The ultimate guide to understanding and treating psoriasis

Psoriasis is a skin disorder that afflicts some 10% of the population worldwide, causing painful red plaque-like flare-ups on the face, arms, torso, and sometimes the entire body. For individuals who suffer from this disorder, their quality of life is severely diminished. Learning how to avoid and manage psoriasis triggers is key because, in this way, one might avoid or at least reduce flare-ups altogether. Modern treatments focus on light therapy and topical treatments. However, new treatments are currently being researched that look highly promising for eliminating psoriasis flare-ups once and for all.

Psoriasis: a socially, physically, and emotionally challenging skin disorder

Psoriasis has plagued individuals for centuries and, still, scientists are not entirely certain what causes psoriasis or how to cure it. They can treat it—but not cure it. That’s chiefly because psoriasis has now been determined to be caused by an autoimmune disease, chiefly, some kind of defect in the autoimmune system which causes inflammation, as they body tries to attack its own tissues like it would a virus. This inflammation response triggers the skin cells to regenerate very rapidly, which is what causes the lesions to surface on the skin. Although psoriasis is not contagious, it is still socially stigmatising, with some flare-ups resulting in angry-looking pustules and peeling, reddish-silver scales that cover most of the face or the hands. Some individuals with severe psoriasis can have flare-ups that cover their entire body, making going to work or school impossible. Psoriasis can be a very hard condition to live with and some doctors believe that it could be solely the debilitating emotional effects of the disease that lead to so many deadly diseases being connected with it—diabetes and heart disease just to name two—as if the condition is so emotionally stressful it wears out the system physically as well. As Dr. Ellen Marmur, chief of the Division of Dermatologic and Cosmetic Surgery at Mount Sinai Hospital in New York City explains, The disease is also economically debilitating as well, as psoriasis sufferers often miss weeks of work every year because of severe and unpredictable breakouts. In fact, Marmur explains, the severity of one’s psoriasis diagnosis is often directly correlated with their income—the more severe the psoriasis, the lower the income from missed work. Because of the disfiguring aspect of this skin disorder and the unpredictability of the flare-ups, the impact on the individual’s life who is plagued with this disease can be immense, causing depression, extreme self-consciousness, low self-esteem, and a retreat from society and avoidance of a normal level of socialisation with others.  As researchers note “Psoriasis generally does not affect survival but has significant, detrimental effect on quality of life (QOL), which may be comparable to that of ischemic heart disease, diabetes, depression, and cancer. The foremost important thing in the management of psoriasis is counselling of the patient.”² Therefore, a good and empathetic dermatologist as well as a good psychiatrist or therapist to help the individual deal with the condition on an emotional level, may be one of the wisest and healthiest investments a patient with psoriasis can make. However, for most individuals psoriasis can be made more manageable by taking a thorough and scrupulous diary of flare-ups and triggers. Like acne and rosacea, psoriasis is a disease that is rooted in triggers. For some, these triggers are easily identifiable and for some, not so much. But learning to pinpoint what triggers psoriasis and eliminating all risk of these triggers, is the only real hope of preventing psoriasis flare-ups rather than treating them once they do occur.

Psoriasis: 100 million diagnosed and still growing 

Psoriasis affects people of all ages and ethnicities and affects individuals in every country on the globe. The World Health Organization estimates that psoriasis affects from .9 to 14% of the global population or roughly 100 million individuals worldwide.³. Psoriasis is a serious, painful, and non-communicable skin disease that can impact the body in all kinds of ways, causing multiple serious conditions. As the World Health Organization notes, “Psoriasis has an unpredictable course of symptoms, a number of external triggers and significant comorbidities, including arthritis, cardiovascular diseases, metabolic syndrome, inflammatory bowel disease and depression.”⁴, There is also a connection between psoriasis and diabetes, according to the National Psoriasis Foundation.5 Today, psoriasis is treated in a range of ways from oral prescriptions to topical ointments, light therapy (phototherapy), laser therapy, and, by holistic practitioners, through lifestyle modifications such as calming therapies (meditation and mindfulness), nutrition, and natural, plant-based topical ointments and treatments.⁶ Some doctors believe that psoriasis is caused, at least to some degree, by one’s lifestyle and behaviours, such as obesity, an unhealthy diet, food allergies, to leaky gut syndrome caused by either diet or behaviours, and they believe that these lifestyle factors act as a catalyst for the inflammation that causes psoriasis and that that is why psoriasis typically onsets in mature persons.⁷ Because there is, as of yet, no known cure for any autoimmune disease, there is no cure for psoriasis. Instead, most dermatologists try to help patients identify triggers for their flare-ups or treat breakouts with medication.

Psoriasis: its origins as a genetic, autoimmune disease

Although researchers are still discovering more and more about how the disease of psoriasis originates within the system and how the condition manifests over time leading to other diseases and disorders, they do know two things for certain:    1. There is a genetic factor to psoriasis. Many persons who are afflicted with psoriasis have a family member who had the disease. If a parent has psoriasis, their children have a 10 percent chance of developing the disease. In sets of identical twins, if one twin has psoriasis, the other has a 70 percent chance of developing it as well. However, researchers are still unclear about the full impact genetics has on psoriasis. Some scientists believe more than 10 percent of the entire population is born with some predisposition toward psoriasis but of this 10 percent, only 2 to 3 percent of them will develop the disease. They now believe it may take a trigger event, such as an illness in one’s youth, combined with a genetic predisposition, for one to develop the disorder.⁸

2. Psoriasis is caused by an autoimmune disorder causing the body to attack its own tissues.

 Researchers don’t know what causes the body of people with psoriasis to begin attacking its own tissues; they just know that it does. They know that people with psoriasis have an overactive immune system that wages war on its own tissues rather than some toxic or viral invader. Inflammation is the key response of the immune system to an invader, so the skin of the individual with psoriasis becomes red and inflamed or in individuals with psoriatic arthritis, the joints. As the National Psoriasis Foundation explains, When T cells recognise something as an invader – also called an antigen—T cells begin an inflammatory attack against the invader. This attack is carried out by cytokines, which are proteins that help control the immune system’s inflammatory response. Cytokines trigger inflammation, causing the blood vessels to expand and send more immune cells to different parts of the body. In psoriasis, this inflammation happens in the skin, leading to the red, itchy and scaly patches known as plaques.⁹

The five types of psoriasis and their symptoms

The symptoms of psoriasis will vary depending upon what type of psoriasis you have. Plaque psoriasis Plaque psoriasis is the most widespread and common form of psoriasis. This type of psoriasis is characterised by raised red, scaly patches frequently covered with a silvery-white film of dead skin cells. Plaque psoriasis frequently manifests on the elbows, the knees, the lower back, or the scalp. Guttate psoriasis This type of psoriasis is easy to recognise as it is the type that appears most like measles, with lots of red, dot-like lesions that frequently appear on the stomach, trunk, back, or limbs. Sometimes the lesions number in the hundreds and most often, this type of psoriasis coexists with another form of the disease, typically plaque psoriasis. Inverse psoriasis This type of psoriasis presents in skin folds as large, flat lesions that are smooth and shiny and look as if they are peeling, like sunburned skin. This type of psoriasis typically accompanies other types, such as pustular or plaque psoriasis. Pustular Pustular psoriasis causes blisters of pus to appear on the skin that are whitish in appearance. The pus is really white blood cells. This type of psoriasis occurs most often on the hands and feet. Erythrodermic Luckily, erythrodermic psoriasis affects only about 3 percent of people with psoriasis, as it is a very painful, itchy form of the diseases. This type of psoriasis presents in fiery red patches that occur over most of the body. It can actually make the skin peel off in sheets.¹⁰ It typically appears only on persons with an unstable form of plaque psoriasis. Unstable plaque psoriasis is the most severe form of the diseases, one that rapidly progresses and can cause dangerous and even fatal health problems.¹¹

Psoriasis and triggers

Although psoriasis is caused by an autoimmune condition, certain triggers can make symptoms worse or cause flare-ups. The National Psoriasis Foundation reports the following “established” triggers among patients.

1. Stress

Stress aggravates all inflammatory disorders and causes inflammation in and of itself, which is likely why stress is the number one trigger for psoriasis flare-ups. In fact, relaxation therapies are one of the most often prescribed therapies for psoriasis patients. Finding ways to relax and avoiding any stimulants like caffeine, green tea, or other beverages and supplements which might make you more stressed out are also key.

2. Injury to skin

It is said that just material rubbing against the skin can provoke a psoriasis breakout. Both irritation and injury to the skin can bring on a flare-up of psoriasis. This is called the Koebner phenomenon.¹² From getting a shot at the doctor’s office to getting scratched by a pet cat, any and all injuries to the skin can provoke psoriasis breakouts.

3. Medications

Certain medications are established psoriasis triggers, especially

• Lithium
• Antimalarials
• Inderal (high blood pressure)
• Quinidine
• Indomethacin

     4. Infections Infections affect the immune system, so of course they can trigger an immune response which can cause a psoriasis flare-up. In fact, certain infections are often when individuals experience the onset of their psoriasis. Strep and staph infections are both known to cause the onset of certain forms of psoriasis.¹³ Although not recognised by the National Psoriasis Foundation, naturopaths and some dermatologists believe food allergies, cold, chapping wind and weather, diet, and other lifestyle factors and environmental conditions can trigger psoriasis. WebMD adds smoking, drinking alcohol, and dry weather as common psoriasis triggers.

Diagnosing psoriasis

If you think you might have psoriasis, it is important to see a dermatologist or a doctor immediately. They can typically diagnose psoriasis by examining a patient’s scalp, nails, and skin. Sometimes, this disorder resembles other skin diseases, such as eczema. If your physician has difficulty diagnosing your condition, he/she will most likely order a skin biopsy which will reveal not only if you truly have psoriasis but what type you have as well.

Treating psoriasis

Treatments for psoriasis focus on reducing inflammation and clearing the skin of symptoms. There are three chief types of psoriasis treatment today:

• Topical ointments
• Light therapy
• Systemic medications¹⁴

Topical treatments for psoriasis

Topical creams and serums commonly prescribed to treat psoriasis include Topical corticosteroids: These drugs are the most frequently prescribed medications for treating mild to moderate psoriasis. They reduce inflammation and relieve itching and may be used with other treatments. Vitamin D analogues: These synthetic forms of vitamin D slow skin cell growth. Since the autoimmune defect that causes psoriasis causes the kind of rapid skin cell turnover that results in flare-ups, vitamin D therapies focus on reducing skin turnover. Anthralin: This medication also helps to slow skin cell growth and is helpful for removing the scales that are common in some forms of psoriasis. Topical retinoids: These are vitamin A-derivatives that work to alleviate the inflammation behind psoriasis. Other commonly prescribed creams and ointments include calcineurin inhibitors and salicylic acid. Salicylic acid is available over the counter and is good for sloughing off scales and the dead silvery skin that accompanies flare-ups. It is also available in shampoos and scalp treatments. Moisturisers : Moisturising the skin is crucial for psoriasis sufferers as dryness and dry weather can trigger psoriasis flare-ups. Mixing moisturisers with psoriasis ointments has proven particularly effective for healing flare-ups and preventing them as well. Other common psoriasis treatments

Light therapy (phototherapy)

This treatment uses natural or artificial UV light. Warm weather and limited sun exposure seem to help psoriasis patients and UV therapy is proving helpful for treating all forms of psoriasis, even severe forms of the disease. Most physicians recommend UV light therapy combined with topical medications as the most effective treatment for psoriasis.

Other treatments

Laser therapy

Laser therapy offers many of the benefits of light therapy, but in concentrated doses that eliminate frequent need for treatments. The lasers doctors use to treat psoriasis are called excimer lasers, and they deliver ultraviolet light to only the affected areas of the skin without harming the healthy skin around them. Like light/phototherapy, laser therapy is highly effective, but utilises strong doses of UV light that can penetrate deep into the affected skin, helping many people to reduce flare-ups or eliminate them for years at a time.

Natural and alternative therapies

Among naturopaths, three specific supplements and plant extracts have proven extremely effective for treating psoriasis. Aloe vera: Aloe vera can ease flare ups and many natural practitioners believe it may reduce risk of flare-ups as well. Aloe is a known anti-inflammatory, and naturopaths advise psoriasis sufferers to use both a topical application and to take an aloe vera supplement or drink aloe vera based beverages. With flare ups, aloe vera reduces redness, scaling, itching and inflammation.¹⁵ Fish oil: Omega-3 fatty acids found in fish oil supplements may reduce the inflammation associated with psoriasis. So far, studies on this have revealed mixed results. However, because Omega 3s, chiefly DHA and EPA are known to prevent and heal inflammation in the body and even reverse conditions associated with inflammation, such as diabetes and metabolic syndrome, taking a high quality fish or krill oil supplement as well as eating more fatty fish cannot hurt, as fatty fish and fish oil are wonderful for the skin (and the health) in general.¹⁶ Oregon grape: Also known as berberine, Oregon grape topicals and oils have been noted to ease psoriasis symptoms. The active compound in Oregon grape, berberine, is a powerful antibacterial and antifungal agent and many dermatologists are excited about the potential of berberine for treating psoriasis.¹⁷

Conclusion: new biologic agents proving helpful in treating psoriasis

Psoriasis sufferers should not despair. Funding has doubled for NIH researchers in the field of psoriasis and new treatments are constantly being investigated. As we speak, scientists are hard at work researching biologic agents as a new treatment for psoriasis. These studies are focusing on taking lab-manufactured proteins or antibodies and injecting these into the skin or bloodstream of patients with psoriasis. These drugs are proving very effective in blocking the impaired part of the immune system that causes the rapid turnover of skin cells, resulting in psoriasis flare-ups. So far, this research is proving quite promising.¹⁸

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Sources and References:

1. Fox News. Psoriasis: a nuisance or deadly disease? https://www.foxnews.com/story/2009/10/13/psoriasis-nuisance-or-deadly-disease.html
2. Sarkar, R., et. al. (2016). General measures and quality of life issues in psoriasis. Indian Dermatology Online, 7(6): 481–488. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5134161/
3. World Health Organization. (2016). Global report on psoriasis. https://apps.who.int/iris/bitstream/10665/204417/1/9789241565189_eng.pdf
4. WHO. Ibid.
5. The National Psoriasis Foundation. About psoriasis. https://www.psoriasis.org/about-psoriasis
6. The Mayo Clinic. Psoriasis.  https://www.mayoclinic.org/diseases-conditions/psoriasis/basics/definition/con-20030838
7. The National Psoriasis Foundation. The immune system and psoriatic disease. https://www.psoriasis.org/research/science-of-psoriasis/immune-system
8. AlShobaili, H. (2010).  Genetic background of psoriasis. International Journal of Health Science. 4(1): 23–29. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3068801/
9. The National Psoriasis Foundation. The immune system and psoriatic disease. https://www.psoriasis.org/research/science-of-psoriasis/immune-system
10. Psoriasis Speaks. Psoriasis types and pictures. https://www.psoriasis.com/psoriasis-types-pictures
11. Psoriasis Institute. Unstable psoriasis. https://www.psoriasisinstitute.com.au/psoriasis-types/unstable-psoriasis
12. HealthCentral. The Koebner phenomenon: managing cuts, scrapes and other skin irritations when you have psoriasis.https://www.healthcentral.com/article/the-koebner-phenomenon-managing-cuts-scrapes-and-other-skin-irritations-when-you-have-psoriasis
13. NPF. Causes and triggers. https://www.psoriasis.org/about-psoriasis/causes
14. WebMD. Psoriasis treatment overview. https://www.webmd.com/skin-problems-and-treatments/psoriasis/understanding-psoriasis-treatment#1
15. Dr. Ed. Zimney. Aloe vera shown effective for psoriasis. https://www.everydayhealth.com/columns/zimney-health-and-medical-news-you-can-use/aloe-vera-shown-effective-for-psoriasis/
16. Healthline. Omega 3s and psoriasis. https://www.healthline.com/health/psoriasis/omega-3-fatty-acids-treatment#overview1
17. Natural News. (2012). Oregon grape root excites dermatologists for the treatment of psoriasis and other skin diseases. https://www.naturalnews.com/037144_Oregon_grape_root_dermatologists_psoriasis.html
18. WebMD. Psoriasis treatment: what’s in the future? https://www.webmd.com/skin-problems-and-treatments/psoriasis/research#1