Sam was studying for his bar exam when he woke up with a red scaly patch over his abdomen. He thought at first it was just a rash, but when the scaliness and itching got worse and started to spread, he saw a dermatologist.
The diagnosis was psoriasis and, at the time, he thought of it as just another embarrassing skin problem, like the acne he had suffered when he was in high school. As stressful as that was to handle, he now knows that psoriasis is an even more serious and persistent disease that can affect virtually all areas of health.
The skin part is bad enough. Red patches covered with silvery scales that itch or burn can occur anywhere on the body, even the genitals or the inside of the mouth. In some cases, the skin can crack and bleed. On the scalp or even on the forearms, the patches may appear to be a bad case of dandruff. They are, in fact, much more persistent and difficult to treat.
Dealing with any skin problem can become extremely stressful. But with psoriasis the stress works both ways. Sam’s doctor believed that his psoriasis might have developed as a result of emotional stress he was experiencing while studying for the bar.
A Systemic Disease
Psoriasis is a disease of the immune system that can cause an inflammatory response anywhere in the body. There is no cure, and it’s a lifelong disorder, although ordinarily with periods of flare and remission.
When the immune system starts to re-produce excess quantities of TNF-alpha and interleukin-12 and 23, skin cells start to produce rapidly, resulting in the raised, red areas of plaque. These flare-ups are often associated with emotional stress, injury to the skin, infections or even reactions to certain drugs.
Sometimes, the reaction is confined to the skin, but it can also cause inflammatory changes elsewhere in the body.
Nail psoriasis affects fingernails and toenails, causing ridges, pitting, discoloration and separation of the nail from the nail bed. Dead skin may build up under the nail.
About 15 percent of psoriasis patients develop psoriatic arthritis. This may occur 12 to 20 years after the skin symptoms; or, in a few cases, several years before any sign of a skin disorder. In the latter case, diagnosis is difficult and is usually best made by a rheumatologist.
Like the skin manifestations, the inflammation in the joints varies widely in severity and has flare/remission cycles that may or may not coincide with the flares of the skin disorder.
The disease is chronic, however, and gets worse over time. It’s important to get diagnosis and treatment early in order to avoid permanent damage to joints and significant disability.
One common sign is painful sausage-like swelling of the fingers. The arthritis may also affect one or both knees or elbows or the joints in the back, hip or neck. Sometimes pain and stiffness occur at the place where tendons and ligaments attach to bones–such as at the back of the heel or the sole of the foot.
Since 40 percent of patients with psoriatic arthritis have a family member with psoriasis, heredity is believed to play a role, as it does with other manifestations of psoriasis.
Moderate to severe psoriasis is also associated with a number of cardiometabolic conditions, including diabetes, obesity, hypertension and high cholesterol. Psoriasis patients frequently have high levels of c-reactive protein (CRP) , a marker of inflammation that has been linked to heart disease. Compared to similar individuals the same age, a patient with moderate to severe psoriasis has a significantly higher risk of suffering a heart attack.
Knowledge about the systemic risks of psoriasis has grown rapidly over the past decade or so; yet the National Psoriasis Foundation estimates that 39 percent of Americans with severe disease are not in treatment while many more are undertreated.
For mild psoriasis confined to the skin, topical treatments, similar to those used for other skin disorders, are usually sufficient. Probably the most effective treatment uses ultraviolet light–either 5 to 10 unprotected minutes in the mid-day sun three times a week or ultraviolet light therapy indoors.
For psoriatic arthritis, NSAIDs such as ibuprofen or naproxen are usually the initial prescription to control pain and inflammation, although these have risks and can make psoriasitic flares on the skin worse.
In most cases, disease-modifying antirheumatic drugs (DMARDs) such as methotrexate are eventually needed to limit joint damage. Immunosuppressant medications such as azathioprine, cyclosporine and leflunomide work by suppressing the immune system. Both of these treatments have side effects, sometimes serious. And immunosuppressants leave the body vulnerable to other attacks such as infections.
The newest drugs are known as biologics. They work by blocking the action of specific substances that are involved in the inflammatory response. These include proteins such as tumor necrosis factor-alpha (TNF-alpha) and interleukins 12 and 23. Because they target selectively, there is less risk of shutting down beneficial parts of the immune system.
Enbrel, Humira, Remicade and Simponi are recently introduced drugs that block TNF-alpha. Stelara selectively targets interleukin-12 and interleukin-13. The first biologic was introduced as recently as 2003, and these medications are still being studied for long-term safety. All are taken by injection or intravenous infusion.
Biologics are typically prescribed for patients with moderate to severe psoriasis or psoriatic arthritis who have not responded to other treatments or have suffered serious side effects.
When started early enough, these drugs offer the potential to prevent permanent damage to joints and head off the serious complications involving metabolism and the cardiovascular system. Unfortunately, for one reason or another, only about one percent of psoriasis patients are now taking a biologic medication.
Many experts believe there is significant undertreatment of the disease, primarily because of the perception, among doctors as well as patients, that it is primarily a cosmetic, dermatological problem. Even long-term patients may fail to connect their joint, cardiovascular and other problems to the systemic inflammation that brought on the scaly red patches on their skin.
Increased knowledge has brought better treatments, and these treatments have the potential to lessen the considerable burden of psoriasis.
REFERENCES:
American Academy of Dermatology, “Psoriatic arthritis.”American College of Rheumatology, “Psoriatic arthritis,” updated September, 2012.
“Biologic drugs: fact sheets,” Psoriasis.org, National Psoriasis Foundation, 2013.
T.W. Chu and T.F. Tsai, “Psoriasis and cardiovascular comorbidities with emphasis in Asia,” G. Ital Dermatol Venereol, April, 2012.
H.J.A. Hunter, C.E.M. Griffiths and C.E. Kleyn, “Does psychosocial stress play a role in the exacerbation of psoriasis?” The British Journal of Dermatology, 20-13;169(5):965-974.
Mariana J. Kaplan, “Cardiometabolic risk in psoriasis: differential effects of biologic agents,” Vascular Health and Risk Management, December, 2008.
Erine A. Kupetsky, D.O., M.Sc, and Matthew Keller, M.D., “Psoriasis vulgaris: an evidence-based guide for primary care,” Journal of the American Board of Family Medicine, 2013;26(6):787-801.
National Psoriasis Foundation, “Systemic medications for psoriasis and psoriatic arthritis including biologics.”
NIH, “Questions and answers about psoriasis,” updated August, 2013.
N. Onumah and L.H. Kircik, “Psoriasis and its comorbidities,” Journal of Drugs in Dermatology, May, 2012.
“Psoriasis,” MedlinePlus, updated November 20, 2012.
“Psoriasis–topic overview,” WebMD, last updated January13, 2010.
“Psoriatic arthritis,” MedicineNet.com, Medically reviewed October 2, 2013.
“Psoriasis is a systemic disease: an expert interview with Alan Menter, M.D.,” Medscape Dermatology,
02/20/2014
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