Psoriasis

By Terry Everitt

Psoriasis is a chronic but treatable condition experienced by an estimated 80 million people around the world. It is a condition or a disorder, not a disease. It is now classified under a newly conceived group of disorders termed Immune Mediated Inflammatory Disorders (IMID).

As Professional skin treatment therapists, it is important that we differentiate this condition to eczema or allergic skin conditions and have a scientific understanding as well as how to address it in the salon.

While psoriasis is not life threatening, it can greatly affect appearance, self-esteem and overall quality of life. It can develop anywhere on the skin, though it usually appears on the scalp, knees, elbows and torso. It also may affect the nails and joints.

Psoriasis has several common symptoms. It is often itchy and may cause painful drying, cracking or blistering of the skin. Psoriasis affecting the joints can cause pain and make movement more difficult. Red, raised areas of skin called plaques characterise plaque psoriasis or psoriasis vulgaris, the most common form of the disease. Plaque psoriasis can range from mild too severe. Approximately 20 to 25 percent of cases are severe.
The earlier the onset, the more severe and more widespread the conditions appears in later life.
Usually is bilateral and non-symmetrical, with dry, grey scaly areas that are rough and hard.
Production of the keratinocytes is increased by shortening the cycle from 311 to 36 hours approx.

Other forms of the disease include guttate psoriasis, erythrodermic psoriasis and pustular psoriasis. Psoriasis also can be categorised by location on the body, such as scalp psoriasis, nail psoriasis, and joint psoriasis, also known as psoriatic arthritis.

Most people with psoriasis develop it in their 20s, but the disease can occur at any age, even childhood. It is equally common in men and women, and is significantly more prevalent amongst relatives of psoriatics, with up to 30% of patients having an affected first-degree relative. Studies on twins reveal a 72% concordance between monozygotic twins.

The exact causes of psoriasis are complex and not fully understood, but genetic traits leading to abnormalities in the body's response to infection are believed to be the underlying basis.
Helper T-cell lymphocytes have been identified as playing a key role in the inflammation that eventually leads to psoriasis plaques and related symptoms. Interestingly, alcohol and smoking also have a part to play.

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Histopathologically the disease is characterised by hyper-proliferation of the epidermis. An accumulation of inflammatory cells, particularly T lymphocytes, monocytes, and neutrophils; elongation and increased tortuosity of dermal papillary blood vessels, all play a part in the development of the condition.

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Plaque Psoriasis is a severe case

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Close up of Plaque Psoriasis

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Typical Pustular Psoriasis

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Knees and elbows are the most common sites on the limbs

Nail Psoriasis

Nail changes, which affect between 10 to 55 percent of people who have psoriasis, are more common in the fingernails than toes. Nail psoriasis can cause:

• Nail discolouration, often a yellowish-brown colour

   

• Pitting or small holes in the nail

   

• Severely misshapen nails, called onychodystrophy

   

• Separation of the nail from the nail bed, called onycholysis

   

Nail psoriasis can sometimes be painful; one study reports that about one-half of patients with nail psoriasis restricted daily activity due to pain.

About one-third of people with nail psoriasis may have a fungal infection, which, if treated, could help their nails to improve. Some treatments used for skin psoriasis also may improve the condition of the nails.

Here are a few handy hints that you can gives your clients:

• Trim your nails to reduce the risk of injuring them; trauma can worsen nail psoriasis.

   

• Try soaking affected nails and follow up with moisturiser. Carefully file thickened toenails with an emery board after soaking.

   

• Reduce toenail pressure and friction which can cause toenails to thicken -- by wearing well-fitted, roomy shoes.

   

• Consider using nail hardeners or artificial nails that can help to improve the appearance of intact nails.

   

• Nails may be surgically removed and replaced with artificial nails.

   

Psoriatic Arthritis

Approximately 10 to 30 percent of people with psoriasis have psoriatic arthritis, which causes joint stiffness, pain and swelling and, frequently, nail changes. Psoriatic arthritis generally affects the fingers and toes, but it can involve the wrists, lower back, knees and ankles. Psoriatic arthritis can be a serious disease, with a large percentage of patients reporting that their symptoms limit their work or home activities.

Psoriatic arthritis usually appears between the ages of 30 and 50. Its symptoms usually include at least one of the following:

• Pain in one or more joints

   

• Movement that is restricted by pain in the joint or surrounding areas

   

• Morning stiffness

   

• Eye pain or redness

   

Because there is no laboratory test for psoriatic arthritis, people with psoriasis and joint pain may want to consult a specialist in joint diseases, to evaluate their symptoms. Other joint diseases such as rheumatoid arthritis, gout, and Reiters syndrome all may be confused with psoriatic arthritis.

Medical Treatments

Because this is a common condition and no one treatment helps all sufferers, there are a variety of different treatments. Several are available without prescription. Treatments are often rotated or used in combination to control psoriasis. It is not an easy condition to control as there are so many individual triggers that may activate the condition.

Cortisone (Steroid) creams
These are the commonest treatment for psoriasis and are helpful in reducing inflammation and irritation. The main concern with all cortisone creams is that thinning of the skin can occur with long term treatment.

Tar
Tar has been used for over one hundred years and is usually effective in treating psoriasis. Unfortunately, it can be smelly and stains clothing. Tars are made from the distillation of coal and wood. They can be used as creams and shampoos. Application is usually at night to minimise odour during the day. Tars can also make the skin more sensitive to the sun, increasing the risk of sunburn.

Calcipotriol
Calcipotriol is a medication related to Vitamin D. The main danger, apart from irritation is the possibility of increasing the level of calcium in the blood.

Dithranol
Dithranol is similar to tar and is made from the bark of a tree. It can be used in a thick ointment that is left on overnight, sometimes under dressings, or applied in higher concentrations for 10-15 minutes before removal.
The main potential problems with dithranol are irritation of the skin, temporary skin discolouration and permanent staining of fabric.

Chicken or the egg of psoriasis

David H. Frankel reported of a landmark study in the prestigious medical journal, The Lancet. Feb 10, 1996 v347 n8998 p386(1), which turned the thinking of the coursative factors held by the medical establishment.

The belief that the primary defect in psoriasis is keratinocytes gone haywire guided researchers and clinicians for nearly three decades prior. Longstanding observation that guttate psoriasis often follows group A streptococcal infection convinced some investigators that the disease was mediated by defects in cellular immunity.

It was shown in controlled studies that psoriasis can be triggered when an antigen (streptococcal, for example) is presented to cutaneous T cells by HLA-DR antigen presenting cells (APCs), which may be Langerhans cells or, possibly, keratinocytes. Activated T cells then migrate into the epidermis and release mediators of inflammation and epidermal growth factors causing rapid turnover of keratinocytes and plaque formation.

To the extent the antigen is genetically determined, psoriasis was found to be an autoimmune disease.

Dr Alice Gottlieb (University of Medicine and Dentistry of New Jersey) and Rockefeller University New York, Dr James Krueger, director of the Rockefeller University Laboratory for Investigative Dermatology and Dr Gerald Weinstein (University of California, Irvine) all found the same responses.

Light Treatment

The majority of patients with psoriasis find that they improve after exposure to the sun and the use of ultraviolet light in the shorter wavelengths as used in a cabinet treatment.
There are three main types of ultraviolet (UV) light treatment used in Australia to treat psoriasis:

Narrow Band UVB - single band of UVB light (around 311 nm)

Broad Band UVB using the complete band of UVB light

PUVA - this is combined with the administration of psoralens, natural substances which come from plants like celery and UVA.

This involves standing in a cabinet to receive a measured dose of the appropriate wavelength of light from a number of fluorescent tubes around the walls of the cabinet.
Unfortunately, as is widely known, ultraviolet light can encourage skin cancer. Consequently, patients are generally discouraged from simply exposing their skin to the sun.
Because it is a powerful and potentially dangerous treatment, practitioners skilled in its use should only administer ultraviolet light. This is not for the Beauty therapist to try. Disadvantages include the need for several treatments a week over several weeks, and long term damage to the skin including a possible increased risk of skin cancers, and increased skin (photo) ageing.

Oral Treatments
A number of tablet treatments are available but all cause potentially significant side effects. These treatments include methotrexate, acitretin and cyclosporin. Careful choice of therapy and skilled monitoring reduce the potential risks of these therapies, which are generally very effective in controlling even severe cases of psoriasis.
With appropriate treatment psoriasis can be well controlled for the vast majority of sufferers and a normal lifestyle enjoyed.

psoriasis