Psoriasis - Causes, Details & Treatment

Psoriasis is an autoimmune skin condition where the immune system attacks healthy skin cells, but it also stimulates the growth of skin cells. It is not contagious, and it can happen in various parts of the body.

Psoriasis is a chronic inflammatory, hyperproliferative skin disease. It is characterized by well-defined, erythematous (dilated skin blood vessels) scaly plaques with white surface scale (rapid keratinocyte proliferation) of diseased skin often at sites of minor trauma particularly affecting extensor surfaces, scalp, and nails, and usually follows a relapsing and remitting course. As psoriasis is caused by immunological disturbances, it is not contagious. Psoriasis not only affects the skin but can also lead to arthritis (inflammation of the joints) in approximately 30% of patients.

There are 7 types of psoriasis with plaque psoriasis being the most common type of psoriasis:

• Plaque psoriasis
• Nail psoriasis
• Guttate psoriasis
• Pustular psoriasis
• Inverse psoriasis
• Erythrodermic psoriasis
• Psoriatic arthritis

Epidemiology of psoriasis

• Geography: Globally 1-2% of the population is affected by psoriasis (125 million people in the UK/USA/Japan alone). It is less common in African, South American and Asian populations; however, psoriasis affects approximately 1.5-3% of Caucasians.
• Sex and age: Psoriasis affects both sexes evenly. It can present at any age and more than fifty percent of patients present before the age of thirty years; although it is seen rarely before the age of five years. There is a bimodal distribution of age of onset, with the early-onset kind occurring in adolescence and early adulthood. This type is usually severe in intensity and patients often have a history of psoriasis in the family. The later-onset kind presents between the ages of fifty and sixty, less severe and is dramatic in intensity. Family history is usually absent in this type.

Pathophysiology of psoriasis

Both genetic and environmental factors are important. A child who has one parent with psoriasis has a one in four chance of developing the disease. If one identical (monozygotic) twin has psoriasis, there is a seventy percent chance that the other will also be affected; however, only a twenty percent chance exists in the non-identical (dizygotic) twins. There is now significant research work showing that psoriasis is also associated with other important comorbidities such as type 2 diabetes (increased risk of 1.4 times), depression, obesity, cardiovascular disease, and reduced quality of life. Environmental factors include:

• Trauma: Lesions can appear at sites of skin trauma, such as scratches or surgical wounds. This phenomenon is named the Köbner isomorphic phenomenon.
• Infection: Throat infections often precede guttate psoriasis. Severe psoriasis may be the initial presentation of HIV infection.
• Sunlight: Psoriasis may occur or worsen after sun exposure.
• Drugs: Many drugs including antimalarials, β-blockers, lithium, and Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) can exacerbate psoriasis. Rebound; flare of psoriasis is often unstable and maybe pustular and may occur after the withdrawal of steroids.
• Psychological factors: Anxiety and stress may exacerbate psoriasis in predisposed individuals.

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The general symptoms of psoriasis include:

• red, inflamed, scaly skin patches
• scaly skin
• dryness and itchiness

The types of psoriasis may be similar, but certain symptoms will differ between the types of psoriasis:

• Plaque psoriasis – this can happen in any area of the body, scaly, raised, dry, itchy, painful, red skin, but these usually happen on the scalp, knees, elbows, and lower back
• Nail psoriasis – small nail pits, ridges, holes in the nail, yellow color, the nail detaching from the nail bed in pieces or completely
• Guttate psoriasis – raised, small red, scaly spots instead of patches
• Pustular psoriasis – white bumps filled with pus surrounded by red blotches
• Inverse psoriasis – mainly appears around the groin, under the breasts, armpits, and genitals, as a smooth, red patches of inflamed skin
• Erythrodermic psoriasis – severe redness, itching, pain, and scaling over a large area, lowered body temperature, fever, faster heartbeat
• Psoriatic arthritis – red, scaly patches, painful and swollen joints, ligaments, and tendons

Clinical appearance

• Plaque psoriasis: This is the most common presentation and usually represents a more stable disease. The typical lesion is a raised, well-demarcated erythematous plaque of variable size. In untreated disease, a silver/white scale is evident and more obvious on scraping the surface, which reveals bleeding points. This is known as the Auspitz sign. The most common sites are the extensor surfaces, notably elbows and knees, and the lower back. Others include:
  • Scalp: involvement is seen in approximately sixty percent of patients. Typically, easily palpable, erythematous scaly plaques are evident within the hair-bearing scalp and there is clear demarcation at or beyond the hair margin. The involvement of the back of the head is common and difficult to treat. Less often, fine diffuse scaling may be present and difficult to distinguish from seborrheic dermatitis (dandruff induced inflammation of the skin). The involvement of other sites such as eyebrows, nose, lips, and upper chest, is not uncommon. Temporary hair loss can occur but a permanent loss is unusual.
  • Nails: Psoriatic nail involvement is characterized by; Onycholysis (lifting of the nail plate off the nail bed, manifesting as a white or salmon patch on the nail), Subungual hyperkeratosis (accumulation of chalky looking material under the nail due to excessive cell division of the nail bed that can ultimately lead to breakdown of nails), Nail pitting (very small depressions in the nail plate which result from loss of special kind of cells from the nail surface), Beau’s lines (transverse lines on the nail plate due to inflammation of the nails leading to a transient arrest in nail growth), Splinter hemorrhages (which look like minute longitudinal black lines due to leakage of blood from dilated tortuous blood vessels).
• Guttate psoriasis: Guttate psoriasis consists of widespread small plaques scattered on the trunk and limbs. Adolescents are most commonly affected and there is often a preceding sore throat. There is frequently a family history of psoriasis. The sudden onset and widespread nature of guttate psoriasis can be very alarming for patients, fortunately, it usually resolves completely, but can be recurrent or herald the onset of chronic plaque psoriasis.
• Palmoplantar pustular psoriasis (PPPP): PPPP is characterized by multiple sterile pustules on the palms and soles. Pustules first appear as yellowish lesions that turn a brown color with chronicity and associated scaling. Most patients with PPPP are smokers.
• Acute generalized pustular psoriasis: Acute generalized pustular psoriasis is thankfully uncommon as it is usually an indicator of severe and unstable psoriasis. Clinically the skin is erythematous and tender with sheets of sterile pustules, which can develop over a few hours/days. It may be precipitated by the patient taking steroids. The pustules usually occur initially at the peripheral margin of plaques which are often sore and erythematous. Pustules eventually dry and the skin desquamates.
• Acropustulosis: Acropustulosis is a rare variant of psoriasis that usually occurs in young children. Here pustules appear around the nails and the fingertips associated with brisk inflammation.
• Flexural psoriasis: Flexural psoriasis produces well-defined erythematous areas in the armpits, groin, groove between the buttocks, beneath the breasts and skin folds. Scaling is minimal or absent. It is hard to distinguish it from a fungal infection. In case of any doubt, the doctor should take a specimen to detect such an infection.
• Napkin psoriasis: Napkin psoriasis in children may present with typical psoriatic lesions or a more diffuse erythematous eruption with exudative (fluid leaking) rather than scaling lesions.
• Erythrodermic psoriasis: Erythrodermic psoriasis is a serious, even life-threatening condition with erythema affecting nearly all of the skin. Diagnosis is not easy as the characteristic scaling of psoriasis is absent. Chronic plaque psoriasis usually, but not always, precedes the erythroderma. Triggers for erythrodermic psoriasis include withdrawal of steroids, infections, excessive alcohol intake, lithium, and low calcium. Complications of erythrodermic psoriasis result from increased cutaneous blood flow and fluid loss, including heart failure, low body temperature, dehydration, low protein content and consequent swelling of the body, secondary infection, and death. Patients should be managed in hospital under the care of a dermatology specialist.
• Psoriatic Arthritis (PA): Between five and ten percent of individuals with psoriasis develop arthritis (inflammation of joints), which can take on several patterns. Joint involvement is more likely in patients with psoriatic nail disease. PA is thought to be an autoimmune joint disease with an inherited genetic predisposition along with environmental triggers. Environmental factors such as infections and trauma have been associated with the onset of PA but the exact mechanisms are poorly understood. Clinically, psoriatic arthritis usually waxes and wanes but can be severe enough to cause significant functional disabilities. Stiffness, pain and joint deformity are the most common manifestations. There are five types of psoriatic arthritis; finger joint involvement (Distal Interphalangeal Joints, 80% have associated nail changes), asymmetrical oligoarticular arthritis (hands and feet, ‘sausage-shaped’ digits, single joints), symmetrical polyarthritis (hands, wrists, ankles, ‘rheumatoid pattern’, multiple joints), arthritis mutilans (resorption of bone leading to resultant ‘telescoping’ of redundant skin), spondylitis (asymmetrical vertebral involvement with male preponderance).

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There might be 7 types of psoriasis, but they all start similarly. Your body's immune system starts to attack healthy cells because of a trigger which causes inflammation and hyperactive skin growth. The hyperactive growth builds up into scaly patches. The cause of immune system malfunction has not been discovered yet, but genetics are likely to play a role in the overreaction of the immune system while environmental factors trigger psoriasis. Although, people with psoriasis may have different triggers. Some of these triggers include:

• infection
• injury
• alcohol
• smoking
• stress
• certain drugs
• dry weather

However, different kinds of psoriasis have small differences in the way they are caused:

• Plaque psoriasis: this base form of psoriasis is the starting point of many different types, and it is simply the inflammation and hyperactive cell growth causing the general symptoms of psoriasis
• Nail psoriasis: psoriasis changes the properties underneath the nail and causes the nail to detach from the nail bed. The gap can become painful, white, or infected causing a yellow discoloration. Cells are lost because of psoriasis and it creates pits in the nail. It also weakens the structure of nails to cause deep indentations in the nail called Beau’s Lines.
• Guttate psoriasis: streptococcal infection or viral infections cause an outbreak throughout the body in the form of spots
• Pustular psoriasis: psoriasis creates the red, inflamed patches, then pustules are formed due to specific triggers like certain drugs, sunlight, stress, infections, and pregnancy
• Inverse psoriasis: sweating and folds like in armpits, folds of skin, genital areas, or under breasts create dampness and friction which are triggers for psoriasis
• Erythrodermic psoriasis: it isn’t yet understood why this type of psoriasis develops, but it is a severe type of psoriasis that destabilizes many aspects of bodily function
• Psoriatic arthritis: inflammation and hyperactive growth from psoriasis spreads to the joints and to where tendons and ligaments meet the bone which causes joint pain and swelling

Patients often wish to know what has caused their psoriasis and are keen for a cure. However, our current understanding of psoriasis is that it is an inherited autoimmune disease that can be suppressed by current therapies rather than cured. Management comprises avoidance of known exacerbating factors (such as, smoking or alcohol), using topical preparations, undertaking phototherapy or photochemotherapy and taking systemic therapy. The selection of the most appropriate treatment for each patient is tailored to the type of psoriasis, their age, comorbidities, social and occupational factors, their level of motivation, quality of life and patient acceptability. As a general rule, there is a treatment ladder that patients may climb as the disease becomes more severe or recalcitrant to treatments. Patients are started initially using simple topical therapy and/or ultraviolet treatment before switching to the stronger systemic agents if their disease is poorly controlled.

Managing psoriasis is as much a challenge for patients as it is for medical practitioners. The appearance of the scaly plaques may cause social embarrassment; time needs to be set aside for the application of creams, and even if the skin is cleared, recurrence is the rule. A specific survey for psoriasis patients is the psoriasis disability index (PDI) which can also be used to assess the impact of the disease on the patient's life. The questionnaires embrace all aspects of life including work, personal relationships, domestic situations, and recreational activities.

Psoriasis does not yet have a cure, but flares can be controlled and prevented. Therefore, long-term treatments options focus on reducing inflammation, itching, scaling, dryness, and skin growth with psoriasis medications.

Home Remedies

While home remedies have taken on popularity, there are little to no studies confirming the effectiveness of such treatments. In some cases, it might even do more harm than good considering their minimal effectiveness versus the unknown side effects they could have on your body. It is best to follow the medical advice of a dermatologist because they know what will or will not treat the disease. Here are some popular home remedies that you should avoid:

• Dietary supplements
• Preventing dry skin
• Sun Exposure
• Apple cider vinegar

Over the Counter Medication

While some over the counter (OTC) medications are effective enough to be given as prescriptions, other OTC medications have limited effects on disease. They might help for mild to moderate cases, but they are not usually effective for severe cases. If used incorrectly and without guidance, they might even prove to be ineffective and produce unforeseen side effects. However, a dermatologist can tell you whether or not these can be effective for you. Here are some OTC medications that may or may not be included in a treatment plan given by one of our dermatologists:

• Salicylic Acid – removes scaling and reduces swelling
• Coal Tar – reduces itching, flaking, redness, swelling, scaling, and hyperactive growth
• Moisturizers – relieves dryness and helps skin heal
• Corticosteroids – relieves itching and skin inflammation
• Anti-itch – reduces the discomfort from itching, but it can also irritate or dry your skin

Prescription Medications

Prescriptions, alongside professional medical advice, are the most effective form of treatment. Home remedies and over the counter treatments take plenty of time, energy, and money, yet are uncertain to work. Our experienced dermatologists take your unique skin, set of symptoms, and medical history into account to take the guessing game out of your road to recovery. Here are some prescriptions your dermatologist might include in your personalized treatment plan:

• Corticosteroids – relieves itching and skin inflammation
• Salicylic Acid – removes scaling and reduces swelling
• Vitamin D – counteracts hyperactive skin growth by slowing it down
• Anthralin – counteracts hyperactive skin growth by slowing it down and removes scales
• Retinoids – reduces inflammation
• Calcineurin Inhibitors – reduces inflammation and plaque
• Cyclosporine – suppresses immune system
• Methotrexate – suppresses immune system and counteracts hyperactive skin growth by slowing it down
• Biologics – suppresses the action of T cells in the immune system for moderate to severe psoriasis
• Moisturizers – relieves dryness and helps skin heal

Dermatology Day Treatment Units:

Patients are often initially managed at dermatology day treatment units in clinics(DDTUs). This facilitates the management of psoriasis, particularly concerning topical therapy, phototherapy, and administration of injections. Benefits of management at the DDTU include compliance, monitoring, education, counseling/support and an overall reduction in the patients’ stress levels. Treatments not possible at home including short-contact dithranol and crude coal tar can be applied to psoriatic plaques by specialist nurses, phototherapy can be delivered in custom-built cabinets and regular administration of biological therapy can be given by specialist dermatology nurses. These units help reduce the number and frequency of in-patient admissions of patients with severe psoriasis.

The treatment approach generally follows a step-wise progression, with treatment categories broadly summarized, as the following initial steps:

• Accurate diagnosis
• Establishing severity and impact
• Removal or treatment of triggers
• Identification of co-morbidities (especially in severe disease)
• Education, support, psychological input

Topical treatment:

Topical treatments are applied directly to the skin surface, including ointments, creams, gels, tars, lotions, pastes and shampoo. The topical approach to therapy results in changes at and just below the skin surface. Conventionally, topical drugs are applied directly to the diseased skin only, in contrast to moisturizers (emollients), which are usually applied more freely. In general, combination therapy is more effective than any single drug, and a change of therapy is superior to continuous usage. The following are the advantages of topical treatments:

• local effects only
• self-application
• safe for long-term use
• relatively cheap

The following are the disadvantages of topical treatments:

• time-consuming in extensive disease
• poor compliance (insufficient amounts and frequency)
• messy and may affect clothing/bedding/hair
• no benefit for associated joint disease
• become less effective with continuous use

Topical treatment options include:

• Emollients: Act as a barrier to skin fluid loss, relieve itching and help replace water and fats and, therefore, restore the barrier function of dry skin. Patients can purchase these over the counter, and personal preference and acceptability usually guide their choice. Regular application of emollients is encouraged in all patients with dry/flaky skin.
• Coal tar: Coal tar is obtained by the distillation of raw coal. Many coal tar preparations are available for purchase over the counter and include ointments, pastes, paints, soaps, solutions, and shampoo. Coal tar normalizes skin cell growth patterns (keratoplastic), reduces itch (antipruritic) and decreases bacterial growth (antimicrobial). It is used on stable chronic plaque psoriasis but will irritate acute, inflamed skin. Coal tar in combination with salicylic acid is usually more effective for very thick plaques.
• Ichthammol: A distillation of sulfur-rich oil. It has anti-inflammatory properties and is, therefore, suitable to be used on unstable or inflamed psoriasis. Various preparations can be purchased over the counter including ichthammol ointment.
• Dithranol: (Goa powder), originally derived from araroba trees, is now produced synthetically. Irritation and burning can occur if it comes into contact with normal skin; therefore, careful application to psoriatic plaques is needed. Normal skin is usually protected with Vaseline (petroleum jelly). Dithranol temporarily stains the skin/hair a purple-brown color. Short/long contact dithranol can be applied by dermatology nurses to chronic stable plaques in specialist units. Dithranol creams can be applied by the patients themselves, left on for 30 min and then washed off. Strengths up to 1% can be purchased over the counter, whereas higher concentrations are available by prescription only.
• Topical vitamin D analogs: Calcipotriol and tacalcitol are vitamin D analogs, used topically for mild or moderate plaque psoriasis. Mild irritation can be experienced and after continuous use, a plateau effect may be encountered with the treatment becoming less effective after an initial response. These preparations are, therefore, best used in combination with other topical agents. It is important not to exceed the maximum recommended dose as there is a risk of altering calcium metabolism.
• Steroids: Steroids in topical formulations are an important adjuvant to the management of patients with psoriasis; these are prescription-only preparations (except very mild steroids) and can be supervised by the general medical practitioner. Steroids help reduce the superficial inflammation within the plaques. However, relapse usually occurs on cessation and decreased effectiveness with continuous use is observed. Topical steroids should be applied to the affected areas of skin only once or twice daily. Manufacturers suggest topical steroids should be applied sparingly but this is difficult for patients to quantify; therefore, practitioners advise the use of fingertip units (FTUs) as a guide. When the steroid ointment/cream is squeezed out from a tube, it comes out in a line, and the quantity between the fingertip and the first skin crease is 1 FTU, enough to cover a hand-sized area of skin (back and front of the hand). The strength of topical steroids is graded from mild to very potent. Prolonged use of very potent topical steroids should generally be avoided in the treatment of chronic skin diseases such as psoriasis. Mild/moderate topical steroids are safe to use on the face and flexural skin and in erythrodermic disease. Moderate or potent preparations can be used on chronic stable plaques on the body. Combination products seem to be among the most effective in the treatment of psoriasis, especially those containing vitamin D, tar and antibiotics. Oral steroids should not be used to treat psoriasis.

Ultraviolet treatment

Phototherapy and photochemotherapy (phototherapy combined with drugs) are delivered in specialist dermatology units. It is suitable for psoriasis patients with extensive disease that has not cleared with topical therapy. Patients are asked to attend the phototherapy suite 2-3 times weekly regularly for approximately 6-8 weeks. Phototherapy is usually avoided if the patient has a history of previous skin cancer and photosensitive diseases. Phototherapy is usually delivered in vertical irradiation units. The dose and time of exposure to light are gradually increased as the treatment progresses. Patients apply a layer of emollient to their skin before standing inside the cabinet (this helps remove surface scale and aids UV penetration), they wear UV protective goggles (to protect against corneal damage and cataract formation) and sanctuary sites (genitals) are covered. There is an increased risk of developing skin cancer with increasing doses of phototherapy. How much phototherapy can be given safely will depend on the patient's skin type and cumulative dose of UV received. In addition to the increased risk of skin cancers, premature aging of the skin can also occur. Two main types of phototherapy are currently available, broadband and narrowband ultraviolet B (UVB) and photochemotherapy ultraviolet A (PUVA). UVB phototherapy has advantages over PUVA as it can be used in children, during pregnancy and does not require the wearing of UV-blocking glasses post-treatment.

Ultraviolet B (UVB)

UVB is a short wavelength ultraviolet light and is administered three times weekly, (20-30 treatments) for widespread psoriasis. Narrowband is more effective than broadband UVB and there is a reduced risk of burning. The starting dose and subsequent increases for patients are based either on measuring the Minimal Erythema Dose (MED), which is the dose of UVB just sufficient to cause erythema (redness). Alternatively, the patient's skin type is used to guide the starting dose. The patient's skin type reflects the skin's tolerance to sunlight. UVB can be given in combination with tar or dithranol for chronic thick plaques of psoriasis. UVB in combination with oral vitamin A derivative can also increase the efficacy.

Ultraviolet A (UVA)

UVA is a long wavelength ultraviolet light and is given in combination with oral or topical drugs twice weekly (20-30 treatments) for widespread thick plaque psoriasis. The Minimum Phototoxic Dose (MPD) or skin type is used to determine the starting dose of UVA and the subsequent increments used. Protective goggles are worn during UVA exposure and sunglasses for 24 hours after a session. Localized PUVA can be given to palmoplantar psoriasis.

If a patient's psoriasis still not controlled by any of the above methods, one of the two below approaches are taken:

In-patient hospital admission for:

• If feasible, for intensive in-patient care
• Phototherapy or PUVA (if needed)
• Systemic treatment (if needed)

Systemic agents: Systemic therapy for severe psoriasis is usually managed by experienced specialist dermatologists. Candidates for systemic therapy include patients with unstable inflamed psoriasis, those with a widespread disease that has failed to respond to topical or phototherapy regimens and associated psoriatic arthritis. The first-line systemic agents in most dermatology centers are methotrexate, acitretin and ciclosporin. Biological therapies can be considered if patients have failed to respond to first-line agents or suffered side effects precluding the continued use of at least two systemic agents.

Methotrexate

ethotrexate is suitable to treat unstable erythrodermic, or pustular, psoriasis in the acute setting as well as maintenance for chronic plaque disease and psoriatic arthritis. Methotrexate is given once weekly as a tablet or injection. Conventionally, patients are given low doses initially that gradually increase until the psoriasis is sufficiently controlled, rather than cleared. Maintenance weekly doses weekly are usually adequate. Adverse effects are that Methotrexate is toxic to the liver; therefore, liver function tests are done before and during therapy. Bone marrow suppression (myelosuppression) can occur in patients taking methotrexate, and its onset may be rapid or insidious. Patients are monitored with regular full blood counts (FBCs). Folic acid supplements are given (at least 5 mg weekly, taken on a different day to the methotrexate). Methotrexate is excreted in the urine; therefore, the dose is reduced in cases of renal impairment.

Acitretin

Acitretin is a vitamin A derivative that is effective in treating chronic plaque psoriasis with approximately 70% clearance in 8 weeks. Increased effectiveness has been observed with combined PUVA when patients require less UV exposure to clear their psoriasis. Adverse effects are that most patients experience symptoms including drying, crusting in the nose, itching, thinning of the hair, and erythema of the palms and nail folds. These are usually not severe and settle when treatment stops. Liver damage and raised fat concentrations occur in 20-30% of patients. Liver function tests and cholesterol/triglyceride concentrations are done to monitor their development. Women during reproductive years are advised to use effective contraception during treatment and for 3 years afterward.

Ciclosporin A

Ciclosporin A is an immuno-suppressant widely used following organ transplantation. It is effective and suitable for the treatment of inflammatory types of psoriasis because of its rapid onset of action. Patients are given two divided doses either for short courses or continuous use up to 2 years maximum. The minimum dose required to control psoriasis should be used. Adverse effects include renal impairment and increased blood pressure. Transient nausea, headaches, gum hypertrophy, and hair thickening may also be observed.

Mycophenolate mofetil (MMF)

MMF is usually used as a second-line systemic agent for treating psoriasis and psoriatic arthritis. Studies have shown that about two-thirds of patients taking MMF for 12 weeks have a significant reduction (50%) in their disease by 12 weeks. Adverse effects include gastrointestinal upset and bone marrow suppression, blood cancers and infections.

Biological agents

iological therapy refers to substances originally derived from living organisms that are designed to block particular steps in the pathway that lead to psoriasis. The main biological agents currently used to treat severe psoriasis are infliximab, etanercept, and adalimumab and ustekinumab. These novel drugs are expensive and can result in chronic suppression of immunity leading to fatal infections or cancers and therefore their usage is managed in specialist units by experienced practitioners. Biological agents are usually injected, with frequencies varying from twice weekly to once per month, in either continuous or discontinuous regimes.

Etanercept

Etanercept is a genetically engineered biological agent. Dosing is twice weekly with given by injection. The higher dose is usually more effective than lower doses, especially in patients who weigh more than 70 kg. The onset of action is relatively slow, with clinical improvement being observed in the majority of patients between 4 and 8 weeks. Patients may initially have courses of treatment lasting 12 weeks; at that stage, an assessment of efficacy should be made; however, continuous therapy may ultimately be needed due to significant disease relapse within 3 months of stopping treatment. Adverse effects associated with etanercept include an increased risk of infections, particularly Tuberculosis and Hepatitis B, gastrointestinal symptoms, hypersensitivity, and blood disorders.

Infliximab:

Infliximab is a biologic agent used for the treatment of severe psoriasis or psoriatic arthritis. Infliximab has a rapid onset of action, usually within 2 weeks in the majority of patients. Doses are calculated according to the patient's weight. Nearly 80% of patients experience significant improvement in the extent and severity of their disease by 10 weeks, which is usually maintained for at least 6 months. Continuous therapy is superior to intermittent treatment. Adverse effects are as with etanercept, along with chest pain, shortness of breath, heart rhythm problems, sleep disturbance, skin pigmentation, gastrointestinal bleeding, and seizures have been reported.

Adalimumab:

Adalimumab is a biological drug used to treat severe psoriasis and psoriatic arthritis. It has a fast onset of activity, usually within 2 weeks and is highly effective in 60-70% of patients. The majority of patients receive adalimumab fortnightly by an injection. Efficacy is assessed at 16 weeks before deciding whether to continue with the treatment. Adverse effects are as with etanercept, plus mouth and lips inflammation, cough, rash, itch, heart rhythm abnormalities, chest pain, flushing, flu-like symptoms, sleep disturbance, electrolyte disturbances and hair loss among others.

Ustekinumab:

Ustekinumab has only been in clinical use for a few years, therefore, there is less long-term safety and efficacy data than the other biologic agents. Efficacy is assessed at 16 weeks and only continued in those who have achieved a 75% reduction in their disease. Adverse effects are as with etanercept, plus allergic reactions, difficulty in breathing, infections, mouth ulcers, bleeding in urine, gastrointestinal symptoms, cough, chest pains, seizures, and visual disturbance.

Treatment of scalp psoriasis:

Scalp psoriasis affects approximately 50% of patients; it can be one of the earliest skin sites affected. Scalp psoriasis is often difficult to treat because of the thick nature of the scales, inaccessibility of the skin (owing to hair getting in the way) and the difficulty of self-application of treatment. Most patients need to treat the scalp regularly. Initially, products are rubbed into the affected scalp skin and left on overnight (combinations of tar and emollient are used), and then washed out with tar-based shampoos; then steroid/salicylic acid/vitamin D-containing scalp applications/gels are applied to the underlying inflamed skin. This sequential and combination approach to scalp treatment is often successful if maintained. Treatment in the DDTU (Dermatology Day Treatment Units) can be immensely helpful in the management of difficult scalp psoriasis for patients who find it difficult to undertake this treatment themselves at home.

Treatment of psoriatic arthritis:

Therapy with non-steroidal anti-inflammatory drugs NSAIDs) and analgesics may be sufficient to manage symptoms in mild disease. Steroid injections in the joint spaces can control isolated inflamed joints. Prolonged rest should be avoided because of the tendency to the development of complications. Therapy with systemic drugs should be considered for persistent arthritis unresponsive to conservative treatment. Methotrexate is the drug of the first choice and is also effective for skin disease. Particular attention is paid to monitoring liver function in patients treated with methotrexate. Biological treatment is considered for individuals with active arthritis who respond inadequately to standard drug therapy. Ustekinumab, Secukinumab, Apremilast are effective in arthritis. Adverse effects include weight loss, depression, and depression.

Our dermatologists have resolved countless psoriasis cases with medications and treatment plans that are proven to control your psoriasis once and for all. Trust dermatologists, the experts on psoriasis.

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After being seen by one of our SkyMD dermatologists, you’ve been equipped with the treatment plan and prescription(s) to treat your discomfort. However, disease can be persistent, so you have to be too. A skin care routine and a set of disease-preventing habits recommended by our dermatologists are essential for long term prevention. Here are some popular prevention strategies that could supplement your personalized treatment plan:

• Avoid psoriasis triggers
• Moisturize often
• Avoid cold, dry weather
• Reduce stress