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Psoriasis

1-2% of Americans have psoriasis, a chronic skin disorder characterized by thick, red plaques of skin with silvery scales. Usually located symmetrically on elbows, knees, hands, or feet, it is also common on the scalp, at the nape of the neck, and just above the buttocks crease. It may appear at any age in either sex. Psoriasis may be an inherited disease. Stress, illness, irritation or injury to the skin, and weather change are among the recognized triggers. Psoriasis is not contagious.

New insights into the causes of psoriasis have reclassified this disease as one of inflammation that may extend to many organs, including the joints, heart, liver, and GI tract, as well as to the increased incidence of certain cancers. Psoriasis is associated with an increased risk of the metabolic syndrome (high blood pressure, abdominal obesity, high cholesterol or lipid levels, and insulin resistance leading to type 2 diabetes.) There is some early evidence suggesting that the treatment of psoriasis to decrease the inflammation may also be beneficial to these other organ systems. This is new, cutting edge information that needs to be borne out in longer, larger studies.

One study showed that smoking led to a 70% increase in incidence of psoriasis, especially in women. Alcohol intake is well known to exacerbate psoriasis. The risks of some of the associated diseases (inflammatory bowel disease, cardiovascular disease, certain cancers) are decreased when patients stop smoking.

What can you do? Losing weight, eating a well-balanced healthy diet, and exercising regularly may help your mood, decrease your risk of stroke or heart attack, and improve your psoriasis. It is reasonable to inform your primary care provider that you may have an additional risk factor for heart disease, diabetes, or arthritis. Regular monitoring of blood pressure and screening for diabetes, high triglyceride and cholesterol levels is recommended.

Multiple topical treatments have proven useful in reducing the signs and symptoms of psoriasis. These include tar, salicylic acid, calcipotriol (Vitamin D), retinoids (Vitamin A derivatives), corticosteroids, and emollients.

Ultraviolet treatments (UVB or PUVA) are usually the first recommendation in more widespread or difficult psoriasis. These treatments probably work via manipulation of the immune system in the skin. They are taken 2-3 times a week initially. The interval between treatments is increased as one sees improvement. This may result in weekly or monthly treatments. A remission period of weeks to months may be achieved in many patients after finishing an appropriate PUVA therapy. Risks may include burning, freckling, wrinkling, and an increased incidence of skin cancer years later.

Methotrexate is a chemotherapy drug that has been the “gold-standard” for treating severe psoriasis for many years. It can be used with reasonable safety as long as it is monitored appropriately for potential blood count or liver toxicity. Frequent blood tests are required early in treatment. After a cumulative dose of 1 – 1.5 grams, a liver biopsy is recommended before further treatment with methotrexate can resume.

Neoral (micronized cyclosporine) is also a great drug for helping stop severe, disabling psoriasis in its tracks. Because it can affect the kidney and lead to hypertension, it is usually used to “rescue” patients with severe disease. It can be used with relative safety for up to a year. If possible, at this time another treatment should be substituted.

Oral retinoids (Soriatane, isotretinoin) may be used in some psoriatics. These drugs are often used in combination with ultraviolet therapy. Close monitoring for Vitamin A toxicity includes monthly blood tests. Women should not get pregnant on these drugs and for a variable period after stopping these drugs. They are required to be on adequate birth control measures.

The strongest drugs against psoriasis are a new class of drugs called “biologics” (Enbrel, Humira, Stellara, Remicade) which come from living tissue. These drugs are injected into the skin, muscle or vein at different intervals. The treatments have many side effects, but are extremely effective in the skin and joint disease associated with arthritis. Patients on these drugs are at increased risk for lymphoma, multiple sclerosis, serious infection (especially tuberculosis) and congestive heart failure. One new study suggests that as one gets into the strongest biologics, risks of cardiovascular events (heart attack and stroke) may increase. As one would expect, these treatments are quite expensive. Insurance plans may not cover them.

The National Psoriasis Foundation has thousands of members who suffer from psoriasis. They maintain a website and a newsletter full of informative suggestions from fellow psoriatics. Remedies including experimental, accidental, anecdotal, and established are often featured in some detail. All patients with psoriasis should check out this organization.

The most important things to remember:

  • You are not alone.
  • You did not cause this.
  • Psoriasis is not contagious.
  • Psoriasis is not CURABLE, but the symptoms are very CONTROLLABLE.
  • Much exciting research is being done in this field.
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