PSORIASIS is an inflammatory skin condition characterized by well-defined red plaques with a white scale surface. Psoriasis affects both children and adults with an incidence roughly equal between men and women.
Over six million Americans, involving all races, are affected. Caucasians, however, have a slightly higher incidence. First involvement usually occurs between adolescence and middle age. The areas involved can
be anywhere on the body. The most common sites are the scalp, elbows, knees and upper buttock area.
The exact cause of psoriasis is unclear; however, genetics and environment play key roles. Examples of environmental influences include climate, trauma
to the skin, or an infection of the ear or upper respiratory tract. There is clear evidence that psoriasis is genetically linked. The National Psoriasis
Foundation® reports incidence rates of approximately ten-percent if one parent has psoriasis compared to fifty-percent if both parents have psoriasis.
Psoriasis is not a skin disease. It is a skin condition characterized by rapidly dividing skin cells. The cells divide and grow at a rate almost ten times faster
than normal skin. The most common type of psoriasis is psoriasis vulgaris (vulgaris meaning common). This presents as plaque-like involvement on the
scalp, trunk and extremities. Guttate psoriasis (numerous small plaques) is another type of psoriasis frequently associated with an ear or upper
respiratory tract infection. Other types of psoriasis include pustular psoriasis (numerous vesicles) and erythroderma (ill-defined and confluent red scaling areas on the trunk and extremities).
Exacerbating Factors:
Injury: Avoid skin injury! Local injury can exacerbate or cause new psoriatic lesions. This is called the Koebner phenomenon. Examples of injuries
include trauma, sunburn, scratches, tight jewelry or restrictive clothing.
Infections: Infections may stimulate the onset of psoriasis. Research in this area is ongoing. It is thought that the stimulus of streptococcal infection
(strep throat) may initiate or exacerbate psoriasis. Guttate psoriasis, in particular, is associated with streptococcal infection. If there is any question
of infection, consult your physician for treatment.
Medications: Some medications may exacerbate psoriasis. Examples include antimalarials, lithium, quinidine, indomethacin, Inderal and other beta-blockers.
Stress: In some people, stress may flare psoriasis. This type of reaction may be seen up to 30 days after a stressful event. If the psoriasis is
uncontrollable, the stress factor may need to be addressed with relaxation, exercise or possibly stress reduction medications.
Diet and Psoriasis
There are varied opinions and theories concerning diets, foods and dietary supplements when treating psoriasis. Unfortunately, most diets and
supplements for psoriasis sound too good to be true. Claims lack long-term clinical follow-up. Diets that have been used historically include: the turkey
diet, the low-protein diet, the starvation and weight-loss diet, the Pagano diet, zinc supplementation, fish oil supplementation, evening primrose oil, lecithin and sassafras.
In addition, vitamins have also been used to treat psoriasis, specifically, vitamins A and E. These vitamins, however, are not beneficial when taken in
safe daily doses. Chinese medicine and acupuncture have also been used to treat psoriasis. These treatments have varying degrees of success and
are not universally recommended as “predictable treatments.”
Much of the problem when treating psoriasis is acknowledging the fact that this is a medical condition. A person’s response to therapy depends on their
genetic background as well as environmental influences. In fact, psoriasis may improve or clear with little or no treatment at all. Conversely, there may
be times when psoriasis is extremely resistant to potent treatments that may have worked in the past.
Keep in mind that psoriasis responds to the physical and emotional well being of the individual. Maintaining a low stress lifestyle along with a
balanced healthy diet is very beneficial in conjunction with proposed treatments.
Emotions and Psoriasis:
Psoriasis is an emotional issue. People with psoriasis may feel “different” from others. There is a sense of depression that may affect day-to-day
interaction as well as personal relationships. Feelings must be addressed so that the condition can be accepted and people can move on with their
lives. Many times, physicians are not responsive to the emotional needs of psoriasis patients. Additional support from close friends and family is
essential. Often, consultation with a professional counselor is beneficial.
Pregnancy and Psoriasis:
Transmission from one generation to another is not completely understood. Genetic predisposition along with environmental influence seem to play key roles.
Although psoriasis can affect the whole body, it does not affect conception or pregnancy. The treatments during pregnancy are more concerning than the
psoriasis itself. While attempting to conceive, the following treatments must be avoided: isotretinoin (Accutane®), acitretin (Soriatane®), PUVA
(psoralen ultraviolet light A), methotrexate, hydroxyurea (Hydrea®), cyclosporine (Neoral®), and calcipotriene (Dovonex®). Consult your
physician if planning a family while on any of these medications. It is generally accepted that topical cortisone and phototherapy (UVB/sunlight) are acceptable during conception.
Pregnancy: During pregnancy, psoriasis may improve, remain the same or worsen. This response varies in each individual. It is reported, however, that
most psoriasis flares occur within the first six months after delivery. During pregnancy, as during conception, systemic medications should be avoided.
Phototherapy (light treatments) and moisturizers are conservative first line treatments during pregnancy. Topical cortisone may be used for severe or
problematic psoriasis. Care must be taken as topical cortisone is absorbed internally if used over large body surfaces. Oral steroids have been used for
severe or resistant cases. Your physician, however, should monitor steroid use closely.
Finally, arthritis can accompany psoriasis and be particularly problematic during pregnancy. This should be discussed with your physician, as many
arthritic medications can be taken and used safely during pregnancy.
Nursing: As with conception and pregnancy, oral treatments must be avoided while nursing. Many of these agents are secreted in breast milk.
Topical agents such as cortisone, tar, Dovonex®, and anthralin may also be secreted in breast milk. Your physician will advise you as to what is
acceptable while breast-feeding. Psoriasis on the nipple will not harm an infant while nursing. Over-the-counter one-percent hydrocortisone ointment is
acceptable if used sparingly. A moisturizer is then used over the hydrocortisone. The nipple area should be cleansed prior to nursing.
Psoriasis in Infants:
Although uncommon, psoriasis may affect infants. Many times the diagnosis is confused with other conditions such as seborrheic dermatitis, ringworm or
diaper rash. Care must be taken, as infant skin is thin and delicate. An infant usually cannot tolerate the same topical medications as an
adult. Conservative treatments with moisturizers and petroleum jelly should be used initially. Treatment should be monitored by your dermatologist.
Recommendations:
Psoriasis treatment depends on the extent and severity of involvement. Many times, simple maintenance strategies help control and maintain the
condition. Treatments are usually combined or rotated to speed clearance and minimize side effects.
Washing: Mild soaps or soap-free cleansers are beneficial, as
they do not irritate or dry out the skin. Soaking in warm baths with bath salts or tar products will help loosen the scales. Use a washcloth or loofah sponge to help exfoliate affected areas.
The skin should then be gently patted dry and medications or moisturizers should be applied immediately.
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Moisturizers: Keeping the skin moisturized has long been known to help psoriasis. Daily lubrication after a shower or bath is essential for treatment
and prevention of psoriasis. Moisturizing gives the skin flexibility and helps reduce flaking and cracking associated with psoriasis. Creams are better
than lotions. The following ingredients are helpful: propylene glycol, glycerin, salicylic acid or lactic acid. Most of these ingredients are readily available in over-the-counter preparations.
Scalp Psoriasis
Almost 50% of patients with psoriasis have scalp
involvement. Conversely, it is unusual to have scalp psoriasis without involvement on other parts of the body. Most patients with scalp psoriasis experience itching and
flaking. This is problematic as the Koebner phenomenon may exacerbate the condition. (The Koebner phenomenon is localized psoriasis that occurs in response to trauma.)
<Black Mud Shampoo
Scalp psoriasis treatment is intensive, as the hair may act as a barrier between topical medications and the psoriasis. Successful treatment is
achieved when the scales are loosened and removed. Products that accomplish this are called keratolytics. These products contain ingredients such as salicylic acid, urea, lactic acid or phenol.
Water and lubricants are often used to soften and loosen scales. To be effective, a shower or wet towel should be used for at least five minutes.
Many people use mineral oil or olive oil overnight. The scalp is saturated with oil and a shower cap is used to prevent the oil staining on the bedding.
Heating the oil or using a hair dryer after application increases the effectiveness of the treatment.
Facial Psoriasis
Facial psoriasis is most commonly seen on the forehead and on the upper lip area. Many times, facial psoriasis can mimic seborrheic dermatitis (dandruff) and therefore is treated inadequately.
First apply a moisturizer or petroleum jelly. If this is ineffective, use an over-the-counter one-percent hydrocortisone cream twice daily. Moisturizers or petroleum
jelly should then be applied over the medication. 1% Hydrocortisone Cream with Aloe>
In addition, 15 to 20 minutes daily of sunlight used with petroleum jelly may be helpful. Care should be taken not to burn, as this may exacerbate the
psoriasis. Remember all creams and ointments should be applied thinly and kept away from the mucous membranes of the eyes. Prolonged use of
topical cortisone can permanently thin the skin. Over-application of all products serves no therapeutic benefit. Use only as directed.
Psoriasis around the Eyes
If the eyelid is involved, this can be cleansed with a solution of tap water and baby shampoo used once or twice daily. A washcloth is then used with gentle
rubbing to remove excess scale. Emollients should be applied. Potent cortisone around the eyes should be avoided as this can lead to glaucoma or cataract.
The inner lining of the eye can also be involved with psoriasis. This is called conjunctivitis. This is a very sensitive area and your ophthalmologist should be consulted for treatment.
Psoriasis in the Ears
The skin in the ears is a delicate area. Care must be taken with any topical treatment. Many times earwax removal kits will also remove psoriasis scale.
Follow the directions on the package insert. After application, warm water and a thin layer of mineral oil can be applied in the ear canal. This helps
keep the area lubricated and controls excess scaling. If needed, over-the–counter one-percent hydrocortisone cream may be used twice
daily. If these conservative treatments are ineffective, prescription medications can be recommended by your dermatologist.
Psoriasis in the Mouth
Sometimes psoriasis may involve the tongue or mucous membranes of the mouth or lips. Exercising good hygiene and rinsing the mouth with saline
solutions can help relieve oral discomfort. In addition, over-the-counter steroid creams such as one-percent hydrocortisone ointment may be applied
liberally to the lips. If the above is ineffective, you should see your dermatologist about other topical treatments.
Psoriasis on the Hands and Feet
Involvement of the hands and feet is common with psoriasis. It creates problems as this can interfere with work and also result in social avoidance.
The hands and feet are treated more aggressively, as they can crack and become infected. Maintenance must be done twice daily.
Soaking in a tar or salt bath helps control the thickness and scaling of the skin. This is done for 20 to 30 minutes at least once a day followed by a skin
file or pumice stone. Soaking also enhances the penetration of topical medications. Fissures should be closed with Superglue or a topical skin bonding “glue” such as Dermaflex.
The action of topical cortisone creams is enhanced by occlusion with cellophane wrap or the use of wet cotton gloves or socks for at least two
hours in the evening. Prescription medication such as Dovonex®, Tazorac® or topical cortisone may be used if the above modalities are
ineffective. Frequently, other therapies such as acitretin (Soriatane®), PUVA (psoralen ultraviolet light A), methotrexate, hydroxyurea (Hydrea®), and
cyclosporine (Neoral®) may be prescribed by your dermatologist.
Nail Psoriasis
Nail psoriasis is common and it affects the majority of psoriasis patients. It presents as nail discoloration or a thickening and irregular growth of the nail
plate. Unfortunately, there are no great topical treatments for nail psoriasis. Some dermatologists inject the nail area with cortisone, which can be
effective. Oral treatments help, however, the risks need to be weighed. Hand PUVA (psoralen ultraviolet light A) is also used by some dermatologists as an option.
Finally, nails can be surgically removed or covered artificially. A manicurist can make a dramatic difference with buffing and polishing. Some people
respond to soaking the nails in a tar or salt bath. This must be done for at least 20 minutes a day and then a moisturizer or a nail conditioner is rubbed
into each cuticle and nail area. The nails are trimmed straight across to the point of attachment. If the nails are thick, trimming should be done with a
heavy-duty nail clipper after soaking. Avoid vigorous cleaning and scraping of the nail area. This can stimulate the psoriasis and make the condition worse.
Genital Psoriasis
Genital psoriasis is also common and may be the only area involved. The skin is naturally thin and sensitive to treatment. It frequently appears as
“non-scaly red plaques” that itch or may even hurt.
Initially, the genital area should be treated similar to the scalp. A medicated shampoo should be applied and left on for 5 to 10 minutes during bathing. A
mild cortisone such as one-percent hydrocortisone may be then applied twice daily. Itching can be addressed with tar or salt baths once or twice daily
for 20 to 30 minutes. Anti-itch creams can also be applied liberally throughout the day for symptomatic relief.
Loose fitting, cotton, breathable fabrics are the least irritating and most comfortable undergarments. Permanent press clothing contains
formaldehyde and may irritate psoriasis. It has been reported that latex products, such as those used for feminine hygiene, may exacerbate psoriasis.
Psoriasis may co-exist, or be confused, with fungal infections in the groin area. Frequently, antifungals are added to the maintenance regimen for a
period of 7 to 10 days. These creams are used twice daily in addition to the maintenance regimen for psoriasis. If the genital areas do not respond to
treatment, consult your dermatologist for further evaluation.
Psoriasis in Skin Folds
Psoriasis, between the skin folds, can frequently mimic another condition called intertrigo. Intertrigo is a rash from a superficial bacterial and fungal
infection. Many times there is overlap between the two conditions and both must be treated simultaneously for improvement. An over-the-counter cortisone anti-inflammatory such as one-percent
hydrocortisone can be used twice daily.
A topical antifungal is added and mixed with the anti-inflammatory cream. The above should be covered with a moisturizer. In addition, salt or tar baths
are soothing and will help improve this condition. If this is ineffective, consult your dermatologist.
Anti-inflammatories
There is an underlying inflammatory component related to psoriasis. The exact role is unclear, however, anti-inflammatories such as topical cortisone
creams are very helpful. These preparations are used daily and must be covered with a thick moisturizer. Prescription strength topical cortisone may
have side effects such as thinning of the skin or internal absorption. These products are all easy to use and often the first line of treatment for localized psoriasis.
Coal Tar
Coal tar has been used for centuries to treat psoriasis. It is now more refined and available as a prescription or over-the-counter medication. It may be
used as a shampoo, bath solution or directly applied to the skin. Individuals usually apply the preparation at bedtime and then wash it off in the
morning. These preparations can have an unpleasant odor and stain clothing; however, they are very effective when used correctly. Coal tar may make the
skin more sun sensitive. Frequently, the combination of coal tar and sunlight is a very effective treatment regimen. (See Light Treatment below)
Climatotherapy
Climatotherapy is the use of sunlight and salt water to treat psoriasis. A popular site for treatment is the Dead Sea located between Israel and
Jordan. This site is 1200 feet below sea level and is the lowest place on earth. Its salt content is thirty-three-percent compared to three-percent in the
ocean. The minimum stay is four weeks with intensive exposure to the Dead Sea salts, mud and sun.
Dead Sea Salts
Scientific studies show that topical application of minerals and ions are readily absorbed into the skin. It is theorized that the influence of the high
concentration of minerals and ions slows down the runaway division of psoriatic cells. The advantages of high mineral and ion topical treatment are
far reaching; the result is skin that is stimulated, nourished and well hydrated. The effect is cumulative and many psoriasis patients have found undeniable relief and prolonged remission. (click here to read more about Dead Sea Minerals)
Light Treatment
For centuries, sunlight has been used to regulate and treat psoriasis. It functions by slowing down skin cell replication that causes psoriasis. The
majority of natural sunlight is ultraviolet light B (UVB). Ultraviolet light A (UVA) is present but in decreased amounts. Both wavelengths vary in intensity throughout the day.
Excess scale should be removed with warm water soaks and a loofah sponge prior to treatment. Tar preparations (see Coal Tar) may be applied
the night before treatment and then washed off in the morning. Small increments of sunlight exposure, 15 to 20 minutes a day, is very beneficial.
Vaseline is placed over the psoriatic areas to increase the intensity of treatment. Sunscreen should be used on uninvolved areas to help prevent
burning and the potential for skin cancer in the future. Sunburn may aggravate the psoriasis. It takes several weeks or longer to see improvement
with sunlight treatment. The risks and benefits of light treatment versus long-term sun damage and possible skin cancer must be weighed.
Some physicians recommend regulated medical light treatments such as PUVA (psoralen ultraviolet light A). This is physician administered and carries the many of the same risks as home light treatment.
Before beginning sunlight therapy, review your medications. Some medications can be sun sensitizing. Examples include: antibiotics, high blood pressure medications, diuretics, non-steroid anti-inflammatory
medications, and some psoriasis medications.
Other Treatments
Fortunately, there are numerous treatments available for psoriasis. The best treatment is the one that works for you. When considering any treatment, the
risks versus benefits must be weighed. If conservative at-home treatments are ineffective, prescription medications are available. These include, and
are not limited to, topical Vitamin D (Dovonex®), topical Vitamin A (Tazorac®), anthralin (Micanol®), PUVA (psoralen ultraviolet light A) and
ultraviolet UVB. Systemic treatments include oral Vitamin A – acitretin (Soriatane®), isotretinoin (Accutane®), hydroxyurea (Hydrea®),
sulfasalazine, cyclosporine (Neoral®), 6-thioguanine and methotrexate.
National Psoriasis Foundation®
The National Psoriasis Foundation® is a nonprofit organization with headquarters in Portland, Oregon. This foundation is committed to education
and research for the millions of people afflicted by psoriasis. It is an invaluable resource for patient education and information. The National
Psoriasis Foundation® does not endorse any medications, products or treatments for psoriasis. (See National Psoriasis Foundation® link.)
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