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Psoriasis

Definition


Disease: Psoriasis Psoriasis
Category: Dermatological diseases
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Disease Definition:

Psoriasis is a common skin disease that affects the life cycle of skin cells. Psoriasis causes cells to build up rapidly on the surface of the skin, forming thick silvery scales and itchy, dry, red patches that are sometimes painful.

One might either have periods when their psoriasis symptoms get better or go into remission alternating with times the psoriasis gets worse.
While psoriasis for certain people might be quite annoying, for others it might be disabling, particularly when associated with arthritis. The treatment of this condition might provide significant relief, but it isn’t a curable condition. Lifestyle measures, like the use of a nonprescription cortisone cream and exposure of skin to minimum amounts of natural sunlight, could relieve symptoms of psoriasis.

Work Group:


Prepared by: Scientific Section

Symptoms, Causes

Symptoms:

Signs and symptoms of psoriasis differs in each individual but might include one or more of the following:

  • Dry, cracked skin that might bleed
  • Swollen and stiff joints
  • Red patches of skin covered with silvery scales
  • Itching, burning or soreness
  • Small scaling spots (commonly seen in children)
  • Thickened, pitted or ridged nails


Psoriasis patches could range from a few spots of dandruff-like scaling to major eruptions covering large regions. When mild cases of psoriasis might be bothersome, for more severe cases it could be painful, disabling and disfiguring. Most kinds of this condition go through cycles, flaring for a few weeks or months, in order to be lessened for a while even going into complete remission. Yet, mostly the disease finally recurs.

The followings are the kinds of psoriasis found:

  • Plaque psoriasis. Dry, raised, red skin lesions (plaques) covered with silvery scales are caused by this most common type of psoriasis. The plaques might itch, be painful and could occur anywhere on the body, such as soft tissue inside the mouth and genitals. One might either have a few plaques or many of them. In severe cases, the skin surrounding joints might crack and bleed.
  • Nail psoriasis. Psoriasis could affect fingernails and toenails, resulting in pitting, abnormal nail development and discoloration. Psoriatic nails might loosen and separate from the nail bed (onycholysis). Severe cases might result in the nail to crumble.
  • Scalp psoriasis. Psoriasis on the scalp looks as red, itchy places with silvery-white scales. One might observe flakes of dead skin in the hair or on the shoulders, particularly after scratching the scalp.
  • Guttate psoriasis. This mainly affects people younger than 30 and is often triggered by a bacterial infection like a strep throat. It is marked by small, water-drop-shaped sores on the trunk, legs, arms and scalp. The sores are covered by a fine scale and aren’t as thick as typical plaques are. One might experience a single outbreak that disappears on its own or they might have repeated episodes, particularly when having ongoing respiratory infections.
  • Inverse psoriasis. Primarily affecting the skin in the armpits, under the breasts, groin and surrounding the genitals, inverse psoriasis results in smooth patches of red, inflamed skin. It’s more typical in people who are overweight and is worsened by friction and sweating.
  • Pustular psoriasis. This uncommon type of psoriasis could occur in widespread patches (generalized pustular psoriasis) or in smaller areas on the hands, fingertips or feet. In general, it rapidly grows, with pus-filled blisters looking just hours after the skin becomes red and tender. The blisters dry within a day or two but might appear once again every few days or weeks. Generalized pustular psoriasis could additionally result in fever, severe itching, fatigue and chills.
  • Erythrodermic psoriasis. This kind of psoriasis seldom takes place, erythrodermic psoriasis could cover the whole body with a red, peeling rash that could itch or burn intensely. It might be triggered by severe sunburn, by corticosteroids and other medications, or by another kind of psoriasis that’s poorly managed.
  • Psoriatic arthritis. Additionally to inflamed scaly skin, psoriatic arthritis results in pitted, discolored nails and the swollen, painful joints that are typical of arthritis. It could contribute to inflammatory eye conditions like conjunctivitis as well. Symptoms range from mild to severe. Even the disease often isn’t as disabling as other types of arthritis might be, it could result in stiffness and progressive joint damage that in most serious cases might contribute to irreversible deformity.


In the case of experiencing psoriasis symptoms, consulting a doctor might be necessary, as well as when the psoriasis:

  • Makes performing routine tasks difficult.
  • Increasing one’s concerns about their appearance of their skin.

Progresses beyond the nuisance stage, causing you discomfort and pain.

In case the signs and symptoms get worse or they don’t seem to get better with treatment, consulting a health provider may be wise. A different medication or a combination of treatments might be required to control the psoriasis.

Causes:

T lymphocyte or T cell is a kind of white blood cell which is a part of the immune system, is considered to be related with the occurrence of psoriasis. T cells under natural circumstances go throughout the body to detect and fight off foreign substances, like bacteria or viruses. When psoriasis takes place, however, the T cells attack healthy skin cells erroneously as if to fight an infection or healing a wound.

Overactive T cells trigger other immune reactions such as dilation of blood vessels in the skin around the plaques and an increase in other white blood cells entering the epidermis. These changes cause an overproduction of both healthy skin cells and more T cells and other white blood cells. The outcome though is an ongoing cycle in which new skin cells move to the outermost layer of skin very rapidly, in days rather than weeks. Dead skin and white blood cells can't slough off quickly enough and build up in thick, scaly patches on the skin’s surface. This often continues until treatment breaks off the cycle.

It isn’t certain why T cells malfunction in people suffering from psoriasis, even though researchers think genetic and environmental factors both play a role.

Psoriasis triggers
Psoriasis commonly begins or gets worse due to a trigger that enables one to identify and avoid. The followings might be included in these triggers:

  • Cold weather.
  • Infections, like strep throat or thrush.
  • Smoking.
  • Heavy alcohol consumption.
  • Stress.
  • Some medications, such as lithium that might be prescribed for bipolar disorder; high blood pressure medications like beta blockers; antimalarial medications; and iodides.
  • Injury to the skin, like a cut or scrape, bug bite, or a severe sunburn.


Psoriasis might be affecting anyone, but the following factors increase the risk of growing the disease:

  • Family history. A higher risk of psoriasis might arise when it runs in the family. About 1 in 3 people suffering from this disease has a close relative who additionally suffers from it.
  • Other medical conditions. There’s a higher likelihood of people suffering from HIV to grow the disease than those who have a healthy immune system. Others who might be susceptible of getting affected are children and young adults who are experiencing a recurring infection, especially strep throat.
  • Stress. High stress levels might raise the risk of psoriasis, since stress could affect one’s immune system.
  • Obesity. Being overweight increases the risk of inverse psoriasis. Additionally, plaques related to all kinds of psoriasis usually grow in skin creases and folds.
  • Smoking. A high risk of psoriasis involves people who smoke tobacco, in addition to elevating the severity of the disease. Smoking might be an important aspect in growing the disease in the first place.

Complications

Complications:

Complications might come up regarding psoriasis according to the kind and location of the disease and how widespread it is, such as:

  • Stress
  • Social isolation
  • Fluid and electrolyte imbalance in severe cases of pustular psoriasis
  • Thickened skin and bacterial skin infections resulted from scratching in an attempt to relieve severe itching
  • Anxiety
  • Low self-esteem
  • Depression
  •  

Psoriatic arthritis could also be draining and painful making it harder to perform dialy activities. Psoriatic arthritis regardless of the medication could result in erosion in the joints.

Treatments:

Psoriasis treatments aim to:

  • Remove scale and smooth the skin that essentially true of topical treatments applied to the skin
  • Break off the cycle that results in an overproduction of skin cells, thereby decreasing inflammation and plaque formation.

Treatments for psoriasis could be divided into three main kinds: topical treatments, light therapy and oral medications.

Topical treatments
Creams and ointments when used alone which applied to the skin might be effective in treating mild to moderate psoriasis. In more severe cases of the disease, creams are likely to be combined with oral medications or light therapy. Topical psoriasis treatments  include the followings:

  • Topical corticosteroids. These strong anti-inflammatory medications are most often prescribed to treat mild to moderate psoriasis. They slow cell turnover by suppressing the immune system that decreases inflammation and relieving related itching. Topical corticosteroids range in strength, from mild to very powerful. Low-potency corticosteroid ointments are often recommended for sensitive areas, like the face or skin folds, and for treating widespread patches of damaged skin. Stronger corticosteroid ointment might be prescribed for smaller areas of the skin, for persistent plaques on the hands or feet, or when other treatments prove not to be effective. Medicated foams and scalp solutions are present to treat psoriasis patches on the scalp. In general, for topical corticosteroids to be more effective and to reduce side effects, they are used on active outbreaks up to when they’re managed.
  • Vitamin D analogues. These synthetic types of vitamin D slow down the skin cells growth. Calcipotriene is a prescription cream, ointment or solution containing a vitamin D analogue that might be used on its own to treat mild to moderate psoriasis or in combination with other topical medications or phototherapy.
  • Anthralin. This medication is considered to be normalizing DNA activity in skin cells. Anthralin could additionally remove scale, smoothing the skin. Yet, this medication stains virtually anything it touches, such as skin, countertops, bedding and clothing, which is why short contact treatment might usually be recommended instead, allowing the cream to remain on skin for a short period of time before washing it off. Anthralin is occasionally used in combination with ultraviolet light.
  • Topical retinoids. Acne and sun-damaged skin are typically treated with the use of these drugs but tazarotene was developed particularly for the treatment of psoriasis. Such as other vitamin A derivatives, it normalizes DNA activity in skin cells and might reduce inflammation. Skin irritation is the most common side effect. Additionally, it might increase sensitivity to sunlight, so sunscreen should be applied while using the medication. Certain information might be required, such as whether the woman’s pregnant or she’s attempting to get pregnant or not, in case she’s been taking tazarotene, even though there is far lower risk of birth defects for topical retinoids.
  • Calcineurin inhibitors. Calcineurin inhibitors presently (tacrolimus and pimecrolimus) are only approved for the treatment of atopic dermatitis, but studies have also proved to be beneficial at times in the treatment of psoriasis. These inhibitors are considered to be disrupting the activation of T cells that successfully decreases inflammation and plaque accumulation. The most typical side effect is skin irritation. Calcineurin inhibitors are not recommended for long-term or continuous use because of a possible higher risk of skin cancer and lymphoma. These inhibitors are only used with the doctor’s input and approval. Calcineurin inhibitors might particularly be effective in areas of thin skin, like around the eyes, where steroid creams or retinoids are too irritating or might result in harmful effects.
  • Salicylic acid. Available over-the-counter (nonprescription) and by prescription, salicylic acid promotes sloughing of dead skin cells and decreasing scaling. Occasionally it is combined with other medications like topical corticosteroids or coal tar, to raise its effectiveness. Salicylic acid is available in medicated shampoos and scalp solutions to treat scalp psoriasis.
  • Coal tar. Available in over-the-counter shampoos, creams and oils is the oldest treatment for psoriasis is a thick, black byproduct of the manufacture of petroleum products and coal, coal tar. This treatment decreases scaling, itching and inflammation, though it isn’t known how exactly it works. Coal tar contains few known side effects, but it’s messy, stains clothing and bedding and has a strong odor.
  • Moisturizers. Moisturizing creams are unable to heal psoriasis on their own, but they could decrease itching and scaling in addition to aid fighting dryness caused by other therapies. Moisturizers in an ointment base are often more effective than are lighter lotions and creams.

 

Light therapy (phototherapy)
This treatment of psoriasis uses natural or artificial ultraviolet light, as is obvious from its name. The simplest and easiest kind of phototherapy including exposure of the skin to controlled amounts of natural sunlight. The use of artificial ultraviolet A (UVA) or ultraviolet B (UVB) light either alone or in combination with medications, are all included in other types of light therapy.

  • Sunlight. Ultraviolet (UV) light is a wavelength of light in a range very short for the human eye to see. The activated T cells in the skin die as soon as they are exposed to UV rays in sunlight or artificial light. This slows skin cell turnover and decreases scaling and inflammation. Brief, daily exposures to small amounts of sunlight might make psoriasis better, but intense sun exposure could make symptoms worse and results in skin damage. Before beginning a sunlight regimen, the patient should ask the doctor about the safest way to use natural sunlight for psoriasis treatment.
  • UVB phototherapy. Symptoms of mild to moderate psoriasis might be relieved with managed doses of UVB light from an artificial light source. UVB phototherapy additionally referred to as broadband UVB could be used to treat single patches, widespread psoriasis and psoriasis resisting topical treatments. Redness, itching and dry skin might be involved in short-term side effects. These side effects might be lessened with the use of moisturizer.
  • Narrowband UVB therapy. Narrowband UVB therapy might be more effective in comparison to broadband UVB treatment, since it is the newer form of treatment for psoriasis. This treatment is often administered two or three times a week until the skin improves, then maintenance might need only weekly sessions. Yet, narrowband UVB therapy might result in more severe and longer lasting burns.
  • Photochemotherapy, or psoralen plus ultraviolet A (PUVA). Photochemotherapy involves taking a light-sensitizing medication (psoralen) preceding exposure to UVA light. UVA light penetrates deeper into the skin than does UVB light, and psoralen makes the skin more responsive to UVA exposure. Skin gets to be better due to this more aggressive treatment which is usually used for more severe cases of psoriasis. PUVA involves two or three treatments a week for a prescribed number of weeks. Nausea, burning, itching and headache are included in the temporary side effects of this aggressive treatment. Whereas long-term side effects include dry and wrinkled skin, freckles and a high risk of skin cancer, such as melanoma, the most serious type of skin cancer.
  • Excimer laser. For mild to moderate cases of psoriasis, this type of light therapy might be used though only treating the involved skin. A managed beam of UVB light of a particular wavelength directed to the psoriasis plaques to manage scaling and inflammation. Healthy skin existing around the patches isn’t harmed. Excimer laser therapy needs fewer sessions than traditional phototherapy does, since stronger UVB light is used. Blistering and redness are among side effects of this therapy.
  • Combination light therapy. The effectiveness of phototherapy might be improved due to the combination of UV light with other treatments like retinoids. Combination therapies are usually used when other phototherapy alternatives are ineffective. UVB treatment is given somtimes in conjunction with coal tar, known as Goekerman treatment. The two therapies together might be stronger in their effectivity than either alone since coal tar makes skin more receptive to UVB light. The Ingram regimen is another technique combining UVB therapy with a coal tar bath and an anthralin-salicylic acid paste that’s left on the skin for many hours or overnight.

 

Oral or injected medications
In severe cases of psoriasis or their being resistant to other kinds of treatment, oral or injected medications might be prescribed. Some of these medications are used for a short period of time and might be alternated with other types of treatment, since these medications may cause severe side effects.

  • Retinoids. This groups of medications might decrease the production of skin cells when experiencing severe psoriasis that doesn’t react to other therapies, retinoids are related to vitamin A. Once therapy is stopped, signs and symptoms often come back. Side effects might include dryness of the skin and mucous membranes, hair loss and itching. Since retinoids like acitretin could result in severe birth defects, women should not attempt to get pregnant for at least three years after taking the medication.
  • Methotrexate. Methotrexate helps psoriasis when taken orally through reducing the production of skin cells and suppressing inflammation. In certain people It might additionally slow the development of psoriatic arthritis. This drug is in general well tolerated in low doses, but might result in upset stomach, fatigue and loss of appetite. Prolonged use of this medication might result in several serious side effects, such as reduced production of red and white blood cells, platelets and severe liver damage.
  • Cyclosporine. This medication suppresses the immune system and resembles methotrexate in its effectiveness. As is other immunosuppressant medications, cyclosporine raises the risk of infection and other health problems, such as cancer. Additionally this medication increases one’s chance to have kidney problems and high blood pressure, as the dose of this medication increases and therapy takes a longer time the risk gets even higher.
  • Hydroxyurea. Hydroxyurea doesn’t work as effectively as cyclosporine or methotrexate does, but despite this fact it could be combined with phototherapy unlike other more powerful medications. This medication might result in potential side effects, such as a reduction in white blood cells and platelets and anemia. Pregnant women or those who are attempting to get pregnant should avoid taking this medication.
  • Immunomodulator drugs (biologics). Many immunomodulator medicataions are approved for the treatment of moderate to severe psoriasis. Such as alefacept, Infliximab, Ustekinumab and etanercept. These medications are given by intravenous infusion, intramuscular injection or subcutaneous injection and are often used for people who have failed to response to traditional therapy or who have associated psoriatic arthritis. Biologics work by preventing interactions between certain immune system cells. Even though they’re derived from natural sources rather than chemical ones, they must be used with care since they have strong effects on the immune system and might result in life-endangering infections.

 

Treatment considerations
The traditional approach is to begin with the mildest treatments, even though treatments based on the type and severity of psoriasis and the areas of skin affected are usually chosen by doctors. Usually the initial treatment begins with Topical creams and ultraviolet light therapy (phototherapy) and later on developing to stronger ones in the case of necessity. The treatment aims at finding the most effective way to slow cell turnover with the fewest possible side effects.

Despite of a wide range of alternatives, effective treatment of psoriasis could be challenging. The disease is irregular, going through cycles of improvement and getting worse seemingly at random. Effects of psoriasis treatments be unpredictable as well, the best working treatment for certain people might be totally ineffective for others. In addition for the skin becoming resistant to several different treatments with time and the most potent psoriasis treatments could have serious side effects.
In case one’s unable to get better after using specific treatment or experiencing uncomfortable side effects, discussing the treatment alternatives with the doctor might be effective. Treatment plan could be adjusted to make sure that you get the best possible control of the symptom

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