Psoriasis
treatment, cause and prevention
Psoriasis is a chronic cutaneous disorder characterized by papules that coalesce to form plaques covered with thick, silvery scales. Psoriasis plaques are caused by the accelerated production of epidermal cells. Psoriasis is most common on the knee, elbow, scalp, groin and sacrum.
TYPES OF PSORIASIS
Psoriasis is normally divided into two types: Major and Minor.
Major psoriasis includes plaque type, guttate, and inverse. Minor psoriasis includes generalized pustular, localized pustular and erythrodermic psoriasis.
CUTANEOUS MANIFESTATIONS
Plaque Type Psoriasis:
Plaque type psoriasis presents as round, red, dry plaques covered with thick, silvery-white adherent scales. The circumscribed plaques range in size from 1 – 10 cm in diameter. Plaque type psoriasis has a predilection for the extensor surfaces of the large joints, scalp and sacrum.
Guttate Psoriasis:
Guttate psoriasis presents as multiple discrete tear-shaped lesions covered with silvery scales. The lesions typically range from 0.5 – 1.5 cm in diameter. Guttate psoriasis has a predilection for the trunk, proximal extremities and the face. It is usually triggered by a viral infection, streptococcal infection, sunburn or withdrawal of systemic corticosteroids. The onset of guttate psoriasis is characterized by an eruption of erythematous macules that persist for 6 – 8 weeks.
Inverse Psoriasis:
Inverse psoriasis presents as reddened, macerated areas of skin that are not scaly. Inverse psoriasis has a predilection for the axillae, gluteal cleft, and perinium.
OTHER MANIFESTATIONS
Nail
This may be the only manifestation of psoriasis. The affected nail may show pitting, leukonychia, longitudinal ridges and grooves, transverse depressions, or a red-brown discolouration of the nail bed. Advanced cases of psoriasis involve crumbling of the nail bed, hyperkeratosis and onycholysis
Psoriatic Arthritis (PsA)
Psoriatic arthritis (PsA) is an inflammatory condition that is associated with psoriasis. It is not presently understood whether psoriatic arthritis is unique or is a variation of psoriasis. (Some evidence suggests, however, that the same autoimmune process may initiate both psoriatic arthritis and psoriasis.) Unlike other forms of psoriasis, psoriatic arthritis (PsA) is systemic in nature.
Psoriatic arthritis is characterized by stiff, tender, and inflamed joints. Arthritic and skin flare-ups tend to occur simultaneously. Psoriatic arthritis (PsA) usually affects less than five joints, and frequently causes deformities in the fingers and toes. About 80 percent of Psoriatic arthritis (PsA) patients have psoriasis in the nails. Psoriatic arthritis (PsA) may also occur in the knees, hips, elbows, and spine (usually the sacrum). Psoriatic arthritis (PsA) is systemic in nature.
ETIOLOGY
The precise etiology of psoriasis remains unknown, however, it is believed that psoriasis originates from genetic abnormalities in the immune system that are triggered by environmental factors.
In terms of genetic predisposition, 58 percent of children affected by psoriasis have a first degree relative with psoriasis. If one parent has psoriasis, the risk of is 25 percent; if both parents are affected, the risk is 60 percent. Scaling may be particularly severe in people taking immunosuppressive drugs, people with AIDS, chemotherapy patients, and those with autoimmune disorders such as rheumatoid arthritis.
Specific triggers include infections such as Group A beta-hemolytic Streptococcus (pharyngeal or rectal), measles and tinea pedis. Trauma that can lead to development of psoriasis includes burns, abrasions, bites, rashes and other skin irritations; sunburn, tattoos, radiation and vaccinations. Lifestyle factors such as obesity, getting too much or too little sunlight, excessive alcohol consumption, and stress also appear to trigger psoriasis. Cold weather also aggravates psoriasis.
Digestive problems (inflammatory bowel diseases such as crohn's disease, ulcerative colitis and diverticulitis) may precede psoriasis; this could be due to abnormal absorption, into the bloodstream, of antigens from the digestive tract.
Since the skin has highly vascularized capillary network, it is susceptible to the deposition of immune complexes that further provoke destructive immune responses. These responses lead to increased capillary permeability, edema, inflammation, redness, itching and pain.
TREATMENT MODALITIES/MANAGEMENT
The goal of psoriasis treatment is to reduce inflammation and to control flaking of the skin. Psoriasis treatment is based on the affected person's health, age, lifestyle, and the severity of the psoriasis. A number of different psoriasis treatments are normally employed to determine which is the most effective.
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Topical Steroids.
Topical steroid medications are one of the most common treatments for mild to moderate psoriasis. They reduce inflammation and itching and stop the rapid build-up of dead skin cells. Topical steroids are available in varying strengths as creams, lotions, ointments, gels or solutions. Potential side effects of topical steroids (depending on the drug's potency) may include burning, irritation, dryness, acne, thinning of the skin, dilated blood vessels and loss of skin colour.
Weaker preparations should be used on sensitive areas of the body such as the face, groin and genitals. Stronger preparations will usually be needed to control psoriasis lesions on the scalp, elbow, knees, palms and soles, and parts of the torso. Side effects of the stronger cortisone preparations include thinning of the skin, stretch marks, dilated blood vessels, bruising, and changes to skin colour. Stopping topical steroid medications suddenly may result in a flare-up. After many months of treatment with steroids, the psoriasis may become resistant to the steroid preparation that has been prescribed. Cortisone is often injected into areas that remain resistant to treatment. High potency steroid drugs carry a small risk for adrenal insufficiency, which can cause serious complications.
Anthralin.
This systemic medication works well on stubborn, thick patches of psoriasis. It slows down skin cell reproduction and may produce remissions that last several months. Anthralin is available as a cream, paste or ointment and works best for patients with plaque or guttate psoriasis. Anthralin may cause skin irritation in some patients and should not therefore be used on the face. Anthralin can also stain the clothes. Recently introduced anthralin preparations and methods of treatment have reduced the likelihood of these side effects.
Vitamin D.
A synthetic form of vitamin D, calcipotriene, is helpful for patients with localized psoriasis. Improvement occurs between two and six weeks and most cases of psoriasis have cleared after 14 to 36 weeks of treatment. Calcipotriene may be used alone but is more often employed with other topical agents or phototherapy. It may cause skin irritation in about 20 percent of patients and should therefore not be used on the face or in the genital area.
Although calcipotriene appears to be safe and effective in children, some health professionals have registered concern that it may lower levels of vitamin D to the extent that bone growth is affected.
Calcipotriene is now available by prescription as an ointment, cream and solution in the US and Canada. Ordinary Vitamin D from a drug or health food store is of no value in treating psoriasis.
Coal Tar.
This topical preparation has been used to treat psoriasis for over 100 years. Today's formulations are greatly improved over older products. Stronger prescriptions may be necessary to treat difficult areas. Coal tar inhibits enzymes that contribute to psoriasis and helps prevent cell proliferation. Tar is often used in combinations with other drugs and with UVB phototherapy.
Phototherapy.
Ultraviolet light, including sunlight, slows down the rapid growth of skin cells. In a 1999 study, phototherapies were much more effective than systemic drugs in achieving the longest remission. Phototherapy also appears to have fewer side effects than most systemic agents. Patients who have widespread psoriasis may require treatment in a medically approved center equipped with light boxes for full body exposure.
PUVA.
This treatment is effective when psoriasis has not responded to other treatments or is widespread. PUVA is effective in 85 to 90 percent of cases. The treatment involves taking psoralen, followed by a carefully measured amount of UVA light. Clearing of lesions normally requires 25 treatments or so, over a two to three-month period. Between 30 - 40 treatments a year are normally required to keep psoriasis under control.
PUVA treatments increase the risk of skin aging, freckles, and skin cancer.
Goeckerman Treatment.
This combination employs coal tar dressings and ultraviolet light to treat patients with severe psoriasis. Goeckerman treatment must be performed on a daily basis in specialized centers.
Methotrexate.
This oral anti-cancer drug produces significant clearing of psoriasis when other treatments have failed. Methotrexate interferes with cell reproduction, has anti-inflammatory properties and is one of the few systemic agents proven to help patients with psoriatic arthritis.
Methotrexate may produce undesirable side effects including nausea and vomiting, rashes, mild hair loss, headache, and mouth sores. It may also cause muscle aches. Since many of these symptoms are due to folic acid deficiency, they often disappear when supplementary folic acid is supplied in the diet. More serious side effects of methotrexate include liver scaring and kidney abnormalities. Patients at particular risk for liver damage from methotrexate include diabetics with existing liver or kidney problems, alcoholics, the obese, and the elderly.
Other methotrexate side effects may include suppression of blood cell production in the bone marrow, osteoporosis and increased risk for infections, including herpes zoster and pneumonia. When a patient is on methotrexate it is important that regular blood tests be performed. Chest x-rays and occasional liver biopsies may also be required.
Patients taking methotrexate should not be on NSAIDs, such as aspirin, ibuprofen (Advil), or naproxen, as these can cause serious toxic interactions. Pregnant and nursing mothers should also not take this drug, which increases the risk for severe birth defects and miscarriage.
Retinoids.
These prescription oral vitamin A-related drugs may be given alone or in combination with ultraviolet light to treat severe psoriasis. Retinoids have anti-inflammatory actions, help regulate cell reproduction and may improve arthritis that accompanies psoriasis.
Side effects of retinoid treatment include dry skin and eyes, chapped lips, bone and joint pain, fatigue, nose bleeds, bruising, headaches, and thinning hair. Blood triglycerides may be elevated and tiny bone spurs may form. Retinoids may also cause eye problems including blurred visions, cataracts and deterioration of night vision, and liver damage.
In rare cases, retinoids may cause a condition called benign intracranial hypertension, symptoms include headache, nausea, vomiting, and blurred vision.
Oral retinoids should never be prescribed for pregnant women or women of childbearing age who intend to become pregnant within three years of discontinuation of therapy. The patient should be closely monitored and given regular blood tests during retinoid treatment.
Cyclosporine.
This immune-suppressing drug is for treatment of widespread psoriasis when other methods have failed. Cyclosporin has a number of undesirable, often serious side effects, including: headaches, joint pain, gout, body hair growth, gingivitis, tremor, and fatigue. Cyclosporine may cause hypertension in up to 30 percent of patients, and may increase blood lipid levels. The prolonged use of cyclosporine always causes some kidney damage and abnormalities in the liver. Long-term use may increase the risk for skin cancers and lymphomas, especially for patients who have had other psoriasis treatments, including PUVA, tar, or radiation therapy, methotrexate, or other immunosuppressive drugs.
Due to cyclosorine's potential impact on the kidneys and blood pressure, close monitoring and regular blood tests are required for patients taking cyclosporine.
SCALP PSORIASIS TREATMENT
The treatment for psoriasis of the scalp depends on the severity of the disease, the person's lifestyle and the length of hair. A variety of prescription and non-prescription shampoos, sprays, oils, and solutions are available. Most of these contain coal tar or cortisone.
MEDICATIONS THAT MAY HELP MODIFY THE DISEASE PROCESS
Nutricol® available as Recovery® in many pharmacies, is proposed to help the skin's natural healing process. This may reduce the likelihood of progression and assist recovery. Nutricol® (Recovery®) is an anti-catabolic agent that works at cellular level to help stabilize cellular structures.
Nutricol® (Recovery®) may be safely combined with other medications or taken on its own to help counter inflammation and flare-ups. It does not produce unpleasant side effects. Since this product works to modify the body's responses, it may take up to six weeks for the patient to experience relief, with most people noticing benefits within a month.
HOW RECOVERY IMPROVES SKIN HEALTH
- 1.Reinforces membrane and matrix structures by increasing aldimine reducible cross-linking of collagen fibers; this acts to reinforce the strength and elasticity of connective tissue structures such as fascia, dermis and blood vessel walls (26,27)
- 2.Neutralizes reactive oxygen species (ROS) and catabolic enzymes before they can negatively impact cellular and extracellular structure and function; this results in increased membrane receptivity to growth factors such as insulin, somatomedins and thyroxin that are required for anabolic repair and cellular maintenance (4,10,13,28-30,35,49)
- 3.Decreases catabolism of membrane and matrix collagen and glycosaminoglycan (GAG) structures via decreasing the pathological production of catabolic enzymes and other biochemicals such as collagenase, elastase, hyaluronidase, tumor necrosis factor, nitric oxide synthase and xanthine oxidase; these biochemicals are released from immune, microbial and damaged cells and cause further damage to connective and epithelial tissue structures, resulting in joint pain, inflammation, capillary fragility and other soft-tissue damage (4,25,31-35)
- 4.Stabilizes cellular membranes, preventing the release of compounds that promote inflammation such as histamine, serine proteases, prostaglandins and leukotrienes by non-competitively inhibiting the release of associated inflammatory enzymes such as cyclo-oxygenase, lipoxygenase and phosphodiesterase (33,36)
- 5.Increases the stability and production of protective epithelial mucosal surfaces in the digestive, respiratory and genitourinary tract to decrease the absorption of antigens (environmental compounds that may initiate immune or non-immune mediated inflammation, spasm and damage within skin structures) (37-40)
Biostructural® Medicine goes beyond simply addressing symptoms and focuses on the degenerative process and optimal healing.
Nutricol® (Recovery®) may be safely combined with other medications or taken on its own to help counter inflammation and improve the quality and rate of healing.
Information for Doctors: Print an 6-page detailed information package that provides the following:
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Click here to view feedback from health professionals and users about the results noted from Recovery® with Nutricol®.