What are the Symptoms of Psoriasis?

Psoriasis is often asymptomatic, so people who have the disease will not be dealing with constant outbreaks.

"Some patients report itching [or a] burning sensation, but that doesn't tend to be the norm. It certainly can happen," Dr. Khattri explains. "Then if you have psoriasis in the genital area, it can feel uncomfortable just because it's in a very sensitive part of the body. But for the most part, it tends to be asymptomatic."

Symptoms associated with the disease include:

• Red patches of skin covered with silvery scales
• Small scaling spots
• Dry, cracked skin that may bleed or itch
• Itching, burning, or soreness
• Thickened or ridged nails
• Swollen or stiff joints

Dr. Khattri recommends seeing a dermatologist if you notice red, scaly spots on the body so a doctor can make a proper diagnosis. Psoriasis patches can vary in how they appear on the skin. The disease may present as just a few spots with dandruff-like scaling or as rashes that cover large parts of the body. The most commonly affected areas are the lower back, elbows, knees, legs, soles of feet, scalp, face, and palms.

Dr. Khattri explains which signs and symptoms may indicate psoriasis. 

What are the Types of Psoriasis?

There are seven different types of psoriasis, with plaque psoriasis being the most common. The types differ in how they present and what they are caused by.

• Plaque psoriasis: This is the most common form of the disease and causes dry, raised skin patches that may be covered in scales. The patches may be itchy and tender.
• Nail psoriasis: This disease can affect fingernails and toenails and might cause nails to loosen from the nail bed.
• Guttate psoriasis: This disease typically affects young adults and children and is often caused by a bacterial infection like strep throat.
• Inverse psoriasis: This type of psoriasis mainly affects skin folds, so it will often present in areas such as the groin, buttocks, or breasts, and can worsen with friction or sweating.
• Pustular psoriasis: This is a rare form of psoriasis that causes pus-filled blisters to develop in widespread patches across the body.
• Erythrodermic psoriasis: This is also a rare form of the disease. It can cover the entire body with a red, peeling rash that may itch or burn intensely.
• Psoriatic arthritis: With this form of the disease, joints may become swollen and painful. Sometimes, joint pain is the first or only symptom, while other times other symptoms like nail changes will occur.

Dr. Khattri provides information on the different types of psoriasis.

How is Psoriasis Managed?

Psoriasis is a chronic disease that does not have a cure, but symptoms can often be managed with different treatments and some lifestyle adjustments. Treatment options basically fall into three categories: topical treatments (which would be ointments or creams you can rub on the skin), phototherapy (using UVB light to treat the disease), or systemic treatments (drugs taken either orally or through an IV that treat symptoms by targeting parts of the immune system).

Topical Treatments

Topicals are considered a mainstay for treating psoriasis, and there are several different options available. When it comes to topicals, the route you go with will depend on what type of psoriasis you have and how symptoms are presenting.

Some of the different topical creams and ointments that may be prescribed include:

• Corticosteroids: These drugs may be prescribed to treat mild to moderate psoriasis and can be a good option during flare ups. They are available as ointments, creams, lotions, gels, foams, sprays, and shampoos.  Topical corticosteroids are classified into seven categories based on their potency, ranging in strength from ultra-high to low. Lower potency corticosteroids are typically used on the face, while areas with thick, chronic plaques often require treatment with  ultrahigh-potency corticosteroids.
• Vitamin D analogues: These synthetic forms of vitamin D can help slow skin growth. The drugs can be used alone or in combination with corticosteroids. Calcipotriene (also known as calcipotriol) and calcitriol are the two commonly used synthetic vitamin D analogues.
• Retinoids: Retinoids can come as a gel or cream and be used to relieve some psoriasis symptoms.  Topical tazarotene can be particularly helpful for palmar-plantar psoriasis (palms and soles) and nail psoriasis, the AAD and NPF guidelines say.
• Calcineurin inhibitors: These drugs reduce inflammation and plaque buildup. These may be helpful in areas where skin is thin, like around the eyes, but should not be used for long periods of time due to potential side effects. Although not FDA approved for psoriasis, the topical calcineurin inhibitors tacrolimus and pimecrolimus are often used in the treatment of psoriasis.
• Salicylic acid: These shampoos and scalp solutions can reduce the symptoms of psoriasis on the scalp. Salicylic acid minimizes scaling and softens plaques. It can also be combined with other topical medications including corticosteroids.
• Coal tar: A product of coal, this medication has been used to treat psoriasis for more than a century, according to AAD and NPF. These drugs can reduce scaling, itching, and inflammation and can be included in shampoos, creams, and oils.

Phototherapy

Another treatment option for psoriasis is phototherapy. This therapy is generally used when medications applied to the skin alone do not work and alternative options are needed. It can also be used for patients who wish to avoid medications that can affect their entire body (system medications).  Phototherapy can also be used in conjunction with topical and/or systemic psoriasis treatments.

Phototherapy exposes patients with psoriasis to narrow band UVB light.

"It's a limited spectrum of the sunlight, which we use. Patients generally have to come to a place that does phototherapy. There's a phototherapy box. You go there. It's generally three times a week in the very beginning until your psoriasis is in control. And beyond that we can space it apart to once a week or twice a week as maintenance," Dr. Khattri says.

Dr. Khattri explains how phototherapy is used to treat psoriasis.

A frequency of twice or three times weekly is effective and is recommended, according to the American Academy of Dermatology (AAD) and National Psoriasis Foundation (NPF) guidelines.

Systemic Treatment

Sometimes treatments applied to the skins' surface just aren't enough to clear stubborn psoriasis. That's where systemic treatment treatment that travels through your entire body rather than being aimed at one area can be beneficial for patients. Systemic treatments are available via oral medication and injections.  Some have been around for decades, while others are relatively new to the landscape.

"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 their psoriasis," Dr. George Han, a dermatologist at Northwell Health/Lenox Hill Hospital, explains to SurvivorNet. "And we'll give the patient a systemic medicine that these days are very effective. We have treatments where over half of the patients who have moderate to severe psoriasis are getting 100% clear."

Systemic treatments may include oral medications like methotrexate, Apremilast (otezla), or cyclosporine. Biologic drugs, or biologics, which are given by injection or intravenous (IV) infusion (a slow drip of medicine into your vein), may also be given. These drugs target only specific parts of the immune system, while other systemic drugs target the whole system.

There are three main categories of biologics used to treat psoriasis, according to Dr. Khattri. These include:

• Injections that target and block TNF, a pro-inflammatory molecule that the body may be producing too much of when a person has psoriasis (includes drugs like Humira, Cimzia, and Enbrel)
• Injections that target and block IL-17, another pro-inflammatory molecule that could trigger psoriasis symptoms (includes drugs like Cosentyx, Taltz, and Siliq)
• Injections that target IL-12 or IL-23, which are also proteins linked to psoriasis symptoms (examples of these drugs include Tremfya and Ilumya)

"All of these are injections which are approved for psoriasis, and some of them are also approved for psoriatic arthritis," Dr. Khattri explains.

Also, with the new FDA-approved drug SOTYKTUâ„¢ (deucravacitinib), people with moderate to severe plaque psoriasis can find even more relief than ever before with oral medications. The advantage of this new drug compared to others is its high efficacy without the side effects that can typically come along with other types of oral drugs for psoriasis.

Dr. April Armstrong explains when deucravacitinib can be used.

"This is a significant breakthrough medication for our patients for a number of reasons. Number one, it has what we call the novel mechanism action. So it works differently from other medications that we have seen," Dr. April Armstrong, Professor of Dermatology at Keck School of Medicine at USC, explained. "And importantly, as an oral medication, it has very high efficacy, so it works quite well, and also it has a good safety profile."