatic arthritis, can worsen the skin rash due to psoriasis worse.

DMARDs are used when NSAIDs fail to work and in patients with erosive disease.

DMARDs that are effective in treating psoriatic arthritis include methotrexate, sulfasalazine, cyclosporine, leflunomide and biologic agents. Sometimes combinations of these drugs may be used together.

The anti-malarial drug usually is avoided as it can cause a flare of psoriasis. Azathioprine may help those with severe forms of psoriatic arthritis.

The biologic agents are among the most exciting drug treatments. Both DMARDS and Biologics not only do these drugs reduce the signs and symptoms of psoriatic arthritis, but they also slow down joint damage.

Enbrel (etanercept)

Humira (adalimumab)

Remicade (inflixamab)

Simponi (golimumab)

Stelara (ustekinumab)

Secukinumab(cosentyx)

Newer agents like tofacitinib also reduce psoriasis and psoriatic arthritis.

Other non-medicine therapies

Exercise: Moderate, regular exercise may relieve joint stiffness and pain caused by the swelling seen with psoriatic arthritis. Range of motion and strengthening exercises specifically for you combined with low impact aerobics may be helpful.

Improper exercise programs may make psoriatic arthritis worse. Before beginning any new exercise program, discuss exercise options with a doctor.

Heat and cold therapy

Heat and cold therapy involve switching the use of moist heat and cold therapy on affected joints. Moist heat supplied by a warm towel, hot pack, or warm bath or shower helps relax aching muscles and relieve joint pain, swelling, and soreness. Cold therapy supplied by a bag of ice can reduce swelling and relieve pain by numbing the affected joints.

Joint protection and energy conservation

Daily activities should be performed in ways that reduce excess stress and fatigue on joints. Proper body mechanics (the way you position your body during a physical task) may protect not only joints but also conserve energy. People with psoriatic arthritis are encouraged to frequently change body position at work, at home, and during leisure activities. Maintaining good posture standing up straight, and not arching your back is helpful for preserving function.

Does surgery have a role?

Surgery: Most people with psoriatic arthritis will never need surgery. However, severely damaged joints may require joint replacement surgery

The goal of surgery is to restore function, relieve pain, improve movement, or improve the physical appearance of the affected area.

Broader health impact of psoriatic arthritis

The impact of psoriatic arthritis depends on the joints involved and the severity of symptoms. Fatigue and anaemia are common.

Some psoriatic arthritis patients also experience mood changes. Treating arthritis and reducing the levels of inflammation helps with these problems.

People with psoriasis are slightly more likely to develop high blood pressure, high cholesterol, obesity or diabetes.

Maintaining a healthy weight and treating high blood pressure and cholesterol are also important aspects of treatment. There is no cure for psoriatic arthritis.

Once you understand the disease and learn to predict the ways in which your body responds to the disease, you can use exercise and therapy to alleviate discomfort and reduce stress and fatigue.

Mental exercises, as well as sharing your experiences with family, a counsellor, or a support group, may help you cope with the emotional stress related to changes in physical appearance and disability associated with the disorder