This article gives information about psoriasis, it is a difficult condition to manage and we have been offered samples for a range that claims to help. We will get all the feed back to you, e mail us if you would like more information.
Psoriasis is a genetically determined disorder characterised by development of chronic, well-defined, scaly, erythematous plaques on the extensor aspect of the extremities, especially on the elbows and knees, trunk, back and scalp. Nail involvement is very frequent and often gives the clue to the diagnosis. Psoriasis can be localised or generalised. High variability and unpredictability is the hallmark of this chronic affliction. The estimated prevalence is 1.5% to 3% in the general population. There is wide ethnic and racial variation. It has a bimodal peak of incidence, at 16-22 years and 57-60 years. Female predominance is noted in the younger age group.
The precipitating and aggravating factors, such as physiological changes of puberty and pregnancy, intercurrent infections, endocrine imbalance, physical trauma (including sunlight) and mental stress, have a definite role in the course and prognosis of the disease. Drugs like b-blockers, antimalarials, NSAIDs, lithium, etc. are known to cause psoriasiform drug reactions and also to precipitate the disease. Obesity and chronic alcoholism are known to be associated with refractory cases. Patients with HIV and AIDS often present with recalcitrant and severe disease at a young age.
The classical lesions are erythematous, scaly, well-defined plaques on the extremities, trunk and scalp. Nail involvement is very common and often precedes the skin lesions.
The initial lesion, an erythematous papule, increases to form a well-circumscribed plaque, covered by dry, loosely attached, silvery-white micaceous scales. On scraping, the white amorphous scales resemble wax candle. Removal of scales reveals a glistening red membrane of Berkeley. Small bleeding points are observed after breaking through the membrane. This is termed Auspitz’s sign and indicates active disease. Auspitz’s sign is often negative in early and healing stages of psoriasis. The plaques often coalesce to form irregular patches especially on the trunk, and have polycyclic or serpiginous borders. Early lesions have a typical salmon-pink colour while the chronic well-established lesions acquire a dusky bluish hue especially on dark skin.
Healing lesions of psoriasis become non scaly and dusky in colour and often assume annular forms. They leave behind post inflammatory hyperpigmented macules often with a ring of hypopigmentation.
Scalp involvement is either localised or diffuse. Well-circumscribed erythematous plaques with loosely adherent silvery scales characteristically project beyond the hair margin especially on the neck and retroauricular region. Scalp lesions need to be differentiated from tinea capitis and seborrhoeic dermatitis.
Flexural involvement is termed inverse psoriasis. The lesions have a shiny smooth surface and conspicuous absence of scaling. Seborrhoeic dermatitis is difficult to distinguish and often co-exists (sebo-psoriasis). Palmoplantar involvement is the most refractory type. Erythematous scaly plaques, plaques studded with pustules, or diffuse thickening of the skin are the common presentation on palms and soles. Nail involvement is frequently associated with this variety of psoriasis.
The chronic plaque type of psoriasis is a very stable form. The lesions remain unchanged for many years except for the customary seasonal variations, with most patients showing winter exacerbation. Aggravating factors sometimes initiate new sets of lesions and consequently the condition of the patient may worsen steadily. This is called the unstable phase and requires the urgent attention of the physician.
Commonly known to present in children and young subjects, the guttate variety is characterised by sudden crops of small erythematous shiny papules appearing on the trunk and proximal part of the extremities. The characteristic scales are usually absent in this variety. In children, upper respiratory tract infection is known to precede the skin lesions by 2-3 weeks. The guttate variety often subsides within a few weeks.
Exfoliative psoriasis (psoriatic erythroderma):
Abrupt discontinuation of systemic steroids, aggressive coal tar or PUVA therapy and administration of antimalarials are some of the precipitating factors of such a sudden widespread involvement. Fully established cases are clinically indistinguishable from other varieties of erythroderma. Severe itching and burning are the disturbing symptoms. Complications like irregularities in thermoregulation and haemodynamics, intestinal absorption of proteins, water and electrolyte balance often prove fatal in elderly subjects. Acute renal failure may ensue due to diversion of large quantity of blood to the skin tissue. High cardiac output may precipitate cardiac failure in those with compromised heart status. The course of exfoliative dermatitis is prolonged as relapses are frequent.
In this variety, tiny, superficial, sterile pustules appear either on the surface of psoriatic lesions or on previously unaffected skin. The degree of underlying erythema is variable but constantly present. The localised variety mainly involves the palms and soles while the generalised type has widespread involvement accompanied by severe constitutional symptoms. The precipitating factors implicated in exfoliative dermatitis are also functional in pustular psoriasis.
Nail changes in psoriasis are observed in 25-50% of cases and in some they may be the only manifestation. Pitting of nails is an early and regular feature. The pits are deep seated and have uniform distribution on nails. They give rise to “thimble nails” appearance. Vertical ridge formations, deep transverse grooves (Beau’s lines), subungual hyperkeratosis, and partial or complete onycholysis are other accompanying findings. Oil drops in the form of localised yellowish spot formation or diffuse nail discolouration, usually yellow, are some added features. Nail involvement is often conspicuously present along with swellings of the distal interphalyngeal joints.
Mucous membrane involvement is not a common feature of psoriasis. It may be seen in the pustular variety or in severe cases of exfoliative dermatitis. Discrete or confluent erosions with raised elevated margins are observed on the buccal mucosa and tongue. The glans penis rarely shows a solitary erythematous patch which may go unnoticed by the patient.
The course of different types of psoriasis is unpredictable and often intractable. Periods of remission are interspersed with seasonal exacerbations, and those during pregnancy and parturition, puberty and menopause, intercurrent infection, physical and mental stress, etc. Guttate variety has an excellent prognosis with the condition subsiding within few weeks, while the erythrodermic and the arthropathic psoriasis have the most unfavourable outcome, often requiring frequent indoor admissions. To date there is no curative modality available.
The treatment of a psoriatic patient needs to be tailor-made. Factors like age, gender, occupation, general health, type and extent of psoriasis, duration and natural course of the condition need consideration. Screening of the family members for psoriasis should be advised.