Psoriasis is a rare multisystem condition, and according to the American Academy of Dermatology, only about 3.2% of the U.S population currently suffers from this disease. Although psoriasis may be incurable, there are many effective treatment and management options available. Treatment guidelines are based on current evidence that specifies the treatment recommendations for dermatologists and the role they have in monitoring and helping educate patients about their rare diseases.
Psoriasis Overview
Psoriasis is rare relapsing (chronic) autoimmune skin condition that is characterized by red, itchy patches that form on the affected person’s skin. These plaques (patches) occur when the life cycle of skin cells is sped up (hyperproliferation), which results in excess cells building up on the skin (creating inflammation of the skin's epidermis and dermis). People who have psoriasis may not even know they have it as it often is asymptomatic until an outbreak occurs, with outbreaks being reported to sporadically occur, lasting anywhere from 1 month to 12 months.
Read MoreCommon symptoms associated with psoriasis:
- Small scaling spots
- Swollen or stiff joints
- Burning, itching, or soreness of the skin
- Small scaling spots
- Cracked and dry skin that may itch or bleed
- Ridged or thickened nails
- Red patches of skin covered with silvery scales
The different types of psoriasis that may present:
- Plaque psoriasis- This is the most common type of psoriasis that may occur, causing itchy and tender, raised, dry skin patches. It is reported that about 80-90% of people who have psoriasis develop this type.
- Nail psoriasis -affects the toenails and the fingernails and may even cause the nails to loosen from the nail bed.
- Guttate psoriasis Young adults and children are normally affected by this disease, which is typically caused by an infection such as strep throat. The bumps appear suddenly. People may get guttate psoriasis for life, with no way to predict future outcomes after the first flare-up of this type of psoriasis.
- Inverse psoriasis The skin folds such as areas in the buttocks, groin, and breasts are mainly affected in this type of psoriasis. Sweating and friction in these areas may cause psoriasis to worsen.
- Psoriatic arthritis This type of psoriasis affects the person’s joints, as they become painful and swollen.
- Pustular psoriasis- This is a rare type of psoriasis that is characterized by the formation of patches of pus-filled blisters throughout the body. This type of psoriasis can be severe and potentially life-threatening.
- Erythrodermic psoriasis- This is another rare type of psoriasis that covers the entire body with a peeling, red rash that may have an intense burning sensation or be itchy. This type of psoriasis is also severe and life-threatening and requires immediate attention if it develops.
What Causes Psoriasis?
Psoriasis is a complex immune-mediated condition that is not contagious and is rather caused by a genetic predisposition; other risk factors include smoking, alcohol consumption, and obesity. Those with psoriasis often do not know they have it until it is triggered by multiple different things such as:- Tobacco
- Stress
- An injury to the skin, such as severe sunburn or a cut
- Some medications, such as prednisone, lithium, and hydroxychloroquine
- Alcohol (excessive drinking)
- Weather conditions, more specifically cold, dry weather
- Infections (Guttate psoriasis has a correlation with strep throat infection)
How Is Psoriasis Diagnosed?
Psoriasis is diagnosed by a doctor or dermatologist based on your answers to their questions and your family history, and when there is any uncertainty, a skin biopsy is taken. Psoriasis is then assessed by evaluating the presence of psoriatic arthritis, the severity using subjective and objective measures, and any associated comorbidities and features.
“Everybody should know that psoriasis is just not limited to the skin,” Dr. Saakshi Khattri, a dermatologist/rheumatologist at Mount Sinai Health System, said in a previous interview with SurvivorNet. “So, as a rheumatologist and a dermatologist, that’s like the biggest thing that I am always on the lookout for when I see a patient with psoriasis… If you have what looks like psoriasis on the skin and then you start to have joint pains or swelling of a joint.”
How Is Psoriasis Severity Determined?
The severity of psoriasis can be determined objectively through thorough assessment using the static Physician's Global Assessment or the Psoriasis Area and Severity Index (PASI) in a specialized setting.
"When I see a psoriasis patient, I first determine the extent of their condition. If it's fairly localized, I'm able to treat the patient with topical therapy by itself," Dr. Linda Stein Gold, Director of Clinical Research in the Department of Dermatology at Henry Ford Health in Detroit, said in a previous interview with SurvivorNet. "But if they have a more widespread condition, topicals alone are not practical."
Psoriasis Treatment Guidelines
Treatment and management guidelines for psoriasis using topical treatments, phototherapy, and systemic treatments were published in 2021 by the National Psoriasis Foundation and the American Academy of Dermatology in the Journal of the American Academy of Dermatology.
"The majority of patients with psoriasis overall are managed with topicals only,” Dr. George Han, a dermatologist at Northwell Health/Lenox Hill Hospital, said in an interview with SurvivorNet. “But I have patients who come in after having been to many other medical practices and not really getting much hope or really good treatments for it, and we’ll give them a systemic medicine that these days are very effective.
“We have treatments where over half of the patients who have moderate, severe psoriasis are getting a 100% clear. So, we definitely are in a good era of treatment when it comes to psoriasis, but, overall, the majority of patients still get topicals first.”
Below we will provide a summary of the treatment guidelines published.
When are you referred to a specialist?
Patients will be referred to a dermatologist or specialist in the following circumstances:
- Children that have psoriasis at the time of their diagnosis
- If there is any uncertainty with a diagnosis
- If the patient has difficult-to-treat sites, such as palms and soles, the face, and genitalia.
- Any patient that has psoriasis which is unable to effectively manage in the general practice (GP) setting.
- Topical therapies alone are not working effectively
- If a patient presents with moderate to severe psoriasis and will need systemic treatment or phototherapy.
- If a patient's psoriasis has a significant impact on their quality of life.
Topical Therapy guidelines
When administering topical therapies, the patient’s preferences, practical and cosmetic aspects of psoriasis treatment need to be considered. Guidelines for administering topical treatments for psoriasis include:
- Discuss the different formulations available with the patient
- Discuss how referral for systemic and phototherapy treatments will be made if the topical treatments do not work effectively
- Ensure that patients understand that: the relapse rate for flair-ups is higher in people who do not get treatment. Treatments can be reduced to an amount that will maintain psoriasis control when the flair-up is cleared or under control. Patients will need to be monitored for a period of time when a new topical treatment is started.
Topical treatment options include:
- Coal tar
- Salicylic acid
- Dithranol
- Soap substitute- such as aqueous cream
- Moisturizer- emollients and ointments
- Corticosteroid
- Calcipotriol
- Retinoids
- Calcineurin inhibitors
Phototherapy Guidelines
Phototherapy appears to reduce the activity of T cells (part of the immune system) and slow keratinization that is involved in the formation of psoriatic patches (plaques). The treatment guidelines for phototherapy include:
- Types of phototherapy are broadband UVB, psoralen plus ultraviolet A (PUVA), and narrowband ultraviolet B (UVB).
- Phototherapy is suitable for most people who have an inadequate response to topical treatments.
- Phototherapy can be administered as a single treatment or in combination with systemic or topical agents.
- Before starting PUVA treatment, the patient should be informed of treatment alternatives and the risk of skin cancer.
Systemic Therapy Guidelines
Indications that a patient needs systemic treatment:
- The patient is at high risk for skin cancer
- There is an inadequate response to phototherapy treatment
- There is a rapid psoriasis flare-up after completion of phototherapy
- Poor tolerance of phototherapy treatments
Systemic treatments should only be initiated in a specialist setting, with ongoing supervision and monitoring. non-biologic systemic therapy can be offered to psoriasis patients if:
- Their psoriasis cannot be controlled or managed with topical therapy.
- Psoriasis has a significant impact on the patients’ physical, social and psychological well-being.
- Phototherapy has been ineffective, cannot be used, or has triggered a psoriasis flare-up.
Patients receiving non-biologic systemic therapy will need close monitoring for any adverse effects. Non-biologic agents include acitretin, methotrexate, apremilast, and ciclosporin.
Biologic systemic therapies are often more effective than non-biologic systemic treatments; however, their long-term risks are still not well known. The use of biologic agents in clinical practice is limited as they are expensive. Biologic agents include adalimumab, etanercept, and infliximab.
Questions To Ask Your Doctor
- What type of psoriasis do I have?
- What kind of treatment is best for me?
- Can I experience any side effects from the treatment?
- Will I permanently have to live with psoriasis outbreaks?
- Can I use multiple topical creams and ointments together?
- How do I manage the appearance of my psoriasis when I have to be in public?
The Bottom Line
Having a rare, incurable disease may seem daunting, and you may worry about the quality of life you are able to lead. You also may suffer emotionally with the cosmetic toll (flaky skin patches) that comes with psoriasis. It's important to remember that there are many treatment options available to help find the best way to manage your symptoms. SurvivorNet has in-depth content to help you understand psoriasis, the different treatment options available, and how to best advocate for yourself.
Learn more about SurvivorNet's rigorous medical review process.