What is Psoriasis?
• Psoriasis is a non-contagious common condition of the skin which usually causes rapid skin cell replication and red, dry patches of thickened skin in classic areas like the elbows and knees. The dry flakes and skin scales are thought to result from the build up of the rapid production of skin cells.
• It is considered a chronic (long term) skin condition causing inflammation and increased turn over or production of skin cells.
• It has a variable course with periodic ups and downs. Sometimes psoriasis may clear for years and stay in remission. Some people have worsening of their symptoms in the colder winter months. Many people report improvement in warmer months, climates, or increased sunlight exposure.
• Psoriasis is seen worldwide, in all races, and both sexes.
• Some people have very mild cases with just small dry patches on their elbows and knees and some people may have very severe disease where their entire body is fully covered with psoriasis.
• Some people with psoriasis may not know they have the disease because it is so mild. Although psoriasis can be seen in any age from babies to seniors, usually patients are first diagnosed in their early adult years.
• Patients with more severe psoriasis may have social embarrassment, job stress, emotional distress, and other personal issues because of the appearance of their skin.
• What causes it?
• What does it look like?
• How many people have it?
• Can it affect my joints?
• Can it affect my nails only?
• Is it curable?
• Is it contagious?
• Can I pass to my children?
• What kind of doctor treats psoriasis?
• How can I find a specialist?
• How is it treated?
• What creams or lotions are available?
• What pills are available?
• What injections are available?
• What about light therapy?
• Where can I get more information?
• Is there a psoriasis support group?
• What is my long term prognosis?
• What does the future hold?
• Psoriasis at a glance.
What causes it?
• The exact cause remains unknown.
• There may a combination of factors including genetic predisposition and environmental factors.
• The immune system is thought to play a major role in most types of psoriasis.
• Despite research over the past 30 years looking at many triggers, the “master switch” is still a mystery.
What does psoriasis look like?
• Psoriasis typically looks like red or pink areas of thickened, raised, dry skin in classic areas like the elbows, knees, and scalp. Essentially any body area may be involved. It tends to be more common in areas of trauma, repeat rubbing, use, or abrasions.
• Psoriasis has many different appearances. It may be small flattened bumps, large thick plaques of raised skin, red patches, and pink mildly dry skin to big flakes of dry skin that flake off.
• There are several different types of psoriasis including Psoriasis Vulgaris ( common type), Guttate Psoriasis (small, drop like spots), Inverse Psoriasis (in the folds like of the underarms, navel, and buttocks), and Pustular Psoriasis ( yellow, liquid filled small blisters).
• Sometimes pulling of one of these small dry white flakes of skin causes a tiny blood spot on the skin. This may be a special diagnostic sign in psoriasis called Auspitz sign.
• Genital lesions especially on the head of the penis are common. Psoriasis in moist areas like the navel or area between the buttocks (intergluteal folds) may look like flat red patches. These atypical appearances may be confused with other skin conditions like fungal infections, yeast infections, skin irritation, or bacterial “staph” infections.
• On the nails it can look like very small pits ( pinpoint depressions or white spots on the nail) or as larger yellowish , brown separations of the nail bed called “oil spots”. Nail psoriasis may be confused with and incorrectly diagnosed as a fungal nail infection.
• On the scalp it may look like severe dandruff with dry flakes and red areas of skin. It may hard to tell the difference between scalp psoriasis and seborrhea ( dandruff). Often, the treatment is very similar for both conditions.
Can it affect my joints?
• Yes, psoriasis affects the joints in about 10-35% of patients.
• In fact, sometimes joint pains maybe the only sign of the disorder with completely clear skin. Patients may have aches of any joints (arthritis), although the joints of the hands, knees, and ankles tend to be most commonly affected.
• The average age for onset of psoriatic arthritis is 30-40 years old.
• In most cases, the skin symptoms occur before the onset of the arthritis.
• The diagnosis of psoriatic arthritis is typically made by a physician examination, medical history, and relevant family history. Sometimes, lab test and x-rays may be used to exclude other diagnosis like rheumatoid arthritis and osteoarthritis.
Can it affect only my nails?
• Yes, psoriasis may involve solely the nails in a limited number of patients. Usually, the nail symptoms accompany the skin and arthritis symptoms. Nails may have small pinpoint pits or large yellowish separations of the nail plate called “oil spots”. Nail psoriasis is typically very difficult to treat. Treatment option are somewhat limited and include potent topical steroids applied at the nail base cuticle, injection of steroids at the nail base cuticle, and oral or systemic medications.
How many people have it?
• You are not alone. Psoriasis is a fairly common skin condition and estimated to affect approximately 1-3% of the U.S. population.
• It currently affects roughly 7.5 to 8.5 million people in the U.S.
• It is seen worldwide in about 125 million people.
• African Americans have about half the rate of psoriasis as Caucasians.
Is it curable?
• No, psoriasis is not currently curable.
• Ongoing research is actively making progress on finding better treatments and a possible cure in the future.
Is Psoriasis contagious?
• No, studies have not shown it to be contagious from person to person.
• You didn’t catch it from anyone and you can’t give it to anyone else by skin to skin contact.
• You can directly touch someone with psoriasis every day and not ever catch the skin condition.
Can I pass it on to my children?
• Yes, it is possible. Although psoriasis is not contagious from person to person, there is a known genetic tendency and it may be genetically passed on from parents to their children.
• It does tend to run in some families and a family history is helpful in the diagnosis.
What kind of doctor treats psoriasis?
• Many kinds of physicians may treat psoriasis including dermatologists, family physicians, internal medicine physicians, rheumatologists, and other medical doctors.
• Some patients have also seen other allied health professionals such as acupuncturists, holistic practitioners, chiropractors, and nutritionists.
• Typically, dermatologists specialize in the diagnosis and treatment of psoriasis and rheumatologists specialize in the treatment of joint disorders and psoriatic arthritis.
How can I find a specialist?
• The American Academy of Dermatology and The National Psoriasis Foundation are excellent references to help find physicians who specialize in this disease.
• Not all dermatologists and rheumatologists treat psoriasis.
• The National Psoriasis Foundation has one of the most up to date databases of current Psoriasis specialists.( http://www.psoriasis.org/treatment/directory / )
• There are many physician experts in this field and several at educational institutions. Dr. Gerald Weinstein at the University of California, Irvine, Dr. John Koo at the University of California, San Francisco, Dr. Mark Lebwohl
Mount Sinai School of Medicine, and Dr Craig Leonardi, of the St Louis University Medical School are four of the many well known experts who have published extensively in the field.
How is it treated?
• There are many effective treatment choices for improving psoriasis. The best treatment is individually determined by your physician depending on the type of disease, the severity, and the total body area involved.
• For mild disease that involves only small areas of the body (like less than 10% of the total skin surface), topical (skin applied) creams, lotions, and sprays may be very effective and safe to use. Occasionally, a small local injection of steroids directly into a tough or resistant isolated psoriasis plaque may be helpful.
• For moderate to severe disease that involves much larger areas of the body (like 20% or more of the total skin surface) topical products may not be effective or practical to apply. These cases may require systemic or total body treatments such as pills, light treatments, or injections. Stronger medications usually have greater associated possible risks.
• For psoriatic arthritis, generally systemic oral or injectable medications may be required. Topical therapies are not effective.
• It is important to keep in mind that as with any medical condition, all medications carry possible side effects. No medication is 100% effective for everyone, and no medication is 100% safe. The decision to use any medication generally requires thorough consideration and discussion with your physician.
• The risks and potential benefit of medications have to be considered for each type of psoriasis and the individual patient. Some patients are not bothered at all by their skin symptoms and may not want any treatment. Other patients are bothered by even small patches of psoriasis and want to keep their skin clear. Everyone is different and therefore treatment choices vary depending on the patient’s goals and expressed wishes.
• A particularly effective approach to psoriasis has been commonly called “rotational” therapy. This is a common practice among some dermatologists who recommend changing cycles of psoriasis treatments every 6-24 months in order to minimize the possible side effects from any one type of therapy or medication.
For example, if a patient has been using oral methotrexate for 2 years, then it may be reasonable to take them off of methotrexate and try light therapy or a biologic injectable medication for a while. By rotating to a medication that doesn’t affect the liver, the potential of liver damage may be reduced.
In another example, a patient who has been using strong topical steroids over large areas of their body for prolonged periods may benefit from stopping the steroids for a while and rotating onto a different therapy like calcipotriene (Dovonex), light therapy, or an injectable biologic.
What creams or lotions are available?
• Topical ( skin applied) medications include topical corticosteroids, vitamin D analogue creams (Dovonex), topical retinoids (Tazorac), moisturizers, topical immunomodulators ( tacrolimus and pimecrolimus) coal tar, anthralin, and others.
-Topical corticosteroids (steroids) are very useful and often first line treatment for limited or small areas of psoriasis. These come in many preparations including sprays, liquid, creams, gels, ointments, and mousses. Steroids come in many different strengths; stronger ones are used for elbows, knees, and tougher skin areas while milder ones are used for areas like the face, underarms, and groin. These are usually applied once or twice a day to affected skin areas.
Strong steroid preparations should be limited in use. Overuse or prolonged use may cause problems including potential permanent skin thinning and damage called atrophy.
-A vitamin D analogue cream called calcipotriene (Dovonex) has also been useful in psoriasis. The advantage of calcipotriene is that it is not known to overly thin the skin like topical steroids. It is important to note that this drug is not regular vitamin D and is not the same as taking regular vitamin D or rubbing it on the skin.
Calcipotriene may be used in combination with topical steroids for better results. There is a newer 2 in 1 combination preparation of calcipotriene and a topical steroid called Taclonex. Results with calcipotriene alone may be slower and less than results achieved with typical topical steroids. Not all patients may respond to calcipotriene as well as to topical steroids.
A special precaution with calcipotriene is that it should not be used in more than 20% of the skin in one person. Overuse may cause absorption of the drug and an abnormal rise in body calcium levels.
-Moisturizers, especially with therapeutic concentrations of salicylic acid, lactic acid, urea, and glycolic acid may be helpful in psoriasis. These moisturizers are available as prescription or over the counter. These help moisten and lessen the appearance of thickened psoriasis scales. Some available preparations include Salex (salicylic acid) , AmLactin ( lactic acid), or Lac Hydrin ( lactic acid) lotions. These may be used 1-3 times a day on the body and do not generally have a risk of problematic skin thinning (atrophy). Overuse or use on broken, inflamed skin may cause stinging, burning, and more irritation. These stronger preparations should not be used over delicate skin like eyelids, face, or genitals. Other bland moisturizers including Vaseline and Crisco Vegetable Shortening may also be helpful in at least reducing the dry appearance of psoriasis.
-Immunomodulators ( tacrolimus and pimecrolimus) have also been used with some success in limited types of psoriasis. These have the advantage of not causing skin thinning. They may have other potential side effects including skin infections and possible malignancies (cancers). The exact association of these immunomodulator creams and cancer is controversial.
-Bath salts or bathing in high salt concentration waters like the Dead Sea in the Middle East may help some psoriasis patients. Epsom salt soaks ( available over the counter) may also be helpful for a number of patients. Overall, these are quite safe and have very few possible side effects.
-Coal tar is available in multiple preparations including shampoos, bath solutions, and creams. Coal tar may help reduce the appearance and decrease the flakes in psoriasis. The odor, staining, and overall messiness with coal tar may make it harder to use and less desirable than other therapies. A major advantage with tar is lack of skin thinning.
-Anthralin is available for topical use as a cream, ointment, or paste. The stinging, possible irritation, and skin discoloration may make this more problematic to use. Anthralin may be applied for 10-30 minutes to psoriatic skin.
What pills are available?
• Oral medications include acitretin, cyclosporine, methotrexate, mycophenalate mofetil, and others. Oral prednisone (corticosteroids) are generally not used in psoriasis and may cause a disease flare if administered to many patients.
• Acitretin (Soriatane) is an oral drug used for certain types of psoriasis. It is not effective in all types of the disease. It may be used in males, and females who are not pregnant and not planning to become pregnant for at least three years. The major side effects include dryness of skin and eyes, and temporarily elevated levels of triglycerides and cholesterol (fatty substance) in the blood. Blood tests are generally required before starting this therapy and periodically to monitor triglyceride levels. Patients should not become pregnant while on this drug and usually for at least 3 years after stopping this medication.
• Cyclosporine is a potent immunosuppressive drug used for other medical uses including organ transplant patients. It may be used for severe, hard to treat cases of widespread psoriasis. Improvement and results may be very rapid in onset. It may be hard to get someone off of cyclosporine without flaring their psoriasis. Because of the potential cumulative toxicity, cyclosporine should not be used for more than 1-2 years for most psoriasis patients. Major possible side effects include kidney and blood pressure problems.
• Methotrexate is a common drug used in rheumatology for rheumatoid arthritis and oncology (cancer treatments). In Psoriasis, it has been used for many years to effectively treat the disease. It is usually given in small weekly doses (5mg to 15mg). Blood tests are required before and during therapy. The drug may cause liver damage in some patients, particularly if there is pre-existing liver disease or if given for prolonged periods of time. Close physician monitoring and monthly to quarterly visits and labs are generally required.
What injections are available?
• The newest category of injectable psoriasis drugs are called biologics. All biologics modulate (adjust) and sometime suppress (quiet) the immune system. These currently available drugs include Amevive, Humira, Remicade, Enbrel, Raptiva, and ustekinumab. Newer drugs are in development and may be on the market in the near future. Some biologics are self injections for home use while others are intravenous or intramuscular injections in the physicians office.
Usually biologics may have some screening requirements such as a tuberculosis screening test (“TB” skin test or PPD test) and other labs prior to starting therapy.
Currently, all of the biologics except Raptiva are dosed as one size fits all. Raptiva has weight adjusted dosing so patient with higher body weights get larger doses. Future testing may support dosage adjustments for other biologics based on weight or other factors.
As with any drug, side effects are possible with all biologic drugs. Common potential side effects include mild local injection site reactions (redness and tenderness). There is concern of serious infections and potential malignancy with nearly all biologic drugs.
Precautions include patients with known or suspected Hepatitis B or C infection, active tuberculosis, and possibly HIV/AIDS. As a general consideration, these drugs may not be an ideal choice for patients with a history of cancer and patients actively undergoing cancer therapy.
In particular, there may be an increased association of lymphoma in patients taking biologics. It is not at all certain if this association is directly caused by these drugs. It is known that certain diseases like rheumatoid arthritis or psoriasis may be associated with an inherent increase in the overall risk of some infections and malignancies.
Biologics are fairly expensive medications ranging in price from several to tens of thousands of dollars per year per person. Their use may be limited by availability, cost, and insurance approval. Not all insurance drug plans may fully cover these drugs for all conditions. You will need to check with your insurance and maybe submit prior authorization requests to your carrier for coverage approval. Some of the biologics manufacturers have patient assistance programs to help with financial issues.
The choice of the right injectable medication for your condition depends on many medical factors. Additionally, convenience of receiving the medication and life style may be factors in choosing the right biologic for you.
• Currently, the four main classes of biologic drugs for psoriasis are:
1. TNF-alpha blockers ( Tumor Necrosis Factor)
2. drugs that block T-cell activation and the movement of T-cells
3. drugs that decrease the number of activated T-cells
4. drugs that interfere with interleukin mechanisms
• TNF blockers include Enbrel (etanercept), Remicade (infliximab) and Humira (adalimumab). TNF-alpha blocking drugs may have an advantage of treating psoriatic arthritis and psoriasis skin disease. Their disadvantage is that some patients may notice a decrease effectiveness of TNF-alpha blocking drugs over months to years.
TNF blockers are generally not used in patients with demyelinating (neurological) diseases like multiple sclerosis, congestive heart failure, or patients with severe overall low blood counts called pancytopenia.
The major side effect of these class of drugs is suppression of the immune system. Because of the increased risk of infections while on these drugs, patients should promptly report fevers or signs of infection to their physicians. Minor side effects have included auto-immune conditions like lupus or flares in lupus. Additionally, it may be best to avoid any live vaccines while patients are on TNF blockers.
-Enbrel (etanercept) is a self injectable medication for home use. It is injected via a small needle just under the skin called subcutaneous injection. It is usually dosed once or twice week by patients at home after training with their physician or the nursing staff. Sometimes a higher loading dose is used for the first 12 weeks and then it is “stepped down” to ½ the dose after the first 12 weeks. Enbrel has the advantage of at least 16 years of clinical use and long term experience.
-Remicade (infliximab) is an intravenous (IV) medication strictly for physician office or special infusion medical center use. It is currently not for home use or self injection. It is injected slowly over time via a small needle into a vein. It may usually be dosed once a week. There have been reports of antibodies to this drug in patients taking it for some time. These antibodies may cause a greater drug dose requirement for achieving disease improvement or failure to improve. The IV route may be more time consuming requiring physician monitoring during the infusions. Remicade has the advantage of fast disease response and good potency.
-Humira (adalimumab)- is a self injectable medication for home use. It is injected via a small needle just under the skin as a subcutaneous dose. It is usually dosed once every other week, totaling 26 injections in one year. Dosing is individualized and should be discussed with your physician. Sometimes a higher loading dose is used for the first dose (80mg) and then it is continued at 40mg every other week . It may give results as soon as 1-2 weeks of therapy. Humira has the advantage of at least 11 years of clinical use and long term experience.
• Raptiva (efalizumab) blocks both T-cell activation and the movement of T-cells into the skin. This is the only biologic drug so far that is dosed specifically based on your weight. Labs are required before starting injections and weekly for the 12 weeks of therapy. Injections are placed just under the skin (sub-cutaneous) and may be given in the physician office or at home.
Currently, Raptiva seems to work well over several years without losing its effectiveness, therefore having the advantage of “staying power”. Raptiva may cause flares of arthritis in some patients.
As with all biologics, Raptiva has been associated with possible infections and malignancy (cancer). The relative risk of these two side effects is fairly low. Raptiva may also cause a decrease or drop in the platelet ( blood clotting cell) count. Platelet counts are usually checked before starting and periodically (often quarterly) while patients continue Raptiva.
Live vaccines are not advised while patients are taking Raptiva. It is usually best to have any required vaccines weeks before starting therapy.
• Amevive (alefacept) decreases the number of available activated T-cells. It is given intramuscularly (injected in the muscle) usually in the physician’s office and given once a week for twelve weeks. Many patients may see improvement in their symptoms that lasts approximately 12 months (more or less). Amevive may not be uniformly effective for all patients and some patients improve more than others. 14 weeks is about the average time to maximum improvement for many patients.
Amevive should generally not be used in patients with HIV infections as the drug causes a decrease in the CD4 cells ( part of the immune system that HIV also attacks).
Also because of the immune system suppression, Amevive may not be a good drug in patients with active cancer or infection.
• Ustekinumab is the newest biologic injectable medication used to modulate the immune system. It is an interleukin-12/23 monoclonal antibody, a type of drug known as a fully human monoclonal antibody. Ustekinumab targets chemical messengers in the immune system involved in skin inflammation and skin cell production. This drug is planned to be dosed subcutaneously (just under the skin) once a quarter ( every 3 months). It has been very promising with very good clearance rates in the clinical trials thus far. A major advantage may be the convenience of a quarterly medication. The concerns for infection and malignancy may be similar to the other biologics.
What about light therapy?
• Light therapy is also called phototherapy. There are several types of traditional medical light therapies called PUVA, UVB, and narrow band UVB. These artificial light sources have been used for decades and generally available in a physician’s office. There are a few companies who may sell light boxes or light bulbs for prescribed home light therapy.
• Old fashioned sunlight is also used to treat psoriasis. Daily, short, controlled exposures to natural sunlight may help or clear psoriasis in some patients. Non psoriasis skin, and sensitive areas such as the face and hands may need to be protected during sun exposure.
• There are also multiple newer light sources like lasers and photodynamic therapy (use of a light activating medication and a special light source) that have been used to treat psoriasis.
• PUVA is a special treatment using a photosensitizing drug and controlled, timed artificial light exposure. The photosensitizing drug in PUVA is called psoralen. These treatments are usually administered in a physician’s office 2-3 times per week. Several weeks of PUVA is usually required before seeing significant results. The light exposure time is slowly and gradually increased during each subsequent treatment.
Psoralens may be given orally as a pill, or topically as a bath or lotion. After a short incubation period, the skin is exposed to a special wavelength of ultraviolet light called UVA. Patients are generally sun sensitive and must avoid sun exposure for a period of time after PUVA.
Common side effects with PUVA include burning, tanning of the skin, potential skin damage, increased brown spots called lentigines, and possible increased risk of skin cancer including melanoma. The relative increase in skin cancer risk with PUVA treatment is controversial. PUVA treatments need to be closely monitored by a physician and discontinued when a maximum number of treatments have been reached.
• UVB phototherapy is an artificial light treatment using a special wavelength of light. It is frequently given daily or 2-3 times per week. UVB is also a component of natural sunlight. UVB dosage is based on time and exposure is gradually increased by 15-60 seconds per treatment or per week. Potential side effects with UVB include skin burning, skin damage, and possible increased risk of skin cancer including melanoma. The relative increase in skin cancer risk with UVB treatment needs further study.
• Sometimes UVB is combined with other treatments such as tar application. Goeckerman is the name of a special psoriasis therapy using this combination. Some centers like (the University of California, San Francisco) have used this therapy in a “day care” type of setting where patients are in the Psoriasis treatment clinic all day for several weeks and go home each night.
Where can I get more up to date information?
Your dermatologist, www.AAD.org, and http://www.psoriasis.org/home/ may be excellent sources of more information.
There are many ongoing clinical trials for psoriasis all over the United States and in the world. Many of these clinical trials are ongoing at academic or university medical centers and are frequently open to patients without cost.
Clinical trials frequently have specific requirements for types and severity of psoriasis that may be enrolled into a specific trial. Patients need to contact these centers and inquire regarding the specific study requirements. Some studies have restrictions on what recent medications have been used for psoriasis, current medication, and overall health.
Some of the many medical centers in the U.S. offering clinical trials for psoriasis include the University of California, San Francisco Department of Dermatology, the University of California, Irvine Department of Dermatology, and the St Louis University Medical School.
Is there a national psoriasis support group?
Yes, the National Psoriasis Foundation (NPF) is a highly reputable and long standing organization dedicated to helping patients with psoriasis and furthering research in this field. They hold national and local chapter meetings. The NPF website shares up to date reliable medical information and statistics on the condition. http://www.psoriasis.org/home/
What is my long term prognosis?
Overall, the prognosis for most patients with psoriasis is fairly good with no related other health issues. While it is not curable, it is controllable.
There have been a few studies showing a possible association of psoriasis and other medical conditions including obesity and heart disease.
What does the future hold?
• Psoriasis research is heavily funded and holds great promise for the future.
• Just the last 5-10 years have brought great strides in treatment of the disease with self- injectabale medications called biologics.
• New biologics are in the pipeline including quarterly subcutaneous injections that modulate the immune system at different levels.
Psoriasis at a glance:
• Chronic inflammatory skin disease
• Unknown cause
• Genetic predisposition
• Not contagious
• Periodic ups and down
• Periodic remissions (clear skin)
• Controllable with medication
• Currently not curable
• Promising therapies with injectable biologic drugs
• Immunotherapies are becoming prime
• Future research promising.