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Psoriasis: Treatment improves symptoms, appearance

Plaque psoriasis is the most common form of the skin disorder.

Psoriasis can cause discomfort and take an emotional toll on those who have the skin disorder. Although it is not curable, treatment options are available to alleviate symptoms and improve appearance.

Psoriasis is an immunological disease. For reasons physicians can’t always pinpoint, the immune system goes a bit off balance and turns on or off signals that are needed for normal skin to form.

In psoriasis, the cells of the immune system release chemicals that make the body create skin thicker and more inflamed than is normal, said Erik Stratman, M.D., a dermatologist at Marshfield Clinic Marshfield Center. “This results in the silvery-scaled pink plaques that are common to psoriasis,” he said.

Many people with psoriasis are treated by a dermatologist, a specialist in diseases affecting the skin. “Many primary care providers effectively treat psoriasis in its initial stages,” Dr. Stratman said. “But if there are large body surfaces affected, stubborn lesions, or arthritis, dermatologists team with the other providers to give care.”

Many types of psoriasis

Psoriasis affects about 1 percent of the population and can occur anywhere on the body, and different kinds of psoriasis often appear in specific areas. Several different types of psoriasis occur:

• Plaque psoriasis is the most common form of the disease. It presents with the well-known silvery white, scaly spots that may or may not itch. These are common on the elbows, knees and scalp.

• Guttate psoriasis is often triggered by an infection, such as strep throat. It generally occurs in youth and young adults and appears like psoriasis “raindrops” on the skin. This can appear all over the body.

• Pustular psoriasis causes large pustules all over the body. People with this usually feel rather ill. “It can be a dermatologic emergency and may require aggressive therapy and often hospitalization,” Dr. Stratman said.

• Erythrodermic psoriasis also is severe. The entire body turns bright red and scaly. Often, people with erythrodermic psoriasis need to be hospitalized for treatment.

• Inverse psoriasis occurs mostly in body folds, under the belly, in the armpits and groin. This appears not as scaly patches, but as glazed red areas.

• Psoriatic arthritis may occur with psoriasis that affects a small part of the body or a significant portion of skin surface. It causes joint pain and damage, just like other forms of arthritis. Sometimes it occurs without any skin lesions.

Psoriasis is not contagious. “There is nothing infectious about psoriasis,” Dr. Stratman said. “It does not spread from one person to another or from one body part to another by touching.”

Some people have a genetic predisposition to psoriasis. In fact, about one-third of people with psoriasis have a close relative who also has the disease. However, many people who have family members with psoriasis do not get the illness, Dr. Stratman said. “There is a genetic component and an environmental one,” he said.

Environmental factors that contribute to either the development of psoriasis or the severity of the disease include smoking, stress and alcoholism, as well as some medications and other illnesses.

In most cases, diagnosis of psoriasis is made by looking at the skin, Dr. Stratman said. “In rare cases, we might take a biopsy, but in classic cases, you do not need to do that.” A biopsy involves sampling the skin and looking at it under a microscope.

As an immunologic disease, psoriasis is difficult to cure, but often symptoms can be controlled with proper treatment. “We would love to cure a patient, but there is no cure yet,” Dr. Stratman said.

People with psoriasis should limit alcohol and should quit smoking, Dr. Stratman said. “Smoking is a known trigger and seems to make the disease worse,” he said.

Treatment options from simple to complex

Treatment begins topically with creams or ointments that are rubbed on the affected skin. Typically, physicians prescribe ointments rather than creams because the ointment penetrates better into the thick, scaly plaque of psoriasis-affected skin. Ointments are greasier than creams, but they do a better job of controlling symptoms when used.

Physicians prescribe a cortisone/steroid medication to be applied twice daily. Another choice, often used in combination with steroids, is a vitamin D cream, calcipotriene. “Most patients also respond to tars, which are cost effective, but messy,” Dr. Stratman said. Sometimes tar is added to another ointment to boost effectiveness.

Other topical medications exist. “There are varying strengths of ointments as well,” Dr. Stratman said. Physicians generally start with a mid-strength medication and move higher in the range if needed for relief.

“Another inexpensive treatment is regular sunlight,” Dr. Stratman said. As a dermatologist, he does not recommend spending a great deal of time outside without sunscreen, but 20 minutes or so, with the areas affected by psoriasis unprotected, may improve the condition. “It works well in the summer, and it’s cheap.”

“There is no question that vitamin D and calcium play a role in psoriasis,” he said.

For people who have more than 15 percent of their body affected by psoriasis (about the size of your back), topical treatments may not be effective. “It becomes difficult to apply an ointment to a large area twice a day,” Dr. Stratman said.

For those people, as well as those who have arthritis induced by psoriasis, a systemic treatment, such as pills or shots, is used. “We always proceed with caution because every one of them has potential side effects,” he said. “For example, Methatrexate is good therapy that you take once a week either as a pill or an injection, but it can cause liver problems. So we don’t like people drinking alcohol when they are on the medication, and we watch blood counts carefully during the course of therapy.”

Another medication, clyclosporine, provides quick relief but it can lead to high blood pressure or kidney problems with long-term use. To gain the benefit while minimizing risks, physicians prescribe it for about a year or less.

Working with patients, dermatologists regularly revisit the medication choices. “We need to consider medication cost, side effects, and how the patient is responding,” Dr. Stratman said. “The idea is to put psoriasis in remission, or as close to remission as you can, while limiting negative side effects.”

Many people who have psoriasis believe they are not being treated aggressively enough. In part, it may be because psoriasis occurs where other people can see it. “If people feel like their doctor is not being aggressive enough with treatment, they need to speak up,” Dr. Stratman said. “Tell your provider that you’re frustrated and would like to consider more aggressive therapies. There are more aggressive therapies, but they come with risks and costs. This conversation needs to start with the patient and the doctor talking about where you are and where you want to be.”

People who think they have psoriasis and are waiting to see a physician can purchase 1 percent hydrocortisone cream, put it on the affected area and wrap that area with plastic wrap overnight. This treatment can be used each night. “Wrapping the area increases the potency of the medicine and may provide some relief,” Dr. Stratman said.

He also recommends exposing the area to sun, but limiting each exposure to about 20 minutes a day.

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