Psoriasis

OVERVIEW

What is psoriasis?

Psoriasis is an auto-immune skin disease that most commonly manifests on the elbows, knees, scalp, lower back, or joints as red, itchy silvery scales. It can range from a few spots of dandruff-like scales to major silvery scales on the skin. It tends to relapse after a few weeks or months and is more likely to affect individuals with family history of similar skin conditions.

It is a common long-term disease that can be treated on the basis of the site and surface area of the skin, the thickness of plaques and scales and if there is involvement of arthritic joints or not.

How does psoriasis develop?

Normally, skin cells take about 3–4 weeks to mature and shed, but in psoriasis, this process occurs in just 3–7 days. In psoriasis, the immune system mistakenly attacks healthy skin cells. Specifically, T-cells, which are white blood cells responsible for defending against infections, become overactive and trigger inflammation. This leads to an accelerated production of skin cells.  The rapid turnover results in the buildup of immature skin cells on the surface, forming the characteristic scaly plaques.

CAUSES

What causes psoriasis?

Psoriasis stems from internal disharmony of the body in terms of disturbed immunity and genetic predisposition along with environmental triggers.

1. Internal factors :
   – Defective immune system
   – Genetics
2. External factors

• Physical trauma including skin conditions (boils ,dermatitis , lichen planus , skin parasites and vitiligo) and skin trauma ( acupuncture , shaving, adhesive taping , chemical irritation, bites , tattoos and vaccinations )
• Certain medications like hypertension medication etc.
• Food allergens
• Triggering Factors
  Many people who are predisposed may be free of any symptoms for many years until the disease is triggered by:-
  – Infections like streptococcus infection of throat
  – Climate (Cold dry weather conditions )
  – Smoking
  – Stress
  – Alcohol consumption

Who is prone to psoriasis?

Psoriasis is a chronic autoimmune skin condition that can affect anyone, but certain individuals are at higher risk due to genetic, environmental, and lifestyle factors.

1. Genetic Factors:

• Family History: Having a parent or sibling with psoriasis increases the risk. The lifetime risk is approximately 14–28% if one parent has it and 40–65% if both parents are affected.

    2. Environmental Triggers:

• Infections: Bacterial infections like strep throat can trigger or worsen psoriasis.

• Skin Injuries: Cuts, sunburns, or insect bites may initiate psoriasis lesions.

• Medications: Certain drugs, including lithium, beta-blockers, and antimalarial medications, can trigger or exacerbate psoriasis symptoms.

    3. Lifestyle Factors:

• Stress: Emotional stress is a common trigger for psoriasis flare-ups.

• Smoking: Tobacco use increases the risk of developing psoriasis and can worsen existing symptoms.

• Alcohol Consumption: Heavy alcohol use is associated with an increased risk of psoriasis and may reduce the effectiveness of treatments.

• Obesity: Excess body weight, particularly abdominal fat, is linked to a higher risk of developing psoriasis and can exacerbate symptoms.

   4. Medical Conditions:

• Autoimmune Diseases: Individuals with other autoimmune conditions, such as rheumatoid arthritis or Crohn’s disease, are more likely to develop psoriasis.

• Chronic Diseases: Conditions like type 2 diabetes and cardiovascular diseases are associated with an increased risk of psoriasis.

TYPES

What are the types of psoriasis?

SIGNS AND SYMPTOMS

What are the signs and symptoms of psoriasis?

Signs and symptoms of psoriasis, a chronic autoimmune condition that accelerates skin cell turnover, leading to various skin manifestations:

Skin Symptoms

1. Red, Raised Patches (Plaques)
   Thick, inflamed areas covered with silvery-white scales. Commonly appear on elbows, knees, scalp, and lower back.

2. Dry, Cracked Skin
   Skin may crack and bleed, leading to discomfort and potential infection.

3. Itching, Burning, or Soreness
   Affected areas can be itchy or sore, causing significant discomfort.

4. Cyclic Flare-ups
   Symptoms may flare for weeks or months and then subside, with periods of remission in between.

Nail Symptoms

5. Pitting
   Small depressions in the nails.

6. Discoloration
   Nails may become discolored or yellowish.

7. Thickening or Crumbling
   Nails may thicken or crumble.

8. Separation from Nail Bed
   Nails may loosen and separate.

Joint Symptoms

9. Psoriatic Arthritis
   Pain, swelling, and stiffness in joints, a condition known as psoriatic arthritis, which affects 10%–30% of individuals with psoriasis.

DIAGNOSIS

How can we diagnose psoriasis?

Diagnosing psoriasis typically involves a combination of clinical evaluation and, when necessary, histopathological examination. Here’s an overview of the standard diagnostic procedures:

Clinical Diagnosis:

1. Physical Examination
   A dermatologist inspects the skin, nails, and scalp for characteristic signs of psoriasis, such as red, raised patches covered with silvery scales. They assess the distribution, size, and appearance of lesions to make a preliminary diagnosis .

2. Medical History Assessment
   The doctor inquires about symptoms like itching, nail changes (e.g., thickening or yellowing), joint pain, family history of psoriasis, and recent stressors or illnesses that might trigger flare-ups .

3. Auspitz Sign
   Gently scraping the surface of a psoriatic plaque may reveal pinpoint bleeding, known as the Auspitz sign, which is indicative of psoriasis .

Confirmatory Tests:

4. Skin Biopsy
   If the diagnosis is uncertain or to differentiate psoriasis from other skin conditions like eczema or fungal infections, a skin biopsy may be performed. A small skin sample is taken and examined under a microscope to confirm the presence of psoriasis .

Severity Assessment Tools:

5. Psoriasis Area and Severity Index (PASI)
   This tool evaluates the severity of psoriasis by assessing the extent of affected skin areas and the severity of erythema (redness), induration (thickness), and desquamation (scaling) .

6. Body Surface Area (BSA)
   Estimates the percentage of the body affected by psoriasis to gauge severity.

7. Psoriasis Epidemiology Screening Tool (PEST)
   A screening tool used to identify signs of psoriatic arthritis in patients with psoriasis .

Additional Diagnostic Measures:

8. Imaging Techniques
   In some cases, advanced imaging methods like high-frequency ultrasound or reflectance confocal microscopy may be employed to assess skin lesions and monitor treatment response .

What is the differential diagnosis of psoriasis?

1. Atopic Dermatitis (Eczema)

Atopic dermatitis is a chronic inflammatory skin condition characterized by dry, itchy patches. Unlike psoriasis, it typically lacks the thick, silvery scales and well-demarcated plaques. Eczema often begins in childhood and commonly affects the flexural areas such as the inside of elbows and behind knees. Psoriasis, on the other hand, frequently affects extensor surfaces like elbows and knees.

2. Seborrheic Dermatitis

Seborrheic dermatitis presents as greasy, yellowish scales on an erythematous base, commonly affecting the scalp, face, and chest. The scales are often white or yellow rather than silvery and feel greasy. In contrast, psoriasis scales tend to be dry and well-defined. 

3. Pityriasis Rosea

Pityriasis rosea typically begins with a large herald patch followed by smaller daughter patches in a “Christmas tree” distribution. It often resolves on its own within eight weeks and is usually self-limiting. In contrast, guttate psoriasis appears as red, teardrop-like scaly spots, often triggered by infections such as strep throat, and may require treatment.

4. Lichen Planus

Lichen planus presents as purple, polygonal, pruritic papules, often involving wrists, ankles, and oral mucosa. Wickham striae (white lines on lesions) are characteristic. Psoriasis typically lacks these features and presents with well-demarcated plaques covered with silvery scales.

5. Tinea Corporis (Ringworm)

Tinea corporis presents as annular, scaly lesions with central clearing and raised borders, caused by dermatophyte infection. In contrast, psoriasis presents as well-demarcated plaques with silvery scales and lacks the central clearing seen in tinea infections.

6. Drug Eruptions

Certain medications can cause drug eruptions that mimic psoriasis, presenting as erythematous, scaly lesions. A detailed history of recent drug intake and temporal relationship with lesion appearance can aid in diagnosis.

Can homoeopathic medicines help in this case?

Yes, homoeopathic medicines are helpful in this case. Some of the homeopathic medicines are:

1. Arsenicum Album

• Indications: Dry, rough, scaly eruptions with intense burning and itching. Symptoms worsen in cold weather and at night, and improve with warmth. Patients may experience restlessness, anxiety, and a desire for frequent sips of water.

2. Graphites

• Indications: Thick, cracked skin with sticky, honey-like discharge. Often used for scalp psoriasis with crusty patches and burning sensations. The skin may be sore to touch, with distressing itching.

3. Sulphur

• Indications: Severe itching and burning in psoriatic lesions, often leading to scratching until bleeding occurs. The skin appears rough, scaly, and painful after scratching. Symptoms worsen in the evening and at night, especially in bed.

4. Petroleum

• Indications: Deep, painful cracks in the skin with intense itching and burning. The skin may be sore, hard, and fissured, often slow to heal. A crawling sensation on the skin may also be present. 

5. Arsenicum Iodatum

• Indications: Shedding of large scales from inflamed patches, leaving raw skin behind. Persistent itching and burning sensations accompany the eruptions.

FREQUENTLY ASKED QUESTIONS

Is Psoriasis and Eczema same disease condition?

Psoriasis and eczema are two common skin conditions, but they are different in causes, appearance, and treatments. While both can cause discomfort and itching, understanding their key differences can help manage them better.  

How Stress Affects Psoriasis?