Psoriasis is a chronic recurrent, inflammatory disease of the skin of unknown origin, it is considered to be inherited as an autosomal dominant character with irregular penetrance. It has been seen in both sexes at any age. It is commonly manifest as well-defined erythematous scaly plaques which become silvery on attempts to scrape. This is known as plaque type psoriasis. The lesion may be present in any part of the body but the extensors of the extremities, especially elbow and knees, and sacral region of the back and scalp are the most favorable sites.
The lesions may be completely asymptomatic. However, some patients may have severe itching. The lesion worsens during winter and improves or even clear in summer. Occasionally, due to excessive treatment with topical irritative agents the lesions become extensive with erythema and scaling with chills and rigors. This is known as exfoliative dermatitis. In another variety known as pustular psoriasis superficially tiny pustules are seen over the existing psoriasis plaques or even on the normal skin which contains a large number of polymorphs. Sometimes the lesions are seen in a linear fashion on the lines of scratch. Sunlight has been found to be beneficial to psoriatics.
It is an inflammatory skin condition. The obvious sign is the colour change associated with the plaques (the raised patches in the skin), although this is more obvious where there is little scale. In fair-skinned people, the plaque will look red (sometimes referred to as salmon pink), whereas in dark-skinned individuals the plaque tends to look a darker shade of the normal skin. Often, however, the white scaling is thick and hides the redness, so psoriasis looks thick, white and, crusty on exposed surfaces regardless of the underlying skin colour.
The thickening is caused by the greatly increased ‘turnover’ of the skin cells. Normally, a living skin cell moves upward from the bottom layer of skin, loses its nucleus and dies. It is then largely made up of a protein called keratin and is shed from the surface of the skin as new cells go through the same process and replace it from underneath. The whole process takes around 28 days, but in psoriasis it is greatly sped up to 3-4 days cycle. Living cells are then much closer to the surface, and as they still need a blood supply, the vessels lie closer to the surface, leading to the redness and heat that many people with psoriasis complain of. The fact that the surface cells are being replaced before they are shed results in a thick layer of scale, which, as everyone with the condition knows, flakes off readily and abundantly.
It is essentially important to understand what psoriasis is not. This can be summarized by saying that it is:
- Not contagious
- Not cancer
- Not related to diet
- Not allergic
Causes of psoriasis
Psoriasis is typically a chronically recurring disease, although cases of complete resolution do occur. The onset of the disease can occur at any age, but the peaks of onset are in the 20s and 50s. HIV-positive patients can have recalcitrant psoriasis.
Causes of psoriasis
Although the exact cause of psoriasis is unknown, there is clearly a hereditary component. When one parent has psoriasis, a child has an 8% chance of having the disease; if both parents have psoriasis, the child’s chance of developing it increases to as high as 41%. Specific HLA types have been noted to have a higher frequency of association with psoriasis, specifically HLA-B13, HLA-B17, HLA-Bw57, and most notably HLA-Cw6.
An acute form of guttate psoriasis, which characteristically develops in children and younger adults, often follows a streptococcal infection and has characteristic smaller sized, drop-shaped lesions
Triggering factors include physical trauma, which can elicit the lesions or any type of excessive rubbing or scratching, which can stimulate the proliferative process. Aggravating factors include psychological stress and certain medications such as systemic glucocorticoids, oral lithium, antimalarial drugs, systemic interferon, Î²-blockers, and potentially angiotensin-converting enzyme inhibitors. Alcohol and smoking (especially pustular psoriasis) may also aggravate psoriasis. Rarely, ultraviolet light worsens psoriasis especially after a sunburn.
Exacerbation is typically seen in the winter, most likely owing to the lack of sunlight and low humidity. Natural ultraviolet light typically cause psoriatic symptoms to improve.
The disease can occur at any age. However, the average onset is typically bimodal, with one peak at approximately 23 years old (although in children, mean onset is 8 years old), and another at age 55.
Psoriasis is not contagious.
Clinical Features of Psoriasis
Sites of predilection
Include scalp, retro auricular area, knees, elbows, sacrum, and nails.
Lesion morphology – sharply bordered erythematous patches and plaques with silvery scale
- Commonly affects knee, elbow and lower back
- Pain cause difficulty in sleeping and walking
- Psychological; stress, depression
- The lesion may be red with dry and silvery scale visible only after scrapping surface
- Scalp lesions are well demarcated, especially palpable area. Temporary hair loss may be there.
- Flexures involves natal cyst, submamary and axillary portion
- Folds are red, skimpy and symmetrical
- On palms it resembles eczema.
Chronic plaque type psoriasis
v Small papules evolve through confluence in to large irregular, well-circumscribed plaques, 3-20 cm.
v Silvery scale is extremely typical
v Sites of predilection include knees, elbow, sacrum, scalp, retinoauricular area
v Untreated, the plaques can remain stable for months or years.
v May be less distinct in dark skin
v Appears as exanthema over 2-3 weeks; starting with small macules and papules that evolve into 1-2 cm plaques with silvery scale
v Favor the trunk, less often extremities or face
v Most patients are children or young adults, usually after streptococcal pharyngitis; sometimes following treatment or tonsillectomy, the psoriasis resolves completely and never returns
v Involves axillae and groin; often misdiagnosed.
v Macerated and fissured; thick plaques and silvery scale usually missing
v Requires less aggressive therapy
v Inverse psoriasis
v Overlaps with intertrginious; form where involvement is flexural and classical sites such as knees and elbows are spared
v Involves the entire integument: can develop suddenly out of a Guttate psoriasis or from long standing psoriasis following too aggressive therapy or abrupt discontinuation of medications.
v Numerous pustules on palms and soles
Drug induced psoriasis
v Medications are common triggers for psoriasis
v Lesions are limited to the soles of the feet and palms of the hands.
How psoriasis is diagnosed?
Psoriasis is often diagnosed by a dermatological or primary care physician by its characteristic appearance and locations on the body. If a person has the skin changes typical of psoriasis, a diagnosis can be made clinically by examination alone, based on the skin’s appearance due to psoriasis, a physician will usually be able to diagnose it.
Grattage Test – Gentle scraping of the surface of a psoriasis plaque with a glass slide will remove the loosely attached scales and reveal a shiny surface peppered with fine bleeding points. These bleeding points represent the dilated and tortuous capillary blood vessels in the papillary dermis, one of the characteristic pathological events taking place in psoriasis affected skin. This sign is known as Auspitz sign, which is a diagnostic sign of psoriasis.
If person looks different than most cases, appears in an unusual location, further test may be needed. The definitive test when a clinical diagnosis of skin disease is a skin biopsy. Usually one test is required, but it may be repeated if the results are not clear or the disease changes over time. If biopsy is performed, histologic findings include the following:
- acanthosis (thickening of the skin);
- increased mitosis of keratinocytes, fibroblasts, and endothelial cells; and
- Inflammatory cells in the dermis and epidermis.
No blood test exists to diagnose psoriasis, and psoriasis does not cause abnormal blood tests for most people. The most common reason to draw blood when treating people for psoriasis is to make sure it is safe to begin a new medication or to watch for a medicine’s possible side effects.
The evaluation of psoriatic arthritis may include X-ray, joint tests, and blood panels to look for other causes of arthritis.
Patient should be encouraged to expose maximum to sunlight and avoid trauma during the active phase.
Allopathic treatment – mainly include Corticosteroids, tar, Vitamin D analogues, Retinoides etc.
Homeopathic treatment of psoriasis
Homeopathy is one of the most popular holistic systems of medicine. The selection of remedy is based upon the theory of individualization and symptoms similarity by using holistic approach.
This is the only way through which a state of complete health can be regained by removing all the sign and symptoms from which the patient is suffering. The aim of homeopathy is not only to treat the primary disease but to address its underlying cause and individual susceptibility. As far as therapeutic medication is concerned; several well-proved homeopathic remedies are available for psoriasis treatment that can be selected on the basis of cause, location, sensation, modalities and extension of the psoriasis. For individualized remedy selection and treatment, the patient should consult a qualified homeopathic doctor in person. Few important homeopathy remedies for the homeopathic treatment of psoriasis are given below:
- Arsenic album – lesions, worse by cold application and wetness, better by warmth. Hyperactive and restless patients with great anxiety about her disease condition. Changing doctors frequently. Burning pains. Midday and midnight aggravation. Fastidious patient, particular about her appearance.
- Sulphur – Long history of use of allopathic ointments, suppressed skin eruptions and discharges. History of itching eruptions. Dirty appearance of skin.
- Kali brom – Psoriasis running in family. Lesions may bleed or ulcerate easily. Skin cold, blue, spotted corrugated, large, indolent, painful pustules.
- Kali ars – Patches on back, arms and spreading from elbows; scaly itches, scaling off leaves behind red skin. Skin is dry, scaly with intolerable itching which feels worse when undressing; psoriasis leading to fissures in the bends of the arms and knees. Also suffering with gout, nodosites which feels worse with the change of weather.
- Thyrodinum – For chilly and anemic subjects. Dry impoverished skin; cold hands and feet. Psoriasis associated with adiposity; skin dry, impoverished. Cold hands and feet. Eczema. Itching without eruptions, worse at night.
- Radium brom – psoriasis of penis, itching eruptions on face oozing, patchy erythema on forehead.
- Arsenic iod – psoriasis that often occurs in emaciated and elderly women; dry, scaly, and itchy skin, scales peel off easily, leaving a raw surface exposed.
- Berberis aquifolium – eruptions appear on scalp and extend to the face and neck, pimply, dry, rough and scaly skin.
- Asterius rubens – skin is itchy and psoriasis mostly affects the left arm and chest; feels worse at night and in damp weather.
- Hydrocotyle – dry eruptions with great thickening of the outer skin layer and exfoliation of scales; psoriasis appears on the trunk, extremities, palms and soles with the usual circular spots with scaly edges.
- Magnum aceticum – suppuration of skin around joints; red, elevated, itching; better, scratching. Deep cracks in bend of elbows, etc. Psoriasis and pityriasis. Burning around ulcers. Chronic eczema associated with amenorrhea, worse at menstrual period or at menopause.
- Chrysarobinum – acts well in skin conditions; useful for skin diseases especially in ringworm, psoriasis, herpes, acne rosacea.
- Cuprum met – bluish, marbled. Ulcers, itching spots, and pimples at the folds of joints. Chronic psoriasis and lepra.
- Corallium Rubum – skin is red with dark red spots which usually change to copper colored spots. Psoriasis develops in the palms and soles.
- Iris versicolor – skin is affected with pustular eruptions and gastric derangement; psoriasis with appearance of irregular patches with shining scales.
- Borax – erysipelas of face, itching on back of finger joints; unhealthy; herpes; trade eruptions on fingers and hands, itching and stinging. Ends of hair become tangled.
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