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Psoriasis sə-ˈrī-ə-səs

by Peter C. Schalock, MD

Psoriasis is a chronic, recurring disease that causes one or more raised, red patches that have silvery scales and a distinct border between the patch and normal skin.

  • A problem with the immune system may play a role, and some people are genetically predisposed to psoriasis.

  • Characteristic scales or red patches can appear anywhere on the body in large or small patches, particularly the elbows, knees, and scalp.

  • This disease is treated with a combination of exposure to ultraviolet light (phototherapy), drugs applied to the skin, and drugs taken by mouth or given by injection.

Psoriasis is common and affects about 1 to 5% of the population worldwide. Light-skinned people are at greater risk, whereas blacks are less likely to get the disease. Psoriasis begins most often in people aged 16 to 22 years and aged 57 to 60 years. However, people in all age groups and races are susceptible.

The patches of psoriasis occur because of an abnormally high rate of growth of skin cells. The reason for the rapid cell growth is unknown, but a problem with the immune system is thought to play a role. The disorder often runs in families, and certain genes are associated with psoriasis.

Symptoms

Psoriasis usually starts as one or more small patches on the scalp, elbows, knees, back, or buttocks. The eyebrows, underarms, navel, the skin around the anus, and the cleft where the buttocks meet the lower back may also be affected. Many people with psoriasis may also have deformed, thickened, and pitted nails.

The first patches may clear up after a few months or remain, sometimes growing together to form larger patches. Some people never have more than one or two small patches, and others have patches covering large areas of the body. Thick patches or patches on the palms of the hands, soles of the feet, or skinfolds of the genitals are more likely to itch or hurt, but many times the person has no symptoms. Although the patches do not cause extreme physical discomfort, they are very obvious and often embarrassing to the person. The psychologic distress caused by psoriasis can be severe.

Psoriasis persists throughout life but may come and go. Symptoms are often diminished during the summer when the skin is exposed to bright sunlight. Some people may go for years between occurrences.

Flare ups

Psoriasis may flare up for no apparent reason or as a result of a variety of circumstances. Flare-ups often result from conditions that irritate the skin, such as minor injuries and severe sunburn. Sometimes flare-ups occur after infections, such as colds and strep throat. Flare-ups are more common in the winter, after drinking alcohol, and after stressful situations. Many drugs, such as antimalarial drugs, lithium, angiotensin-converting enzyme (ACE) inhibitors, terbinafine, interferon-alpha, and beta-blockers, can also cause psoriasis to flare up. Flare-ups are also more common among people who are obese, infected with the human immunodeficiency virus (HIV), or smoke tobacco.


Uncommon types of psoriasis

Some uncommon types of psoriasis can have more serious effects.

Psoriatic arthritis causes joint pain and swelling (see Psoriatic Arthritis).

Erythrodermic psoriasis causes all of the skin on the body to become red and scaly. This form of psoriasis is serious because, like a burn, it keeps the skin from serving as a protective barrier against injury and infection.

Pustular psoriasis is another uncommon form of psoriasis. In this form, large and small pus-filled blisters (pustules) are scattered widely on the body.

Palmoplantar pustulosis is a form of psoriasis that involves pustules. In this form, the pustules occur primarily on the hands and feet.


Diagnosis

  • A doctor's evaluation

  • Rarely skin biopsy

Doctors base the diagnosis on how the scales and plaques look and where they appear on the body. Rarely, doctors take a sample of skin tissue and examine it under a microscope to rule out other disorders (such as skin cancer).

Treatment

  • Topical drugs

  • Phototherapy

  • Systemic drugs

Many drugs are available to treat psoriasis. Most often, a combination of drugs is used, depending on the severity and extent of the person's symptoms.

Topical drugs

Topical drugs (drugs applied to the skin) are used most commonly. Nearly everyone with psoriasis benefits from skin moisturizers (emollients).

Other topical agents include corticosteroids, often used together with calcipotriene (also called calcipotriol), which is a form of vitamin D, or coal tar. Tacrolimus and pimecrolimus are used to treat psoriasis that appears on delicate skin (such as on the face or groin or in skinfolds). Tazarotene or anthralin may also be used. Very thick patches can be thinned with ointments containing salicylic acid, which make the other drugs more effective. Many of these drugs are irritating to the skin, and doctors must find which ones work best for each person.

Phototherapy

Phototherapy (exposure to ultraviolet light) also can help clear up psoriasis for several months at a time (see Phototherapy: Using Ultraviolet Light to Treat Skin Disorders). Phototherapy is often used in combination with various topical drugs, particularly when large areas of skin are involved. Traditionally, treatment has been with phototherapy combined with the use of psoralens (drugs that make the skin more sensitive to the effects of ultraviolet light). This treatment is called PUVA (psoralen plus ultraviolet A). Many doctors are now using narrowband ultraviolet B (UVB) treatments, which are equally effective but avoid the need to use psoralens and the side effects they cause, such as extreme sensitivity to sunshine. Doctors can also treat specific patches of the skin directly by using a laser that focuses ultraviolet light.

Systemic drugs

For serious forms of psoriasis and psoriatic arthritis, drugs taken by mouth or given by injection are used. These drugs include cyclosporine, mycophenolate, methotrexate, and acitretin.

Cyclosporine is a drug that suppresses the immune system (immunosuppressant) and may cause high blood pressure and damage the kidneys.

Mycophenolate is an immunosuppressant that commonly causes gastrointestinal problems and bone marrow suppression (decreased production of red blood cells, white blood cells, and platelets). It may also increase the risk of lymphoma and other cancers.

Methotrexate decreases inflammation in the body and interferes with the growth and multiplication of skin cells. Doctors use methotrexate to treat people whose psoriasis is severe or does not respond to less harmful forms of therapy. Liver damage and impaired immunity are possible side effects.

Acitretin is particularly effective in treating pustular psoriasis but often raises fat (lipid) levels in the blood and might cause problems with the liver and bones as well as reversible hair loss. It causes severe birth defects and should not be taken by women who may become pregnant. Women should wait at least 3 years after their last dose of acitretin before attempting pregnancy.

People may also be given injections of etanercept, adalimumab, infliximab, alefacept, or ustekinumab. These drugs inhibit certain chemicals involved in the immune system and are called biologic agents. They tend to be the most effective drugs for severe psoriasis, but long-term safety is not clear.

Resources In This Article

Drugs Mentioned In This Article

  • Generic Name
    Select Brand Names
  • LAMISIL
  • LITHOBID
  • No US brand name
  • AVAGE, TAZORAC
  • ELIDEL
  • PROGRAF
  • DOVONEX
  • ENBREL
  • SORIATANE
  • REMICADE
  • OTREXUP
  • NEORAL, SANDIMMUNE
  • HUMIRA