You should see your doctor or health care practitioner if you have symptoms of psoriasis, such as red raised patches of skin with silvery scales, and do not feel comfortable with how your skin looks or feels. Psoriasis is usually a mild inconvenience to most people. However, for others, it may be disabling or painful. The doctor can prescribe treatments that help. If symptoms are treated when they first appear, the condition will usually not progress.
When someone with psoriasis visits the doctor, he or she is usually concerned about raised, itchy, red areas on the skin that are scaly or peeling. The individual is typically self-conscious about the plaques or scaly areas and uses clothing to cover the affected skin to avoid being embarrassed in public.
Those with psoriasis commonly recognize that new areas of psoriasis occur within 7-10 days after the skin has been injured. This has been called the Koebner reaction. Sometimes, the reverse occurs in which psoriasis clears after injury to the skin.
You should always see your doctor if you have psoriasis and develop significant joint pain, stiffness, or deformity. You may be in the reported 10% of individuals with psoriasis that develop psoriatic arthritis.
You also should always see your doctor if signs of infection develop. Common signs of infection are red streaks or pus from the red areas, fever with no other cause, or increased pain.
See your doctor if you have serious side affects from your medications. (See Understanding Psoriasis Medications.)
Exams and Tests
Psoriasis is typically diagnosed after the doctor or health care practitioner does a physical exam. The doctor generally can tell if it is psoriasis just by observing the patches on the skin. The typical appearance of psoriasis is noted in Symptoms.
Skin biopsies can confirm the diagnosis of plaque psoriasis. However, they are usually used to evaluate unusual cases or to rule out other conditions when the diagnosis is not certain.
Psoriasis Treatment
Self-Care at Home
Exposure to sunlight helps many people with psoriasis.
Keeping the skin soft and moist is helpful. Apply heavy moisturizers after bathing.
Do not use irritating cosmetics or soaps.
Avoid scratching or itching that can cause bleeding or excessive irritation.
Soaking in bath water with oil added and using moisturizers may help. Bath soaks with coal tar or other agents that remove scales and reduce the plaque may also help.
Cortisone creams can reduce the itching of mild psoriasis and are available without a prescription.
Some people use an ultraviolet B unit at home under a doctor’s supervision. A dermatologist may prescribe the unit and instruct the patient on home use, especially if it is difficult for the patient to get to the doctor’s office for phototherapy treatment.
Medical Treatment
Psoriasis is a chronic skin condition. Any approach to the treatment of this disease must be considered for the long term. Treatment regimens must be individualized according to age, sex, occupation, personal motivation, other health conditions, and available resources. Disease severity is defined not only by the number and extent of plaques present but also by the patient's perception and acceptance of the disease. Treatment must be designed with the patient's specific expectations in mind, rather than focusing on the extent of body surface area involved.
Many treatments exist for psoriasis. However, the construction of an effective therapeutic regimen is not necessarily complicated.
There are 3 basic types of treatments for psoriasis: (1) topical therapy (drugs used on the skin), (2) phototherapy (light therapy), and (3) systemic therapy (drugs taken into the body). All of these treatments may be used alone or in combination.
Topical agents: Medications applied directly to the skin are the first course of treatment options. The main topical treatments are corticosteroids, vitamin D-3 derivatives, coal tar, anthralin, or retinoids. There isn't one topical drug that is best for all people with psoriasis. Because each drug has specific adverse effects, it is common to rotate them. Sometimes drugs are combined with other drugs to make a preparation that is more helpful than an individual topical medication. For example, keratolytics (substances used to break down scales or excess skin cells) are often added to these preparations. Some drugs are incompatible with the active ingredients of these preparations. For example, salicylic acid (a component of aspirin) inactivates calcipotriene (form of vitamin D-3). On the other hand, drugs such as anthralin (tree bark extract) require addition of salicylic acid to work effectively.
Phototherapy (light therapy): The ultraviolet (UV) light from the sun slows the production of skin cells and reduces inflammation. Sunlight helps reduce psoriasis symptoms in some people. If psoriasis is widespread, as defined by more patches than can easily be counted, then artificial light therapy may be used. Resistance to topical treatment is another indication for light therapy. Proper facilities are required for the two main forms of light therapy. The medical light source in a physician's office is not the same as the light sources generally found in tanning salons.
UV-B: Ultraviolet B (UV-B) light is used to treat psoriasis. UV-B is light with wavelengths of 290-320 nanometers (nm). (The visible light range is 400-700 nm.) UV-B therapy is usually combined with one or more topical treatments. UV-B phototherapy is extremely effective for treating moderate-to-severe plaque psoriasis. The major drawbacks of this therapy are the time commitment required for treatments and the accessibility of UV-B equipment.
The Goeckerman regimen uses coal tar followed by UV-B exposure and has been shown to cause remission in more than 80% of patients. Patients may complain of the strong odor when coal tar is added.
In the Ingram method, the drug anthralin is applied to the skin after a tar bath and UV-B treatment.
UV-B therapy is usually combined with the topical application of corticosteroids, calcipotriene (Dovonex), tazarotene (Tazorac), or creams or ointments that soothe and soften the skin.
PUVA: PUVA is the therapy that combines a psoralen drug with ultraviolet A (UV-A) light therapy. Psoralen drugs make the skin more sensitive to light and the sun. Methoxsalen is a psoralen that is taken by mouth several hours before UV-A light therapy. UV-A is light with wavelengths of 320-400 nm. More than 85% of patients report relief of disease symptoms with 20-30 treatments. Therapy is usually given 2-3 times per week on an outpatient basis, with maintenance treatments every 2-4 weeks until remission. Adverse effects of PUVA therapy include nausea, itching, and burning. Long-term complications include increased risks of sensitivity to the sun, sunburn, skin cancer, and cataracts.
Systemic agents (drugs taken within the body): These drugs are generally started only after both topical treatment and phototherapy have failed. For generalized pustular psoriasis, systemic agents such as retinoids may be required from the beginning of treatment. This may be followed by PUVA treatment. For milder and chronic forms of pustular psoriasis, topical treatment or light treatment may be tried first. Systemic agents may be considered for very active psoriatic arthritis. People whose disease is disabling because of physical, psychological, social, or economic reasons may also be considered for systemic treatment.
Medications
Medications applied directly to the skin are the first course of treatment options. The main topical treatments are corticosteroids, vitamin D-3 derivatives, coal tar, anthralin, or retinoids. For more detailed information on each medication, see Understanding Psoriasis Medications. Generic drug names are listed below with examples of brands in parentheses.
Topical medications
Vitamin D: Calcipotriene (Dovonex) is a form of vitamin D-3 and slows the production of excess skin cells. It is used in the treatment of moderate psoriasis. This cream, ointment, or solution is applied to the skin 2 times a day.
Coal Tar: Coal tar (DHS Tar, Doak Tar, Theraplex T) contains literally thousands of different substances that are extracted from the coal carbonization process. Coal tar is applied topically and is available as shampoo, bath oil, ointment, cream, gel, lotion, ointment, paste, and other types of preparations. The tar decreases itching and slows the production of excess skin cells.
Corticosteroids: Clobetasol (Temovate), fluocinolone (Synalar), and betamethasone (Diprolene) are commonly prescribed corticosteroids. These creams or ointments are usually applied twice a day, but the dose depends on the severity of the psoriasis.
Tree Bark Extract: Anthralin (Dithranol, Anthra-Derm, Drithocreme) is considered to be one of the most effective antipsoriatic agents available. It does have potential to cause skin irritation and staining of clothing and skin. Apply the cream, ointment, or paste sparingly to the patches on the skin. On the scalp, rub into affected areas. Avoid the forehead, eyes, and any skin that does not have patches. Do not apply excessive quantities.
Topical retinoid: Tazarotene (Tazorac) is a topical retinoid that is available as a gel or cream. Tazarotene reduces the size of the patches and the redness of the skin. This medicine is sometimes combined with corticosteroids to decrease skin irritation and to increase effectiveness. Tazarotene is particularly useful for psoriasis of the scalp. Apply a thin film to the affected skin every day or as instructed. Dry skin before using this medicine. Irritation may occur when applied to damp skin. Wash hands after application. Do not cover with a bandage.
Systemic medications (those taken by mouth or injection)
Psoralens: Methoxsalen (Oxsoralen-Ultra) and trioxsalen (Trisoralen) are commonly prescribed drugs called psoralens. Psoralens make the skin more sensitive to light. These drugs have no effect unless carefully combined with ultraviolet light therapy. This therapy, called PUVA, uses a psoralen drug with ultraviolet A (UV-A) light to treat psoriasis. This treatment is used when psoriasis is severe or when it covers a large area of the skin. Psoralens are taken by mouth several hours before PUVA therapy or sunlight exposure. They are also available as creams, lotions, or in bath soaks. More than 85% of patients report relief of disease symptoms with 20-30 treatments. Therapy is usually given 2-3 times per week on an outpatient basis, with maintenance treatments every 2-4 weeks until remission. Adverse effects of PUVA therapy include nausea, itching, and burning. These drugs cause sensitivity to sunlight, risk of sunburn, skin cancer, and cataracts.
Etanercept (Enbrel): This is the first drug that the FDA approved for treating psoriatic arthritis. It is a manufactured protein that works with the immune system to reduce inflammation. Etanercept is given as an injection 2 times per week. The drug can be injected at home. Rotate the site of injection (thigh, upper arm, abdomen). Do not inject into bruised, hard, or tender skin. Enbrel affects your immune system and rarely is associated with heart failure.
Methotrexate (Rheumatrex): This drug is used to treat plaque psoriasis or psoriatic arthritis. It suppresses the immune system and slows the production of skin cells. Methotrexate is taken by mouth (tablet) or as an injection once per week. Women who are planning to become pregnant or who are pregnant should not take this drug. Men must not take this drug if there is a possibility that they will impregnate their partners because it can go into the sperm. The doctor will order blood tests to check your blood cell count and liver and kidney function on a regular basis while on this medicine.
Cyclosporine (Sandimmune, Neoral): This drug suppresses the immune system and slows the production of skin cells. Cyclosporine is taken by mouth once a day. Your doctor will order tests to check your kidney and liver function and levels of cyclosporine in your blood while you are on this medicine. Cyclosporine may increase the risk of infection or lymphoma, and it may cause high blood pressure.
Alefacept (Amevive): In 2003, the FDA approved this drug for the treatment of psoriasis. It suppresses the immune system to slow down the production of skin cells. Alefacept is given as an injection once per week. Women who become pregnant while taking alefacept should be enrolled in the manufacturer’s pregnancy registry by calling (866) 263-8483. Alefacept may increase the risk of malignancy or infection; may cause allergy or swelling of the throat or tongue; and may cause a hard lump, inflammation, or bleeding at the injection site.
Other Therapy
Conventional therapy has been tested with clinical trials. The FDA has approved conventional drugs for the treatment of psoriasis. Some look to alternative therapy, diet changes, supplements, or stress reducing techniques to help reduce symptoms. For the most part, alternative therapies have not been tested with clinical trials, and the FDA has not approved dietary supplements for treatment of psoriasis. However, some other therapies can be found on the National Psoriasis Foundation Web site. Individuals should check with their doctors before starting any therapy.
Follow-up
Plaque psoriasis is a chronic disease that goes away and returns. Follow-up care depends on the severity of the disease at any given time.
If a patient has evidence of psoriatic arthritis, a consultation with a rheumatologist (one who specializes in arthritis) is helpful.
Prevention
Avoiding environmental factors that trigger psoriasis, such as smoking, sun exposure, and stress, may help prevent or minimize flare-ups of psoriasis. Sun exposure may help in many cases of psoriasis and aggravate it in others.
Alcohol is considered a risk factor for psoriasis in young to middle-aged men. Avoid or minimize alcohol use if you have psoriasis.
Specific dietary restrictions or supplements other than a well-balanced and adequate diet are unimportant in the management of plaque psoriasis.
Outlook
Psoriasis is more of an inconvenience in most cases than it is threatening. However, it is a chronic disease and reoccurs. The itching, peeling, and splitting of skin at joints can lead to significant pain and self-esteem issues. By far, the patient's quality of life is affected most with plaque psoriasis. Self-consciousness and embarrassment about appearance, inconvenience, and high costs of treatment options all affect one’s outlook when living with psoriasis.
Complications of the disease are relatively uncommon. Many of the complications of plaque psoriasis are related to the treatments used for the disease. Overly aggressive use of topical steroids could lead to more severe forms of psoriasis (from plaque to pustular for example). Bandages should not be used with topical steroids because inflammation and swelling may occur. Oversensitivity to the sun is possible with many of the treatment options (especially phototherapy).
About 10% percent of all cases of plaque psoriasis are associated with psoriatic arthritis.
Anxiety, depression, or stress may worsen symptoms and increase the tendency to itch.
Methotrexate, PUVA, cyclosporine, and oral retinoids all have helped to induce and maintain remission in severe cases of plaque psoriasis.
Support Groups and Counseling
Patient education is one of the foundations for managing this chronic and typically relapsing disorder. Patients should be familiar with the treatment options in order to make proper informed decisions about therapy. The National Psoriasis Foundation is an excellent organization that provides support to patients with psoriasis.
For More Information
National Psoriasis Foundation
6600 SW 92nd Ave, Suite 300
Portland, OR 97223-7195
(800) 723-9166
National Institute of Arthritis and Musculoskeletal and Skin Diseases
Information Clearinghouse
National Institutes of Health
1 AMS Circle
Bethesda, MD 20892-3675
(877) 22-NIAMS
American Academy of Dermatology
PO Box 4014
Schaumburg, IL 60168-4014
(847) 330-0230
From:
http://www.emedicinehealth.com/scrip...48&pf=3&page=1
psoriasis
