Psoriasis is an autoimmune, common and chronic skin condition affecting approximately 1‑3% of the world population. Psoriasis usually occurs as erythematosus plaques covered by silver scales, which are detached from the skin. It occurs mainly on the knees and elbows, the nails and the scalp, but it can also occur anywhere on the body and in different types. The affected area can be red and scaly or it can display blisters, depending on the type of psoriasis.
Psoriasis affects men and women equally and can occur at any age.
The duration of the disease varies depending on the case, but in most patients the exacerbation and remission periods alternate for many years during their life in different clinical stages of psoriasis. With proper treatment, patients can learn to leave with their condition and to be in remission for a long time.
There are 5 basic types of psoriasis:
It is the most common type of psoriasis which is manifested by red and white scaly plaques on the skin surface and its characteristic symptoms include itching, peeling and bleeding.
It is characterized by the onset of small, scaly lesions that have pink or red color and the shape of a teardrop. These lesions occur in extensive areas of the body, such as the trunk, limbs and scalp. It usually occurs very suddenly in younger patients, mainly following a streptococcus infection.
It usually occurs in overweight people, in the armpit, groin, under the abdomen and the chest. It exacerbates by friction and sweat, is susceptible to fungal infections and can cause severe pain and pruritus.
It occurs as clearly defined, small raised bumps that are filled with pus, mainly on the palms and the soles. The skin around them is sensitive, red and dry. There are 2 basic types of pustural psoriasis, the localized which is confined to the hands and feet and the generalized in which the bumps occur anywhere on the body
It is a particularly inflammatory form of psoriasis that occurs as extensive inflammation and peeling of the skin on almost the entire surface of the body. This form is characterized by redness and exfoliation of the skin which is accompanied by pruritus, swelling and pain. It can be fatal, because it increases the heart rate and raises the body temperature.
Other types of psoriasis
It occurs on the fingernails and toenails. It causes depigmentation, cracks, lines along the nails and hardening of the epidermis under the nail. The nails become friable and are surrounded by inflammation.
The patient is suffering from both psoriasis and arthritis, and the symptoms include inflammation in the joints and the connective tissue. It is more common in the fingers and toes and causes swelling. It also affects the hips, knees and the spine. Approximately 10‑30% of psoriasis sufferers also has psoriatic arthritis.
There are various clinical stages of psoriasis:
Clinical stage – Acute guttate (rapidly progressing) psoriasis
Guttate psoriasis which occupies the entire body.
Clinical stage – Chronic progressive psoriasis
The common plaque psoriasis where the skin is very sensitive.
Clinical stage – Chronic stationary psoriasis
In this stage the psoriatic lesions remain stationary, do not increase in size, have a dull red color and minimum size.
Clinical stage – Chronic regressive psoriasis
At this stage, usually after treatment of psoriasis, the blisters become smaller; their color changes to dull red and they gradually fade.
Clinical classification of psoriasis
Psoriasis is characterized as mild when is limited to less than 5% of the body surface. Patients can minimize the symptoms, their quality of life is not affected and they may not require treatment.
Psoriasis is characterized as moderate when it affects 2‑20% of the body surface. The patient’s quality of life is not affected whereas treatment is required.
It is the type of psoriasis that affects more than 10% of body surface. It affects quality of life and patients will have to accept side effects that will alleviate or eliminate the symptoms.
Psoriasis causes pruritus in 60‑70% of cases, is not contagious, is not caused by an allergy and is attributed to genetic or hereditary predisposition. Approximately 1/3 of people with psoriasis have a member in their family with psoriasis.
Other causes of psoriasis include smoking, sun exposure, alternation of the seasons, the friction caused by clothing on the skin, stress, some medications and alcoholism; all of the above can affect the onset and duration of the exacerbation of psoriasis.
The initial occurrence and recurrent flares of psoriasis are often accompanied with psychological trauma caused by strong emotions such as grief or separation or by physical injury, such as an accident or a surgery. Stress increases the likelihood of new flares, which means that patients can easily get into a vicious circle.
The psychological impact of psoriasis is severe and the patient is advised to follow any of the treatments of psoriasis.
Topical treatment of psoriasis
Topical steroids are synthetic drugs that resemble the hormones present in our body and often are being used as the initial treatment for small areas where psoriasis occurs. Corticosteroids are frequently used for the treatment of mild and moderate forms of psoriasis because they reduce the growth rate of skin cells and reduce inflammation and itching. There are potent corticosteroids applied on the elbows and knees and milder ones that are used on the face, armpits and the groin. Potent steroids should be used with caution, as their long-term use can lead to permanent skin sensitivity and atrophy.
Calcipotriene is a vitamin D derivative, which delays the growth of skin cells and is used for the treatment of plaque psoriasis. It is not as affective as topical corticosteroids, but when combined the outcome is very good.
Moisturizing creams containing salicylic acid, lactic acid, urea and glycolic acid can help in cases of psoriasis treatment. Salicylic acid has keratolytic effect that helps in the reduction of psoriasis scars. Topical medications can penetrate the skin more effectively if are being used after the salicylic acid. Stronger medicines should not be used in sensitive areas, such as the eyelids, face and genitals.
The Dovobet ointment contains two active ingredients: Betamethasone and Calcipotriene.
Calcipotriene is a vitamin D derivative; it reduces the excessive skin cell production and enhances their normal growth. Betamethasone is a topical corticosteroid that helps in the reduction of inflammation. The ointment with this combination of active ingredients is used for the treatment of stationary plaque psoriasis.
Natural light and the different forms of treatment with UV radiation are beneficial for the skin and can improve psoriasis.
Phototherapy is a psoriasis treatment that involves exposing the skin to UV radiation from artificial sources with or without concomitant medication that increases the sensitivity of the skin to light. The light reduces inflammation, delays the production of skin cells and contributes to the elimination or reduction of psoriasis.
Treatment of psoriasis with Excimer laser
This psoriasis treatment uses localized light laser beams in order to control the mild and moderate forms of psoriasis without harming the healthy surrounding area. The Excimer laser produces ultraviolet B (UVB) at a specific wavelength (308 nm) directly to the affected area. It does not come in contact with healthy skin, and therefore, the risk of exposure to ultraviolet radiation is reduced. Its efficacy is the same with traditional phototherapy, but fewer sessions are required, because the light is stronger and penetrates deeper in to the skin.
Biological agents in the treatment of psoriasis
Biological agents are proteins which are derived from living cells cultured in the laboratory. They are widely used in the last decades for the treatment of various autoimmune diseases such as rheumatoid arthritis, ankylosing spondylitis, Crohn’s disease, psoriasis and psoriatic arthritis. Conventional treatments cause generalized immunosuppression. On the contrary, biological agents are more specialized treatments and are thus called targeted therapies. These factors affect specific pathways of the immune system such as cytokines, without causing generalized immunosuppression.
Biological treatments are used in various forms of psoriasis as well as in psoriatic arthritis. The administration of biological agents is preferred in severe forms of the disease and when conventional treatments have failed or there is a contraindication for the administration or there is an increased risk of toxicity from their use and if psoriasis is very unstable and significantly affects the quality of life or is dangerous for the patient’s life.
The fact that biological agents do not cause hepatotoxicity or nephrotoxicity offers the potential for their long-term administration and better patient compliance. Biological agents are injectables that they are administered either subcutaneously or intravenously. The intervals of administration and their dosage vary with the type of the biological agent to be used.
Before the administration of any biological agent, it is necessary to conduct clinical and laboratory investigations.
The extent of psoriasis is determined clinically whereas laboratory examinations are performed, such as hematology examinations and chest X-ray to rule out possible infections. Meanwhile, before the initiation of biological treatments the necessary vaccination program should be conducted against flu or any other vaccine that needs to be administered.
The approved biological agents for the treatment of psoriasis are the following:
Anti-TNF biological agents
Etanercept – Enbrel
It has been approved for the treatment of rheumatoid arthritis, chronic plaque psoriasis and psoriatic arthritis. It is subcutaneously administered 2 times per week. Satisfactory results are obtained within 4 to 8 weeks.
Infliximab – Remicade
Very effective treatment for plaque psoriasis and useful for cases where rapid control of psoriasis is required, such as in erythrodermic and pustular psoriasis. The results are noticeable within a period of 2 weeks. The treatment is administered intravenously at intervals of 0, 2 and 6 weeks and then every 8 weeks. It also helps significantly in psoriatic arthritis.
Adalimumab – Humira
It is used in patients with moderate to severe chronic plaque psoriasis. It is administered subcutaneously in intervals of 0 and 1 week and then every 2nd week. It has a fast onset time with good results over a period of 2 weeks.
Ustekinumab – Stelara
Fully human monoclonal antibody that suppresses inflammation associated with psoriasis. It is used in adults with moderate to severe chronic plaque psoriasis. It is administered subcutaneously at intervals of 0 and 4 weeks and then every 12 weeks.
Secukinumab – Cosentyx
Fully human monoclonal antibody against interleukin 17Α. It is administered subcutaneously at weeks 0, 1, 2 and 3 and then every month. It is a latest-generation drug that was recently launched. It is considered particularly effective with rapid results and mild adverse reactions such as upper respiratory infections.
Cosmetic Derma Medicine uses a comprehensive approach to the treatment of psoriasis and is specialized in both the conventional and newer biological methods.
The specialized dermatologists of our clinic have considerable experience on the use of biological agents for the treatment of psoriasis.
Dr. Amalia Tsiatoura MD, is a physician specialized in cases of psoriasis, she held a research assistant position in the Psoriasis Department of the Dermatology Clinic of “Andreas Syggros” Hospital and was a researcher in several studies and clinical trials of new methods of treatment of psoriasis and other dermatological diseases.