Psoriasis Treatment

What is Psoriasis?

Psoriasis is an inflammatory skin condition that leads to the development of scaly plaques on the extensor regions of the body – posterior neck, elbows, lower back, knees, and posterior ankles.  The cosmetic appearance of psoriasis can lead to self-consciousness and psychological problems in some patients.

Patients with severe cases may have diffuse body involvement.  Sometimes flare-up in these patients is so severe that they require hospitalization at a burn center.  Psoriasis is also closely associated with cardiovascular disease – it is considered an independent predictor of coronary artery disease besides common risk factors such as smoking, hypertension, and diabetes.

Due to the importance of this condition, it is critical that patients understand its causes, symptoms, and treatment.  By the end of this article, you will have the answers to these essential questions

What causes Psoriasis?

Psoriasis is an inflammatory skin disorder that is likely caused by a combination of genetic and environmental factors.  The most common risk factors for psoriasis include:

  • Family history
  • Smoking
  • Obesity
  • Infections – HIV
  • Alcohol use
  • Vitamin D deficiency

How common is Psoriasis?

Psoriasis is a relatively common skin disorder and often presents to primary care clinics.  Severe cases typically require referral to a dermatology specialist.

The prevalence of psoriasis in adults is approximately 1%-8%.  The prevalence in children is about 0%-2%.  The farther you are away from the equator, the higher the prevalence of psoriasis.  There are two peaks of age for the development of psoriasis – age 30-40 and age 50-70.  The incidence of psoriasis appears to be rising.

What are the symptoms and signs of Psoriasis?

Psoriasis typically presents with a classic silvery, scaly rash in the extension regions of the body such as the back of the head, neck, elbows, knees, low back, posterior ankles.  The rash can be cosmetically displeasing and can result in self-consciousness or social embarrassment. The rash can occasionally be itchy and painful.  There are various other appearances and forms of psoriasis including guttate psoriasis, pustular psoriasis, and erythrodermic psoriasis.

The lesions may bleed and can become superinfection with bacteria – resulting in cellulitis.  Patients with cellulitis generally have spreading redness, warmth, pain, swelling, and fever.  Patients with severe psoriasis may have a diffuse rash involving the whole body.  They patients are often managed as burn patients and often requires specialty care with a plastic surgeon and dermatologist.

Psoriatic arthritis is characterized by psoriasis in addition to these features:

  • Sausage digits – swollen fingers and toes
  • Low back pain – sacroiliitis
  • Pitting of fingernails

Joint pain is typically worse in the first hour of waking and improves throughout the day.  Joints often become red, swollen, and tender.

How is Psoriasis diagnosed?

The diagnosis of psoriasis is based on the classic appearance of silvery, scaly, erythematous plaques on the extensor regions of the body.  Some patients with psoriasis have a condition called psoriatic arthritis.  These patients typically develop inflammation in the fingers and low back – a type of arthritis called ankylosing spondylitis.  In atypical cases, you doctor may refer you to a dermatologist for definitive diagnosis with skin biopsy.

Patients with widespread skin involvement or systemic symptoms or signs often warrant blood tests such as a CMP (comprehensive metabolic panel), CBC (complete blood cell count), and inflammatory markers (ESR/CRP).  They will also usually check your cholesterol levels and screen for diabetes due to increased cardiovascular risk.

How is Psoriasis treated?

Mild cases of psoriasis are typically treated with phototherapy and topical corticosteroid creams or ointments such as:

  • Cortizone (hydrocortisone)
  • Kenalog (triamcinolone)
  • Temovate (clobetasol)

Alternatives to topical corticosteroids may include topical tar, retinoids (tazarotene), and vitamin D.  Topical tacrolimus or pimecrolimus may also be considered for use on the face or intertriginous areas.

Systemic agents such as retinoids, methotrexate, and cyclosporine are sometimes considered.

Biologic agents are a new class of medications that may be beneficial.  The most commonly prescribed agents include:

  • Humira (adalimumab)
  • Enbrel (etanercept)
  • Remicade (infliximab)

Patients often benefit from the use of emollients over the skin such as Aquaphor.  These topical moisturizers help promote tissue healing.

Patients with bacterial coinfection resulting in cellulitis typically require treatment with oral antibiotics.  Commonly prescribed antimicrobial therapy for cellulitis includes:

Cellulitis is treated with various antibiotics which most often include:

  • Keflex (cephalexin)
  • Augmentin (amoxicillin-clavulanate)
  • Ancef (cephazolin)
  • Tetracycline (doxycycline)
  • Bactrim (trimethoprim-sulfamethoxazole)
  • Clindamycin

Severe cases of cellulitis may require intravenous antibiotics such as Vancomycin and Zosyn (piperacillin-tazobactam).

Psoriasis Patient Summary:

  • Psoriasis is an inflammatory skin condition that leads to the development of scaly plaques on the extensor regions of the body – posterior neck, elbows, knees, and posterior ankles.
  • The cosmetic appearance of psoriasis can also lead to self-consciousness and psychological problems in some patients.
  • The most common risk factors for psoriasis include: family history, smoking, obesity, infections, alcohol use, and vitamin D deficiency.
  • The diagnosis of psoriasis is based on the classic appearance of silvery, scaly, erythematous plaques on the extensor regions of the body.
  • Some patients with psoriasis have a condition called psoriatic arthritis. These patients typically develop inflammation in the fingers and low back – a type of arthritis called ankylosing spondylitis.
  • In atypical cases, you doctor may refer you to a dermatologist for definitive diagnosis with a skin biopsy.
  • Mild cases of psoriasis are typically treated with phototherapy and topical corticosteroid creams or ointments such as: Cortizone (hydrocortisone), Kenalog (triamcinolone), and Temovate (clobetasol).
  • Alternatives to topical corticosteroids may include topical tar, retinoids (tazarotene), and vitamin D. Topical tacrolimus or pimecrolimus may also be considered for use on the face or intertriginous areas. 
  • Systemic agents such as retinoids, methotrexate, and cyclosporine are sometimes considered.
  • Biologic agents are a new class of medications that may be beneficial, especially for patients with psoriatic arthritis. The most commonly prescribed agents include: Humira (adalimumab), Enbrel (etanercept), and Remicade (infliximab).
  • Patients often benefit from the use of emollients over the skin such as Aquaphor. These topical moisturizers help promote tissue healing.
  • Patients with bacterial coinfection resulting in cellulitis typically require treatment with oral antibiotics.

References:

  1. Armstrong AW, Robertson AD, Wu J, et al. Undertreatment, treatment trends, and treatment dissatisfaction among patients with psoriasis and psoriatic arthritis in the United States: findings from the National Psoriasis Foundation surveys, 2003-2011. JAMA Dermatol 2013; 149:1180.
  2. Samarasekera EJ, Sawyer L, Wonderling D, et al. Topical therapies for the treatment of plaque psoriasis: systematic review and network meta-analyses. Br J Dermatol 2013; 168:954.

The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.