Psoriasis Index Page

Psoriasis... Conventional Medical Treatment


Definition of psoriasis
Psoriasis is a skin condition characterized by red scaly patches.  There is a rapid increase in cell turnover within these patches resulting in scaling of the skin. The condition often runs in families and the possibility of genetic factors may play a part in inheriting psoriasis.  Psoriasis is non-infectious and cannot be caught or passed on by contact with someone who has psoriasis.

Incidence
2% of the UK population suffer from psoriasis which is visibly apparent. 5% of the population have psoriasis which is detectable upon close inspection of the skin. Psoriasis is found in all races but is often more apparent in cultures exposed to less sun.

Age and Sex
It commonly occurs in men and women at any stage in their lives and affects males and females equally.  Psoriasis is not common in childhood and early teens and normally first presents in late teens and early adulthood.


Causes and effects

Many factors may trigger an episode of psoriasis in a susceptible individual, although the exact cause of psoriasis is not known. Throat infections can cause flare-ups particularly in children. Skin injury may result in psoriasis outbreaks 5 or 6 weeks later at the injury site. Stress is also a factor in the flare-up of psoriasis for many individuals.

Although a few individuals may notice some aggravation to psoriasis lesions from exposure to the sun, the sun does seem to help improve the condition for most sufferers.

Psoriasis may be aggravated by alcohol but the role alcohol plays is uncertain. Some people believe that psoriasis may be aggravated by diet or improved by diet.  However no apparent connection between psoriasis and diet has been scientifically established although much anecdotal evidence exists. The anecdotal evidence would suggest that diet does play a vital part in the treatment and elimination of psoriasis. 

Within the epidermis, (the outer layers of the skin) the cells move up on a continual basis and are constantly being cast off. In a normal individual this process takes between 3 and 4 weeks. However, for an individual suffering from psoriasis the rate of cell cast off is substantially increased. The process of cell shedding may be as short as 3 or 4 days. The result is a build up of scale on the surface of the skin waiting to be shed off.

Signs and Symptoms
Scaly patches over the external areas of joints like the elbows and front of the knees is where psoriasis typically presents. Sometimes pressure occurring on these joints from kneeling or by leaning on the elbows at a desk, can cause mild psoriasis outbreaks. However, psoriasis may occur on the body anywhere. In 1% of individuals affected by psoriasis, it may also occur on the face. Other common sites for psoriasis are nails and on the scalp. Often psoriasis is non-itchy however, many sufferers have significant skin irritation and in some extreme cases severe itching.

Complications of Disorder
The problem of dry skin affecting elbows and knees is not recognised by the majority of people as in fact being psoriasis and often they are totally unaware they have the condition. Most people who are diagnosed with psoriasis experience occasional and irregular flare-ups of the condition and often lengthy periods of inactivity of the psoriasis. However a significant percentage of people do experience  psoriasis in its more extensive and disabling forms. (
severe psoriasis). In extreme cases psoriasis can affect all the skin of the patient. Psoriasis then has the potential to be life threatening, similar to severe sunburn.

Where sterile pustules develop in the skin, this is another form of psoriasis albeit quite rare. If this occurs over a wide area of the body, psoriasis again, can be a life threatening condition. The number of sufferers with psoriasis that exhibit these severe conditions is fortunately quite rare however.

Diagnostic Tests
A skin (clinical) examination will determine whether the patient has psoriasis or not.

When a suspect skin lesion is gently scratched with a finger nail or spatula and pin point bleeding is evident then this is a sure sign of psoriasis.

Treatment

The majority of medical treatment for psoriasis is dependent upon locally applied topical creams. Which include:

Emollients and Salicylic Acid

Aqueous cream emollients or greasier ones such as 50% white soft paraffin in liquid paraffin may help to reduce scaling. These can be applied whenever the skin feels dry. Preparations containing salicylic acid can be used on very scaly patches (known as plaques).

Topical Steroids
In certain situations these steroid preparations may be indicated. On trunk and limb psoriasis they tend to be largely ineffective. They are used when psoriasis affects the face, hairline, ears, umbilicus (tummy button), or groin. They are also used when there is psoriasis present on the scalp. Potent (strong) steroids are required to control psoriasis in these areas. If ongoing treatment is required on a non hair bearing area then close supervision is required and an ongoing potent treatment should not be encouraged because of serious future side effects. Once psoriasis has cleared locally it is often possible to control the psoriasis in these areas with a milder preparation which is safer for long-term usage.

Coal Tar Preparations
There are purified tar preparations which can help to reduce the inflammation and irritation of psoriasis, as well as being effective at clearing the disease. In practice these take at least 6 to 8 weeks to achieve any real response. The purified tars are clean to use and do not stain clothing. Messier tar preparations are sometimes used but usually only in severer psoriasis. Recent court cases in the US have resulted in coal tar preparations being labelled with cancer warnings.  Continued long-term use of coal tar preparations due to their carcinogenity is not recommended.

Dithranol
Dithranol is a helpful treatment for resistant psoriasis as it slows up cell turnover in the surface of the skin. When used at home the most cosmetically acceptable way of using the product is the short contact Dithranol method. If Dithranol is left in contact with normal skin it can cause burning, staining and damage any clothing worn.

Short contact Dithranol involves applying a Dithranol cream to the affected areas of psoriasis with gentle rubbing in until it is absorbed. Although usually recommended to be left on for 30 to 60 minutes, in practice the majority of individuals find that it works as well when left on for 10 minutes. This then is usually a more acceptable way of using the product as an individual will either have to stand naked with the cream on for 10 minutes or wear an old dressing gown which may then become stained. If used for a 10 minute regime then small amounts of Dithranol landing on normal skin should not cause any problems provided this is washed off thoroughly. After 10 minutes the preparation is washed off with copious amounts of soap and water in the shower or bath, the skin dried with an old towel and then a moisturizing cream applied to prevent any drying out from all the soap that has been used.

As the psoriasis starts to clear the treated areas will gradually stain brown, particularly on the skin around. This staining will disappear once the Dithranol is discontinued. The Dithranol has to be repeated on a daily basis and after the first week the strength can be increased. The strength of the Dithranol is usually increased at weekly intervals to the maximum that an individual is able to tolerate without burning. Dithranol treatment is mainly used for psoriasis on the trunk and limbs.

If Dithranol is effective it can be used on any subsequent outbreaks of psoriasis but should always be started at a weak level. If burning of the skin results then discontinuation of treatment may be necessary or reduction to a weaker strength may be required.

Vitamin D Analogues (Calcipotriol and Tacalcitol Preparations)
Preparations related to vitamin D, known as vitamin D analogues have been introduced for the treatment of psoriasis. They can be helpful in some individuals and are cosmetically highly acceptable. They appear to be relatively safe, although at the present time their safety in pregnancy and in breast feeding is not clearly established. It can take typically 4 or 6 weeks to know whether these preparations are effective. They are usually of benefit in reducing scaling but may not actually clear psoriasis completely when compared to Dithranol therapy. Irritation can occur if the vitamin D analogue is applied onto facial skin or genital skin.

Vitamin A Analogues (Tazarotene)
Tazarotene is new vitamin A gel applied once daily to patches of psoriasis. Some irritation may occur with its usage but otherwise it appears to be a cosmetically acceptable product effective in some individuals.

Special Sites

Scalp
Regular shampooing is required to control psoriasis in this area. If regular shampooing (daily) does not control it then a steroid scalp application or vitamin D analogue scalp lotion can be used. These appear to be safe for usage in the scalp even in the long term. If there are thick areas of scaling in the scalp preparations containing salicylic acid (Ung Cocois Co, Ung Pyragallol Co) may have to be used. These are messy preparations which are usually required to be left on overnight under a shower cap and washed off with a strong medicated shampoo in the morning. There are a number of new shampoos containing salicylic acid which when used twice a week in addition to regular daily shampooing with ordinary shampoos can help to reduce the subsequent rebuilding up of the scalp.

[Eds note: Under no circumstances use any shampoo that contains Sodium Lauryl Sulphate (SLS).  This is a toxic irritating chemical and is implicated with aggravating psoriasis. It is a strong irritant and can lead to outbreaks of eczema and psoriasis of the scalp in many people who are prone to skin conditions.  Also look out for Propylene Glycol (PG) and Sodium Hydroxide.  Both chemicals are may be strong irritants for susceptible people and should not be in contact with the skin.  Read our report about the role chemicals play in auto-immune disease

Nails
There is no effective treatment for nail psoriasis.

Ultraviolet Light Treatment
Sunlight is an effective treatment for psoriasis. Phototherapy (artificial ultraviolet light) may be indicated for resistant psoriasis (see moderate and severe psoriasis).

Outcome

In the majority of individuals it is possible to treat psoriasis reasonably effectively but not cure the problem. 1 out of 5 individuals may not see any recurrence within a 5 year period. 4 out of 5 individuals however will experience a recurrence of their psoriasis during the time and require further repeat treatment.


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