Psoriasis, a chronic skin disorder is characterized by skin cells replicating at an extremely rapid rate with new skin cells production being eight times faster than normal over several days instead of a month. Well defined with noticeable red patches covered by silvery, flaky dead scale on the extensor surfaces and the scalp, its periodic flare-ups can cause tremendous inconvenience, anxiety and duress upon a person who suffers from psoriasis.

Its manifestation, at its mildest, can be itchy and sore but rarely life-threatening. At its worst extreme, it is painful, disfiguring, and debilitating; giving rise to loss of self-esteem, freedom to mix around and perhaps shunning public appearance. Psoriasis affects an estimated 1-3 percent of the world's population with 125 million people worldwide having to face its wrath, according to the World Psoriasis Day consortium. According to the National Institutes of Health (NIH), between 5.8 and 7.5 million Americans have psoriasis. Statistically, studies have shown that:-

• between 10 percent and 30 percent of people with psoriasis also develop psoriatic arthritis,
• about one out of three people with psoriasis report that a relative had psoriasis,
• a child has about a 10 percent chance of having psoriasis if one parent has psoriasis and the chances increase to 50% if both parents have psoriasis.

Psoriasis can strike at any age but mostly develops between 11 and 45 years old; often at puberty or after puberty. The ratio of mild form against moderate to severe forms is 2:1. Psoriasis usually comes in five forms; namely:-

• Plaque psoriasis

About 80% of the people with psoriasis have this form, making it the most common type. Its symptoms are dry, red skin lesions known as plaques that are covered in silver scales. Mostly appearing on the elbows, knees, scalp and lower back but can appear anywhere on the body. The plaques are normally itchy, sore, or both. In severe cases the skin around your joints may crack and bleed. The plaques of psoriasis occur most frequently on the elbows, knees, other parts of the legs, scalp, back, face, palms, and soles of the feet. Psoriasis can also affect the fingernails and toenails, causing pitting, discoloration, or tissue buildup around the nails. According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases, about 15 percent of people with psoriasis also get psoriatic arthritis, which can be progressively disabling if untreated.There are several variations of psoriasis but the most common type is chronic plaque psoriasis.

• Nail psoriasis

Noticeable within the nail region, causing them to pit, discolor and grow abnormally. Often nails can become loose and separate from the nail bed and crumble in severe cases.

• Guttate psoriasis

Occurring mostly following a throat infection (streptococci), it is more common among children and teenagers. Manifesting as small water-drop-shaped sores on your chest, arms, legs and scalp, this form stands a good chance to disappear completely but some young people go on to develop plaque psoriasis.

• Scalp psoriasis

Normally affects the back of your head but it can occur in other parts of your scalp or with incidences on the whole scalp. Some people find scalp psoriasis extremely itchy, while others have no discomfort as this causes red patches of skin covered in thick silvery-white scales. In extreme cases it can cause hair loss, but not permanent balding.

• Inverse psoriasis

Mainly seen within the skin that are in folds or creases such as the armpits, groin, and the skin between the buttocks and under the breasts. Most common with overweight people and made worse by friction and sweating, it can cause large smooth red patches to occur in some or all of these areas and can be uncomfortable in hot weather.

• Pustular psoriasis

Being the rare type, pus-filled blisters or pustules appear on the skin. Different types of pustular psoriasis affect different parts of the body:-

• von Zumbusch pustules psoriasis

Pustules develops very quickly and appears across a wide area of the skin with uninfected white blood cell pus. The pustules dry and peel off within a couple of days, leaving the skin shiny, smooth and may reappear every few days or weeks in cycles. During the start of these cycles von Zumbasch pustules psoriasis can cause fever, chills, weight loss and fatigue.

• Palmaplanter pustular psoriasis

Pustules tend to appear on the palms and soles of the feet. Gradually develop into circular, brown, scaly spots which then peel off and may reappear every few days or weeks.

• Acropustulosis pustules psoriasis

Mainly appears on the fingers and toes and will burst leaving bright red areas that may ooze or become scaly. These may lead to painful nail deformities.

• Erythrodermic psoriasis

As the rarest form of all and covering the body with a widespread red rash that causes intense itching or burning, Erythrodermic psoriasis inflicts upon the body to lose proteins and fluid which can lead to serious illnesses such as dehydration, heart failure, hypothermia and malnutrition.

Causes of Psoriasis

• Genetic Causes

It has been, according to researches, largely attributed to mutation of 9 genes that may be involved in causing psoriasis. One of these mutations on chromosome 6, called PSORS-1, appears to be a major factor that can lead to psoriasis. Mutations on genes seem to largely affect the T-helper cells to function differently.

• Immune System Causes

In a normally functioning immune system, white blood cells produce antibodies to fight off foreign invaders such as bacteria and viruses and in doing so, they also produce chemicals that aid in healing and fighting infective agents. However, in psoriasis, special white blood cells called T-cells become overactive when they become defective thereby attacking the body's own skin cells and set off a cascade of events that make the skin cells multiply so fast they start to stack up on the surface of the skin. Normal skin cells form, mature, then are sloughed off every 28-30 days but in plaque psoriasis the skin cells go through this whole process in just 3-6 days. Under normal circumstances, T-cells produce chemicals that help heal the skin. In psoriasis, T-cells produce an abnormally large amount of these chemicals and actually cause more inflammation in the skin and joints.

• Environmental Causes

Not everyone who has these gene mutations gets psoriasis and there are several other forms of psoriasis that people can develop. Certain environmental factors trigger play a role in causing psoriasis in people who have these gene mutations.

Diagnosis and Treatment

There are no single test which can be used to diagnose psoriasis. Dermatologists can usually determine it by the appearance of the skin and by inquiring into an individual's personal and family medical history. In some cases, a specialist will confirm the diagnosis through biopsy of the skin under a microscope. Psoriasis treatments are normally treated via external topical medications applied to the skin, phototherapy with ultraviolet light applied to the skin and systemic medications taken orally or by injection.

• Topical Treatments

Topical lotions, ointments, creams, gels, and shampoos for the skin and scalp are prescribed for mild-to-moderate cases of psoriasis or in combination with other treatments for more severe cases. FDA-approved prescription topicals to treat psoriasis include a combination of drugs corticosteroids, retinoids, calcipotriene, and coal tar products which are applied to slow down skin cell production and reduce inflammation.

A synthetic drug resembling naturally occurring hormone, corticosteroids have side effects which may include thinning of the skin and stretch marks at the topical application area. Besides that, corticosteroids may also suppress the adrenal glands' production of natural steroids which could leave the body susceptible to disease for long term application.

Retinoids and calcipotriene are derivatives of vitamin A and a synthetic form of vitamin D respectively. As opposed to those over-the-counter vitamin A and D supplements which have no value for treating psoriasis, these topical psoriasis creams are able to deliver to the affected skin area the vitamin-like chemicals right to where it is needed. Skin irritation where the topical is applied may be a side effect. Retinoids are also available by prescription as oral systemic drugs.

Though coal tar products can help with scaling, itching, and inflammation, they are not used as commonly as some other topicals due the its messiness, stain and the strong odor it carries along.

Prolonged use of a certain drug or steroid can cause down-regulation (tachyphylaxis) of steroid receptors in cells. The net effect is that the skin becomes less responsive to steroids over time which explains why there is a need to keep changing topical creams. The unresponsiveness may be a temporary effect and a patient may need to be off the steroid for a few days or a week and when put back on it, the responsiveness could come back.

• Phototherapy

This involves exposing the skin to ultraviolet light (UV); either from the sun or an artificial source which sets off a biological process that kills T cells to slow down the buildup of skin cells and reduces inflammation. Treatment with these devices is complex where an individual's sensitivity to UV must taken into consideration to ensure the most effective treatment with the least risk of side effects which includes burning, darkened skin, premature aging and skin cancer. Three to five treatments per week for several weeks or months may be needed to get the psoriasis under control to be followed by weekly maintenance treatments. The PUVA treatment comprising of a longer wavelength of ultraviolet light, called UVA and a combination of an oral or topical drug called psoralen is used to treat people with resistant moderate-to-severe psoriasis.

• Systemic Treatments

The FDA has approved oral and injected drugs that circulate throughout the body to treat psoriasis that is moderate, severe, or disabling. These systemic drugs are very powerful, and while some may be used continuously, others can only be used for a limited time because of their severe side effects. Once a drug is discontinued, the psoriasis may reactivate as psoriasis is thought to have no cure. Systemic drugs that may be prescribed for psoriasis include acitretin, methotrexate, cyclosporine, and biologics, which are drugs made from proteins of living cells. Methotrexate, cyclosporine, and the biologic drugs are immunosuppressants which suppress the immune cells that cause psoriasis but the setback with these drugs is they do not distinguish these cells from the immune cells that protect your body from infections. In short, it compromises your immune system; opening it to vulnerable attacks. Acitretin, a retinoid that is given orally for severe psoriasis, helps normalize the growth of skin cells but its side effects is raised fat (lipid) levels in the blood. Those on this drug are required to have regular blood tests to monitor their cholesterol and triglyceride levels. Methotrexate and cyclosporine slow the growth of skin cells. Methotrexate, taken orally or by injection, is also a chemotherapy drug for cancer patients. Cyclosporine, taken orally, was first approved to prevent organ rejection in transplant recipients. People using either of these drugs must be closely monitored and should use them only for short periods of time because of serious, potentially fatal, side effects.

Biologics are the newest systemic psoriasis treatments. Since 2003, the FDA has licensed three biologics to treat moderate-to-severe plaque psoriasis namely Amevive (alefacept), manufactured by Biogen Inc.; Raptiva (efalizumab), made by Genentech Inc.; and Enbrel (etanercept), marketed by Amgen Inc. and Wyeth Pharmaceuticals. Licensed in 2002, Enbrel was first used to treat the arthritis associated with psoriasis, and in 2004 to treat psoriasis itself. All are immunosuppressive and have different proposed mechanisms. Amevive simultaneously reduces the number of immune cells, including T cells, and inhibits T-cell activation. Raptiva inhibits the activation of T cells and the migration of those cells across blood vessels and into tissues, including the skin. Enbrel inhibits the action of an inflammatory chemical messenger in the immune system called tumor necrosis factor-alpha (TNF-alpha), which is believed to play a role in both the skin and the joint symptoms of psoriasis. It is common knowledge that in 80 % of the cases the biologic agents are quite effective in successfully treating symptoms of psoriasis. Nonetheless, when treatment is stopped, psoriasis erupts quite rigorously, far worst than before the start of treatment requiring repeated cycles of treatments. These drugs disable protective aspect of the immune system, leaving patients vulnerable to infection and cancer

As in all immunosuppressants, biologic drugs are no different in that they may carry an increased risk of infection and cancer. Rare but serious effects have also included blood abnormalities and autoimmune diseases such as lupus. Other side effects are flu-like symptoms and pain and inflammation at the injection site. Some dermatologists prescribe biologics alone for psoriasis or in combination with topical treatments. Biologics, other systemic drugs and phototherapy are powerful treatments with increased risks for developing cancer and serious bacterial or fungal infections that spread throughout the body (sepsis).

Meanwhile, cyclosporine can damage the kidneys, methotrexate puts the liver and lungs at risk, and phototherapy can cause skin cancer. To reduce these risks, doctors often put patients on rotational therapy where it is envisaged that by moving from one therapy to another therapy over time, the risk to any individual organ is reduced. Such are the concerns one must calculate in choosing a drug with an appropriate benefit-risk ratio. Solution to mild psoriasis is prescription of a topical steroid whereas for more severe disease, where it becomes impractical to apply topicals over a large surface area several times a day, a patient may need a systemic treatment. Most of the highly effective treatments for psoriasis affect the immune system in some way. For steroid drugs, which have been around for more than 50 years, the risks are well known. But less is known about the long-term side effects of newer drugs, such as the biologics. The safety and side effects of biologics and other immune-suppressing drugs to treat psoriasis continue to be monitored by drug manufacturers and the FDA.

While the disease never goes away, remission of psoriasis symptoms can be for a while and then flare-ups can recur. Remission can last for years in some people while in others flare-ups occur every few weeks. Extreme care has to be exercised as certain triggers, such as stress and seasonal changes, can reactivate psoriasis.

• Psoriasis Triggers

Psoriasis symptoms can be made worse due to a trigger event which comprises alcohol consumption, smoking, an injury to your skin such as a cut, scrape, insect bite, sunburn and stress. So can certain drugs prescribed for other purposes including but not limited to lithium which is prescribed for bipolar disorder or manic-depressive illness or in contact with certain medicines like lithium, antimalarial medicines, anti-inflammatory medicines including ibuprofen, ACE inhibitors (used to treat hypertension) and beta blockers (used to treat congestive heart failure).

• Emotional Impact

Managing the emotional impact of psoriasis can be as challenging as treating the disease. Staring at you is common, avoiding you is another psychological effect that you may have to bear with. People who do not know the conditions of psoriasis may think that it is related to AIDS. It is understandable to feel down with psoriasis but you have to toughen yourself for the experience of going about doing the things that you want to do; of course without the consciousness of people around you staring at you. Try ignoring those who stare at you and join a support group for psoriasis sufferers to lend support to each other. Invite psychiatrists and dermatologists to be involve in your support group or adopt meditation, practise yoga and dance classes to de-stress.

Psoriasis is a common papulosquamous skin disease. The histopathology is characterized by epidermal hyperplasia and inflammation. Recent studies suggest that keratinocyte proliferation and inflammation in psoriasis are manifestations of the same underlying pathological process. Interleukin 6 (IL-6), a cytokine that is a major mediator of the host response to tissue injury and infection, is produced by both keratinocytes and leukocytes in culture. IL-6 expression was studied in psoriatic plaques by immunoperoxidase staining with two different polyclonal anti-recombinant IL-6 antisera and by in situ nucleic acid hybridization with IL-6 cRNA probes. Epidermal and dermal cells in active psoriatic plaques from 35 psoriasis patients stained heavily for IL-6 as compared with nonlesional skin and with plaques after treatment with antimetabolic and antiinflammatory agents. Absorption of the anti-recombinant IL-6 antisera with purified fibroblast-derived IL-6 or with recombinant IL-6, but not bovine serum albumin, removed the immunostaining. Increased levels of IL-6 were detected in the plasma of patients with active psoriasis (mean 3 ng/ml) by using two different bioassays. IL-6 production by proliferating keratinocytes was suggested by IL-6-specific immunostaining in cultured normal and psoriatic keratinocytes and by the detection of mRNA specific for IL-6 in psoriatic epidermis by in situ hybridization. IL-6 stimulated the proliferation of cultured, normal human keratinocytes as assessed by two different assays. Thus, IL-6 could directly contribute to the epidermal hyperplasia seen in psoriatic epithelium as well as affect the function of dermal inflammatory cells.

Recent breakthroughs in the treatment of psoriasis have led to improved understanding of the pathogenesis of this disease. Activation of T lymphocytes leading to release of cytokines results in proliferation of keratinocytes. Several new biological therapies have been developed, which target specific steps in the pathogenesis of psoriasis. With these new treatments, variable degrees of clearing occur. Initial data suggest improved safety over older agents such as methotrexate and ciclosporin, but long-term data are necessary. Enhancements in topical therapy and phototherapy have also increased the armamentarium of treatments available for this disorder.

Researchers, in continuing to look for reasons such as why immune cells overreact and what genes may be responsible for psoriasis, are now about to see some breakthrough in Transfer Factor being used to manage the immune system in finding better treatments and eventually a cure. Most drugs being used now is based on solving the symptoms but not the root cause of the psoriasis problem. Pharmaceutical companies stand to lose millions of dollars in profits if they tell you the truth. In most cases, current treatments are far too expensive and completely ineffective as all of the potions used to remove the dead cells are buffered by or contain lubricating agents. They require too many applications and are somewhat ineffective in quickly removing the silvery patches with one or two applications. Moreover, most of the topical application of moisturizing creams, ointments and lotions containing coal tar, lactic acid, urea, anthralin, salicylic acid, derivatives of vitamins A and D, and steroids do not penetrate silvery patches or dislodge the tough plaques. Psoriasis treatment research is only aided by the visibility of the symptoms on the skin. No invasive testing to see the effects of therapy is needed and psoriasis research has tremendous spillover into other fields besides dermatology and there is urgent and huge need to develop drugs to suppress the immune system without the side effects; otherwise it is no different from the drugs that are being applied today. Being in the same autoimmune diseases category as psoriasis, multiple sclerosis, Crohn's disease, rheumatoid arthritis and type 1 diabetes are just a few of the diseases that may also benefit from psoriasis research.

Tags: chronic skin disorder, duress, flare ups, psoriasis, skin lesions

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