PSORIASIS OVERVIEW

Psoriasis is a chronic skin disorder that causes areas of thickened, inflamed, red skin, often covered with silvery scales. Children and adolescents can develop psoriasis, but it occurs primarily in adults. Women and men are equally affected.

The severity of psoriasis is determined by how much of the body’s surface is covered and how much it affects a person's quality of life. Psoriasis is not curable, although many treatments are available to reduce the bothersome symptoms and appearance of the disease.

PSORIASIS CAUSES

Researchers have not identified the exact cause of psoriasis. However, they believe that the disease develops due to a combination of immune, genetic, and environmental factors. There are some common triggers such as cold weather, medications, or stress, although many triggers of psoriasis are unique to an individual.

Immune system — The skin is made up of three layers. The top layer is the epidermis, the middle layer is the dermis, and the inner layer is the subcutaneous layer (figure 1). In the epidermis, there are several layers of skin that are constantly being shed. To replace the lost cells, the body makes more epidermal cells.

Psoriasis appears to be caused by the action of the immune system. Immune cells enter the skin through blood vessels and cause the top layer of skin, the epidermis, to grow too quickly and to stop shedding properly. This causes the scaly build-up seen on areas affected by psoriasis.

Genetics — Genetic factors play a role in determining whether someone develops psoriasis. About 40 percent of people with psoriasis or psoriatic arthritis (a type of arthritis closely related to psoriasis) have family members with the disorder (see "Patient information: Psoriatic arthritis (Beyond the Basics)"). Several genes have been identified that make people more susceptible to psoriasis, but there is no genetic test that can definitely tell whether an individual will develop the disease.

Infections or medications — Infections caused by bacteria and viruses can cause flares of psoriasis symptoms. Certain medications can worsen psoriasis symptoms, including beta blockers (eg, propranolol), lithium, and antimalarial drugs (eg, hydroxychloroquine, Plaquenil^®).

Environment and behavior — Environmental and behavioral factors also affect the risk of developing psoriasis. It is unclear if these factors actually cause psoriasis.

Physical or psychological stress may trigger the development of psoriasis in people with a genetic risk of the disease. Psoriasis has been associated with obesity and an increased risk of heart disease. Smoking appears to increase the risk and severity of psoriasis, particularly for psoriasis of the palms and soles.

PSORIASIS SYMPTOMS

Symptoms of psoriasis include:

• Areas of skin that are dry or red, usually covered with silvery-white scales, and sometimes with raised edges
• Rashes on the scalp, genitals, or in the skin folds
• Itching and skin pain
• Joint pain or aching
• Nail abnormalities, such as pitted, discolored, or crumbly nails

TYPES OF PSORIASIS

There are several common types of psoriasis:

Plaque psoriasis — Plaque psoriasis tends to affect young and middle aged adults, but can occur at any age. The skin plaques (which can range from 0.4 to 4 inches (1 to 10 cm) or more) usually spread evenly across a person's scalp, elbows, knees, and back (picture 1).

Guttate psoriasis — This type of psoriasis is sometimes linked to a recent streptococcal infection, usually pharyngitis (eg, strep throat). It often affects children or young adults with no past history of psoriasis, and causes a sudden eruption of small plaques on the trunk of the body.

Pustular psoriasis — Pustular psoriasis can be a severe, and occasionally life-threatening, form of psoriasis. It develops quickly, with multiple small pustules that may join into larger areas (picture 2). Symptoms can include fever and abnormal blood levels of white blood cells and calcium. Pustular psoriasis can also cause pus-filled blisters on the palms of the hands and soles of the feet. These blisters can crack, causing painful breaks in the skin.

Inverse psoriasis — This type of psoriasis affects less visible body areas, such as the groin, armpits, buttocks, genitals, and the area under the breasts (picture 3). Sometimes this is mistakenly diagnosed as a fungal or bacterial infection.

Nail psoriasis — Some people with psoriasis develop nail problems, including tiny pits over the surface of the nails. The pits look as if someone has taken a pin and pricked the nail several times. Their nails may change to a tan-brown color and they may separate from the nail bed, a condition known as onycholysis (picture 4). In more severe cases, people have thick, crumbling nails.

Treatment of nail psoriasis is difficult, and may include injections of steroids into the nail bed, or oral medications such as methotrexate, cyclosporine, or immunomodulatory drugs. (See 'Psoriasis treatment' below.)

Psoriatic arthritis — Up to one-third of people with psoriasis also have psoriatic arthritis, a condition that causes joint pain and swelling. Skin signs usually develop first, although about 15 percent of patients develop arthritis (joint swelling and stiffness) before symptoms of psoriasis. People with psoriatic arthritis often have severe nail problems. (See "Patient information: Psoriatic arthritis (Beyond the Basics)".)

HIV-associated psoriasis — In addition to the specific types of psoriasis listed above, psoriasis may develop in people infected with the human immunodeficiency virus (HIV). Symptoms include sores on the palms of the hands and the soles of the feet, nail problems, joint pain, and swollen, red sores all over the body. However, most people with psoriasis do not have HIV infection.

PSORIASIS DISEASE COURSE

Psoriasis is a lifelong condition that is not currently curable, although the severity of the disease can improve or worsen over time. About 25 percent of people have periods when their symptoms go away, called remission periods.

However, in people with certain forms of the disease, itching or pain and stiffness is severe and disabling. Many people with visible psoriasis lesions are embarrassed by their appearance, and suffer with stress, anxiety, loneliness, and low self-esteem as a result.

People with psoriasis have higher rates of depression compared to those without the condition. Patients often benefit from working with a psychologist, clinical social worker, or other therapist to discuss their illness and possible ways to cope. A number of organizations, such as the National Psoriasis Foundation, are available to provide support to patients with psoriasis and their families (see 'Where to get more information' below).

PSORIASIS DIAGNOSIS

Psoriasis can be diagnosed by examining the skin. Rarely, a skin biopsy or scraping may be taken to rule out other disorders. There is no blood test that can definitively diagnose psoriasis.

PSORIASIS TREATMENT

Psoriasis is not curable but many treatments are available that can reduce the bothersome symptoms and appearance of the disease. Treatment depends upon the severity of the disease, the cost and convenience of the treatment, and a person's response to the treatment. A combination of therapies is often recommended.

Referral to a dermatologist (a doctor who specializes in skin conditions) may be needed if the diagnosis of psoriasis is uncertain, if the initial treatment does not improve symptoms, or if the disease is widespread or severe. People with psoriatic arthritis may need to see a rheumatologist (a doctor who specializes in joint conditions).

Medicines applied to the skin

Emollients — Keeping skin soft and moist can minimizes itching and tenderness. Topical emollients (or creams) such as petroleum jelly or thick creams may be recommended; these should be applied immediately after bathing or showering.

Topical corticosteroids — Corticosteroids (sometimes called “steroids” but distinct from body building steroids) that are applied to the skin help to reduce inflammation. These cortisone-type creams and ointments are available in a variety of strengths (potencies); the least potent are available without a prescription (eg, hydrocortisone 1% cream). More potent formulations require a prescription.

Applying hydrocortisone cream or another corticosteroid directly to the skin (usually twice daily) can decrease the inflammation and development of new skin patches, although complete and long-lasting relief is hard to predict. Clear liquid, foam or spray forms may be easier to apply, particularly to the scalp.

Calcipotriene or calcitriol — Calcipotriene (Dovonex^®) and calcitriol (Vectical^®) work by slowing the growth of skin cells in the epidermis. These medicines can be used instead of or in addition to topical corticosteroids. They are usually applied twice a day when used alone. The side effects are usually minimal, with skin irritation being the most common problem.

Another preparation, Taclonex^®, combines calcipotriene with a corticosteroid (betamethasone) in a once daily treatment.  Although Taclonex^® is effective, it is quite expensive.

Tar — Tar is a substance distilled from coal that has been used to treat psoriasis for many years. It is not completely clear how tar works, although it appears to reduce the overproduction of skin cells that leads to psoriasis. Tar preparations are available in shampoos, creams, oils, and lotions without a prescription, and are usually applied to the skin or scalp once or twice a day. Tar products do not cause serious side effects, although they can stain skin, hair, and clothing. Tar products are often used along with corticosteroids.

Tazarotene — Tazarotene (Tazorac^®) is a skin treatment derived from vitamin A that is available in a cream or gel. It is usually applied once per day, in the evening. It may also be applied for 20 minutes and then washed off if skin irritation develops. Improvement should be seen within two months of treatment.

Calcineurin inhibitors — Topical calcineurin inhibitors, including tacrolimus (Protopic^®) and pimecrolimus (Elidel^®) creams, can be used to treat psoriasis, especially on the face and is skin folds, such as in the armpits or under the breasts.

Ultraviolet light — Exposure to ultraviolet light is another way to treat psoriasis. During the summer months, people with psoriasis often notice that their symptoms improve. Ultraviolet light treatment (from a dermatologist) may be recommended to treat psoriasis. However, it is important to discuss the potential risks and benefits of ultraviolet light therapy before beginning treatment.

Before receiving ultraviolet light therapy, you may be asked to bathe and gently scrub areas affected by psoriasis, and then apply mineral oil to these areas; the oil allows the light to penetrate the skin more easily.

Although ultraviolet light therapy is effective for treating psoriasis, office treatment can be inconvenient and expensive, despite insurance coverage. Some dermatologists may recommend brief sun exposure or home light treatment as alternatives to office treatment.

Risks — Long term ultraviolet light therapy may increase risk for skin cancer. UV light therapy is not recommended for people with a history of melanoma or other skin cancers. (See "Patient information: Melanoma treatment; localized melanoma (Beyond the Basics)".)

Some clinicians also use lasers to treat psoriasis. The laser allows higher doses of UVB radiation to be directed to skin areas affected by lesions; as a result, skin may heal more quickly than with traditional ultraviolet light therapy. Laser treatment is most suitable for people who have small areas of psoriasis.

Oral medications

Methotrexate — Methotrexate treats psoriasis by suppressing the immune response that triggers the disease. This drug is often used to treat moderate to severe psoriasis and/or psoriatic arthritis. It is usually taken once per week, and it may be taken in oral (pill) form or as an injection.

Methotrexate can be used for long-term treatment of psoriasis, although it is important to have your liver monitored during treatment; methotrexate can affect liver function in some people. Improvement may not be seen until three months of methotrexate treatment are completed.

While taking methotrexate, many providers recommend taking folic acid 1 mg daily or folinic acid 5 mg weekly to reduce the risk of certain methotrexate side effects, such as upset stomach and a sore mouth.

Severe side effects can occur with methotrexate, including damage to the lungs, liver and bone marrow, so careful monitoring is essential. Serious interactions may occur with certain medications, particularly sulfa-type antibiotics.

Retinoids — Retinoids are derived from vitamin A. An oral form (acitretin, Soriatane^®) may be recommended to people with severe forms of psoriasis. Improvement may be noticeable within one month, although the full effect of retinoids may take up to 3 to 6 months.

Side effects of retinoids include cracking and drying of the lips and hair loss. Acitretin may cause increased levels of triglycerides and liver enzymes in the blood; blood testing is usually recommended to monitor for these changes. Acitretin can cause severe birth defects and is only slowly removed from the body, so this medication usually is not used in women of child-bearing potential.

Other immunosuppressive drugs — Several medications that suppress the immune system can be used to treat severe psoriasis for a short period of time. These include cyclosporine, hydroxyurea, and azathioprine.

Injectable medications — Several injectable medications, known as "biologics", target the immune system and may be beneficial in the treatment of psoriasis. Medications include etanercept (Enbrel^®), alefacept (Amevive^®), infliximab (Remicade^®), adalimumab (Humira^®), and ustekinumab (Stelara^®).

These medications can cost several thousand dollars per week, may affect immune function, and are generally reserved for people with moderate to severe psoriasis that has not responded to other treatments. Improvement in skin symptoms usually begins within a few weeks of starting treatment.

Etanercept, alefacept, and adalimumab are injected into the skin or muscle by the patient, a family member, or nurse. Ustekinumab injections should be given only by trained healthcare providers. Infliximab must be given into a vein over two to three hours, typically in a doctor's office or clinic.

Biologics, like methotrexate and cyclosporine, affect the immune system and should not be used in people with serious infections. Screening for tuberculosis is necessary before starting therapy since the risk of developing active TB infection is increased. If there is evidence of prior infection with tuberculosis, treatment to prevent reactivation is recommended. (See "Patient information: Tuberculosis (Beyond the Basics)".)

There may be an increased risk of lymphoma in people who take biologics and other drugs that affect the immune system; more research is needed to define this risk. (See "Overview of biologic agents in the rheumatic diseases".)

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Psoriasis (The Basics)
Patient information: Psoriatic arthritis in adults (The Basics)
Patient information: Psoriatic arthritis in children (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: Psoriatic arthritis (Beyond the Basics)
Patient information: Melanoma treatment; localized melanoma (Beyond the Basics)
Patient information: Tuberculosis (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Approach to the patient with a scalp eruption
Approach to the patient with anal pruritus
Approach to the patient with pustular skin lesions
Clinical manifestations and diagnosis of psoriatic arthritis
Epidemiology, clinical manifestations, and diagnosis of psoriasis
Management of psoriasis in pregnant women
Pathogenesis of psoriatic arthritis
Treatment of psoriasis
Treatment of psoriatic arthritis
Overview of biologic agents in the rheumatic diseases

The following organizations also provide reliable health information.

• National Library of Medicine

     (www.nlm.nih.gov/medlineplus/healthtopics.html)

• National Institute on Arthritis and Musculoskeletal and Skin Diseases

     (www.nih.gov/niams/healthinfo/)

• American Academy of Dermatology

     (www.skincarephysicians.com/psoriasisnet/whatis.html)

• American Academy of Allergy, Asthma and Immunology

     (www.aaaai.org)

• National Psoriasis Foundation

     1-800-723-9166
     (www.psoriasis.org/home/)

[1-5]